Ureteral Stricture: Causes, Symptoms & Treatment

What Is a Ureteral Stricture?

A ureteral stricture is a pathological narrowing of the ureter, the muscular tube that carries urine from the kidney to the urinary bladder. When this channel becomes constricted, urine cannot drain freely, causing a back-up of urine into the kidney known as hydronephrosis. If left untreated, the resulting pressure can permanently damage kidney function.

Causes

Ureteral strictures can develop due to a variety of causes:

• Scar tissue from surgery: Operations on the ureter, kidney, or adjacent organs may lead to scarring and subsequent narrowing.
• Ureteral stones: Kidney stones passing through the ureter can injure the mucosal lining and leave behind a fibrous stricture.
• Infections and inflammation: Bacterial infections (e.g., urinary tuberculosis) or chronic inflammatory conditions can cause tissue fibrosis.
• Radiation therapy: Pelvic irradiation (e.g., for prostate or cervical cancer) may damage ureteral tissue.
• Congenital anomalies: In rare cases, a stricture is present from birth.
• External compression: Tumours or enlarged lymph nodes in the surrounding area can compress the ureter from the outside.
• Endoscopic procedures: Instrumentation of the ureter (e.g., ureteroscopy) can occasionally cause scar formation.

Symptoms

Symptoms of a ureteral stricture depend on the degree of narrowing and may develop gradually or suddenly:

• Flank pain or dull aching in the back and kidney region
• Colicky, cramping pain similar to that caused by kidney stones
• Frequent urge to urinate or reduced urine output
• Recurrent urinary tract infections
• Blood in the urine (hematuria)
• Nausea and vomiting with severe obstruction
• In advanced cases: signs of impaired kidney function (fatigue, fluid retention)

Mild strictures may remain asymptomatic for extended periods.

Diagnosis

Several diagnostic methods are available to confirm a ureteral stricture:

• Ultrasound: Initial assessment; detects hydronephrosis as a sign of obstruction.
• CT urography (CT-IVP): Detailed imaging of the urinary tract with contrast agent; considered the standard diagnostic tool.
• MR urography: Radiation-free alternative, particularly useful in pregnant women or children.
• Retrograde pyelography: Endoscopic contrast study from the bladder upward; allows precise localization and length measurement of the stricture.
• Renal scintigraphy: Assesses the functional capacity of the affected kidney.
• Laboratory tests: Blood and urine analysis to evaluate kidney function and rule out infection.

Treatment

Treatment is tailored to the cause, location, length, and severity of the stricture, as well as the overall health of the patient.

Minimally Invasive Procedures

• Endoscopic incision (endoureterotomy): The narrowed segment is cut open from the inside using an endoscope. Suitable for short, less dense strictures.
• Balloon dilation: A balloon catheter is inserted into the ureter and inflated to widen the constricted area.
• Double-J stent (DJ stent): An internal stent is placed to temporarily bridge and keep the ureter open.

Surgical Procedures

• Ureteral resection and reconstruction: The narrowed segment is surgically removed and the ureteral ends are reconnected (ureteroureterostomy).
• Pyeloplasty: For strictures near the kidney, the narrowed area is surgically widened.
• Bowel interposition: In extensive strictures, a segment of small intestine may be used as a substitute for the ureter.
• Renal autotransplantation: In rare and severe cases, the kidney is relocated to the pelvis to allow direct attachment to the bladder.

Supportive Measures

• Treatment of concurrent infections with antibiotics
• Close follow-up and regular monitoring of kidney function

Prognosis

The outlook depends largely on early diagnosis and the underlying cause of the stricture. When treated in a timely manner, permanent kidney damage can be prevented in most cases. Modern surgical reconstruction techniques achieve high success rates; however, regular follow-up examinations are essential, as recurrence of the stricture remains possible.

References

1. European Association of Urology (EAU): Guidelines on Urological Trauma and Upper Urinary Tract Reconstruction. uroweb.org
2. Wein AJ et al. (eds.): Campbell-Walsh Urology. 11th Edition. Elsevier Saunders, Philadelphia, 2016.
3. Nakada SY, Hsu THS: Management of upper urinary tract obstruction. In: Wein AJ et al. (eds.): Campbell-Walsh Urology. Elsevier, 2016.