Urethral Stricture (Urethral Stenosis)

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l-stricture

Gray1142[1]

An urethral stricture is defined as a shortening of the diameter of the urethral lumen by

fibrosis as a complication of various pathologies. A strictured and narrowed urethra causes
obstruction of the passage of urine. This is clinically manifested as a problem in the
micturition-process and thus severely impairs the day to day activities of the patient. Urethral
stricture, if it remains untreated, can ultimately affect the bladder, ureters and kidneys,
resulting in a permanent loss of the renal function.

This disease is caused by the following process: anatomic/foreign.

Presentation
Workup
 Treatment
Prognosis
Etiology
Epidemiology
Pathophysiology
Prevention
Summary
Patient Information
References

Presentation
In the initial phase, the urethral stricture may remain asymptomatic. Symptoms may not
occur until the urethral diameter has attained a considerable narrow caliber that impedes the
urine flow significantly.

The main symptoms of urethral stricture consist of two types, obstructive and irritative. The
most common obstructive urinary symptoms comprise retention of urine and urinary tract
infections. Voiding dysfunctions of obstructive types are characterized by an intermittent
urinary flow, decreased force of stream despite effort, as well as a feeling of an incomplete
evacuation along with terminal dribbling of urine [10]. These symptoms may be progressive
in many patients. Double urinary stream, hesitancy, weak urinary stream or recurrent urinary
tract infection including prostatitis or epididymitis are other suggestive symptoms [10]. A
long-standing untreated urethral stricture can cause renal impairment and hence reduce the
quality of life of the patient substantially.

Some patients suffering from urinary retention may be subsequently diagnosed with an
urethral stricture. This is not an uncommon event. It is suggested that in the initial phase, an
impaired flow caused by urethral narrowing can be overcome by raising the intra-vesical
pressure by detrusor hyperactivity to some extent. Finally, these changes causing a high
pressure reflux transmitted through the ureters may harm the kidneys and lead to permanent
damage of the upper renal system including bilateral kidneys [11]. Some less frequent
complications including carcinoma of the urethra, kidney failure, Fournier's gangrene, and
atonic bladder have been reported [6].

Workup
A suggestive history, relevant clinical findings, radiological observations and endoscopic
evaluation can detect an urethral stricture. Retrograde urethrogram or antegrade
cystourethrogram, in the presence of a suprapubic catheter, are the two commonly employed
diagnostic approaches. Ultrasonography of the male urethra may also be useful to assess the
stricture. It can evaluate the length and the depth of the strictured spongiofibrotic segment.
However, only a retrograde urethrography or cystoscopy can precisely locate and
demonstrate the extent and depth of an urethral stricture.

Uroflowmetry is another test that can be employed for diagnostic purpose [11]. This
investigation provides the data about the urine flow as volume passed per unit of time as well
as total stream urination time.
By urethroscopy, the exact location of the stricture can be assessed, but in case the the
stricture cannot be circumvented the exact length of the lesion remains uncertain.

Other ancillary diagnostic procedures include abdominal ultrasonography to determine any

residual urinary volume in the bladder as well as any hydronephrotic changes already present
due to obstructive uropathy.

Treatment
Treatment options for urethral stricture include urethral dilatation, endoscopic internal
urethrotomy, open urethroplasty and placement of urethral stents.

Urethral dilatation: Periodic urethral dilation is a procedure where the stricture is an

isolated one, epithelial in nature and not involving deep up to the corpus spongiosum.
The target is to achieve adequate dilatation without producing any further scarring.
Thus, it may be curative for those groups of patients with superficial strictures.
Usually no further treatment is needed.
Internal urethrotomy: This is an endoscopic procedure where the stricture is incised
transurethrally to release scar tissue and widen the lumen. The success of this
procedure depends on the epithelialization process after the incision as the possibility
of development of an early wound contracture before complete epithelization often
reduces the effective lumen caliber. Early scar formation as a result thus can explain
the high recurrence rate related to this procedure.
Open urethroplasty: Primary repair termed open urethroplasty is indicated where the
stricture length is about 1-2 cm. This procedure needs removal of the fibrosis along
with an end to end re-anastomosis. The basic three steps to avoid recurrence following
primary repair are complete removal of the fibrotic portion, end to end tension-free
anastomosis, and finally, reconstruction of a widely patent anastomosis.
Stents: Permanent urethral stents are another option where the strictures are of short-
length and located in the bulbar urethra. They are placed endoscopically into the
strictured portion so as to provide a patent urethral lumen. They are most appreciated
and useful in those circumstances as mentioned above and found to be having a very
high acceptance rate.

