A urethral stricture is a narrowing caused by scar tissue or inflammation in the urethra, the tube that drains urine from the bladder. Men are much more commonly affected than women. Strictures may occur in any portion of the urethra.
Symptoms of a stricture may include bothersome urination with poor stream and incomplete emptying, or recurrent urinary tract infections or epididymitis.
Causes and Risk Factors
In about 40% of urethral stricture cases, no specific cause can be identified. Specific causes may include prior injury, inflammation, catheterization or urethral instrumentation. Narrowing in the urethra closer to the bladder can be caused by pelvic fracture or prostatectomy. Strictures near the tip of the penis may be caused by inflammatory skin condition such as lichen sclerosis and should be biopsied.
When to Speak with a Urologist about Urethral Stricture
You should talk to a Urologist about urethral stricture if you have persistent bothersome slow urinary stream and risk factors such as prior trauma or difficult catheterization.
What to Expect when Seeking Treatment
In addition to a history and physical examination, initial assessment includes urinalysis, uroflow and assessment of postvoid residual to determine if an infection is present and the severity of the possible obstruction. If urethral stricture is suspected, diagnosis should be confirmed with cystoscopy by passing a flexible camera into the urethra and x-ray imaging with contrast in the urethra (retrograde urethrogram and voiding cystogram) to measure the length of the stricture. These studies should be performed about 10-12 weeks following any instrumentation or dilation to provide accurate assessment.
Treatment Options
Treatment options depend on the location and extent of the stricture. Strictures may be managed endoscopically with instruments passed up the urethra or with a reconstructive surgery called urethroplasty.
Endoscopic procedures include urethral dilation and direct vision internal urethrotomy (DVIU). Urethral dilation and DVIU are appropriate initial management for a stricture less than 2 cm in length located in the bulbar urethra with success rates around 50%. A catheter will be in place after the procedure for several days. Stricture recurrences after initial endoscopic treatment are very rarely successfully treated with repeat endoscopic procedures (failure rate over 80%) and therefore definitive treatment with urethroplasty is advisable if recurrence occurs. An alternative may be routine dilation with daily self-catheterization to maintain urethral patency.
Urethroplasty should be considered as an initial option for penile strictures or bulbar strictures over 2 cm due to much higher success rates than endoscopic management (over 80% vs around 20%). Urethroplasty may involve removing the strictured segment and reconnecting the healthy ends of the urethra or it may involve placing a graft of tissue from the inner cheek for longer defects. Urethroplasty typically involves placement of a suprapubic tube to drain the bladder through the lower abdomen for about 10-12 weeks prior to enable maturation of the stricture. With urethroplasty, ejaculatory dysfunction may occur in 20% of men while erectile dysfunction is very uncommon.
Very complicated strictures may be managed long-term with a chronic suprapubic tube or diverting the urethra to empty below the scrotum with a procedure called perineal urethrostomy.