Urethral Stricture

Overview

A urethral stricture is a narrowing of the urethra caused by scar tissue formation. The urethra carries urine from the bladder out of the body, and when scar tissue develops within or around it, the channel becomes obstructed. This condition occurs almost exclusively in men due to their longer urethra, which measures approximately 18 to 22 centimeters compared to about 4 centimeters in women.

Urethral strictures affect roughly 0.2 to 0.6 percent of men, with incidence increasing with age and the growing number of urological procedures performed. Strictures can develop anywhere along the urethra, though the bulbar urethra (the section behind the scrotum) is the most common site. The male urethra consists of several segments: the meatus at the tip of the penis, the fossa navicularis within the glans, the penile urethra through the shaft, the bulbar urethra, the membranous urethra through the urinary sphincter, and the prostatic urethra through the prostate. Understanding stricture location is essential for treatment planning.

Without treatment, urethral strictures can lead to urinary retention, recurrent urinary tract infections, bladder stones, and in severe cases, kidney damage from prolonged back-pressure on the urinary system.

Symptoms

The hallmark symptom of urethral stricture is a weak urinary stream that typically develops gradually over months or years. Many men do not notice the decline in force until the obstruction becomes significant. As the stricture worsens, the stream may spray in multiple directions or split into two streams, making urination difficult to control.

Straining to urinate becomes necessary as the narrowing progresses. Men often use their abdominal muscles to generate enough pressure to empty the bladder. Urination takes longer to complete, and a persistent feeling of incomplete emptying is common. The stream may start and stop repeatedly during a single void, and post-void dribbling occurs when urine trapped behind the stricture continues to leak after voiding ends.

Storage symptoms frequently accompany obstructive symptoms. Frequent urination develops as the bladder compensates for incomplete emptying by triggering more frequent voiding attempts. Urgency may occur, and dysuria (painful urination) can signal associated inflammation or infection.

Complications often bring men to medical attention. Acute urinary retention represents a medical emergency where the bladder cannot empty at all. Recurrent UTIs develop when bacteria accumulate in stagnant urine behind the stricture. The infection may spread to the prostate, causing chronic prostatitis. Bladder stones can form in residual urine. Severe untreated strictures may progress to urethral abscess or fistula formation.

Causes

Medical procedures represent the most common cause of urethral stricture today. Catheterization, whether from traumatic insertion, prolonged indwelling use, or repeated catheterization, damages the urethral lining and triggers scar formation. This mechanism makes strictures particularly common in older men who have undergone hospitalization. Urological procedures including cystoscopy, transurethral prostate surgery (TURP), and any urethral instrumentation carry stricture risk. Brachytherapy and external beam radiation for prostate cancer treatment can also cause urethral damage.

External trauma is a significant cause, particularly straddle injuries where the perineum strikes a hard object such as a bicycle crossbar or fence. This type of injury typically damages the bulbar urethra. Pelvic fractures from motor vehicle accidents or falls can disrupt the membranous urethra at the level of the urinary sphincter, resulting in complex injuries requiring specialized reconstruction.

Sexually transmitted infections, particularly gonorrhea, were historically the leading cause of urethral stricture. Although antibiotic treatment has reduced this incidence in developed countries, infection-related strictures remain common in parts of the developing world. Other infections including urethritis and chronic urinary tract infections can contribute to stricture formation.

Lichen sclerosus, also called balanitis xerotica obliterans (BXO), is a chronic inflammatory skin condition that affects the glans penis and can extend into the fossa navicularis and more proximal urethra. This condition causes progressive stricture disease that is particularly challenging to treat and often requires tissue transfer techniques during reconstruction.

Congenital strictures present from birth are rare and typically occur in the fossa navicularis or at the meatus (see meatal stenosis). In 30 to 40 percent of cases, no clear cause can be identified. These idiopathic strictures may result from unrecognized minor trauma during childhood or adolescence.

Diagnosis

Evaluation begins with a detailed history focusing on symptom onset and progression, previous urethral procedures, catheterization history, trauma, sexually transmitted infections, and the impact on quality of life. Physical examination includes inspection of the external genitalia and meatus for signs of meatal stenosis or lichen sclerosus, palpation along the urethra for areas of induration or palpable scar tissue, and digital rectal examination to assess the prostate.

Uroflowmetry provides objective measurement of urinary flow rate. A characteristic flat, prolonged curve with peak flow below 10 milliliters per second suggests obstruction. Post-void residual measurement using ultrasound determines how much urine remains in the bladder after voiding, indicating the degree of incomplete emptying.

