Urethral stricture – narrowing of the urethra

A urethral stricture is a narrowing of the urethra (the tube that carries urine out of the body) caused by scar tissue, which stops urine from flowing freely out of the bladder. It affects men almost exclusively, because the male urethra is long and vulnerable to injuries, infections and medical procedures.

The symptoms develop slowly and many men put them down to age or to the prostate. The difference matters: a stricture does not respond to medicines, and if it is neglected for a long time it endangers the bladder and the kidneys.

What a urethral stricture is

The urethra is the tube that carries urine from the bladder to the outside; in men it passes through the prostate, the pelvic floor and the penis. When the lining and the tissue beneath it are damaged, healing leaves a scar that contracts and narrows the channel. Strictures are described by location and length – they are most common in the bulbar part below the pelvic floor, followed by the penile part and the external opening. The length varies from millimetres to almost the entire channel and determines the choice of treatment.

Symptoms

• a weak, thin, spraying or split stream;
• straining and taking longer to pass urine;
• dribbling after you finish and a feeling that the bladder has not emptied completely;
• passing urine often, including at night;
• repeated infections of the urinary tract or the prostate;
• sometimes blood in the urine or pain when passing urine.

If you suddenly cannot pass urine at all and your bladder is painfully swollen, this is acute urinary retention – go to an emergency department immediately or call 112 (the European emergency number); with a stricture, it may be impossible to insert a catheter. A fever with shivering when you have difficulty passing urine also needs an urgent examination.

Causes and risk factors

The most common causes today are medical procedures – a catheter left in for a long time, cystoscopies, endoscopic operations on the prostate and bladder, and operations for hypospadias in childhood. Next come injuries – a blow to the crotch in a fall or a fractured pelvis. Untreated or late-treated urethritis, especially gonorrhoea, leaves long scars in the penile urethra. Lichen sclerosus – a chronic skin condition of the foreskin and the glans – narrows the external opening and can progress further inwards. In some patients no cause is found.

Diagnosis

Dr Penev starts with a conversation about when the symptoms began and about previous infections, injuries and procedures, followed by an examination of the genitals, the opening of the urethra and the prostate. A urine test looks for infection, and uroflowmetry shows a typical low, flat flow curve. Ultrasound assesses the residual urine, the bladder wall and the kidneys. The location and length of the narrowing are determined with urethrography – an X-ray with contrast that outlines the channel. If needed, a urethrocystoscopy is done with a thin, flexible instrument. Tests are planned according to the case, at the practice in Plovdiv or at Kaspela University Hospital (UMBAL Kaspela), Plovdiv.

Treatment

The choice depends on the length, location and cause of the stricture and on whether it is the first one or a recurrence.

Dilatation (bougienage) – gradual widening with special instruments. It brings quick relief but is rarely lasting; it is suitable for short narrowings or when surgery is risky.

Internal optical urethrotomy – endoscopic cutting of the scar under direct vision, under anaesthetic, with a catheter for a few days. It is most suitable for short bulbar strictures of up to about one to two centimetres when it is done for the first time. If the stricture recurs, repeated cuts rarely give a lasting result, and European guidelines recommend reconstruction.

Urethroplasty – open reconstructive surgery. With short strictures, the scar is cut out and the healthy ends are stitched together; with longer ones, the channel is widened with a graft, most often taken from the lining of the cheek. This is the treatment with the longest-lasting result. The operation is planned individually according to the length and location of the stricture; the hospital stay is usually a few days, and the catheter stays in for about two to three weeks.

Complications – bladder stones, persistent infections, kidney involvement – are treated at the same time; more about the overfull bladder can be found in the article on difficulty passing urine and urinary retention.

When to see a urologist

Your stream has been getting weaker or splitting for weeks; you strain to pass urine or need several attempts; you dribble after you finish; you have repeated urinary tract infections; after a catheter, an injury to the crotch or a bout of urethritis, passing urine is not the same as before. Patients from Karlovo can have their initial consultation at Vita Med Medical Centre, Karlovo, by appointment.

Prevention

Treat urethritis promptly and completely, use a condom with a new partner and do not put off an examination if you notice whitish, tightening changes on the foreskin. After urethrotomy, keep to your follow-up checks with uroflowmetry – detecting a recurrence early leaves more options open.

A stricture has clear, proven solutions, and the earlier it is recognised, the gentler the treatment. Book an appointment with Dr Penev if the way you pass urine has changed – a single uroflowmetry test answers many questions.