An Overview of Urethral Stricture

A urethral stricture is a narrowing of the urethra, the tube through which urine leaves the bladder and exits the body.  A scar in the urethra from swelling, previous procedures, injury or infection may cause a urethral stricutre and block or slow the flow of urine in the urethra. This often causes difficulty with passing urine, including straining and pain in the urethra. 

Urethral strictures are most common in men, but can occur in women as well. Men over the age of 55 are most prone to urethral strictures.

Signs and Symptoms

In males, the urethra is on average 10 inches from the end of the bladder to the tip of the penis. The first 1-2 inches of the urethra is called the posterior urethra and the rest of the urethra is called the anterior urethra. Strictures can occur in both the posterior and anterior urethra. The path to diagnosis of strictures is fairly uniform but the treatment can vary based on where the stricture is located.

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

• Straining to urinate: The individual may have to push harder than usual to start and continue a urine stream.
• 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. 
• Prostatitis: Inflammation or infection of the prostate gland can be triggered by back pressure caused by the stricture.
• Urinary frequency: Trips to the bathroom become more frequent, but may be smaller in amount.
• Urinary tract infection (UTI): Urinary tract infections are uncommon in men. 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.
• 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, including strictures.
• 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.

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.

Iatrogenic Causes

Swelling or scarring can occur from any procedure or instrumentation on the urethra. It's important to ask your healthcare provider about risks of any procedures that may include risks to the urethra.

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 perineal 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 that 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 benign prostatic hyperplasia, infection, irritation, or cancer can decrease the flow of urine through the urethra. In this case, it's not a stricture that is blocking the flow of urine, but the actual enlarged prostate causing a narrowing around 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.

Prevention

Most individuals are unable to prevent the formation of urethral strictures. For some, they are a known potential side effect of surgery. 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 it 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 is less from scarring and more from the anatomic changes caused by the mechanism of injury.

Treatment may be done on an emergent basis for a stricture that is causing a complete inability to urinate or when found incidentally during planned surgical procedures.

Surgical Treatment

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

Urethrotomy

A urethrotomy, also known as a Direct Visualization Internal Urethrotomy (DVIU), is a minimally invasive procedure where a cystoscope (rigid instrument used to look inside the bladder), balloon, laser, or sharp instrument is used to open the stricture so that it no longer stops the flow of urine through the urethra. 

Some of these procedures can be done in the office or bedside using local anesthesia in emergency situations. During a planned procedure your healthcare provider may choose to use general anesthesia or twilight sleep. Once the procedure is complete, you would likely go home with a Foley catheter (tube with ballon that stays in your bladder and urethra to drain your urine) to help with recovery. The Foley does the job of draining urine but also helps keep the newly released strictures open. It is removed a few days later. At this point, your healthcare provider may teach you how to catheterize yourself to keep the stricture open or discuss other more invasive procedures.

In emergency situations, or when your healthcare provider can not get past the stricture, they may opt to placed a suprapubic tube to drain the bladder. This is where a tube is placed directly from your lower abdomen into the bladder.

Urethroplasty

The urethroplasty, also known as “open surgery,” is the surgical removal of the stricture with the reconstruction of the urethra. While this procedure is more involved and far more complex than other treatments, it is thought to have 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. 

The procedure may start 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. 

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 potential complications that patients should be aware of, as they can be present in up to 20% of surgery patients:

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

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.

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.