Urethral stricture

What a urethral stricture is

The urethra is the tube that carries urine from the bladder out through the penis. A stricture is a narrowing of that tube caused by scar tissue. As the scar contracts, the channel gets tighter, the stream slows, and the bladder has to work progressively harder to empty.

Strictures are described by where they sit — bulbar (in the section beneath the scrotum, the most common site), penile, or panurethral where a long segment is involved. The location and length are the main factors determining which repair is appropriate.

Symptoms

• A slow, weak or spraying stream, or a stream that splits in two
• Straining to pass urine, and taking longer than you used to
• A feeling that the bladder has not emptied, and dribbling afterwards
• Needing to pass urine more often, and urgently
• Recurrent urinary infections, or infection of the prostate or epididymis
• Blood in the urine or semen, and discomfort on passing urine
• In severe cases, complete inability to pass urine — a medical emergency

Causes

• Instrumentation — previous catheterisation, cystoscopy or prostate surgery. This is now the commonest cause in the UK.
• Trauma — a straddle injury, pelvic fracture or direct injury to the perineum, sometimes decades earlier.
• Infection and inflammation — historically gonorrhoea; today more often lichen sclerosus, a skin condition that can affect the foreskin, glans and urethra.
• Previous hypospadias surgery — strictures can appear many years after childhood repair.
• Idiopathic — a substantial number have no identifiable cause.

How it is assessed

Accurate mapping of the stricture is what determines the right operation, so assessment is thorough:

• Flow rate and bladder scan — measuring how fast you void and how much urine is left behind
• Flexible cystoscopy — direct inspection of the urethra with a fine telescope
• Urethrogram — contrast X-ray imaging that shows the exact position and length of the narrowing
• Ultrasound urethrography in selected cases, to assess the depth of scar tissue
• Examination of the genital skin, since lichen sclerosus changes the surgical plan considerably — skin from the affected area cannot be used as a graft

Treatment

Options depend on the site, length, cause and what has been done before:

• Observation where symptoms are mild and the bladder is emptying safely
• Urethrotomy or dilatation for a short, first-presentation bulbar stricture
• The Optilume drug-coated balloon, which dilates the stricture and delivers an agent intended to reduce scar re-formation, in appropriately selected men
• Urethroplasty — open reconstruction, which is the definitive treatment. Techniques include excision of the scar with primary anastomosis, non-transecting repairs that preserve blood supply, and graft augmentation using buccal (inner cheek), lingual or preputial tissue. Long or complex strictures may be repaired in one stage or two.
• Perineal urethrostomy in selected men where reconstruction is not appropriate

My practice

I set up and lead the Southeast London Urethral Reconstruction Team at Guy's Hospital, established in 2012. I perform primary and redo adult hypospadias repair, bulbar urethroplasty by excision and primary anastomosis, non-transecting and dorsal or ventral graft augmentation techniques, one and two-stage penile urethroplasty, staged and Malone meatoplasty, and one-stage panurethroplasty by the Kulkarni approach, using buccal, lingual and preputial grafts. With my consultant colleague Raj Nair, a leading robotic surgeon, the team also offers buccal graft reconstruction of bladder neck, ureteric and PUJ strictures — the largest experience of this type of robotic reconstruction in the UK.