Urethral Stricture

A urethral stricture is a narrowing of the urethra, the tube that carries urine from the bladder to the outside of the body. This condition primarily affects men and can cause significant urinary problems, including difficulty urinating, urinary retention, and recurrent infections. Strictures can result from injury, infection, or scarring and may require various treatment approaches depending on their location, length, and severity.

Medical Disclaimer: This information is for educational purposes only and should not replace professional medical advice. If you experience symptoms of urethral stricture, consult with a urologist for proper evaluation and treatment.

Overview

The urethra is a crucial part of the urinary system, serving as the conduit through which urine exits the body. In men, the urethra is approximately 20-25 cm long and passes through the prostate gland, while in women, it is much shorter at about 4 cm. A urethral stricture occurs when scar tissue forms within the urethra, causing it to narrow and restrict the flow of urine.

Urethral strictures are significantly more common in men than in women due to the longer male urethra and its passage through the prostate. The condition affects approximately 200-300 per 100,000 men, with incidence increasing with age. Most strictures in men occur in the bulbar urethra (the portion that passes through the corpus spongiosum) or the penile urethra.

The severity of symptoms depends on the degree of narrowing, the length of the stricture, and its location within the urethra. Some patients may have minimal symptoms with minor narrowing, while others may experience complete urinary retention requiring emergency intervention. Without proper treatment, urethral strictures can lead to serious complications including urinary tract infections, bladder stones, kidney damage, and chronic urinary retention.

Modern treatment approaches have evolved significantly, with various surgical and non-surgical options available. The choice of treatment depends on factors such as stricture characteristics, patient age and health status, and previous treatment history. Early recognition and appropriate treatment can prevent complications and significantly improve quality of life.

Symptoms

The symptoms of urethral stricture can develop gradually or appear suddenly, depending on the underlying cause and rate of stricture formation. The severity of symptoms typically correlates with the degree of urethral narrowing.

Primary Urinary Symptoms

  • Painful urination - burning or stinging sensation during urination
  • Retention of urine - difficulty emptying the bladder completely
  • Weak or interrupted urine stream
  • Straining to urinate
  • Prolonged urination time
  • Dribbling after urination
  • Frequent urination, especially at night

Associated Symptoms

Complications-Related Symptoms

  • Symptoms of bladder complications - chronic fullness, bladder pain
  • Symptoms of prostate involvement - prostate tenderness or enlargement
  • Symptoms of the scrotum and testes - swelling or pain from back-pressure
  • Signs of kidney involvement - flank pain, decreased urine output

Emergency Symptoms

  • Complete inability to urinate (urinary retention)
  • Severe abdominal or pelvic pain
  • Signs of infection - fever, chills, confusion
  • Visible blood in urine with clots
  • Severe flank pain suggesting kidney involvement

Causes

Urethral strictures can result from various factors that lead to inflammation, injury, or scarring of the urethral tissue. Understanding these causes helps in prevention and treatment planning.

Traumatic Causes

  • Pelvic fractures: High-impact injuries affecting the posterior urethra
  • Straddle injuries: Falls or impacts that compress the urethra against the pubic bone
  • Penetrating trauma: Gunshot wounds or stab injuries to the pelvis
  • Blunt perineal trauma: Sports injuries or motorcycle accidents
  • Self-inflicted trauma: Insertion of foreign objects

Iatrogenic (Medical Procedure-Related) Causes

  • Urethral catheterization: Especially prolonged or traumatic insertion
  • Transurethral procedures: TURP, ureteroscopy, cystoscopy
  • Urethral surgery: Previous stricture repairs or other urethral operations
  • Radiation therapy: Treatment for prostate or pelvic cancers
  • Penile implant surgery: Complications from prosthetic placement

Infectious Causes

  • Sexually transmitted infections:
    • Gonorrhea (historically most common)
    • Chlamydia
    • Herpes simplex virus
  • Non-gonococcal urethritis: Various bacterial infections
  • Tuberculosis: Rare but can cause extensive scarring
  • Schistosomiasis: Parasitic infection in endemic areas

Inflammatory and Other Causes

  • Lichen sclerosus: Chronic inflammatory skin condition
  • Balanitis xerotica obliterans: Affects the glans and foreskin
  • Congenital abnormalities: Developmental defects of the urethra
  • Idiopathic: Unknown cause (approximately 30% of cases)

Risk Factors

Several factors increase the likelihood of developing urethral strictures. Identifying these risk factors helps in prevention and early detection.

