Urethral Narrowing, Urethral Stricture, and Urethral Stenosis—Causes, Symptoms, and Treatment

The most important symptom of urethral stricture is a change in the urine stream. For example, the stream may be weaker than usual, or it may change direction or shape. In addition, those affected often have to consciously strain when urinating, which is not necessary under normal circumstances.

There is also often a delay in urination, as the urine must first pass through the narrowed area. Afterward, residual urine may remain in the bladder, a condition known as residual urine. Together with the reduced urine stream, this increases the risk of urinary tract infections.

Furthermore, urethral stricture can lead to the following symptoms:

• Interruptions during urination
• Uncontrolled urine leakage
• Frequent urination in small amounts
• Blood in the urine
• Urinary stones (due to potential residual urine in the bladder)

In severe cases, the narrowing can be so severe that the urethra is completely blocked, leading to urinary retention. This causes severe pain, and urine backs up all the way to the kidneys. This backflow can trigger life-threatening kidney failure, which is why immediate treatment is necessary.

In summary, the following symptoms are the most common:

• Weak urine stream
• Split or twisted urine stream
• Prolonged urination time
• Increased urge to urinate and increased frequency
• Pain during urination
• Incomplete bladder emptying (risk of residual urine)

There are various causes of urethral stricture:

• The main cause in approximately 40 to 50% of cases is the formation of scar tissue due to injuries to the urethra (cystoscopy or catheterization)
• In about 20% of cases, it is caused by urethritis (inflammation of the urethra), usually bacterial, but rarely viral
• Accidents (such as pelvic fractures or blunt trauma to the groin)
• Hypospadias (a congenital malformation of the urethra)
• Meatal stenosis (narrowing of the urethral opening)
• Congenital urethral valves (narrowing of the urethra caused by a sail-like membrane)
• Lichen sclerosus (an inflammatory skin condition characterized by connective tissue thickening of the glans and foreskin of the penis)
• Mechanical causes (e.g., cancerous tumors or polyps)

In just under 30 percent of cases, no cause for the narrowing of the urethra can be identified. Doctors then refer to this as idiopathic urethral stricture.

If urethral stricture is suspected, a urologist—a specialist in diseases of the urinary tract—is the appropriate healthcare provider to consult.

The doctor will first review the patient’s medical history and then perform several tests. During the physical examination, the doctor will try to identify any external causes of the narrowing. A urinalysis is also recommended to rule out urinary retention.

The doctor checks the urine flow using a uroflowmeter. During this test, the patient must urinate into a toilet equipped to measure urine flow while the bladder is full. If there is a narrowing of the urethra, urination takes longer and the urine stream is weaker than normal. This test reveals typical changes in urine flow. The doctor then uses an ultrasound to check whether there is urine in the bladder. In addition, the doctor assesses the condition of the bladder and kidneys. If the tests confirm the suspicion of a urethral stricture, the doctor determines its type, length, and location. 

To do this, the doctor performs the following procedures:

• Retrograde urethrography
• Anterograde urethrography

During retrograde urethrography, the doctor injects a contrast agent into the urinary tract. During anterograde urethrography, the doctor introduces the contrast agent into the bladder through a urethral catheter or through the abdominal wall. The doctor uses the resulting X-ray image to assess the narrowing.

Alternatively, a urethroscopy may be performed, in which the doctor examines the urethra using a camera attached to an endoscope.

However, there may be cases where the stethoscope cannot pass through the narrowing. In such cases, the doctor cannot determine the length of the narrowing.

If you have urethral stricture, a urologist is the right person to consult @ Pixel-Shot /AdobeStock

Treatment for urethral stricture can vary depending on the length and location of the stricture. Treatment may be conservative or surgical. 

The appropriate treatment option depends on the location and size of the stricture, as well as whether previous treatments have been attempted.

• Bougienage

Bougienage, or dilation, is the oldest treatment method for urethral stricture. In this procedure, doctors insert a special catheter into the urethra to dilate it. 

However, the effect of this treatment does not last long. Therefore, the dilation must be repeated periodically. The urethral strictures that recur afterward (recurrences) are often longer than the original stricture.

This method is suitable for people who do not wish to undergo surgery or for whom the risk of anesthesia is too high. With conventional dilation procedures, new strictures occur in 80% of cases, and these become longer over time.

• Stent

In this procedure, doctors use an endoscope to insert a stent at the site of the narrowing. This is a small tube that keeps the urethra open. 

Some stents remain in the urethra, while others must be replaced after several months. This can lead to further scarring and therefore worsen the condition. For this reason, it is used only in exceptional cases.

A stent can be inserted at the site of the urethral narrowing using an endoscope @ Özgür Güvenç /AdobeStock

• Drug-Coated Balloon Dilatation (Optilume Method®)

In this procedure, physicians insert a drug-coated balloon catheter into the urethra. At the affected site, they gently inflate the balloon to deliver the drug (paclitaxel) to the surrounding tissue. 

This procedure gently dilates the stricture. As a chemotherapy drug, paclitaxel inhibits the formation of new cells. This results in a lower rate of stricture recurrence. 

According to recent studies, this dilation procedure is superior to conventional dilation methods. It is a minimally invasive treatment option.

• Incision

In this method, doctors make an incision in the stricture endoscopically using a scalpel or a laser to widen the narrowing. As with conventional dilation procedures, there is a risk of recurrence. 

Incision should not be performed too frequently, as it can cause damage to healthy tissue at the site of the narrowing. This can lead to the stricture becoming larger.

• Surgical Urethral Reconstruction

In the case of a short urethral stricture, the surgeon excises the narrowed section from the urethra. He then sutures the two ends directly together. Doctors refer to this procedure as an end-to-end anastomosis.

If the narrowing is extensive, surgery followed by urethral replacement—known as graft urethroplasty—may be considered. For this procedure, doctors often use foreskin or oral mucosa to reconstruct the excised section. This treatment requires sufficient experience in this field to avoid complications such as recurrent strictures and fistula formation.