Andrew Siegel MD 12/29/2018
A urethral stricture is scarring within the urethra (the channel that conducts urine out of the bladder), resulting in a narrowed diameter and obstructive lower urinary tract symptoms. The urethra is one of the parts of the body that is a particularly bad place for scarring, since it is a highly functional structure that is put into use numerous times daily.
The Male Urethra
Attribution of image above: OpenStax Anatomy and PhysiologyOpenStax [CC BY 4.0 (https://creativecommons.org/licenses/by/4.0)%5D, via Wikimedia Commons
Image above indicates the great variety of strictures in terms of length and depth
Urethral strictures, although occasionally present in females, are much more common in males. The male urethra begins at the neck of the urinary bladder and ends at the tip of the penis. The innermost portion of the urethral is enveloped by the prostate gland. Thereafter the urethra runs through the perineum (between scrotum and the anus) where it is enveloped by the corpus spongiosum–a thick, vascular, cushiony structure– and thereafter the urethra extends through the penis (also surrounded by the corpus spongiosum) where it ends at the urethral meatus (the slit-like opening).
Urethral scarring results in a narrowed or blocked passageway that can give rise to obstructive voiding including one or more of the following symptoms: slow, weak, hesitant, spraying and intermittent urinary stream, prolonged emptying, incomplete emptying or inability to empty, painful urination and blood in the urine. It can also cause urinary infections, bladder stones and cause difficulties/pain with ejaculation.
Urethral strictures often result from trauma, infection or inflammation. External trauma can be caused by either a straddle injury (when the perineum abruptly strikes a fence or bicycle top tube) or a crush injury. Internal injury is often due to passage of urethral instruments, indwelling urethral catheters, or transurethral surgery. Inflammatory processes such as urethritis and sexually transmitted diseases also can result in urethral stricture formation.
When a urethral stricture is suspected, a urinary flow rate and an ultrasound-guided determination of how much urine is left in the bladder after urinating are obtained. These painless and noninvasive procedures will precisely characterize the extent of compromised urinary flow as well as the ability to effectively empty the bladder. Most strictures cause poor flow rates and elevated bladder residuals. Urethroscopy is a procedure in which a narrow, flexible, lighted instrument is placed in the urethra in order to directly examine it, ascertaining the location, extent and length of the stricture. At times, imaging studies of the urethra–retrograde urethrogram, voiding cysto-urethrogram, or urethral ultrasound are performed to gain further information. With urethroscopy and imaging studies, the location, length, and depth of the scar and degree of extension into the spongy tissue that surrounds the urethra can be deduced.
Mild strictures can be managed with simple urethral dilation that may be curative. This involves the passage of sequentially larger dilating instruments through the stricture to open up the scar tissue. If a urethral stricture is short and involves only the urethra or superficial spongy tissues in the bulbar urethra (the portion that travels through the perineum), optical internal urethrotomy is often the treatment of choice. This is a procedure done under anesthesia that utilizes an endoscopic instrument to incise open the urethra. Typically, a catheter is left in the urethra for several days thereafter to maintain the opening that has been made. This procedure can be performed on an outpatient basis. It will not always be curative because scar tissue can and often does recur. Dilation and optical urethrotomy are best for relative short strictures located in the bulbar urethra with success rates in the 35-70% range, often with the need for a repeat procedure because of recurrent scarring.
A useful tool after dilation or optical urethrotomy is to teach the patient self-catheterization to maintain the urethral opening. If obstructive symptoms recur and studies demonstrate little or no improvement, an open surgical treatment called urethroplasty can be a consideration. It is rarely necessary as an initial therapeutic option, but is appropriate for longer and recurrent urethral strictures or those involving extensive scarring. Excision of the stricture with urethroplasty has a 90-95% success rate, although it is a much more involved procedure than dilation or optical urethrotomy. If the stricture is located in the penile urethra as opposed to the bulbar urethra, urethroplasty should be offered since strictures at this location are less likely to respond to dilation or optical urethrotomy. Lengthy strictures require graft material to repair, often buccal mucosa ( graft material harvested from inside the mouth).
At times the stricture is confined to the part of the urethra located at the tip of the penis where it is known as a urethral meatal stricture. This situation can be rectified with dilation or a minor procedure called a meatotomy/meatoplasty.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.
Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:
MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health
PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food
These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.
Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx
New video on female pelvic floor exercises: Learn about your pelvic floor
Our Greatest Wealth Is Health 