Demographic Risk Factors

  • Male gender: Significantly higher risk due to longer urethra
  • Age: Increasing incidence with advancing age
  • Ethnicity: Higher rates in certain populations

Behavioral and Lifestyle Risk Factors

  • High-risk sexual behavior: Multiple partners, unprotected sex
  • Participation in contact sports: Rugby, football, wrestling
  • Motorcycle or bicycle riding: Risk of straddle injuries
  • Occupational hazards: Jobs with risk of pelvic trauma

Medical Risk Factors

  • History of urethral catheterization: Especially long-term or repeated
  • Previous urological procedures: Cystoscopy, TURP, stone removal
  • Chronic inflammatory conditions: Lichen sclerosus, Crohn's disease
  • Recurrent urinary tract infections: Chronic inflammation
  • Diabetes mellitus: Increased infection risk and poor healing

Anatomical Risk Factors

  • Congenital urethral abnormalities: Hypospadias, epispadias
  • Previous stricture disease: Recurrence is common
  • Prostate enlargement: Can predispose to catheterization

Diagnosis

Accurate diagnosis of urethral strictures requires a combination of clinical assessment, patient history, and specialized imaging studies. Early diagnosis is crucial for preventing complications and planning appropriate treatment.

Medical History and Physical Examination

  • Symptom assessment: Detailed evaluation of urinary symptoms
  • Medical history: Previous infections, trauma, or procedures
  • Physical examination: Assessment of external genitalia and perineum
  • Digital rectal exam: Evaluation of prostate and posterior urethra

Urinalysis and Laboratory Tests

  • Urinalysis: Check for infection, blood, or other abnormalities
  • Urine culture: Identify specific bacterial infections
  • Post-void residual: Measure remaining urine after urination
  • Serum creatinine: Assess kidney function

Imaging Studies

Retrograde Urethrography (RUG)

  • Gold standard for evaluating urethral strictures
  • Provides detailed anatomy of stricture location and length
  • Shows degree of narrowing and surrounding anatomy
  • Essential for surgical planning

Voiding Cystourethrography (VCUG)

  • Evaluates the urethra during active voiding
  • Shows dynamic function and bladder neck
  • Complements retrograde urethrography
  • Useful for assessing treatment outcomes

Additional Imaging

  • Ultrasound: Non-invasive assessment of post-void residual
  • CT or MRI: For complex cases or when complications suspected
  • Uroflowmetry: Objective measurement of urine flow rate

Endoscopic Evaluation

  • Cystoscopy: Direct visualization of the urethra and bladder
  • Flexible ureteroscopy: Less traumatic evaluation option
  • Assessment of stricture characteristics: Length, location, degree
  • Biopsy if indicated: Rule out malignancy in suspicious lesions

Treatment Options

Treatment of urethral strictures depends on multiple factors including stricture location, length, etiology, patient age, and previous treatment history. Options range from minimally invasive procedures to complex reconstructive surgery.

Conservative Management

  • Observation: For asymptomatic or mildly symptomatic strictures
  • Intermittent catheterization: Self-catheterization to prevent recurrence
  • Alpha-blockers: Medications to improve urinary flow
  • Treatment of underlying conditions: Infections, inflammation

Minimally Invasive Procedures

Urethral Dilation

  • Gradual stretching of the stricture using progressively larger instruments
  • Quick outpatient procedure with minimal anesthesia
  • High recurrence rate, often requiring repeated procedures
  • Best for short, soft strictures

Internal Urethrotomy

  • Endoscopic incision of the stricture using a knife or laser
  • Success rates of 70-80% for first-time, short strictures
  • Lower success rates for recurrent or long strictures
  • Often combined with steroid injection or mitomycin C

