A urethral stricture is an abnormal narrowing of a part of the urethra, the tube that carries urine from the bladder out the tip of the penis. A urethral stricture can not only cause difficulty with urination, but also urine infections, bladder damage, and even kidney damage if untreated. Fortunately, urethral strictures can be cured with surgery.
Symptoms that suggest a urethral stricture are a slow prolonged urinary stream, straining to urinate, and-or a feeling of incomplete bladder emptying. When a urethral stricture is suspected, the best way for this do be diagnosed is for the patient to see a Urologist who can perform a test called a cystoscopy to make the urethral stricture diagnosis (more on this to follow). Once it is known that there is a stricture as the cause of the symptoms, then urethral X-ray imaging is the indicated next step to determine the exact stricture length, location, and severity. After this diagnostic information is obtained, treatment options can be discussed including urethral stricture dilation, an internal incision called a direct vision internal urethrotomy or DVIU, and an open repair of the urethral stricture, called urethroplasty. A properly performed urethroplasty has the highest success rate.
Some of our patients come to our Center because they suspect they have a urethral stricture based on having a slow urinary stream or other symptoms, and they want to be properly and gently evaluated. However, approximately 90% of our patients are referred to us or seek our care without referral with known urethral stricture disease. Of these patients, approximately 90% have come to us after they have had multiple failed treatments (usually dilation or internal urethrotomy) without first having appropriate diagnostic imaging or being told that they can be cured with up to a 98+% cure rate with a single surgery, rather than suffer with recurrent strictures and be managed with repeated procedures that only offer temporary relief. We recently published this data in the Urology Practice Journal, an official publication of the American Urological Association, as part of our efforts to educate Urologists about importance of patients being made aware of what is usually the best option for urethral stricture treatment – urethroplasty.
If you have a urethral stricture, it is likely that you saw a Urologist who looks up your urethra with a flexible telescope called a cystoscope and saw an area where the urethra became narrow and said “you have a urethral stricture”.
Pinpoint urethral stricture
From a scope diagnosing a urethral stricture
This test is easily performed by Urologists as cystoscopy is as basic to General Urology practice as the use of a stethoscope is to a Cardiologist. However, while this test definitively diagnoses a urethral stricture, it does not determine the length and exact location of the stricture. That detailed information requires X-ray urethral imaging (called a retrograde urethrogram or RUG, and a voiding cystourethrogram for VCUG). This imaging, to be done properly, requires specific expertise and equipment.
Cone shaped adaptor to form a seal at opening of urethra
Retrograde urethrogram showing a long urethral stricture
Urethral stricture X-ray imaging at our Center is performed using a specific technique modified by Dr. Gelman to gently provide high resolution images that accurately determine the stricture length, location, and severity. The picture on the left shows a cone shaped adaptor being used to gently form a seal at the opening of the urethra. This specific technique, first used by Dr. Gelman in 1997, is now illustrated in Campbell-Walsh Urology, the major Textbook in Urology. This plastic adaptor used to be commercially available and was discontinued. In response, we developed a better surgical grade stainless steel adaptor, the Gelman adaptor. The film on the right is a retrograde urethrogram in a patient with a long urethral stricture. If a cystoscope were to be advanced up the urethra, it would advance to the area as shown. At that point, the urethra would be smaller than the scope. When looking through the small opening, the Urologist would see a wider area just beyond the narrow stricture and could mistakenly think this was a short urethral stricture. However, as shown, there is additional stricture farther in, and the only way to obtain this detail is by performing urethral imaging. The section on diagnostic evaluation will provide detailed information on how we image the urethra.
If urethral X-ray imaging is performed (not counting men who have a severed urethra from a pelvic fracture which is a different evaluation), the findings will be a short stricture of the urethra or a longer stricture. For short strictures when there has been no prior treatment, one option easily performed by most Urologist is a procedure to dilate or cut open the narrow urethra internally, a procedure called a direct vision internal urethrotomy or DVIU. The section on urethral dilation and urethrotomy will discuss these options, which often provide temporary relief of symptoms but are seldom curative. The option with the highest success rate is an open repair, called urethroplasty and detailed information about urethroplasty can be found in the urethroplasty section.
As showed in the simplified decision tree algorithm, treatment options for urethral strictures also include anastomotic urethroplasty for short strictures, and for the rest, substitution urethroplasty.
Anastomotic urethroplasty which is also called excision and primary anastomosis, is a urethral stricture operation where the bad part is removed, and the healthy ends of the urethra are re-connected. The urethra has a bit of elasticity and ability to stretch and therefore, when a small stricture section is removed, the healthy wide ends can be then re-connected. This is the operation we typically perform when the urethra under the scrotum (called the bulbar urethra) has been injured by a straddle injury trauma. This is a common stricture, and therefore, we discuss this surgery in a section on bulbar strictures.
When strictures are longer, urethral reconstruction with anastomotic urethroplasty is not possible. In these cases, we open up the area of stricture and add substitute tissue to the narrow urethra to make the narrow urethra wider. This is called tissue transfer or substitution urethroplasty. One cause of longer strictures is an inflammatory condition that affects the penis skin and urethra called Lichen Sclerosus = Lichen Sclerosis also known as Balanitis Xerotica Obliterans or BXO. Other causes of longer complex strictures include prior failed surgery for stricture or complications of the treatment of incomplete development of the urethra (called hypospadias).
In 2001, the Center for Reconstructive Urology launched urethralstricture.com, becoming the first internet website devoted to providing men with urethral strictures detailed information about urethral strictures and the best treatment.
We launched this educational website because many of our patients suffered for years with urethral stricture disease without being offered effective treatment. Unless or until they were referred to our Center, they were not aware that their condition could actually be cured! At that time, the domain name urethralstricture.com was not a “premium domain name” as no one else had an interest in ownership or providing educational information about urethral strictures and urethroplasty surgery. When we expanded our website, we forwarded this domain to the Center for Reconstructive Urology, but you can still reach our site by typing urethralstricure.com or stricture.com.