Urethral Strictures

Overview

A urethral stricture is a narrowing of the urethra that makes it difficult for a man to pass urine. The narrowing can occur anywhere along the urethra, from the bladder neck, to the end of the penis. It may be caused by scarring from an injury, infection or swelling. When a narrowing in the ureter occurs, the kidney cannot function normally and will be damaged over time.

If you are experiencing pain, having problems when urinating or have been told you have a urethral stricture, talk to City of Hope. Our team of expert urologists use leading-edge methods to diagnose and treat the various urologic conditions that affect millions of men.

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As a founding member of the National Comprehensive Cancer Network, our doctors also help develop and improve evidence-based prostate cancer treatment guidelines for patients throughout the country.

The physicians in our Division of Urology and Urologic Oncology are leading experts in treating patients with all types of urologic disorders and cancers. Just as no two patients are alike, urethral strictures require a unique treatment plan tailored to each individual to attain the best possible outcomes.
 

About the urethra

The urethra runs through the prostate, which surrounds it like a doughnut. It is comprised of three sections and urethral strictures can occur in any part. Treatment depends on the location of the strictures, cause and prior treatments.

First, the urethra exits the pelvis through a muscular sphincter that stays closed at rest and opens during urination.

Next, the urethra widens into the bulbar urethra, the part of the urethra located between the sphincter and the base of the penis. The bulbar urethra is surrounded by a thick layer of spongy tissue called the spongiosum. Outside of the spongiosum is the bulbospongiosus muscle.

At the end of the muscle begins the penile, or pendulous, portion of the urethra. As the name implies, this is the part of the urethra on the underside of the visible portion of the penis.

Within the head of the penis (called the glans) the urethra widens to form the fossa navicularis before ending at the meatus.

When a scar from an injury, infection or swelling blocks the flow of urine in the urethra, it is called a urethral stricture. Men are more likely to have a urethral disease or injury because of their longer urethra. Therefore, strictures are more common in men.

Symptoms of urethral stricture include:

  • A slow urine stream
  • Pain when urinating
  • Urinary tract infections
  • Increased frequency and urgency of urination
  • Loss of bladder control
 
 

How we diagnose urethral strictures

Diagnosing urethral strictures usually involves a combination of radiographic imaging and cystoscopy. The tests we use to make a diagnosis include:

  • Retrograde urethrogram: This is the most important test used to diagnose urethral strictures. It involves placing a small amount of contrast dye into the urethra in order to outline the entire area. This allows the surgeon to identify the location and length of the stricture.
  • Cystoscopy:  A cystoscopy involves placing a small camera into the urethra and bladder. This procedure can be helpful in detecting strictures. Rarely, if the entire length of stricture can be seen through the scope or if the stricture is at the bladder neck, a retrograde urethrogram is not needed.
  • Voiding cystourethrogram: For this test, the bladder is filled with contrast dye and captures images of the full bladder and urethra while the patient urinates. This is a very important diagnostic test for pelvic fracture urethral injuries and any instance of the urethra being entirely obstructed.
  • Flow rate and residual urine assessment: For this test, a patient urinates into a funnel for doctors to measure the strength of the urine stream. Following the test, the residual urine left in the bladder is also measured.  
  • Urine culture: Urine cultures are collected prior to any surgery to ensure there is no active infection and to help guide antibiotics prior to the operation.

Urethral stricuture treatments

For anyone who has been told they have a urethral stricture (or narrowing of the urethra), it is important to know the following: 

  • All strictures should be properly imaged prior to any surgery
  • Dilations and incisions should only be performed on short strictures
  • Repeat dilations and incisions don’t cure the problem and they may decrease the success of future urethroplasty.
  • The current standard of care is imaging, one incision or dilation, followed by the urethroplasty procedure.

Most types of urethral strictures can be treated with surgery, specifically a urethroplasty, which is the surgical repair to the narrowing of the urethra. It is often performed through an incision in the perineum (the area between the anus and the scrotum).

The best treatment option for a urethral stricture depends on the cause, the length, the exact location and any prior treatments. At City of Hope, our highly skilled team will create a personalized treatment plan for your specific diagnosis. The team features fellowship-trained urologists who hold the rare distinction of specializing in the repair of male urethral strictures.

Treatments for bulbar strictures

Bulbar urethral strictures may arise from trauma, instrumentation or infection. These are the most common types of strictures that reconstructive urologists treat.

Short strictures that are appropriately imaged may benefit from a direct visual internal urethrotomy (DVIU). For this treatment, the scar tissue in the urethra is cut with a knife to open the urethra. Patients should only have one DVIU, as repeat DVIUs do not cure the disease and can render more effective urethroplasties less effective.

Urethroplasty is the operation used to repair a urethral stricture. There are two primary types of urethroplasty operations for bulbar urethral strictures:

  • Anastomotic urethroplasty: Also called excision and primary anastomosis, this procedure cuts out the scarred portion and reattaches the healthy ends of the urethra. This is best for traumatic strictures and short strictures. Some doctors report an unacceptably high rate of sexual side effects with this approach and many experts have aborted this procedure, except in the setting of trauma.
  • Buccal mucosa urethroplasty: This procedure opens the urethra and patches the narrow area with an alternative tissue to widen the lumen. This is usually performed with the tissue from the inside of the mouth (buccal mucosa), but penile skin or skin from other sites on the body may also be used.

