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Urethral Stricture Disease

The urethra is an important part of the urinary tract. While it’s primary job in both genders is to pass urine outside the body, this channel also has an important role in ejaculating semen from the reproductive tract of men. Most people will not have any problems with the urethra, but a few of us may experience the discomfort and dysfunction associated with urethral stricture disease. What is this and how can it be treated? The information below should help you talk with your urologist.

What happens under normal conditions?

During urination, the bladder empties through the urethra and out of the body. Urine passes through an opening called the bladder neck into a portion of the urethra surrounded by the prostate, called the prostatic urethra. The next segment of the urethra is called the membranous urethra and it contains a muscle called the external urinary sphincter. This sphincter allows a patient to voluntarily hold urine and to stop during urination. Together, the prostatic urethra and the membranous urethra make up the posterior urethra, and are approximately one to two inches long. The urine then enters the bulbar urethra, followed by the penile urethra. The penile urethra is the segment that runs along the bottom surface of the penis. The exit at the tip of the penis is called the meatus. The bulbar urethra, penile urethra and meatus make up the anterior urethra, which is nine to 10 inches long.

What is a urethral stricture?

A urethral stricture is a scar in or around the urethra, which can block the flow of urine, and is a result of inflammation, injury or infection.

Who is at risk for urethral strictures?

Urethral strictures are more common in men because their urethras are longer than those in women. Thus men's urethras are more susceptible to disease or injury. A person is rarely born with urethral strictures and women rarely develop urethral strictures.

What are some causes of urethral stricture?

Stricture disease may occur anywhere from the bladder to the tip of the penis. The common causes of stricture are trauma to the urethra and infections such as sexually transmitted disease or damage from instrumentation. However, in most cases, no cause can be identified. Stricture of the posterior urethra is often caused by a urethral injury associated with a pelvic bone fracture (e.g., motor vehicle or industrial accident). Patients who sustain posterior urethral injuries from pelvic fracture generally suffer a disruption of the urethra, where the urethra is cut and separated. These patients are completely unable to urinate and must have a catheter to realign the urethra. The catheter is placed through the penis up into the bladder to allow urine to drain until a repair can be performed. Trauma such as straddle injuries, direct trauma to the penis and catheterization can result in strictures of the anterior urethra. In adults, urethral strictures may occur after prostate surgery, removal of kidney stones, urinary catheterization or other instrumentation. In children, urethral strictures most often follow reconstructive surgery for congenital abnormalities of the penis and urethra, cystoscopy and urethral catheter drainage.

What are the symptoms of urethral strictures?

Some symptoms that may be an indication of urethral strictures can include:

  • painful urination
  • slow urine stream
  • decreased urine output
  • spraying of the urine stream
  • blood in the urine
  • abdominal pain
  • urethral discharge
  • urinary tract infections in men
  • infertility

How are urethral strictures diagnosed?

Simply put, the urethra is like a garden hose. When there is a kink or narrowing along the hose, no matter how short or long, flow can be significantly reduced. When a stricture becomes narrow enough to decrease urine flow, the patient will develop symptoms. Frequent urination, urinary tract infections and inflammation or infections of the prostate and scrotal contents (epididymis) may occur. With long-term severe obstruction, damage to the kidneys can occur.

Evaluation of patients with urethral stricture disease includes a physical examination, urethral imaging (X-rays or ultrasound) and sometimes urethroscopy. The retrograde urethrogram is an invaluable test to evaluate and document the stricture and define the stricture recurrence. Combined with antegrade urethrogram, length of the stricture in order to plan surgical correction can be determined. The retrograde urethrogram is performed as an outpatient X-ray procedure and can define indicate the number, position, length and severity of the stricture(s). This study involves insertion of contrast dye (fluid that can be seen on an X-ray) into the urethra at the tip of the penis. No needles or catheters are used. The retrograde urethrogram study allows doctors to see the entire urethra and outlines the area of narrowing at the stricture. Ultrasound is performed by placing a small, pencil-like ultrasound wand on the skin over the stricture to view it and surrounding tissue. Urethroscopy is a procedure where the doctor gently places a small, flexible, lubricated telescope into the urethra and advances it to the stricture. This study permits the doctor to see the urethra between the tip of the penis and the stricture. All of these tests can be performed in an office setting and will allow the urologist to provide treatment recommendations.

In the case of urethral trauma, once emergency treatment has been provided, the evaluation of patients with posterior urethral disruptions involves a retrograde urethrogram, and if a suprapubic catheter is present, injection of contrast dye through this tube at the same time. Contrast injected from below fills the urethra up to the injured area, and contrast injected from above fills the bladder and the urethra down to the stricture. These two films together allow the surgeon to determine the gap between the two ends in order to plan the surgical repair.

