Urethral Stricture

Aka: Urethral Stricture

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II. Definitions

  1. Urethral Stricture
    1. Abnormal narrowing of the Urethral lumen due to inflammation, dysplasia or scar

III. Epidemiology

  1. Males are primarily affected (rare in females)
  2. Annual U.S. Incidence: 0.9% in males
  3. Prevalence
    1. Young males: 200 per 100,000
    2. Age >65 year males: 600 per 100,000

IV. Pathophysiology

  1. Inflammation (esp. leakage of urine in a break of the Urethral epithelium) or Trauma to the corpus spongiousum

V. Causes

  1. Idiopathic (30% of cases)
  2. Iatrogenic (45% of cases)
    1. Indwelling Urinary Catheter (esp. prolonged catheterization; less common with silicone catheters)
    2. Transurethral Procedures (e.g. TURP)
    3. Hypospadias correction
    4. Prostatectomy
    5. Brachytherapy
  3. Trauma
    1. Pelvic Fracture with Urethral rupture
    2. Straddle or perineal injury (e.g. Bicycle riding)
  4. Infection
    1. Bacterial Urethritis (20% of cases)
      1. Gonorrhea
      2. Chlamydia
      3. Tuberculosis
      4. Schistosomiasis
    2. Recurrent Urinary Tract Infection (esp. Escherichia coli)
  5. Inflammatory Conditions
    1. Lichen Sclerosus et atrophicus
    2. Balanitis Xerotica Obliterans

VI. Types

  1. Posterior Urethra (rare location for strictures)
    1. Prostatic Urethra
    2. Membranous Urethra (passes through pelvic floor)
  2. Anterior Urethra (most cases)
    1. Bulbar Urethra (fixed to pelvic floor, 50% of strictures)
    2. Penile Urethra (30% of strictures)
    3. Glandular Urethra including the navicular fossa (20% of strictures)

VII. Symptoms

  1. Decreased, slower, weaker urine flow with prolonged urination time
  2. Incomplete Bladder emptying
  3. Urinary Frequency
  4. Urinary urgency
  5. Irritative symptoms on urinating (Dysuria)

VIII. Exam

  1. Skin changes (e.g. Lichen Sclerosus)
  2. Penile Urethra may have palpable fibrous swelling
  3. Prostate exam (BPH, Prostatitis, nodularity)

IX. Diagnostics

  1. Uroflowmetry (measures urine flow rate over time)
    1. Low urine flow (flat plateau)
    2. Prolonged urination time
  2. Retrograde Cystourethrogram (with or without Voiding Cystourethrogram)
    1. Identifies Urethral Stricture length and location
  3. Cystoscopy
    1. Cystourethrogram is preferred over cystoscopy for defining the extent of stricture
    2. Cystoscope may not be able to pass the stricture

X. Differential Diagnosis

  1. See Urinary Retention
  2. See Medication Causes of Urinary Retention
  3. Benign Prostatic Hyperplasia
  4. Prostatitis

XI. Management: Acute

  1. Manage complete urinary obstruction
    1. Avoid indwelling Foley Catheter if possible (tissue Trauma worsens the stricture)
    2. Subprapubic catheter is preferred
  2. Treat acute infection (e.g. Gonorrhea)

XII. Management: Surgery

  1. Precautions
    1. Stricture recur regardless of treatment strategy
  2. Endoscopic Procedures
    1. Bougienage
      1. Temporary solution only in nonsurgical candidates
      2. Stricture typically recurs after only 4-6 weeks
      3. Results in increased Urethral scarring
    2. Internal urethrotomy
      1. Stricture scar incised via endoscopy
      2. Results in increased Urethral scarring that is always longer than the original scar
      3. Recurs in 50-60% of cases
      4. Consider in short (<1.5 cm) or first time strictures of the bulbar Urethra
  3. Open Surgical Procedures
    1. Stricture resection and end-to-end anastomosis
      1. Most effective in short strictures (<2.5 cm) of the bulbar Urethra
      2. Risk of Urethral shortening and downward bent Erection
      3. Contraindicated in prior Hypospadias repair
    2. Urethroplasty with Free Graft
      1. Indicated in long bulbar stricture and penile strictures
    3. Urethroplasty with pedicled flap
      1. Indicated in long bulbar stricture and penile strictures
      2. Complicated by fistula formation (5%) and skin necrosis (15%)
    4. Perineal Urethostomy (Boutonniere)
      1. Palliative procedure in complex recurrent strictures
      2. Bulbar Urethra is Sutured directly into the perineal skin inferior to the Scrotum
    5. Bulboprostatic anastomosis

XIII. Prognosis

  1. Strictures recur
  2. Factors predicting worse outcome
    1. Extensive stricture
    2. Distal stricture
    3. History of prior stricture treatment

XIV. Complications

  1. Recurrent Urinary Tract Infection
  2. Acute Urinary Retention
  3. Bladder Diverticulum
  4. Vesicoureteral reflux

XV. References

  1. Abdeen (2021) Urethral Strictures, StatPearls, Treasure Island, accessed 4/13/2022 [PubMed]
  2. Tritchler (2013) Dtsch Arztebl Int 110(13): 220-6 [PubMed]