This is best for long strictures and strictures caused from lichen sclerosis. In addition, this form of repair may have fewer sexual side effects than an anastomotic urethroplasty.

Treatments for bladder neck contractures

Bladder neck contractures typically form after a prior treatment for enlarged prostate, particularly laser treatments and button transurethral resection of the prostate.

Another scenario that can cause a bladder neck contracture is when someone has their prostate removed surgically and a scar forms at the site where the bladder is sewn back to the urethra.

The first treatment option in these scenarios is to perform an incision through the stricture, known as a transurethral incision of the bladder neck contracture. Some doctors then inject a small dose of chemotherapy to prevent the scar from returning. To date, there have been no trials to show that this truly makes a difference, but early reports seem promising.

In cases of radiation induced (or associated) strictures, the success rate decreases with this procedure.

Advanced cases often involve a more aggressive approach. We currently perform anastomosis revision surgery, bladder augmentation surgeries or, if a patient cannot tolerate a large operation, we can place a Foley catheter to aid in bladder drainage.

Treatments for pelvic fracture urethral injury (PFUI)

As the name implies, this is a urethral injury associated with a pelvic bone fracture (usually due to a car accident). When the pelvic bone breaks, the urethra can be torn in half. Many times a catheter will be placed despite the injury. In other cases, the urethra is injured so severely that a tube has to be placed into the bladder through the skin of the low abdomen.

After appropriate imaging, the best option for repair can be determined. In some cases, a direct visual internal urethrotomy (DVIU) may be performed. But like other strictures, only one DVIU should be performed before undergoing an urethroplasty.

In the setting of PFUI, the only option is to perform an anastomotic urethroplasty, focusing on removal of all scar tissue in the urethra.

Treatments for penile urethral stricture and pan-urethral strictures

Penile urethral strictures are caused by a number of conditions: failed hypospadias surgeries, instrumentation, lichen sclerosis (a scarring disease of the penile skin and urethra), infections and trauma. These can occur anywhere along the penile urethra.

The preferred treatment for penile urethral strictures and pan-urethral strictures is a buccal graft urethroplasty. This is a versatile option that can be placed anywhere along the urethra and can even extend the entire length of the urethra. This is particularly true in cases of lichen sclerosis, when the penile skin is likely involved with the disease and therefore should not be used.

In the case of a failed hypospadias repair or previous failed urethroplasty, the procedure is performed in stages. The first stage involves opening the urethra and sewing it to the skin. The second procedure recreates a tube with the help of buccal grafts if needed.

In certain cases, penile skin may be used to widen the narrowed urethra, but using penile skin poses a higher risk of complications than other approaches.

In severe cases, a perineal urethrostomy may be necessary. This procedure involves making the opening of the urethra come out of the perineum (the area between the anus and scrotum), which allows for normal urinary control but does require a man to sit to urinate. This is a highly effective choice but is often considered a last resort.

Treatment options for meatal stricture

Meatal stricture is a narrowing at the very end of the urethra, at the tip of the penis. These strictures can be caused by trauma, lichen sclerosis, instrumentation, infection, failed urethroplasty and other unknown causes. Despite the fact that these strictures seem simpler, proper imaging is still required to help determine proper management.

Meatoplasty is a small incision on the underside of the head of the penis (the glans), essentially making the opening larger. This is an effective option for small, short strictures. When the stricture extends into the fossa or penile urethra, they are treated in a similar fashion to those strictures of the penile urethra.

City of Hope brings expert urologic care to treating any urologic condition.

Urologic Surgeons - Duarte

Clayton S. Lau, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Kevin G. Chan, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Laura Crocitto, M.D., M.H.A.

Clinical Specialties

  • Urologic Oncology
  • Urology
Jonathan Lim Yamzon, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Bertram Yuh, M.D., M.S.H.C.P.M., M.I.S.M.

Clinical Specialties

  • Urologic Oncology
  • Urology

Urologic Surgeons - Community

Clayton S. Lau, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Seth A. Cohen, M.D.

Clinical Specialties

  • Female Pelvic Medicine and Reconstructive Surgery
Donald Hannoun, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
Roger W. Satterthwaite, M.D., M.P.H.

Clinical Specialties

  • Urologic Oncology
  • Urology
Jonathan N. Warner, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
  • Reconstructive Urology
Kristina Wittig, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
Jonathan Lim Yamzon, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Benjamin J. Yuh, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Bertram Yuh, M.D., M.S.H.C.P.M., M.I.S.M.

Clinical Specialties

  • Urologic Oncology
  • Urology
Ali Zhumkhawala, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology

Urologists - Community

Edward L. Davis, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
Philip G. Pearson, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
David W. Rhodes, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
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