The patient in AUR caused by stricture disease has the same requirement for bladder drainage as the patient with obstruction caused by BPH. However, urethral access is almost invariably not available. In these cases, insertion of a suprapubic catheter is often the only option available. This is discussed further in Chap. 19, "Surgical Techniques and Percutaneous Procedures". Rarely, suprapubic catheterization may be contraindi-cated (e.g., urothelial malignancy, although this is a relative contraindication in the acute setting) or technically impossible (e.g., morbid obesity, presence of abdominal viscerabetween abdominal wall on ultrasonographic examination). In these cases, the only two options available both involve surgical intervention. Open surgical cystostomy is one option, with the attending risks of an abdominal incision (although the peritoneum need not be opened in most cases). The other option would be to attempt direct inline visual urethroto-my (DIVU) after passing a guidewire across the stricture and incising it, although very dense strictures are usually not successfully by-passed in this manner. A last-resort option would be to consider acute-setting formal urethroplasty, but this is so rarely carried out that it should not be considered unless everything else has failed.
It is very rare for suprapubic drainage to be impossible, and once established, the patient can safely be managed with a suprapubic catheter until definitive treatment for their stricture can be planned.
In cases of AUR due purely to phimosis, acute circumcision or a dorsal slit procedure of the prepuce can be performed to allow the patient to void, or if necessary allow access to the urethral meatus for catheterization. Similarly, meatal dilatation under local anesthetic can relieve meatal stenosis sufficiently to allow the patient to void (or a urethral catheter to be passed as indicated) if this is the cause of the AUR. Meatal dilatation is usually performed with urethral sounds, graduated female urethral dilators, or bougies, depending on local availability. Some patients will need definitive treatment at a later date for these conditions; others can be managed conservatively.
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