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Related Studies

Ontology: Urethral Stricture (C0041974)

Definition (MSHCZE) Zúžení jakékoli části močové trubice (URETRA). Je charakterizováno ubývajícím močovým proudem a často jinými obstrukčními mikčními symptomy.
Definition (NCI) Narrowing of the lumen of the urethra.
Definition (MSH) Narrowing of any part of the URETHRA. It is characterized by decreased urinary stream and often other obstructive voiding symptoms.
Concepts Anatomical Abnormality (T190) , Disease or Syndrome (T047)
MSH D014525
ICD9 598.9, 598
ICD10 N35 , N35.9
SnomedCT 197912001, 155894009, 197921000, 76618002, 236647003
English Stricture, Urethral, Strictures, Urethral, Urethral Stricture, Urethral Strictures, Urethral Stenosis, Stenoses, Urethral, Stenosis, Urethral, Urethral Stenoses, urethra stricture, Urethral strictures, urethral stenosis, urethral stenosis (diagnosis), urethral stricture (diagnosis), urethral stricture, Urethral Stricture [Disease/Finding], stenosis urethra, urethra stenosis, stricture urethra, Stenosis;urethral, Stricture;urethral, stricture urethral, urethral strictures, stenosis urethral, strictures urethra, Stricture - urethral, Urethral stricture NOS (disorder), Urethra--Stricture, Urethral stricture, Urethral stenosis, Urethral stenosis (disorder), Urethral stricture (disorder), narrowing; urethra, stenosis; urethra, stricture; urethra, ankylurethria, urethra; contracture, urethra; narrowing, urethra; stenosis, urethra; stricture, Urethral stricture, NOS, Urethral stricture NOS, Urethral stricture, unspecified
Dutch stenose van urethra, niet-gespecificeerde uretraalstrictuur, uretraalstrictuur, uretraalstrictuur NAO, stenose; urethra, strictuur; urethra, urethra; contractuur, urethra; stenose, urethra; strictuur, urethra; vernauwing, vernauwing; urethra, Urethrastrictuur, niet gespecificeerd, Strictuur, urethra-, Urethrastenose, Urethrastrictuur
Portuguese Estenose uretral, Aperto uretral, Aperto da uretra NE, Estenose Uretral, Estreitamento Uretral
Spanish Estenosis uretral, Constricción uretral, Constricción uretral NEOM, Constricción uretral no especificada, estrechez uretral, SAI, estrechez uretral, SAI (trastorno), estenosis uretral (trastorno), estenosis uretral, estrechez uretral (trastorno), estrechez uretral, Estenosis Uretral, Estrechez Uretral
French Rétrécissement uréthral, non précisé, Rétrécissement de l'urètre SAI, Rétrécissement urétral, Rétrécissement de l'urètre, Sténose de l'urèthre, Sténose de l'urètre, Sténose uréthrale, Sténose urétrale
German Striktur der Harnroehre NNB, Harnroehrenverengung, Striktur der Harnroehre, unspezifisch, Urethrastenose, Urethralstriktur, Harnröhrenstenose, Urethralstenose, Harnroehrenstriktur, nicht naeher bezeichnet, Harnroehrenstriktur, Urethrastriktur, Harnröhrenstriktur
Italian Stenosi uretrale, non specificata, Restringimento dell'uretra NAS, Stenosi uretrale
Japanese 尿道狭窄ＮＯＳ, 尿道狭窄、詳細不明, ﾆｮｳﾄﾞｳｷｮｳｻｸｼｮｳｻｲﾌﾒｲ, ﾆｮｳﾄﾞｳｷｮｳｻｸ, ﾆｮｳﾄﾞｳｷｮｳｻｸNOS, 尿道狭窄, 尿道狭窄症
Swedish Urinrörsförträngning
Finnish Virtsaputken kurouma
Russian URETRY STRIKTURA, MOCHEISPUSKATEL'NOGO KANALA STENOZ, URETRAL'NYI STENOZ, STENOZ URETRY, MOCHEISPUSKATEL'NOGO KANALA STRIKTURA, МОЧЕИСПУСКАТЕЛЬНОГО КАНАЛА СТЕНОЗ, МОЧЕИСПУСКАТЕЛЬНОГО КАНАЛА СТРИКТУРА, СТЕНОЗ УРЕТРЫ, УРЕТРАЛЬНЫЙ СТЕНОЗ, УРЕТРЫ СТРИКТУРА
Czech Striktura močové trubice NOS, Striktura močové trubice, blíže neurčená, Stenóza dělohy, Striktura močové trubice, striktura uretry, zúžení močové trubice, stenóza uretry, uretra - striktura
Korean 요도 협착, 상세불명의 요도 협착
Croatian URETERNA STRIKTURA
Polish Zwężenie cewki moczowej
Hungarian Húgycső szűkület, nem meghatározott, urethralis stenosis, Urethra szűkület, Urethra szűkület k.m.n.
Norwegian Stenose i urinrøret, Urethrastenose, Striktur i urinrøret
Derived from the NIH UMLS (Unified Medical Language System)

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