What Is Urethral Stricture

The urethra is the tube that allows passage of urine from the urinary bladder to outside the body. Urethral stricture is a condition where this tube becomes narrowed, which can cause very slow urine flow, meaning that the bladder can’t be fully emptied. This can cause discomfort and can cause many health problems, such as infection or inflammation.

Usually, this narrowing is caused by scar tissue formation around the urethra. Urethral stricture can cause pain, bleeding, and fear of urinating. It may feel like you have to urinate, even after going to the bathroom frequently.

Urethral stricture may be from infection, injury, or a medical or surgical procedure. Urethral stricture can cause bladder damage, recurrent urinary tract infections (UTIs), and permanent kidney damage.                     

Overview

Urethral stricture is a condition where the narrowing of the urethral tube causes slow flow of urine from the urinary bladder and out of the body during urination. This is due to the scar tissue formation near the urethra, often after surgery or illness. Urethral strictures can cause recurrent urinary infections, and damage to the bladder and kidneys.

Causes of urethral stricture

Men are more likely to have a urethral stricture because of their longer urethra, meaning that they are more prone to have urethral disease and injury than others. Women and infants are less likely to have urethral strictures. Urethral stricture can happen at any point of the urethra, causing disruption of urine flow. Some common causes are:

• Injury - an injury,  for example from a car or bike accident, where the urethra is damaged, can cause it to heal with excess scar tissue which may cause stricture. Any injury to the penis, scrotum, or general genital region may cause this kind of damage
• Medical complications - damage to the urethra from surgical toolsduring surgery, or during other medical procedures, such as:
  • Cancer - radiotherapy may damage the urethra
  • Pressure from a tumour
  • Prostate surgery - a surgery to remove or reduce the enlarged prostate gland
  • Kidney stone removal
  • Urinary catheter - intermittent or long-term use of a urinary catheter (tube) to drain urine from the bladder
  • Endoscopy - a medical procedure that involves inserting an camera for visualisation of internal structures
• Infections - any infection affecting the urethra, such as:
  • Recurrent urinary tract infections
  • Sexually transmitted infections like chlamydia or gonorrhoea
  • Infection following long-term use of a urinary catheter
• Underdevelopment while in the uterus in rare cases, urethral stricture can be present from birth (congenital)

Scar tissue causes the urethra to become narrow and it leads to difficulty in urination and emptying of the bladder completely. Sometimes, urethral stricture can manifest immediately after it’s cause, whereas other times it may appear a while after.                                  

Signs and symptoms of urethral stricture

The most important sign of urethral stricture is the weakness of the urinary system. In mild cases there may not be any initial symptoms, however, as the condition worsens, symptoms may begin to appear.

These may include:

• Reduced urine flow - this will often involve straining to pass urine, complete blockage is rare
• Spraying of urine or double stream
• More frequent urination
• Dribbling of urine after urination
• Pain while passing urine
• Bloody or dark urine
• Urinary retention (incomplete bladder emptying)
• Pain in pelvis or lower abdominal region
• Loss of bladder control (incontinence)
• Urinary tract infections (UTIs)
• Prostatitis (inflammation of the prostate)
• Hydronephrosis - a condition of the urinary tract where one or both the kidneys swell. This occurs when urine is not drained from the bladder
• Renal failure - due to incomplete draining of the bladder
• Erectile dysfunction

Management and treatment for urethral stricture

Treatment is usually given to improve urine flow, ease any other symptoms, and prevent later complications.

Urologists are surgeons who treat problems affecting the urinary tract,  such as conditions affecting the prostate, bladder, kidneys, and penis. Surgical procedures may be recommended depending on factors such as, location and length of the urethral stricture, as well as the age of the person.

Treatments include:¹

• Urethral dilatation:

This procedure is mainly done under either local or general anaesthesia. An increasing thickness of rods are inserted gradually to stretch the narrowed tissue without causing additional scarring. However, the stricture tends to gradually narrow again after each dilatation.  

