Urethral Stricture – Causes, Symptoms & Treatment

What Is a Urethral Stricture?

A urethral stricture is an abnormal narrowing of the urethra -- the tube that carries urine from the bladder out of the body. This narrowing is caused by the formation of scar tissue (fibrosis) within the urethral wall, which reduces its internal diameter and restricts the flow of urine. Urethral strictures are significantly more common in men than in women, largely due to the greater length and anatomical complexity of the male urethra.

Causes

Urethral strictures can develop as a result of various conditions and events:

• Trauma and injury: Pelvic fractures, straddle injuries, or direct trauma to the perineum can damage the urethra and lead to scarring.
• Infections and inflammation: Sexually transmitted infections (STIs) such as gonorrhoea (gonorrhea) are a well-known cause of urethral scarring, particularly in the anterior urethra.
• Medical procedures: Urethral catheterisation, cystoscopy, or pelvic surgery can cause mechanical injury and subsequent scar formation.
• Radiation therapy: Pelvic radiotherapy, for example during prostate cancer treatment, may damage urethral tissue over time.
• Congenital causes: In rare cases, a narrowing may be present from birth.
• Idiopathic causes: In some patients, no clear underlying cause can be identified.

Symptoms

The symptoms of a urethral stricture result from impaired urine flow and may vary in severity:

• Weak or intermittent urinary stream
• Difficulty or pain when urinating (dysuria)
• Sensation of incomplete bladder emptying
• Increased urinary frequency and urgency, including at night (nocturia)
• Acute urinary retention (complete inability to urinate) -- a medical emergency
• Recurrent urinary tract infections (UTIs)
• Blood in the urine (haematuria) or semen

Diagnosis

Several diagnostic methods are used to confirm and characterise a urethral stricture:

• Uroflowmetry: Measures the rate and pattern of urine flow; a reduced peak flow rate suggests an obstruction.
• Urethrocystoscopy: A thin flexible or rigid endoscope is passed into the urethra to directly visualise the stricture.
• Retrograde urethrography (RUG) and voiding cystourethrography (VCUG): X-ray imaging with contrast medium to determine the exact location, length, and severity of the stricture.
• Ultrasound: Used to assess post-void residual urine volume and evaluate the bladder and upper urinary tract.
• Urine analysis and cultures: To detect or rule out concurrent infections.

Treatment

Treatment depends on the location, length, and severity of the stricture, as well as the overall health of the patient.

Minimally Invasive Approaches

• Urethral dilation: Gradual widening of the urethra using graduated instruments (bougies or balloon dilators). This method often provides only temporary relief and carries a risk of recurrence.
• Direct vision internal urethrotomy (DVIU): An endoscopic procedure in which the scar tissue is incised from within the urethra. Best suited for short, non-recurring strictures.

Surgical Approaches

• Urethroplasty: Open surgical reconstruction of the urethra, either by excision and primary anastomosis (for short strictures) or by augmentation using a graft (commonly buccal mucosa from the inner cheek). Urethroplasty offers the best long-term success rates.
• Urethral stents: Metal mesh devices placed to keep the urethra open; rarely used today due to high complication rates.

Emergency Management

In cases of acute urinary retention, a suprapubic catheter (inserted through the lower abdominal wall into the bladder) is placed as a temporary measure to relieve pressure before definitive surgical treatment.

Outlook and Prognosis

If left untreated, urethral strictures can progress and lead to serious complications, including recurrent urinary tract infections, bladder stones, long-term bladder dysfunction, and kidney damage due to urinary backflow (hydronephrosis). With appropriate treatment -- particularly urethroplasty -- outcomes are generally favourable. However, recurrences can occur, and regular urological follow-up is recommended to monitor for relapse.

References

1. Lumen N, Baert L, et al. - EAU Guidelines on Urethral Strictures. European Association of Urology (EAU), 2023. Available at: https://uroweb.org/guidelines/urethral-strictures
2. Chapple C, Andrich D, et al. - SIU/ICUD Consultation on Urethral Strictures. World Journal of Urology, 2015; 33(1): 1-2.
3. Wein AJ, Kavoussi LR, et al. - Campbell-Walsh-Wein Urology. 12th edition. Elsevier, Philadelphia, 2021.