Urethral Stricture: What You Need to Know

A urethral stricture occurs when a segment of the urethra, the tube through which urine exits the body when it leaves the bladder, narrows. This narrowing can occur anywhere along the length of the urethra. While urethral strictures can occur in both men and women, they are relatively rare in females. It can affect how well the bladder drains urine, which, as you may expect, can create a significant lifestyle impediment and accounts for many ER visits and hospital admissions. Urethral strictures are quite prevalent, with two in every thousand men under 65 experiencing one and rising to six in every thousand over 65.

Symptoms of a Urethral Stricture:

  • slow or weak urinary stream
  • difficulty urinating/straining
  • incomplete bladder emptying
  • urinary tract infections
  • frequent urination
  • blood in the urine

Occasionally, the symptoms can be severe enough to prevent urine from exiting the bladder, known as urinary retention, often prompting patients to visit an emergency room. Fortunately, this is rare.

Causes:

Many times, the cause of a urethral stricture remains unknown. However, some risk factors are known to be associated with stricture development. These include a history of:

  • direct trauma (such as a bike straddling accident or being kicked in the scrotal area)
  • previous catheter use for urine drainage
  • procedural scope insertion
  • previous surgical procedures on the bladder or prostate
  • prostate radiation therapy or prostatectomy
  • some sexually transmitted infections
  • hypospadias repair

It is not uncommon for symptoms to develop many years after the causative event.

Diagnosis:

Uroflowmetry is often used as an initial test as it can give us a good idea of urine flow through the urethra. Peak urinary flow under 12 mL/s indicates a stricture or obstruction. Strictures often provide a distinct flow curve shape, giving your urologist a good idea of whether this is indeed to blame.

Post-void residual urine volume may be helpful to your urologist to get an objective take on bladder emptying, though this test does not rule out BPH/enlarged prostate as the cause.

Cystoscopy involves a small flexible camera inserted into the urethra to inspect it and diagnose a urethral stricture. This visualization identifies both the stricture’s location and the urethra’s width. Cystoscopy is the definitive diagnostic tool for diagnosing a urethral stricture, but it requires a more extensive, though still minimally invasive, procedural intervention.

Treatment of a Urethral Stricture:

Once a stricture is diagnosed and assessed, there are varied treatment options. The stricture is usually asymptomatic if the peak urine flow rate is between ten and 12 mL/s – considered low in a healthy young male. At this point, we would only continue treatment if the patient were experiencing incomplete emptying or increased thickness in the bladder wall.

For peak flow rates under ten mL/s, the patient will usually experience obstruction and potentially some severe symptoms. Flow rates under five mL/s increase the risk of urinary retention. Fortunately, this is rare.

Endoscopy can be utilized for smaller, less severe strictures. Endoscopic urethral dilation utilizes a unique device known as a dilator to stretch the urethral tissue and increase the diameter of the urethra at the stricture point. While this method is successful, about two-thirds of patients will need retreatment within three years. This procedure is minimally invasive and typically performed under sedation. Temporary discomfort and bleeding are quite common.

In response to this high recurrence rate, Optilume, a drug-coated dilation balloon, was developed to address this and other concerns associated with previous stricture solutions. This novel therapy uses mechanical balloon dilation of the stricture and subsequent drug delivery to the submucosa. This reduces fibrotic scar tissue regeneration, reducing recurrence compared to mechanical dilation alone.

Direct vision internal urethrotomy, or DVIU, involves an incision at the stricture point to release pressure and allow the body to heal naturally. Complication rates are relatively high, with approximately a 5% risk of erectile dysfunction and a 4% risk of urinary incontinence.

Reconstruction of the urethra, known as a urethroplasty, can be performed by removing the narrow segment of the urethra and reconnecting the healthy ends of the tube or by transferring tissue from elsewhere in the body to the urethra to rebuild it. Most commonly, this tissue is taken from the inner lining of the cheeks but can also be harvested from the foreskin. Success rates for a urethroplasty are relatively high at over 85%, and complications are uncommon, though erectile dysfunction, incontinence, UTIs, and more can occur. A urethroplasty is often chosen if endoscopic options have not worked and is usually indicated when the stricture is related to a hypospadias repair.

Occasionally, patients may choose to insert a catheter in the bladder instead of pursuing a procedure or surgery. This is known as intermittent self-catheterization. Results are depending on the patient’s particular anatomy and adherence to instructions. Patients reported fewer recurrences when self-catheterization was performed for more than four months rather than stopping within the first three months.

If you believe you may be suffering from a urethral stricture, contact Georgia Urology to schedule a consultation.