Urethral Stricture
What is a Urethral Stricture?
A urethral stricture is a scar that develops within the urethra (the urinary channel leading from the bladder to the end of the penis) which narrows or obliterates the channel leading to urinary symptoms or an inability to void entirely.
Urethral stricture may be caused by inflammation or scar tissue from surgery, disease, or injury. It may also be caused by external pressure from an enlarging tumor near the urethra, although this is rare.
Increased risk is associated with men who have a history of sexually transmitted disease (STD), repeated episodes of urethritis, or benign prostatic hyperplasia (BPH). There is also increased risk of urethral stricture after an injury or trauma to the pelvic region. Any instrumentation entering the urethra (such as catheterization or cystoscopy) increases the chance of developing urethral strictures.
Congenital (present at birth) pediatric strictures are rare, as are true strictures in women. Since males have a longer urethra than females, urethra stricture is common in men, but rare in women. Urethral stricture can vary depending on the cause of scarring and length of the scar.
Symptoms
- Dysuria (painful urination)
- Difficulty urinating
- Slow urine stream (may develop suddenly or gradually)
- Spraying of urine stream
- Decreased urine output
- Increased urinary frequency or urgency
- Incontinence
- Blood in the semen
- Pelvic pain
- Lower abdominal pain
- Bloody or dark urine
- Discharge from the urethra
- Swelling of the penis
- Urinary retention
A physical examination may reveal the following:
- Decreased urinary stream
- Enlarged or tender lymph nodes in the inguinal (groin) areas
- Redness or swelling of the penis
- Urethral discharge
- Enlarged or tender prostate
- Distended bladder
- Hardness (induration) on the under surface of the penis
Diagnosis
It is important to have an accurate diagnosis and assessment of the location and length of the urethral stricture, and to identify the underlying cause. Following diagnosis, the patient and physician can decide on the appropriate treatment and discuss how to avoid a recurrence of the problem. Without appropriate treatment, the stricture will recur almost 100 percent of the time. Evaluation of the patients with urethral stricture disease includes a physical examination, imaging (such as x-rays using contrast dyes or ultrasound) and sometimes urethroscopy. Urethroscopy involves the insertion of a small, flexible, lubricated telescope into the urethra up to the point of the stricture. This study permits the doctor to see the urethra between the tip of the penis and the stricture.
Treatment
The treatment of a urethral stricture is predicated on the length, location, and persistence of the stricture. In general, first time urethral strictures which are short (<1.5cm) in length can usually be treated with either endoscopic incision or dilation. Although this form of treatment provides only a modest success rate, it is minimally invasive with few procedure related complications. Recurrent strictures or strictures longer than 2cm generally are not amenable to endoscopic incision or dilation, and this form of therapy proves to be a "temporizing" measure without much long term success in most cases. If urethral dilation is not possible, surgery may be necessary to correct the condition. Surgical options vary depending on the location and the length of the stricture.
An open urethroplasty may be performed for longer stricture by removing the diseased portion and/or replacing it with other tissue. The results vary depending on the size and location of urethroplasty, the number of prior therapies, and the experience of the surgeon.
Endoscopic internal urethrotomy
For short to medium strictures at the external end of the urethra, the physician uses an endoscope to view inside the urethra and cut open the stricture with a knife, laser or electrocautery (electric pulses cauterize the scarred tissue).
This minimally invasive procedure sometimes only requires local anesthesia.
An endoscope is a small, flexible tube with an attached optical system that is inserted into the body through the urethra or through a small incision. The optical system allows a physician to see inside the body and perform surgery by inserting and manipulating equipment through the tube.
Internal urethrotomy is performed in the operating room using an endoscope, a slim instrument through which a physician can view internal structures or perform procedures. Through the endoscope, an incision is made in the stricture to "open it." Then a catheter is inserted to hold the urethra open.
Management afterward may include intermittent self-catheterization to maintain the opening of the stricture. In self-catheterization, an individual inserts a catheter into his urethra periodically to prevent stricture from recurring.