How can urethral strictures be prevented?

The most important preventive measure is to avoid injury to the urethra and pelvis. Also, if a patient is performing self-catheterization they should exercise care, to liberally instill lubricating jelly into the urethra, and to use the smallest possible catheter necessary for the shortest period of time.

Acquired strictures may be a result of inflammation caused by sexually transmitted infections (STIs). Although gonorrhea was once the most common cause of inflammatory strictures antibiotic therapy has proven effective in reducing the number of resulting strictures. Chlamydia is now the more common cause, but strictures caused by this infection may be prevented by avoiding contact with infected individuals or by using condoms. When infection does occur, prompt and complete treatment of the STI with appropriate antibiotics will help prevent future problems.

What are some treatment options?

Treatment options for urethral stricture disease are varied and selection depends upon the length, location and degree of scar tissue associated with the stricture. Options include enlarging the stricture by gradual stretching (dilation), cutting the stricture with a laser or knife through a scope (urethrotomy) and surgical removal (excision) of the stricture with reconnection and reconstruction possibly with grafts.

Dilation
This is usually performed in the urologist's office under local anesthetic and involves stretching the stricture using progressively larger dilators called "sounds." Alternatively, the stricture can be dilated with a special balloon on a catheter. Dilation is rarely a cure and needs to be periodically repeated. If the stricture recurs too rapidly the patient may be taught how to insert a catheter into the urethra periodically to prevent early closure.

Pain, bleeding and infection are the main problems associated with dilation procedures. Occasionally, a "false passage" or second urethral channel may be formed from traumatic passage of the "sound."

Urethrotomy
This procedure involves use of a specially designed cystoscope that is advanced along the urethra until the stricture is encountered. A knife blade or laser operating from the end of the cystoscope is then used to cut the stricture, creating a gap in the narrowing. A catheter may be placed into the urethra to hold the cleft open for a period of time after the procedure to allow healing in the open position. The suggested length of time for leaving a catheter tube draining after stricture treatment can vary.

Urethral Stent
This procedure involves placement of a metallic stent that has the appearance of a circular chain link fence. The stent is placed into the urethra through the penis using a specially designed cystoscopic insertion tool after the urethra is widened. The stent expands within the widened stricture and prevents the urethra from closing. The lining of the urethra eventually covers the stent, which remains in place permanently. This treatment has the advantage of being "minimally invasive." However, it is only suited to very select strictures and frequently causes significant swelling around the device. Removal of these devices is very difficult and may result in a more significant stricture.

Open surgical urethral reconstruction
Many different reconstructive procedures have been used to treat strictures, some of which require one or two operations. In all cases, the choice of repair is influenced by the characteristics of the stricture (such as location, length and severity), and no single repair is appropriate for all situations. Open reconstruction of a short urethral stricture may involve surgery to remove the stricture and reconnect the two ends (anastomotic urethroplasty). When the stricture is long and this repair is not possible, tissue can be transferred to enlarge the segment to normal (substitution procedures). Substitution repairs may need to be performed in stages in difficult circumstances.

Anastomotic Procedures
These are usually reserved for short urethral strictures where the urethra can be reconnected after removing the stricture. This procedure involves a cut between the scrotum and rectum. This is usually performed as an outpatient procedure or with a brief hospitalization. A small, soft catheter will be left in the penis for 10 to 21 days and removed after an X-ray is performed to ensure healing of the repair.

Substitution Procedures

  • Free Graft Procedures: Longer strictures may be repaired with a free graft procedure to enlarge the urethra. The graft may be skin (usually removed from the shaft of the penis) or buccal mucosa removed from inside the cheek. Brief hospitalization and catheterization for two or three weeks are usually required after this procedure.
  • Skin Flap Procedures: When a long stricture is associated with severe scarring and a free graft would not survive, flaps of skin can be rotated from the penis to ensure survival of the newly created urethra. These procedures are complex and require a surgeon experienced in plastic surgery techniques. Brief hospitalization and catheterization for two or three weeks are usually required after this procedure.
  • Staged Procedure: When sufficient local tissue is not available for a skin flap procedure and local tissue factors are not suitable for a free graft, a staged procedure may be required. The first stage in a staged procedure focuses on opening the underside of the urethra to expose the complete length of the stricture. A graft is secured to the edges of the opened urethra and allowed to heal and mature over a period of three months to a year. During that time, patients urinate through a new opening behind the stricture, which in some cases will require the patient to sit down to urinate. The second stage is performed several months after the graft around the urethra has healed and is soft and flexible. At this stage the graft is formed into a tube and the urethra is returned to normal. A small, soft catheter will be left in the penis for 10 to 21 days.

