A urethral stricture is when a portion of the urethra is abnormally narrowed. The urethra is the tube that carries urine from the bladder out the tip of the penis, and the narrowing of the urethra results in difficulty with urination, and can lead to urine infections, prostatitis, bladder damage, and even kidney failure if left untreated. Fortunately, there is a curative surgical treatment that resolves all symptoms of the disease.
The first thing you will notice is difficulty or irregularities while urinating. Some specific symptoms to look out for include a slow prolonged urinary stream, straining to urinate, and/or a feeling of incomplete bladder emptying. However, in order to have a diagnosis, it is best to visit a urologist who will perform a test to diagnose the disease, called a cystoscopy. Once the cystoscopy confirms the diagnosis, X-ray imaging is the next step to determine the exact length, location, and severity of the stricture.
After learning the exact details of the disease, treatment options can then be discussed. Common treatment methods include A urethral stricture dilation technique, an internal incision called a direct vision internal urethrotomy or DVIU, and an open repair of the urethral stricture, called a urethroplasty. Of all of these treatment options, a properly performed urethroplasty has the highest success rate, however, a urethral stricture dilation and DVIU are still viable options.
Whether you have been diagnosed with a urethral stricture or not, we can help. Some of our patients come to us because they suspect something is wrong 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 come in already with a diagnosis, either because they are referred to us or seek our care without a referral. Most of these patients come to us because they have tried and failed multiple treatments (usually dilation or internal urethrotomy) at different urology centers. However, these urology centers usually do not get appropriate diagnostic imaging or tell the patient that they can be cured with up to a 98+% cure rate with a single surgery. Instead of suffering from recurrent procedures that only offer temporary relief, surgery can provide a permanent fix. 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 the importance of patients being made aware that urethroplasty is usually the best treatment option.
Urology Practice Journal paper authored by Joel Gelman, M.D. and Rachel Quinn, M.D.
The most common way to diagnose the disease is for a urologist to look up your urethra with a flexible telescope called a cystoscope. The cystoscope enables the urologist to identify exactly where the urethra becomes narrow, allowing them to make a fairly accurate diagnosis.
Flexible cystoscope
Pinpoint urethral stricture
From a scope diagnosing a narrow urethra
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, the main limitation with this test is that it is unable to 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
The cutting-edge X-ray imaging at our Center is performed using a specific technique modified by Dr. Gelman. This technology allows us to gently provide high-resolution images that accurately determine the strictures 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 plastic adaptor used to be commercially available but was discontinued, so we developed a better surgical grade stainless steel adaptor. This is now commercially available by CS Surgical and called the Gelman adaptor. This specific technique, first used by Dr. Gelman in 1997, is now illustrated in Campbell-Walsh Urology, the major Textbook in Urology. The film on the right is a retrograde urethrogram in a patient with a long urethral stricture. The image clearly documents the limitations of a cystoscope, as it is only able to see a small portion of the stricture. When looking through the small opening, the Urologist would see a wider area just beyond the narrowed urethra 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.
Urethral X-ray imaging will reveal either a short or long stricture of the urethra, excluding men who have a severed urethra from a pelvic fracture, which requires a different evaluation. The best choice for treatment will depend on the length of the stricture, as well as if there was any prior treatment. For short strictures with no prior treatment most Urologists may choose to perform a procedure called a direct vision internal urethrotomy or DVIU. A DVIU is a procedure in which the Urologist dilates or cuts open the narrow urethra internally, providing some temporary relief of symptoms but does not offer a long lasting cure, making it an ineffective treatment option. To learn more, read the section on urethral dilation and urethrotomy, which will discuss these options. However, the most successful option is a urethroplasty. A urethroplasty is an open repair of the urethra, and detailed information about urethroplasty can be found in the urethroplasty section
Refer to the above simplified decision tree algorithm to learn about additional treatment options. An additional treatment for short strictures is an anastomotic urethroplasty, and for other potential issues, a substitution urethroplasty may be best.
Anastomotic Urethroplasty
Substitution Urethroplasty
Anastomotic urethroplasty, also called excision and primary anastomosis, is a procedure in which the troublesome section is removed and the healthy ends of the urethra are re-connected. Since the urethra has a bit of elasticity and ability to stretch, after a section is removed the healthy sections can be successfully re-connected. An anastomotic urethroplasty is most typically performed when the urethra under the scrotum, known as the bulbar urethra, has been injured by a straddle injury trauma. To learn more about this type of surgery, read the section on bulbar strictures.
Since anastomotic urethroplasty requires removing a portion of the urethra, when strictures are longer this procedure is no longer possible. In these cases, instead of removing the troublesome section we instead widen it. We open up the problem area and add substitute tissue to the narrow urethra to make the narrow urethra wider. This is called tissue transfer or substitution urethroplasty. We recently published our results with anastomotic and substitution urethroplasty, and our technical early success rate was 100% with anastomotic urethroplasty and 97.3% with substitution urethroplasty (short bulbar strictures), with the highest reported short and long term success rates.
There are a few different causes for longer strictures. One cause 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 include prior failed surgeries or complications stemming from the treatment of incomplete development of the urethra (called hypospadias).
