A Urethral Stricture is scarring in or around the urethra that narrows or blocks the passageway through which urine flows from the bladder. The stricture results from inflammation, infection or injury, and is much more common in men than in women. The scarring can occur anywhere between the bladder and the tip of the penis. In addition to uncomfortable urinary symptoms such as reduced flow rate and more frequent urination, a urethral stricture can lead to complications that include urinary tract infections, prostatitis, urinary retention and kidney damage.
The most common cause appears to be chronic inflammation or the development of scar tissue. Scar tissue can gradually form from:
- An injury to the penis or scrotum or a straddle injury.
- An infection, most often sexually transmitted diseases like chlamydia.
- Placement of catheters or instruments used by urologists during surgery or procedures to examine the urethra and bladder.
The scar tissue causes the urethra to become gradually narrow, making it more difficult for urine to flow. Sometimes, the inflammation/injury to the urethra happens long before the stricture becomes noticeable. In other cases, the stricture happens soon after a urethral injury.
Dilation and other endoscopic approaches
Urethral dilation and other endoscopic approaches such as direct vision internal urethrotomy (DVIU), laser urethrotomy, and self intermittent dilation are the most commonly used treatments for urethral stricture. However, these approaches are associated with low success rates and may worsen the stricture, making future attempts to surgically repair the urethra more difficult.
A Cochrane review found that performing intermittent self-dilatation may confer a reduced risk of recurrent urethral stricture after endoscopic treatment, but the evidence is weak.
Cell therapy approach through endoscopy
Buccal mucosal tissue harvested under local anesthesia after culturing in the lab when applied through endoscopy after urethrotomy in a pilot study has yielded encouraging results. This method named as BEES-HAUS procedure needs to be validated through a larger multicentric study before becoming a routine application.
Urethroplasty refers to any open reconstruction of the urethra. Success rates range from 85% to 95% and depend on a variety of clinical factors, such as stricture as the cause, length, location, and caliber. Urethroplasty can be performed safely on men of all ages.
In the posterior urethra, anastomotic urethroplasty (with or without preservation of bulbar arteries) is typically performed after removing scar tissue.
In the bulbar urethra, the most common types of urethroplasty are anastomotic (with or without preservation of corpus spongiosum and bulbar arteries) and substitution with buccal mucosa graft, full-thickness skin graft, or split thickness skin graft. These are nearly always done in a single setting (or stage).
In the penile urethra, anastomotic urethroplasties are rare because they can lead to chordee (penile curvature due to a shortened urethra). Instead, most penile urethroplasties are substitution procedures utilizing buccal mucosa graft, full-thickness skin graft, or split thickness skin graft. These can be done in one or more setting, depending on stricture location, severity, cause and patient or surgeon preference.
A permanent urethral stent was approved for use in men with bulbar urethral strictures in 1996, but was recently removed from the market.
A temporary thermoexpandable urethral stent (Memotherm) is available in Europe, but is not currently approved for use in the United States.
When in acute urinary retention, treatment of the urethral stricture or diversion is an emergency. Options include:
- Urethral dilatation and catheter placement. This can be performed in the Emergency Department, a practitioner’s office or an operating room. The advantage of this approach is that the urethra may remain patent for a period of time after the dilation, though long-term success rates are low.
- Insertion of a suprapubic catheter with catheter drainage system. This procedure is performed in an Operating Room, Emergency Department or practitioner’s office. The advantage of this approach is that it does not disrupt the scar and interfere with future definitive surgery.
Following urethroplasty, patients should be monitored for a minimum of 1 year, since the vast majority of recurrences occur within 1 year.
Because of the high rate of recurrence following dilation and other endoscopic approaches, the provider must maintain a high index of suspicion for recurrence when the patient presents with obstructive voiding symptoms or urinary tract infection.