Urethral strictures are much more common than most people think. The following article is for anyone worried about - or experiencing a lack of flow of urine and therefore needing this symptom to be properly checked. Also, those men who have been diagnosed with a urethral stricture and would like an expert view on what the most appropriate treatment options are.
What is Urethral Stricture?
The urethra is the tube that carries urine from the bladder to the outside of the body and it is usually wide enough to allow urine to flow freely and without difficulty. Urethral stricture refers to inflammation or scarring that occurs in or around the urethra causing it to become narrower. This in turn restricts the flow of urine from the bladder, which can lead to a variety of problems in the urinary tract, including inflammation and infection. Severe blockage that lasts a long time can result in kidney damage. Urethral strictures are rare in women but in men they are more common than is generally thought and can occur at any point from the bladder to the tip of the penis.
Contents
- Symptoms of urethral stricture
- The causes of urethral stricture
- Diagnosing Urethral Stricture
- Treatment options for urethral stricture
e) Implanted stent or permanent catheter
1. Symptoms of urethral stricture
The signs and symptoms of urethral stricture include:
- Decrease in urine stream
- Inability to completely empty bladder
- Spraying of the urine stream
- Difficulty, straining or pain when urinating
- Increased urge to urinate or more-frequent urination
- Urinary tract infection
- Abdominal pain
- Urinary retention
- Swelling of the penis
- Loss of bladder control
2. The causes of urethral stricture
The cause of urethral stricture is very often unknown, however scarring of the urethra resulting in narrowing can be due to a number of different factors including:
- A medical procedure that involves inserting an instrument, such as an endoscope, into the urethra
- Intermittent or long-term use of a tube inserted through the urethra to drain the bladder (catheter)
- Trauma to the urethra or pelvis, often caused by a straddle injury (caused by falling onto an object where the legs are on either side).
- An enlarged prostate or previous surgery to remove or reduce an enlarged prostate gland
- Cancer of the urethra or prostate
- Sexually transmitted infections
Strictures that happen in the first 2.5 to 5 cm of the urethra that urine passes through are called posterior strictures. This sort of stricture is generally caused by injury linked to a fracture of the pelvis.
In men, the final 23 to 25 cm of the urethra is called the anterior urethra. The anterior urethra includes:
- the bulbar urethra (under the scrotum and perineum- the area between the scrotum and anus)
- the penile urethra (along the bottom of the penis)
- the meatus (the exit at the tip of the penis)
Strictures that happen in this section of the urethra are called anterior strictures.
3. Diagnosing Urethral Stricture
There are several tests that are carried out if symptoms are the result of urethral stricture, including:
- physical examination
- urethral imaging (X-rays or ultrasound)
- urethroscopy (to see the inside of the urethra)
- retrograde urethrogram
Urethroscopy
This involves inserting a small, flexible, lubricated lens (that enables the narrowed area to be viewed), into the urethra.
Retrograde urethrogram
Retrograde means the opposite direction to the normal downward flow of urine. This diagnostic imaging test enables more detailed assessment of the stricture(s), including their length, location and precise position. This is done as an outpatient procedure. It involves inserting a contrast dye, which is a fluid that can be seen by the scanner into the urethra at the tip of the penis. This allows the entire urethra to be viewed and demonstrates the narrowed area. This can also be combined with an antegrade urethrogram (antegrade means with the normal flow of urine). Contrast dye inserted from above through a urethral catheter fills the bladder and the urethra down to the stricture. This combination of ‘up’ and ‘down’ tests allows a full picture to be obtained.
If a urethrogram remains inconclusive, direct endoscopic visualisation of the stricture may be a useful approach.
4. Treatment options for urethral stricture
There are a number of treatment options for urethral stricture and the one that is best will depend on individual circumstances. No two strictures are the same even if they occur in the same segment of the urethra. Patient factors such as symptom severity, impact on overall quality of life, erectile function, comorbidities and the ideas, concerns and expectations of each man will play a vital role in the shared decision-making process about treatment.
The therapeutic options are quite diverse, ranging from minimally invasive techniques such as urethral dilatation and internal imaging to urethral reconstruction. If symptoms are not particularly troublesome, a conservative approach to treatment is entirely reasonable in the absence of complications such as impaired kidney function.
a) Catheterisation
This involves inserting a small tube (catheter) into the bladder in order to drain urine away is usually the first step for treating urine blockage. Antibiotics may also be prescribed to treat any infection.
b) Urethral dilatation
This is the simplest form of intervention and involves stretching the urethra. A tiny wire is inserted through the urethra and into the bladder. Progressively larger dilators pass over the wire to gradually increase the size of the urethral opening. This is usually an outpatient procedure and is often an option for recurrent urethral strictures. However, the cure rate (as a permanent solution) is only around 50%, if that. The long-term success rate and cost-effectiveness decrease even further with subsequent attempts at endoscopic intervention. Nevertheless, there is still an important role for repeating this procedure for men who are not keen on surgical reconstruction, for those who require it only infrequently, those who are not fit to have general anaesthetic or those who have failed multiple previous surgical interventions, but who want to preserve urethral voiding.
c) Urethroplasty
This remains the only curative treatment option for many men. It involves surgically removing the narrowed section of the urethra or enlarging it. The procedure might also involve reconstruction of the surrounding tissues. Tissues from other areas of the body, such as the mouth, may be used as a graft during reconstruction. The recurrence of urethral stricture after a urethroplasty is low. A man’s first urethroplasty has the highest chance of being successful and the best results are achieved in specialist, high-volume centres. Therefore it is very important to get an early referral to a specialist unit.
d) Endoscopic urethrotomy
for this procedure a thin optical device (cystoscope) is inserted into the urethra. Instruments are then inserted through the cystoscope to remove the stricture. This procedure offers a faster recovery, minimal scarring and less risk of infection, although recurrence is possible.
e) Implanted stent or permanent catheter
if a severe stricture is present and surgery is not an option it is possible to opt for a permanent artificial tube (stent) to keep the urethra open, or a permanent catheter to drain the bladder. However, these procedures have several disadvantages, including a risk of bladder irritation, discomfort and urinary tract infections. They also require close monitoring. Urethral stents are a last resort treatment.
Urethral stricture is much more common than people think
Urethral stricture is a complex health problem that causes progressive lower urinary tract symptoms in men and is much more common than people think. The factors concerning each individual case and the characteristics of the urethral stricture are equally important in the shared decision-making process that guides management of this condition