Reconstructive Surgery (Urethroplasty)

End-to-End Anastomosis

  • Excision of strictured segment with primary reconnection
  • Best for short strictures (less than 2 cm)
  • Highest success rates (90-95%)
  • Limited by amount of urethra that can be excised

Substitution Urethroplasty

  • Buccal mucosa graft: Using tissue from inside the cheek
  • Penile skin flap: Local tissue transfer
  • Lingual mucosa: Alternative for complex cases
  • Success rates of 85-90% for appropriate cases

Staged Urethroplasty

  • Two-stage procedure for complex or long strictures
  • First stage creates a dorsally opened urethra
  • Second stage completes the tubularization
  • Reserved for the most challenging cases

Emergency Treatment

  • Urethral catheterization: For acute retention when possible
  • Suprapubic catheter: When urethral catheter cannot be placed
  • Percutaneous nephrostomy: For upper tract decompression
  • Emergency urethrotomy: In select cases with complete obstruction

Treatment Selection Criteria

  • Short strictures (<2 cm): End-to-end anastomosis preferred
  • Long strictures: Substitution urethroplasty
  • Recurrent strictures: Formal urethroplasty rather than repeated dilation
  • Pan-urethral strictures: Staged reconstruction

Prevention

While not all urethral strictures can be prevented, many risk factors are modifiable. Prevention strategies focus on reducing trauma, preventing infections, and minimizing iatrogenic causes.

Infection Prevention

  • Safe sexual practices: Use condoms, limit number of partners
  • Prompt treatment of UTIs: Early antibiotic therapy for infections
  • STI screening and treatment: Regular testing for sexually active individuals
  • Good hygiene practices: Proper genital cleansing

Trauma Prevention

  • Protective equipment: Appropriate gear for contact sports
  • Safe driving practices: Seat belts, motorcycle safety
  • Workplace safety: Proper protective equipment
  • Avoid self-instrumentation: Never insert foreign objects

Medical Care Prevention

  • Gentle catheterization: Proper technique and appropriate catheter size
  • Minimize catheter duration: Remove as soon as medically appropriate
  • Use alternatives when possible: Condom catheters, intermittent catheterization
  • Experienced operators: Ensure procedures performed by skilled clinicians

Secondary Prevention

  • Regular follow-up: Monitoring after procedures or trauma
  • Early symptom recognition: Prompt evaluation of urinary changes
  • Treatment of underlying conditions: Management of inflammatory diseases
  • Patient education: Awareness of symptoms and when to seek care

When to See a Doctor

Seek immediate emergency care for:

  • Complete inability to urinate (urinary retention)
  • Severe abdominal or pelvic pain with urinary symptoms
  • Signs of serious infection: fever, chills, confusion
  • Visible blood in urine with clots
  • Severe flank pain suggesting kidney problems

Schedule urgent appointment for:

Routine consultation recommended for:

  • Gradual changes in urinary stream or flow
  • History of urethral trauma or infection
  • Previous urological procedures with new symptoms
  • Persistent urinary frequency or urgency
  • Concern about urinary function after catheterization

Related Conditions

References

  1. Latini JM, McAninch JW, Brandes SB, et al. SIU/ICUD Consultation on Urethral Strictures: Epidemiology, etiology, anatomy, and nomenclature of urethral stenoses, strictures, and pelvic fracture urethral disruption injuries. Urology. 2014;83(3 Suppl):S1-7.
  2. Wessells H, Angermeier KW, Elliott S, et al. Male Urethral Stricture: American Urological Association Guideline. J Urol. 2017;197(1):182-190.
  3. Barbagli G, Kulkarni SB, Fossati N, et al. Long-term followup and deterioration rate of anterior substitution urethroplasty. J Urol. 2014;192(3):808-813.
  4. Mundy AR, Andrich DE. Urethral strictures. BJU Int. 2011;107(1):6-26.
  5. Chapple C, Andrich D, Atala A, et al. SIU/ICUD Consultation on Urethral Strictures: The management of anterior urethral stricture disease using substitution urethroplasty. Urology. 2014;83(3 Suppl):S31-47.