Of the existing treatment options, the appropriate one has to be chosen by considering all
coexisting factors. The decision depends on the nature of the urethral stricture (length or
proximity of stricture), recurrence of stricture or allied complicating co-factors.

Dilation of the urethra along with internal urethrotomy performed as a combined procedure is
a commonly conducted operation. However, in complicated or recurrent strictures as well as
in very long persistent strictures daily self-catheterization is the most appropriate treatment
option compared to dilation and endoscopy.

Open urethroplasty is only effective short strictures (<2.5 cm) that are located in the bulbar
urethra.

To conclude, short urethral strictures should be initially dealt with an endoscopic internal
urethrotomy. In cases of recurrence, open reconstruction is the optimum choice treatment to
avoid expanding the defect by repeated procedures like urethrotomies.
Prognosis
The risk of recurrence must be kept in mind whatever treatment option for urethral stricture
has been chosen. Long-term outcome following surgery depends on various factors like the
length of the strictured portion, location of the stricture as well as the number of previous
procedures adopted [7] [9]. A comparative study between internal urethrotomy and urethral
dilation found the two procedures to be equally effective in the treatment of male urethral
stricture when applied as initial treatment [7]. The recurrence rate of an urethral stricture is
found to be directly related to the length of the pretreatment strictured portion. Post treatment
recurrence rates at the end of 12 months are found to be 40%, 50%, and 80% while
pretreatment stricture lengths were of less than 2 cm, 2-4 cm, and greater than 4 cm
respectively. The need for a repeated procedure may be as high as 75% at the end of 48
months follow-up for strictures of 2-4 cm length. A follow-up data at the end of five years
after placement of urethral stenting in recurrent strictures revealed a moderately high success
rate of 84% as well as a very good score of patient satisfaction [8].

Urethral stricture shows more severe complications in the form of acute retention of urine,
Fournier's gangrene, bladder atony and even renal failure as long-term squeal [6]. The
treatment procedures for urethral stricture hold many inherent complications which could
amplify the burden.

Etiology
An urethral stricture may result due to different causes. Any infection or any procedure that
has the potentiality to damage the urethral epithelium or the or corpus spongiosum may lead
to the development of a stricture. Common causes of development of urethral stricture are:

Traumatic or iatrogenic: Both of them are acquired causes as in almost all cases an
inciting factor can be identified [1] [2]. These are the most frequent reasons for the
development of urethral stricture. Trauma to the urethra may be a result of a straddle
injury or injury acquired following any procedure through the urethra. The main
reasons (45%) of urethral stricture are thus iatrogenic and could be as a result from
any form of urethral manipulations due to diverse reasons (trauma received during
urinary catheterization, different transurethral manipulations and instrumentations,
surgery for hypospadias, prostate operation, brachytherapy, etc.) [1] [2].
Idiopathic: Almost in 30% cases of urethral strictures no preceding event can be
pointed out [1]. It was thought to be due to a consequence following some form of
forgotten minor trauma (e.g. acquiring a perineal injury while falling over the rod of a
bicycle) [3].
Inflammatory or infectious: Gonococcal urethritis is the most common
infectious etiology of urethral stricture. It is found more commonly in high-risk
population.
Malignancy
Congenital

Epidemiology
Urethral stricture is one of the most commonly encountered urological diseases affecting any
age irrespective of sex. Its incidence in males is reported to be 0.9% in developed countries.
However, the recurrence rate is quite high [4]. The survey from medicare utilization for men
aged 65 years and above revealed the incidences of urethral stricture were estimated to be
0.9% in 2001. This showed a significant decrease from the previous incidence, 1.4% in 1992
[5]. A figure of 193 per 100,000 (0.2%) was found as per the incidences notified from the
Veteran Affairs (VA) in 2003 [6].

Sex distribution

Age distribution

Pathophysiology
An urethral stricture may be a congenital event. It results due to a developmental
defect following an improper adherence of the anterior and posterior urethra. The effective
urethral length is found to be short and infection has no role for its pathogenesis.This is,
however, an extremely rare condition.

An acquired stricture is caused by any damage to the urethral mucosa by either trauma or
infective pathology. These cause the formation of scar tissues and subsequent narrowing of
the urethral lumen.

Prevention
Preventive approaches for urethral stricture focus mainly on prevention of urinary tract
infection as well as avoidance of any urethral procedure as far as possible.

Previous studies suggest an association between urinary tract infections and urethral
strictures. Romero et al showed that out of 175 patients with urethral stricture, 63 (36%) had
evidence of urinary tract infection [12]. Prevention of blind catheterization is another
important step and bougienage of the urethra with the help of an indwelling catheter should
be abandoned in patients with retention of urine. These patients often benefit from a
suprapubic catheter placement.