What are the possibilities of recurrence?

Because urethral strictures can recur at any time after surgery, patients should be monitored by an urologist. After removal of the catheter, follow-up of the repair should be performed intermittently with physical examination and X-ray studies being performed as necessary. Sometimes, the doctor will perform urethroscopy to evaluate the repaired area. Some patients will have recurrence of stricture at the site of the prior repair. These are sometimes mild and require no intervention, but if they cause obstruction they can be treated with urethrotomy or dilation. A repeat open surgical repair may be needed for significant recurrent strictures.

Frequently asked questions:

Can urethral strictures be treated with medicine?

No.

What can occur if no treatment is taken?

The patient would have to continue to tolerate problems with urination. Urinary and/or testicular infections and stones can develop. Also, there is a risk that urinary retention may occur which can cause the bladder to enlarge and also lead to kidney problems.

Is there a risk of infecting others with urethral strictures?

Urethral strictures are not contagious but the underlying cause, like an STI, may be contagious.

Reviewed January 2011

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Urethral Stricture Disease Glossary
  • abdominal: in the abdomen, the cavity of this part of the body containing the stomach, intestines and bladder.

  • anesthetic: A substance that causes lack of feeling or awareness.

  • anterior: At or near the front.

  • antibiotic: Drug that kills bacteria or prevents them from multiplying.

  • bladder: The bladder is a thick muscular balloon-shaped pouch in which urine is stored before being discharged through the urethra.

  • bladder neck: Area of thickened muscle fiber where the bladder joins the urethra. Acting on signals from the brain, bladder neck muscles can either tighten to hold urine in the bladder or relax to allow urine out and into the urethra. These muscles also tighten during ejaculation to prevent backflow of semen into the bladder.

  • bulbar: Bulb-shaped.

  • catheter: A thin tube that is inserted through the urethra into the bladder to allow urine to drain or for performance of a procedure or test, such as insertion of a substance during a bladder X-ray.

  • catheterization: Insertion of a narrow tube through the urethra or through the front of the abdominal wall into the bladder to allow urine drainage.

  • condoms: Close-fitting rubber worn by a man over the penis during sexual intercourse to prevent pregnancy and/or spread of sexually transmitted diseases.

  • congenital: Present at birth.

  • congenital abnormalities: Abnormalities present at birth.

  • cyst: An abnormal sac containing gas, fluid or a semisolid material. Cysts may form in kidneys or other parts of the body.

  • cystoscope: A narrow, tube-like instrument fitted with lenses and a light passed through the urethra to look inside the bladder. The procedure is called cystoscopy (sis-TAW-skuh-pee).

  • cystoscopic: Viewing the bladder with a narrow, tube-like instrument passed through the urethra.

  • cystoscopy: Also known as cystourethroscopy. An examination with a narrow, flexible tube-like instrument passed through the urethra to examine the bladder and urinary tract for structural abnormalities or obstructions, such as tumors or stones.

  • dilate: Widen.

  • dilated: Widened.

  • dilation: The stretching or enlargement of a hollow organ or body cavity.

  • dilator: An instrument to stretch body tis-sues and enlarge an opening, passage or canal.

  • dilator: An instrument to stretch body tissues and enlarge an opening, passage or canal.

  • epididymis: A coiled tube attached to the back and upper side of the testicle that stores sperm and is connected to the vas deferens

  • excision: Surgical cut.

  • fertility: The ability to conceive and have children.

  • gene: The basic unit capable of transmitting characteristics from one generation to the next.

  • gonorrhea: A sexually transmitted disease that causes inflammation of the genital mucous membrane, burning pain when urinating, and a discharge. It is caused by a gonococcus bacterium.

  • graft: Healthy skin, bone or tissue taken from one part of the body to replace diseased or injured tissue removed from another part of the body.

  • infection: A condition resulting from the presence of bacteria or other microorganisms.

  • infertility: The diminished ability or the inability to conceive and have offspring.

  • inflammation: Swelling, redness, heat and/or pain produced in the area of the body as a result of irritation, injury or infection.

  • inflammatory: Characterized or caused by swelling, redness, heat and/or pain produced in an area of the body as a result of irritation, injury or infection.

  • invasive: Having or showing a tendency to spread from the point of origin to adjacent tissue, as some cancers do. Involving cutting or puncturing the skin or inserting instruments into the body.

  • invasive: Not just on the surface; with regard to bladder cancer, a tumor that has grown into the bladder wall.

  • ions: Electrically charged atoms.

  • kidney: One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.

