Urethral Stricture

Urethral stricture at a glance

• The urethra is the tube that transports urine from the bladder to the exterior of the body, and urethral stricture is a narrowing of the urethra due to scarring or swelling from an injury or infection.
• Urethral strictures can result in difficulty passing urine, urinary tract infections, swelling, infections or injury of the kidneys.
• Currently, there are no medications to treat stricture, but procedures like dilation, urethrotomy and urethroplasty can be curative.
• Men are significantly more likely to be affected by urethral stricture than women.

---

What is urethral stricture?

Urethral stricture refers to the buildup of scar tissue in the urethra, which is the passage that empties urine from the bladder, slowing or blocking the ability to urinate. Men have a longer urethra and are more likely to experience scarring or narrowing of their urethra than women and infants.

The average male urethra, which runs from the bladder to the tip of the penis, is about 20 centimeters or approximately 8 inches in length and is surrounded by vascular tissue known as the corpus spongiosum. Stricture or narrowing can occur at any point in the urethra and is categorized based on where it occurs along the urethra.

Anterior urethral stricture

Anterior urethral strictures are the most common and occur anywhere along the urethra from the urethral meatus at the tip of the penis, in the penile urethra or in the bulbar urethra, which is located behind the scrotum. Anterior strictures are often caused by genital injuries, including straddle injuries where the legs fall on either side of an object, such as the crossbar on a bicycle.

Posterior urethral stricture

Scar tissue development and narrowing of the urethra within 1-2 inches of the bladder is linked to more severe injuries such as pelvic fracture or radiation therapy. Posterior cases often result in a complete blockage or a cut that separates one part of the urethra from another, preventing urine from passing.

Causes of urethral stricture

Stricture or narrowing typically occurs due to chronic inflammation or the development of scar tissue at any point along the urethra. In many cases, the exact cause of scarring remains unknown, but there are a number of risk factors known to increase the risk of strictures including:

• Injury or trauma to external genitalia, perineum or pelvis.
• Damage from previous medical procedures such as prostate surgery or ureteroscopic kidney stone removal.
• Intermittent or long-term use of catheters.
• Sexually transmitted infections like gonorrhea and chlamydia.
• Prostate, penile and other urologic cancers.
• Radiation therapy.

Urethral stricture symptoms

Patients often experience a slowing of their urine stream as their urethra starts to narrow. This decreased flow of urine can lead to difficulty emptying the bladder or pain during urination. In the most severe cases, patients cannot empty the bladder at all. Other signs that a urethral stricture is forming or has formed include:

• Bloody or dark urine.
• Bloody semen.
• An increase in urinary frequency and urgency.
• Urine stream spraying.
• Abdominal pain.
• Penile swelling.
• Urinary tract infections.

Many patients with stricture will experience a slow progression of symptoms and discomfort. Others may experience symptoms suddenly and require more immediate care.

If left untreated, urethral narrowing causes the body to retain urine, which can cause the bladder to become enlarged and damage the kidneys.

Diagnosing & treating urethral stricture

Urethral strictures can be diagnosed via physical exam, using X-ray or ultrasound technology, or using a cystoscope, a small and flexible viewing instrument that is inserted into the urethra.

One popular method for diagnosis in males is a retrograde urethrogram. Retrograde urethrograms use contrast dye inserted through the opening of the penis and X-ray technology to locate urethral strictures and measure how much of the urethra is affected by scarred tissue.

Once the location and severity of the stricture have been identified, the doctor will discuss methods for relieving the blockage and restoring urine flow. Currently there are not any medications available to treat stricture. However, there are a number of effective procedures that can treat stricture disease depending on the location of the scar tissue, how much of the urethra is involved, and what treatments have been tried in the past.

Dilation and urethrotomy

Dilation and urethrotomy are two less invasive methods of treating simple strictures that are short (< 1.5 cm in length), located in the bulbar urethra (the part behind the scrotum and inside the body), and when the patient has not had other treatments in the past. Both procedures involve opening the narrowed urethra to allow the tissue to heal with a wider diameter and improve the urinary stream.

Dilation is a process of gradually stretching the part of the urethra that has been narrowing. This process uses small balloons or catheters known as “sounds” to gently stretch the tissue within the urethra. This treatment option must be repeated regularly. Dilation can lead to bleeding and infection, or cause a second, or false, urethra to form.

Urethrotomy is another method to open the scarred urethra, using a cystoscope to visualize the stricture and cut the scarred tissue to widen the urethra. This restores the ability to urinate and is typically performed in an outpatient facility, with the patient typically being discharged the day of the procedure. Urethrotomy can also lead to bleeding and infection, but these are self-limiting and resolve over 1-2 days.

Both dilation and urethrotomy offer initial treatment options for men with short strictures and can be successful in as many as 50%-75% of cases. However, patients should not have repeated procedures, as more than 1-2 dilation/urethrotomy procedures can lengthen or worsen the scar tissue.

Urethroplasty

Urethroplasty offers a definitive and highly successful surgical treatment for men who have longer strictures or scar tissue outside of the bulbar urethra, and for those who have not had success after less invasive procedures. Urethroplasty is a reconstructive surgery that restores the flow of fluid through the urethra, and has the best long-term results for treating stricture disease.

In most cases, the scarred segment of the urethra is removed and two resulting ends are sewn together to reconnect the tube. For longer strictures or those located closer to the tip of the penis, a graft from the surrounding skin or from inside the cheek may be needed to patch the urethra and create a wider tube. Urethroplasty is considered the gold standard of urethral stricture treatments and, depending on the technique, has a long-term success rate of 80%-95% when performed by a trained specialist.