Urethral stricture

This page is about urethral strictures in men. At Central East Urology, Dr. Jafar Hussaen treats men with urethral stricture.

What causes it?

A stricture forms when the inside of the urethra is hurt and heals with scar tissue. Over time, the scar tightens and the tube gets narrower. Causes include:

• An injury, such as falling hard onto a bar or fence, or a broken pelvis
• A catheter or a scope that was passed into the bladder
• Surgery on the prostate
• Radiation treatment for prostate cancer
• An infection
• A skin condition called lichen sclerosus
• Surgery as a child to fix the opening of the penis (hypospadias)

Often, no cause is found. Strictures become more common as men get older.

Common symptoms

• A weak or slow urine stream
• Pushing or straining to urinate
• Trouble getting started
• Getting up at night to urinate, or going often
• Feeling that your bladder is not empty

Some men also have bladder infections, pain, blood in the urine, a discharge from the penis, or problems with ejaculation. A stricture can sometimes block urine completely. This needs care right away.

How we assess it

• Questions about your symptoms and health, and a physical exam
• A urine test, and a blood test to check how well your kidneys work
• A short form about your symptoms
• A urine flow test, which measures how fast you pass urine
• A bladder scan, which shows how much urine is left after you go
• A cystoscopy. A thin, bendable camera looks inside the urethra. It is usually done in the clinic with numbing gel. This is the first test Canadian experts suggest to find a stricture.

If a stricture comes back after treatment, you may have a special X-ray called a urethrogram. Dye is put into the urethra so the X-ray can show how long the stricture is and exactly where it is. This helps plan surgery. An MRI scan is not usually needed.

Treatment options

The best treatment depends on your symptoms, any problems the stricture has caused, treatments you have had before, and how much it affects your life. Your urologist will talk with you about which options fit you.

Stretching or cutting the stricture

There are two ways to open the narrow spot from the inside, with no cuts on the skin:

• Dilation. The narrow spot is gently stretched wider. This can be done in the clinic.
• Urethrotomy. In the operating room, the doctor passes a thin scope into the urethra. A small blade or a laser cuts through the scar to open it.

Canadian experts suggest trying one of these first for most men with a new stricture. They work best for short strictures (under 1 cm) that have not been treated many times. But strictures often come back. In studies, about 4 in 10 came back after these treatments. After two tries that don't last, another stretch or cut is very unlikely to fix the stricture for good.

Surgery to rebuild the urethra (urethroplasty)

Urethroplasty is surgery that repairs the urethra. It is done in one of two main ways:

• Removing the narrow part. The scarred piece is cut out, and the healthy ends are joined. This works well for short strictures. More than 9 in 10 stay open.
• Widening the urethra with a graft. A small piece of tissue is used to make the tube wider. It is most often taken from the inside of the cheek.

If a stricture keeps coming back, Canadian experts suggest urethroplasty instead of more stretching or cutting. In studies, strictures came back much less often after urethroplasty, about 1.5 in 10. Like any surgery, it has risks. Your urologist will go over them with you.

Other options

• Using a catheter at home. Some men pass a thin tube into the urethra themselves on a regular schedule. This can help keep the urethra open longer after a urethrotomy.
• A new opening for urine. For some men, surgery can make a new opening between the scrotum and the anus. Urine comes out there, and you sit to urinate. This is called a perineal urethrostomy.

Special situations

• After a broken pelvis. The urethra is usually repaired 3 to 6 months after the injury. Repeated stretching or cutting is not advised.
• After a fall onto a hard object. Urethroplasty usually works best, because the scar tends to be deep.
• Lichen sclerosus. This skin condition is often treated with a steroid cream. Strictures it causes tend to grow and come back. Repair usually uses a graft from the cheek. You will need regular check-ups.
• After radiation or prostate surgery. Narrowing can happen deeper inside, near the prostate or bladder. These are often harder to treat, and your urologist will explain your options.

Based on the Canadian Urological Association guideline on male urethral stricture (Rourke KF et al. Can Urol Assoc J 2020;14(10):305-16).