Ureteral Stricture – Causes, Symptoms and Treatment

What Is a Ureteral Stricture?

A ureteral stricture, also referred to as ureteric stenosis or ureterostenosis, is a pathological narrowing of the ureter – the tube-like structure that carries urine from the kidney to the urinary bladder. When the ureter becomes narrowed, the normal flow of urine is obstructed, causing urine to back up into the kidney. This backup is known as hydronephrosis, which, if left untreated, can lead to progressive kidney damage and loss of function.

Causes

Ureteral strictures may be present from birth (congenital) or develop later in life (acquired). Common causes include:

• Congenital abnormalities: Such as a narrowing at the junction between the renal pelvis and the ureter (ureteropelvic junction obstruction).
• Kidney or ureteral stones: Stones that become lodged in the ureter can cause inflammation and subsequent scarring.
• Infections and inflammation: Recurrent urinary tract infections or urinary tuberculosis can lead to scar tissue formation within the ureter.
• Tumors: Malignant or benign growths in or near the ureter, bladder, or adjacent organs may compress or invade the ureter.
• Surgical procedures or radiation therapy: Scar tissue following abdominal or pelvic surgery, or fibrosis caused by radiation, can narrow the ureter.
• Retroperitoneal fibrosis: A rare condition in which fibrous tissue behind the peritoneum compresses the ureter from the outside.
• Endometriosis: Endometrial tissue growing outside the uterus can encroach on the ureter.

Symptoms

The symptoms of a ureteral stricture vary depending on the severity and cause of the narrowing. Common signs and symptoms include:

• Flank pain or dull aching on one side of the back
• Colicky, wave-like pain during acute urinary obstruction
• Frequent urge to urinate or difficulty passing urine
• Blood in the urine (hematuria)
• Recurrent urinary tract infections
• Nausea and vomiting during severe obstruction
• In advanced cases: reduced urine output and signs of kidney failure

In some cases, a ureteral stricture may be asymptomatic for a long period and discovered incidentally during an ultrasound examination.

Diagnosis

Several diagnostic methods are used to evaluate a ureteral stricture:

• Ultrasound (sonography): The initial test used to detect hydronephrosis or dilation of the collecting system.
• Computed tomography (CT scan): Provides detailed images of the urinary tract to identify the location and likely cause of the stricture.
• Magnetic resonance imaging (MRI): Particularly useful when soft tissue detail is needed or in children to avoid radiation exposure.
• Intravenous urography (IVU): An X-ray procedure using contrast dye to visualize the upper urinary tract.
• Ureteroscopy: Direct visualization of the ureter using a thin, flexible or rigid endoscope.
• Renal scintigraphy: A nuclear medicine test that assesses kidney function and the degree of urinary obstruction.

Treatment

Treatment depends on the underlying cause, the location and length of the stricture, and the overall health of the patient. The primary goal is to restore normal urine drainage and preserve kidney function.

Conservative and Temporary Measures

A ureteral stent (double-J stent) can be placed endoscopically to keep the ureter open and allow urine to drain. This is often used as an initial or bridging measure while planning definitive treatment.

Surgical Treatment Options

• Endoscopic incision (ureterotomy): The stricture is cut open from the inside using a knife or laser.
• Ureteral reconstruction (ureteroplasty): The narrowed segment is surgically removed and the healthy ends are reconnected.
• Ureteral replacement: In cases of long-segment strictures, a segment of bowel or other tissue may be used to replace the damaged portion of the ureter.
• Pyeloplasty: Surgical reshaping of the ureteropelvic junction when the stricture is located at that site.
• Nephrostomy: As an emergency measure in severe obstruction, a catheter is placed through the skin directly into the kidney to drain urine.

Treatment of the Underlying Cause

When the stricture results from an underlying condition such as a tumor, chronic infection, or endometriosis, targeted treatment of that condition is essential to resolve the obstruction and prevent recurrence.

Prognosis

The outlook for patients with a ureteral stricture depends largely on the cause, severity, and duration of the obstruction, as well as how promptly treatment is initiated. When diagnosed and treated early, kidney function can usually be preserved or restored. Prolonged untreated obstruction, however, carries the risk of permanent kidney damage or loss of function.

References

1. Wein, A. J. et al.: Campbell-Walsh-Wein Urology. 12th Edition. Elsevier, Philadelphia 2021.
2. European Association of Urology (EAU): Guidelines on Upper Urinary Tract Obstruction. EAU Guidelines 2023. Available at: https://uroweb.org/guidelines
3. Brandes, S. B. and Stringer, M. D.: Ureteral Stricture Disease. In: Journal of Urology and Endourology, Vol. 38, 2022, pp. 112-128.