Urethral Stricture

How urethral strictures form

The urethra is lined by a delicate layer of tissue surrounded by spongy tissue (corpus spongiosum) in men. Injury or inflammation causes scarring (spongiofibrosis), which contracts and narrows the channel. The narrowing makes the bladder work harder and can block urine flow.

In men, strictures are described by location:

• meatal: at the opening of the penis
• penile: along the shaft
• bulbar: under the scrotum, the most common site
• posterior: near the prostate, usually after pelvic fractures or prostate treatment

Women can get urethral strictures, but they are uncommon.

Causes

Symptoms

• weak or slow urine stream
• spraying or split stream
• straining to urinate
• dribbling after urinating
• feeling that the bladder has not emptied
• frequent urination or urgency
• recurrent urinary tract infections or prostatitis
• painful urination
• blood in the urine
• in severe cases, urinary retention

Symptoms overlap with an enlarged prostate. A urethral stricture is more likely in younger men, after injury or catheterization, or when the stream is spraying.

Diagnosis

• History and examination, including the genitals
• Uroflowmetry: measures urine flow rate; a flat, prolonged curve suggests a stricture
• Post-void residual: ultrasound to see how much urine remains
• Urinalysis and culture
• Cystoscopy: a camera into the urethra shows the narrowing
• Retrograde urethrogram and voiding cystourethrogram: X-rays with contrast show the stricture's location and length, which guide treatment
• Ultrasound of the urethra in some centers

Treatment

Endoscopic treatment

• Urethral dilation: stretching the stricture with progressively larger instruments or a balloon
• Direct vision internal urethrotomy (DVIU): cutting the scar with a blade through a scope

These are reasonable first options for a short (under about 2 cm) first-time bulbar stricture. Recurrence is common, and repeated dilation or urethrotomy has diminishing success. The AUA recommends offering urethroplasty rather than repeated endoscopic procedures for recurrent strictures.

Urethroplasty

Open reconstructive surgery by a specialist:

• excision and primary anastomosis: removing the scarred segment and joining the healthy ends, for short bulbar strictures
• graft urethroplasty: widening the narrowed area with a graft, most often from the inside of the cheek (buccal mucosa), for longer strictures
• staged repairs for complex or lichen sclerosus-related strictures

Success rates are high, often 85 to 90% or more in experienced hands.

Other options

• intermittent self-dilation with a catheter to keep a stricture open
• perineal urethrostomy: a new opening behind the scrotum for complex cases
• suprapubic catheter for emergencies or when surgery is not possible

Complications

• urinary retention
• bladder stones and diverticula
• recurrent infections, prostatitis and epididymitis
• kidney damage from back pressure in long-standing cases
• fistulas and abscesses (rare)

Prevention

• avoid unnecessary urinary catheterization and use proper technique
• prompt treatment of sexually transmitted infections
• early treatment of lichen sclerosus with steroid creams
• protective measures to avoid straddle injuries

Frequently asked questions

What are the symptoms of a urethral stricture?

The main symptoms are a weak or slow urine stream, spraying or splitting, straining, dribbling and a feeling of incomplete emptying. Some people have frequent urinary infections or blood in the urine. Severe strictures can stop urine flow completely.

What causes urethral stricture?

Common causes are injury from catheters and urological procedures, straddle injuries or pelvic fractures, lichen sclerosus, and past infections such as gonorrhea. In many men, no specific cause is found.

Can a urethral stricture be cured?

Yes. Urethroplasty, a reconstructive surgery, cures most strictures with success rates often above 85 to 90%. Dilation and urethrotomy can help short first-time strictures but frequently need repeating.

How do I know if it's a stricture or an enlarged prostate?

Both cause a weak stream. Strictures are more likely in younger men, after catheters, procedures or injury, and often cause a spraying stream. A flow test, cystoscopy or urethrogram can tell them apart.