The retrograde urethrogram (RUG) is the gold standard imaging study for stricture evaluation. Contrast material injected through the urethral meatus outlines the entire anterior urethra and demonstrates stricture location, length, and severity. A voiding cystourethrogram (VCUG), where contrast fills the bladder and images are taken during voiding, shows the proximal extent of the stricture and complements the retrograde study. Together, these studies provide a complete picture for surgical planning.

Cystourethroscopy allows direct visualization of the stricture and can be combined with treatment when appropriate. However, endoscopy alone may underestimate stricture length and cannot assess the depth of scar tissue (spongiofibrosis) surrounding the urethra. Ultrasound evaluation of the urethra can help characterize the extent of spongiofibrosis in select cases.

Treatment

Treatment selection depends on stricture location, length, etiology, previous treatment attempts, and patient factors. Short strictures under 1 to 2 centimeters in the bulbar urethra have multiple treatment options, while longer strictures or those involving the penile urethra generally require open surgical reconstruction.

Urethral Dilation. This technique involves passing progressively larger instruments through the stricture to stretch the scar tissue. Dilation can be performed in the office or operating room and offers quick relief with minimal morbidity. However, recurrence rates range from 50 to 80 percent because the scar tissue is stretched rather than removed. Dilation serves best as a temporizing measure, for patient self-maintenance between treatments, or when surgery is not feasible. Repeated dilations can cause additional trauma and worsen the stricture over time.

Internal Urethrotomy (DVIU). Direct vision internal urethrotomy is an endoscopic procedure where the stricture is incised with a cold knife or laser to open the narrowed segment. A catheter remains in place briefly while the incision heals. For first-time treatment of short bulbar strictures, success rates reach 50 to 60 percent. However, repeat urethrotomy has success rates below 20 percent, and multiple procedures make subsequent reconstruction more difficult. This procedure is best reserved for short, first-time strictures when definitive surgery is declined or not available.

Urethroplasty. Open surgical reconstruction represents the gold standard for definitive treatment, with overall success rates of 85 to 95 percent depending on stricture characteristics and technique. Excision and primary anastomosis (EPA) removes the strictured segment and reconnects the healthy urethral ends directly. This technique works best for short bulbar strictures under 2 to 3 centimeters and achieves success rates of 90 to 95 percent.

Substitution urethroplasty uses tissue grafts or flaps to widen or replace the diseased urethral segment. Buccal mucosa grafts harvested from the inner cheek have become the preferred tissue source due to their resilience, elasticity, and favorable healing characteristics. This approach is necessary for longer strictures, penile urethral disease, or when primary anastomosis would create excessive tension.

Staged urethroplasty is reserved for complex cases, particularly those involving lichen sclerosus or extensive prior surgery. The first stage opens the urethra and places a graft that heals for several months. The second stage reconstructs the urethral tube using the matured graft tissue. This approach achieves better results in difficult cases where single-stage repair would likely fail.

Permanent Diversion. For severe or unreconstructable strictures, options include long-term suprapubic catheter drainage or perineal urethrostomy (creation of a permanent opening behind the scrotum). These represent last-resort solutions when reconstruction is not possible.

When to See a Doctor

Seek evaluation if you notice a progressively weakening urinary stream, difficulty starting or maintaining urination, spraying or splitting of the stream, a sense of incomplete bladder emptying, or recurrent urinary tract infections. These symptoms warrant urological assessment even if they develop gradually and seem manageable.

Urgent evaluation is needed for fever with urinary symptoms, which may indicate infection spreading behind the stricture to involve the prostate or kidneys. Complete inability to urinate constitutes a medical emergency requiring immediate catheterization.

After any stricture treatment, long-term follow-up is essential because recurrence can develop months to years later. Regular uroflowmetry and symptom assessment detect recurrence early, when intervention is simpler. Signs of recurrence include decreasing flow rate, return of obstructive symptoms, recurrent UTIs, or difficulty passing a catheter if intermittent catheterization is part of your management plan.

If you have undergone dilation or urethrotomy with recurrent stricture, discuss urethroplasty with a reconstructive urologist. Definitive surgical repair offers the best chance for lasting relief when endoscopic treatments have failed. Continuing repeated dilations or urethrotomies generally produces diminishing returns and can complicate eventual reconstruction.