Urethral Stricture

The urethra, a thin-walled tube, carries urine out of the body. In men, it is a long tube that runs through their penis. In women, the urethra is short and resides just above the vaginal opening. Normally, the urethra is wide enough to allow the urine to pass through it freely. However, sometimes, scarring can cause the urethra to narrow, restricting the free flow of urine. This medical condition is known as urethral stricture and can cause various problems in the urinary tract. Urethral stricture usually affects men.

There are two types of urethral stricture in men, which include:-

1. A posterior urethral stricture occurs in the first 1-2 inches of the urethra that passes from the bladder through the prostate and pelvic floor muscles. These most commonly occur due to an injury to the pelvis, such as a pelvic fracture in a motor vehicle accident. 
2. An anterior urethral stricture occurs downstream from the posterior section on the last 9-10 inches of the urethra. The causes of anterior urethral stricture include catheterisation, direct injury to the penis, or trauma from a straddle injury. 

You may experience various symptoms of urethral stricture, including:-

1. Weakened urinary system or decrease in the urine flow
2. Sudden urges to urinate
3. Straining to urinate
4. Burning or pain during urination
5. Incomplete bladder emptying
6. Incontinence (inability to control urine)
7. Prostatitis (inflammation of the prostate)
8. Urinary retention (inability to urinate, which is a medical emergency)
9. Hydronephrosis (kidney swelling due to backup of urine into the kidneys)
10. Urinary tract infections
11. Pelvic or lower abdominal pain
12. Urethral discharge
13. Swelling and pain in the penis
14. Darkening of the urine
15. Blood in the urine or semen

Urethral strictures are usually caused due to chronic tissue inflammation or the presence of scar tissue. The causes of scar tissue can include:-

1. Congenital 
   1. Improperly developed genitals or urinary structures
   2. Hypospadias (a birth irregularity in boys in which the urethral opening is not located at the tip of the penis)
2. Acquired
   1. Injury or Trauma
      1. Injury to the pelvis, urethra, penis, or scrotum
      2. Straddle injury (falling or landing with the legs on each side of the object) to the scrotum or perineum
   2. Medical Complications
      1. Procedures that require inserting instruments such as an endoscope into the urethra
      2. Insertion of catheters through the urethra to drain the bladder
      3. Surgery to remove an enlarged prostate gland
      4. Radiation therapy
   3. Inflammatory Conditions and Infections
      1. Benign prostatic hyperplasia (an enlarged prostate)
      2. Urethral or prostate cancer
      3. Sexually transmitted infections (STIs) such as chlamydia and gonorrhoea
      4. Repetitive urinary tract infections

The risk of urethral stricture increases with the following factors:-

Uncontrollable Factors

1. An enlarged prostate
2. A recent catheter placement
3. Urethritis (inflammation of the urethra)

Controllable Factors

One or more sexually transmitted infections

To diagnose urethral stricture, your doctor will ask about your symptoms, evaluate your medical history, and conduct a physical exam of the penis area. A physical exam may reveal the following:-

1. Urethral discharge
2. Decreased urinary stream
3. Enlarged prostate
4. Enlarged bladder
5. Hardness under the penis surface
6. Redness or swelling of the penis

Your doctor may recommend several other tests to identify the cause and location of urethral stricture. These diagnostic tests include:-

1. Urinalysis: The test detects signs of infections, cancer, or blood in the urine.
2. Peak flow urine study: The test measures the rate of urine flow from your bladder to the end of the urethra.
3. Urethral ultrasound: The doctor uses this test to examine the length of your stricture.
4. Pelvic ultrasound: The test checks the presence of urine in the bladder after urination. 
5. Retrograde urethrogram: During this procedure, the doctor injects a contrast dye into your urethra through a catheter. Next, they take X-rays of your genital and lower pelvic area to determine the length and location of the stricture. 
6. Antegrade urethrogram: The procedure is similar to retrograde urethrogram, except that the doctor injects contrast dye in the bladder instead of the urethra. Next, the doctor uses X-ray images to examine the narrowing of the first part of the urethra. 
7. Pelvic MRI: The doctor uses imaging tests to view your urethra and the surrounding tissue. 
8. Cystoscopy: The doctor inserts a small, flexible camera, called a cystoscope, into your penis. A cystoscope enables the doctor to look inside the urethra.

The treatment for urethral stricture depends on the severity of your condition. 

Nonsurgical Treatments

1. Urethral Dilation: In this procedure, the doctor inserts a wire through your urethra into the bladder. Over time, larger dilators will pass through the wire to gradually increase the width of the urethra. It is an outpatient procedure used for recurrent urethral stricture. 
2. Catheterisation: The doctor inserts a small catheter into your bladder to drain urine and treat urine blockage. If the urethral stricture is short, the doctor may recommend self-catheterisation. 
3. Permanent Catheterisation or Implanted Stent: The procedure involves a permanent catheter to drain the bladder or a permanent stent to keep the urethra open. However, these procedures are only used as a last resort as they have various disadvantages, such as irritation and urinary tract infections. 

Surgical Treatments

1. Urethroplasty: It is the most preferred surgical treatment that involves enlarging the narrowed section of the urethra or removing it. It may also require rebuilding the urethra with tissue from your penis or scrotum. The chances of stricture recurrence after a urethroplasty are low. 
2. Urethrotomy: This surgical procedure involves removing or vaporising the stricture with a laser and scope. It offers a faster recovery and less risk of infections. However, recurrence of urethral stricture is possible after the surgery. 
3. Urine Flow Diversion: In severe cases of urethral stricture, the surgeon may perform a urinary diversion. In this surgical procedure, the surgeon creates a new way for the urine to exit your body. They use part of the intestine to connect the ureters to an opening in the abdomen. This surgery is performed only when the bladder is severely damaged or if it needs to be removed. 

Please note that the selection of the treatment approach for urethral stricture is based on your condition and your doctor’s opinion.

If delayed or left untreated, urethral strictures can cause severe complications, such as kidney stones and infections. Moreover, urinary retention can cause your bladder to become enlarged and dysfunctional with time and damage your kidneys.