An Overview of Urethral Stricture

A common cause of painful urination

A urethral stricture is a narrowing of the urethra, the tube through which urine leaves the bladder and exits the body. This narrowing causes difficulty with passing urine, including straining and pain in the urethra

This condition occurs in up to 600 out of every 100,000 men, with men over 65 the most likely to develop this type of stricture. Women and children can also develop urethral strictures but are far less likely to do so than adult males.

urethral stricture symptoms
Illustration by JR Bee, Verywell

Signs and Symptoms

A urethral stricture can cause mild to severe issues with urination. These symptoms include:

  • Straining to urinate: The individual may have to push harder than usual to start and continue a urine stream.
  • Prostatitis: Inflammation of the prostate gland can be triggered by a stricture. The prostate can also be the cause of a stricture. 
  • Urinary frequency: Trips to the bathroom become more frequent, but may be smaller in amount.
  • Urinary tract infection (UTI): Men typically do not get urinary tract infections, a UTI can be a sign of a problem with the urethra.
  • Urinary urgency: The urge to urinate is sudden and may feel like a bathroom emergency.
  • Slow or decreased urine stream: When urine cannot move through the urethra easily, the amount of urine flowing at a given time may be decreased or there may be a weak stream. 
  • Pain during urination: Urination is not typically painful, and a new onset of pain during urination may be a sign of one of many issues with the urinary tract.
  • Blood in urine: Blood in the urine is never considered normal and should lead to a visit with a medical professional.
  • Urine spraying: Urine may not come out of the body in a smooth stream but in unexpected directions or a divided stream.
  • Urinary retention: This is the inability to completely empty the bladder, even when it feels like urine remains. It can also lead to abdominal tenderness, swelling, and pain below the belly button.
  • Blood in semen: Like blood in the urine, blood in the semen is not considered normal and can be a sign of many different issues, including stricture.
  • Abdominal pain: Individuals with urinary retention may have abdominal pain if their bladder is overly full. This can also lead to a bulge in the low abdomen below the belly button.
  • Urethral leaking: Urine dripping or unexpectedly leaking without a clear explanation, such as a hard sneeze in an individual who would typically have issues with dripping after sneezing or coughing. Loss of bladder control is also possible.
  • Swelling of the penis: Some types of strictures can lead to swelling of the penis.
  • Inability to urinate: This is a medical emergency and should be addressed immediately, typically at an emergency room, unless a urologist is available for immediate treatment.

    Causes

    There are many reasons why a urethral stricture may occur. Some patients may never know what the initial cause of the stricture was, while others may have been warned by a surgeon of a stricture as a potential side effect of surgery.

    Types of Stricture

    There are four general types of urethral stricture:

    • Iatrogenic: These are strictures caused by medical treatment of a different condition.
    • Idiopathic: The cause of the stricture is unknown.
    • Inflammatory: An infection or another problem caused inflammation in the urethra.
    • Traumatic: An injury damaging the urethra caused the stricture, such as a fracture of the pelvis.


    Iatrogenic Causes

    Swelling or scarring from surgeries on the urethra, such as surgery to correct hypospadias, and procedures in or through the urethra can also cause strictures to form. 

    Transurethral resection of the prostate, also known as a TURP procedure, can cause scarring of the urethra, as can any procedure that requires instruments to be inserted into the urethra.

    Cystoscopy, transurethral bladder procedures, and endoscopic kidney procedures are also procedures known to increase the risk of urethral strictures. The use of urinary catheters, such as a foley or straight catheter, can lead to urinary strictures, particularly when used for extended periods of time.

    Traumatic Causes

    Injury may cause damage to the urethra, and during or after healing symptoms may start. Pelvic fractures and perineum trauma are commonly associated with urethral strictures. 

    While many strictures take months or years to form, a patient may have normal urination before a trauma and after a trauma may have significant urethral stricture due to injury or the swelling caused by the injury.

    Inflammatory Causes

    Inflammatory causes of urethral stricture include:

    • Malignancy: Cancer and treatment of cancer can lead to scarring and other types of strictures.
    • Inflammation of the urethra: There are many causes of inflammation that can happen in the urethra, which can lead to narrowing, which may be temporary or permanent.
    • Infection: Most commonly gonorrhea, but can be due to other types of sexually transmitted diseases or urinary tract infections.
    • Lichen sclerosus: A rare skin condition that typically affects women, white patches of skin start to appear—often on the genitals—causing pain, itching, and thinning of the skin. 
    • Prostate disease: Enlargement of the prostate, due to infection, irritation, cancer, or another cause, can decrease the flow of urine through the urethra.

    Congenital strictures—strictures present at birth—are far less common than strictures that occur later in life, but they are also possible.

    Risk Factors

    While urethral strictures are far more common in men, they do occur in women and children. The typical patient is male and may have a history of the following.

    Common Risk Factors

    Prevention

    Most individuals are unable to prevent the formation of urethral strictures, for some they are a known potential complication of surgery, for others, a complication of prostate disease. Individuals who use urinary catheters can decrease their risk of stricture by using an appropriate size catheter and only using the catheter for as long as is absolutely necessary. 

    Avoid sexually transmitted and other types of urinary tract infections, but more importantly, seek treatment quickly if one is suspected.

    Diagnosis

    The diagnosis of a urethral stricture starts with the physical examination by a healthcare provider. If a urethral stricture is suspected, imaging studies such as an ultrasound or X-rays may be done.