Repeated dilatation is often needed when the symptoms reoccur. If the stricture narrows back very quickly, the person will be taught to insert a catheter to keep the urethral stricture dilated. Side effects include bleeding and infection. There is a chance of cure with dilation if the stricture is relatively short, it is less effective with longer strictures.

• Urethrotomy:

Cystoscopy is the procedure done to look inside the bladder using a thin camera called a cystoscope. A small knife is attached at the end of the cystoscope to cut the stricture and create a gap. A catheter is placed in the urethra to hold the gap open and allow time to heal. Based on the length of the urethral stricture, the catheter is kept inserted.

• Open surgery:¹ A urethral reconstruction is needed when removal or reconstruction of the urethra is performed,known as urethroplasty.  Many types of procedures are used to treat the urethral stricture, the treatment choice is based on the severity, location, and length of the stricture. Mainly there are two types: anastomotic urethroplasty^2,3 and substitution urethroplasty.
  • Anastomotic urethroplasty - this method is usually to reverse short urethral strictures. In this procedure, a cut is made and two ends of a healthy urethra are connected after removing the stricture. A catheter is placed and it is removed after taking an x-ray to make sure the stricture is healed
  • Substitution urethroplasty⁴ - In this procedure, a tissue is replaced in the area of the stricture. This can be done in 3 ways:
    • Free graft - in this method, the urethra is enlarged or replaced using our own tissue. The tissue is taken from the inside of the cheek (buccal mucosa¹), or skin around the vagina or underneath the penis
    • Skin flap - in this procedure, a flap of skin is taken to create a new section of urethra. This is used when the grafts need to be longer and the stricture is more severe
    • Staged - this method is used when the local tissue does not work for a free graft or skin flap. In this method, the underside of the urethra is opened and a graft is secured to the opened urethra and is left to heal. During this time a new opening behind the urethral stricture is used to urinate. After several months, the graft around the urethra is healed and is formed into a tube
• Antibiotics - a long course of antibiotics is needed to prevent urinary tract infections until the urethral stricture is widened.

Diagnosis of urethral stricture

There are several tests to determine the presence of a urethral stricture, including:

• Physical examination - the doctor will ask you about your symptoms, such as questions about your urine flow rate. Reduced flow rate can indicate stricture
• Cystoscopy - a small flexible camera, called a cytoscope, is inserted to view the inside of the urethra
• Retrograde urethrogram - this is an x-ray that uses a contrast agent which helps in locating the area of the urethral stricture and its length

FAQs

Can urethral stricture be prevented?

It is not always possible to prevent a urethral stricture, but you can reduce the chance by using condoms during sex to avoid sexually transmitted diseases, which is a risk factor. Taking safety precautions to avoid pelvic trauma can also reduce your risk.

How common is urethral stricture?

Urethral stricture is not very common in men, but it is even more rare in women and infants. Men are more likely to have urethral stricture due to their longer urethra.

Who are at risk of urethral stricture?

• Those with recurrent urinary infections
• Sexually transmitted disease, due to having sex without condoms
• Infection or other complication due to long-term use of a urinary catheter
• Medical complications from conditions like - cancer, tumours, an enlarged prostate, kidney stones, etc

When should I see a doctor?

It is best to see a doctor when you start experiencing early symptoms, such as, discomfort, and difficulty and urgency of urination.

Summary

Urethral stricture is a condition where the urethra becomes narrowed, causing difficulty and discomfort during urination.

Men are more common to have urethral stricture as they have longer urethra. It is more rare in women and infants. Urethral stricture may be caused by trauma or infection.

Urethral stricture is diagnosed by asking questions about your symptoms, physical examination, and various imaging techniques.

There are many treatment options available to treat the urethral stricture, depending on the area of appearance and the length.  These may include, dilation of the urethra, removal of the urethra, various surgical procedures, and/or antibiotics.