  • kidney stone: A stone that develops from crystals that form in urine and build up on the inner surfaces of the kidney, in the renal pelvis or in the ureters. (Also see nephrolithiasis.)

  • kidneys: One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.

  • laser: Device that utilizes the ability of certain substances to absorb electromagnetic energy and re-radiates as a highly focused beam of synchronized single wave-length radiation.

  • meatus: The opening of the urethra.

  • membranous: Relating to or similar to a membrane, especially in being thin, pliable, and often translucent.

  • obstruction: something that obstructs, blocks, or closes up with an obstacle

  • pelvic: Relating to, involving or located in or near the pelvis.

  • pelvis: The bowl-shaped bone that supports the spine and holds up the digestive, urinary and reproductive organs. The legs connect to the body at the pelvis.

  • penis: The male organ used for urination and sex.

  • posterior: Situated at the rear or behind something.

  • prostate: A walnut-shaped gland in men that surrounds the urethra at the neck of the bladder. The prostate supplies fluid that goes into semen.

  • prostatic: Pertaining to the prostate.

  • rectum: The lower part of the large intestine, ending in the anal opening.

  • retention: In ability to empty urine from the bladder, which can be caused by atonic bladder or obstruction of the urethra.

  • retrograde: Backwards.

  • retrograde urethrogram: X-ray diagnostic test to evaluate appearance and integrity of the urethra.

  • scrotal: Relating to the scrotum, the sac of tissue that hangs below the penis and contains the testicles.

  • scrotal: Relating to the scrotum, the sac of tissue that hangs below the penis and contains the testicles.

  • scrotum: Also referred to as the scrotal sac. The sac of tissue that hangs below the penis and contains the testicles.

  • self-catheterization: Inserting a thin, flexible tube into the bladder through the urethra to allow drainage of urine.

  • semen: Also known as seminal fluid or ejaculate fluid. Thick, whitish fluid produced by glands of the male reproductive system, that carries the sperm (reproductive cells) through the penis during ejaculation.

  • semen: The thick whitish fluid, produced by glands of the male reproductive system, that carries the sperm (reproductive cells) through the penis during ejaculation.

  • shaft: Cylindrical part of the penis.

  • sphincter: A round muscle that opens and closes to let fluid or other matter pass into or out of an organ. Sphincter muscles keep the bladder closed until it is time to urinate.

  • stage: Classification of the progress of a disease.

  • stent: With regard to treating ureteral stones, a tube inserted through the urethra and bladder and into the ureter. Stents are used to aid treatment in various ways, such as preventing stone fragments from blocking the flow of urine.

  • stone: Small hard mass of mineral material formed in an organ.

  • stricture: Abnormal narrowing of a body passage.

  • stricture disease: Condition where there is an abnormal narrowing of a body opening.

  • suprapubic: An area of the central lower abdomen above the bony pelvis and overlying the bladder.

  • testicular: Relating to the testicle (testis).

  • tissue: Group of cells in an organism that are similar in form and function.

  • ultrasound: Also referred to as a sonogram. A technique that bounces painless sound waves off organs to create an image of their structure to detect abnormalities.

  • urethra: A tube that carries urine from the bladder to the outside of the body. In males, the urethra serves as the channel through which semen is ejaculated and it extends from the bladder to the tip of the penis. In females, the urethra is much shorter than in males.

  • urethral: Relating to the urethra, the tube tha carries urine from the bladder to outside the body.

  • urethral stricture: Scarring of tissue that causes narrowing or blockage of the canal leading from the bladder, discharging the urine externally.

  • urethral stricture disease: Scarring and narrowing at one or more points in the urethra and of variable severity.

  • urethroplasty: Surgical repair of the urethra.

  • urethroscopy: Inspection of the urethra with a urethroscope.

  • urethrotomy: Surgical incision of a stricture of the urethra.

  • urethrotomy: Operating of cutting a stricture in the urethra.

  • urge: Strong desire to urinate.

  • urinary: Relating to urine.

  • urinary retention: Failure to empty the bladder totally.

  • urinary tract: The system that takes wastes from the blood and carries them out of the body in the form of urine. Passageway from the kidneys to the ureters, bladder and urethra.

  • urinary tract infection: Also referred to as UTI. An illness caused by harmful bacteria, viruses or yeast growing in the urinary tract.

  • urinate: To release urine from the bladder to the outside. Also referred to as void.

  • urination: The passing of urine.

  • urine: Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.

  • urologist: A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system. Click here to learn more about urologists. (Download the free Acrobat reader.)

  • vas: Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.

  • void: To urinate, empty the bladder.

  • voiding: Urinating.

Urethral Stricture Disease Anatomical Drawings

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