    Urethroscopy is a procedure using a fiber optic scope to look in the urethra when a stricture is suspected. A retrograde urethrogram is a procedure where contrast dye is injected into the urethra to see if the urethra is leaking. The urethrogram is typically done for patients who have had a pelvic fracture or trauma and is often used to determine if surgery may be necessary. 

    In the case of trauma, the stricture may be caused by the trauma itself, or the swelling of damaged tissue in response to trauma that compressed the urethra and makes it difficult for urine to flow properly. 

    Treatment may be done on an emergent basis for an acute stricture such as those that occur after a pelvic fracture, but prompt treatment is essential for other patients due to the potential for complications including renal insufficiency, bladder stones, recurring infections, and fistulas.

    Surgical Treatment

    Options for treatment of urethral strictures primarily involve surgery, including:

    Urethrotomy

    The urethrotomy, also known as a Direct Visualization Internal Urethrotomy (DVIU), is a minimally invasive procedure where, using a scope, a laser or sharp instrument is used to cut the stricture so that it no longer stops the flow of urine through the urethra. The procedure is typically done using monitored anesthesia or twilight sleep, but general anesthesia is also used for some patients. 

    Once the patient is sedated, the procedure begins with numbing medication being infused into the urethra. Once the medication takes effect, a small instrument with a blade is inserted and moved into the urethra until the stricture is reached and the blade is used to release the stricture. 

    The instrument can then be withdrawn and a foley catheter is placed by being inserted through the urethra and up into the bladder where a balloon is inflated to keep it in place during the recovery period. The foley, in this case, does the job of draining urine, but also helps keep the newly released strictures open.

    Urethroplasty

    The urethroplasty, also known as “open surgery,” is the surgical removal of the stricture with reconstruction of the urethra. While this procedure is more involved and far more complex than other treatments, it is considered the gold standard of urethral stricture treatment, with the best long-term outcomes and lowest rate of reoccurrence.

    There are multiple types of urethroplasty, depending on the location of the stricture in the urethra, the severity, and the cause of the issue. 

    Generally, the procedure starts with the placement of a suprapubic catheter, a type of catheter that is placed in the bladder through an incision made in the abdomen. This diverts urine away from the urethra so the procedure can be performed.

    The procedure then may include the harvesting of tissue from the inside of the cheek of the patient or from the penis, if the surgeon believes extra tissue will be needed to reconstruct the urethra. If the tissue is not expected to be needed, the surgeon may proceed to surgically release the narrowed area in the urethra once it has been numbed with medication.

    Once the urethra is exposed, the area with the narrowing can be cut open, with the harvested tissue used to create a larger urethra. The area is closed and the surgeon checks for good blood flow in the area. In the case of trauma, the area is typically packed with surgical gauze and left open with the intention of closing it at a later date when appropriate.

    Recovery From Surgery

    Most patients are able to return to their normal activities within a few weeks of surgery. Most regain the ability to urinate without difficulty, but a rare few will have the stricture return in the future. Between 2 percent and 10 percent of male patients will experience erectile dysfunction, either during their recovery or long term. 

    The urethrotomy is almost always done expecting to retreat the patient in the future, as very few patients have long-term relief from the procedure. In some cases, the urethrotomy is done to buy time, such as waiting for a pediatric patient to grow for a few more years before making a final decision about how to address the issue permanently.

    Non-Surgical Treatment

    Non-surgical treatment is very limited, as there are no medications available currently to treat a urethral stricture. The only potentially effective treatment outside of surgery is dilation of the urethra using special rods called sounds that very gradually get larger from one end to the other. As the sound is gently advanced into the urethra, the tissue is stretched, a process that may gradually loosen the stricture. 

    While some patients get some relief with this method, most require surgery to get significant, long-lasting relief or to prevent complications.

    Risks of Surgical Treatment

    All surgeries have risks, including the general risks associated with any surgery and the risk that is associated with anesthesia. The surgical procedures done to treat urethral strictures have additional risks specific to this type of procedure.

    There are two complications that patients should be aware of, as they can be present in up to 20 percent of surgery patients:

    • Perineal Hematoma: This is a collection of blood in the area between the scrotum and anus. Worse than a bruise, the hematoma can be tender or even painful and may take weeks to resolve completely. This can occur after urethroplasty procedures. 
    • Urethral Bleeding: This complication is often present in urethral stricture treatment, but ranges from minor bleeding to significant bleeding, with serious bleeding being far less common.

    Compartment syndrome is more common in procedures that use the lithotomy position—lying flat on your back with your legs up—and procedures that last more than six hours. Complicated urethroplasty procedures can last six hours or longer, and the lithotomy position is always used.

    Other potential complications include urinary incontinence or urinary retention, erectile dysfunction, retrograde ejaculation, decreased sensation in the penis, and infection. 

    A Word From Verywell

    Urethral strictures can cause significant problems with the ability to urinate. In general, it is best to seek care immediately if problems develop, as there are many problems that can lead to difficulty urinating and many problems that can also be caused by problems with urination. These issues range from minor to life-threatening, so a quick diagnosis along with prompt treatment is important.

    While there is no medication that can treat urinary strictures, there are procedures that are highly effective in treating the problem and provide fast relief. For most, the urethroplasty will be the best treatment to achieve a long-term solution.

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    Article Sources
    • Urethral Strictures. Urethral Care Foundation.

    • Smith TG. Current management of urethral stricture disease. Indian Journal of Urology : IJU : Journal of the Urological Society of India. 2016;32(1):27-33. DOI: 10.4103/0970-1591.173108.