Urethral stricture may cause an urinary stasis and lead to an urinary tract infection. Thus, the
possibility of any urinary tract infection has to be ruled out in a patient with already
diagnosed with urethral stricture as it may further incite an inflammation and worsen the
present condition. Any infection of the urinary tract must be treated with appropriate
antibiotics, according to laboratory test results [12].

Frequent instrumentation often employed for the diagnostic purpose as well as for the
management of urethral stricture can also lead to infection. These may cause retrograde
transmission of organism causing urinary tract infection and worsening the condition further.

Summary
Urethral stricture is usually an acquired condition resulting from a shortening of the urethral
lumen mostly due to scarring. This leads to an obstructive voiding dysfunction and if not
treated properly, can have a major impact on the urinary bladder, ureters and kidneys. An
urethral stricture can be a squeal of diverse pathological conditions and may have a wide
range of presenting symptoms. It may remain asymptomatic in some patients, only diagnosed
accidentally, or may cause severe discomfort due to urinary retention. A detailed anatomical
and pathophysiological knowledge of the urinary system is necessary before opting any
procedure to create an effective outflow tract of the urinary bladder for treating the stricture.

Patient Information
An urethral stricture is most commonly developed as a result of previous injury or infection.
Sexually transmitted infections seldom cause urethral stricture. Often no cause may be
detected. Strictures are rarely congenital. Less forceful urination despite a full effort or
experiencing a double stream of urine is an indicator of a mild stricture. Severe forms of
strictures may cause a complete obstruction of the outflow of urine leading to retention. As
there is an incomplete evacuation of the bladder and urinary stasis urinary tract infections are
often the consequence of a stricture. Treatment of this condition is done by the urologist who
dilates the urethra and widens the strictured portion by inserting an instrument under
anesthesia. In some cases the strictured portion has to be excised by inserting an instrument
through the urethral lumen.

Self-assessment

References
1. Lumen N, Hoebeke P, Willemsen P, De Troyer B, Pieters R, Oosterlinck W. Etiology
of urethral stricture disease in the 21st century. J Urol. 2009 Sep;182(3):983-7.
2. Fenton AS, Morey AF, Aviles R, Garcia CR. Anterior urethral strictures: etiology and
characteristics. Urology. 2005 Jun;65(6):1055-8.
3. Park S, McAninch JW. Straddle injuries to the bulbar urethra: management
and outcomes in 78 patients. J Urol. 2004 Feb;171(2 Pt 1):722-5.
4. Anger JT, Buckley JC, Santucci RA, Elliott SP, Saigal CS. Urologic Diseases
in America Project. Trends in stricture management among male
Medicare beneficiaries: underuse of urethroplasty? Urology. 2011 Feb;77(2):481-5.
5. Anger JT, Buckley J, Santucci R, Saigal C, Project UDoA. Trends in stricture
mangement among male Medicare beneficiaries: Underuse of Urethroplasty?
Presented at the 2008 Society for Urodynamics and Female Urology annual meeting
Miami, February 2008. 2008.
6. Santucci R, Joyce G, Wise M. In: Urologic Diseases in America. Litwin MS, Saigal
CS, editor. US Department of Health and Human Services, Public Health Service,
National Institutes of Health, National Institute of Diabetes and Digestive and Kidney
Diseases. Washington, DC: US Government Publishing Office, 2004; NIH
Publication No. 04-5512; Male urethral stricture disease; pp. 533551.
7. Steenkamp JW, Heyns CF, de Kock ML. Internal urethrotomy versus dilation as
treatment for male urethral strictures: a prospective, randomized comparison. J Urol.
1997 Jan. 157(1):98-101.
8. Milroy E, Allen A. Long-term results of urolume urethral stent for recurrent urethral
strictures. J Urol. 1996 Mar. 155(3):904-8.
9. Breyer BN, McAninch JW, Whitson JM, Eisenberg ML, Mehdizadeh JF, Myers
JB, Voelzke BB. Multivariate analysis of risk factors for long-term
urethroplasty outcome. J Urol. 2010 Feb;183(2):613-7.
10. Fenton AS, Morey AF, Aviles R, Garcia CR. Anterior urethral strictures: etiology and
characteristics. Urology. 2005 Jun;65(6):1055-8.
11. Brandes SB. Totowa: Humana Press; 2008. Urethral Reconstructive Surgery.
12. Romero Prez P, Mira Llinares A. [Urinary infection and urethral stenosis in males].
Actas Urol Esp. 1990 Nov-Dec;14(6):401-6.

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