Surgery chapters
Urethral stricture
Anatomy of the male urethra, causes and sites of urethral stricture (inflammatory, traumatic, iatrogenic, lichen sclerosus), symptoms and complications, diagnosis by flow rate, urethrogram and urethroscopy, and treatment by dilatation, optical urethrotomy, self-dilatation and urethroplasty.
- A urethral stricture is a scar of the urethral lining and corpus spongiosum (spongiofibrosis); causes are inflammatory (gonorrhoea, lichen sclerosus), traumatic (straddle → bulbar; pelvic fracture → membranous) and iatrogenic (catheters, TURP).
- A young man with a poor stream, straining, prolonged voiding and dribble has a stricture until proven otherwise; the flow curve is flat and prolonged (plateau) and a retrograde urethrogram shows site and length.
- New short bulbar strictures get optical (internal) urethrotomy; recurrent or traumatic strictures need urethroplasty; retention with a stricture is managed by suprapubic catheter.
On this page
Overview
A urethral stricture is a narrowing of the urethra caused by scar tissue. In men the scar involves both the lining epithelium and the surrounding corpus spongiosum (spongiofibrosis). Strictures are much rarer in women.
The clinical clue is a younger man with obstructive voiding symptoms, too young for prostatic enlargement. Strictures tend to recur, so choosing the right first treatment matters.
Applied anatomy of the male urethra
| Part | Location | Clinical notes |
|---|---|---|
| Prostatic | Bladder neck to verumontanum | Slit-like; median lobe, posterior urethral valves just below the verumontanum |
| Membranous | Passes through the pelvic floor (urogenital diaphragm); contains the external sphincter | Pelvic fracture injury; shortest and least distensible |
| Bulbar | From the perineal membrane to the penoscrotal junction, within the corpus spongiosum | Commonest site of stricture; straddle injury |
| Penile (pendulous) | Penile shaft to the meatus | Lichen sclerosus, catheter strictures, hypospadias repairs |
| External meatus | Tip of the glans | Narrowest part; meatal stenosis |
The posterior urethra = prostatic + membranous; the anterior urethra = bulbar + penile (surrounded by spongiosum).
Causes
| Group | Causes | Typical site |
|---|---|---|
| Inflammatory | Gonococcal and non-gonococcal urethritis (spread to periurethral glands, then fibrosis); balanitis xerotica obliterans (lichen sclerosus); TB (rare) | Bulbar (post-gonococcal); meatus and penile (BXO) |
| Traumatic | Straddle (fall-astride) injury crushing the urethra against the pubis; pelvic fracture (urethral distraction injury); penile fracture | Bulbar (straddle); membranous (pelvic fracture) |
| Iatrogenic | Urethral catheterisation (large or prolonged), instrumentation and cystoscopy, TURP, radical prostatectomy (bladder neck), radiotherapy, hypospadias repair | Meatus, bulbar, membranous, bladder neck |
| Congenital | Rare congenital strictures and valves | — |
| Neoplastic | Urethral carcinoma (rare) | — |
| Idiopathic | Many bulbar strictures | Bulbar |
- Post-inflammatory strictures have become less common with effective treatment of gonorrhoea. They usually appear within a year of infection but may not cause symptoms until later.
- BXO scars the foreskin (phimosis); it spreads to the glans and meatus in about 10% and sometimes into the penile urethra, causing long, difficult strictures.
- Instrumentation strictures form where the urethra bends or narrows: the submeatal area, the bulbar urethra and near the membranous urethra.
Straddle injury → bulbar urethra. Pelvic fracture → membranous urethra. The pelvic-fracture "stricture" is really a gap filled with scar after the urethra is torn apart.
Clinical features
Symptoms
- Poor stream, straining, hesitancy and a prolonged void.
- Post-micturition dribbling (urine held up in the dilated urethra behind the stricture).
- Spraying or a split stream (meatal strictures).
- Frequency and nocturia from incomplete emptying, infection or overactivity.
- Recurrent UTI, epididymo-orchitis or prostatitis.
- Acute retention (uncommon; usually only with very tight strictures).
Signs
- Often none. Sometimes a palpable induration along the urethra, meatal narrowing or BXO changes on the glans.
- A palpable bladder in chronic retention.
- Watering-can perineum (multiple urethrocutaneous fistulae) in neglected cases behind a tight stricture.
A young man labelled with "prostatitis" or "recurrent UTI" and a poor stream may really have a stricture. Do a flow rate and urethrogram rather than repeating antibiotics.
Complications
| Complication | Mechanism |
|---|---|
| Urinary tract infection | Commonest; residual urine |
| Acute or chronic retention, overflow | Outflow obstruction |
| Bladder trabeculation, diverticula, bladder stones | Chronic obstruction |
| Upper tract dilatation and renal impairment | High-pressure obstruction (uncommon) |
| Periurethral abscess and urethral fistula (watering-can perineum) | Infection behind the stricture |
| Urethral diverticulum, urethral calculus | Stasis |
| Epididymo-orchitis, prostatitis | Infected urine refluxing |
| False passage | Forceful catheterisation |
| Squamous cell carcinoma | Long-standing squamous metaplasia (rare, poor prognosis) |
Investigations
| Test | What it shows |
|---|---|
| Urine culture | Infection (treat first) |
| Uroflowmetry | Low peak flow with a flat, box-like, prolonged plateau curve |
| Post-void residual (ultrasound) | Incomplete emptying; upper tract dilatation |
| Retrograde (ascending) urethrogram | Investigation of choice: site, length and number of strictures |
| Micturating (descending) cystourethrogram | Urethra above the stricture; combined with the ascending study for long or complete strictures and pelvic-fracture injuries ("up-and-down-o-gram" through a suprapubic tube) |
| Urethroscopy | Direct view: a pale circumferential scar; openings of false passages |
| Ultrasound urethrography | Depth and length of spongiofibrosis (planning urethroplasty) |
| U&E | Renal function |
Flat curve, young man = stricture. A BPH flow curve is low but still dome-shaped; a stricture curve is a long flat plateau.
Do not use an IVU or a static cystogram to image the urethra. The retrograde urethrogram is the key test, and it is also the first test when urethral injury is suspected after trauma.
Treatment
Principles
- Treat infection first.
- Choose the method according to site, length, cause and recurrence.
- Avoid repeated blind dilatation or repeated urethrotomy in strictures that keep coming back; refer for urethroplasty.
Options
| Method | How | Best for | Results and problems |
|---|---|---|---|
| Urethral dilatation | Gradually larger dilators (bougies, sounds) passed under local anaesthetic gel | Elderly or unfit men with short, infrequently recurring strictures; strictures at the sphincter or bladder neck after radical prostatectomy | Done "blind": false passage risk; needs repeating |
| Optical internal urethrotomy (DVIU) | Scar cut under direct vision with a knife (or laser) through a urethroscope, usually at 12 o'clock, after passing a guidewire to the bladder; catheter for 1–3 days | First-line for newly diagnosed short bulbar strictures (not traumatic) | About 50% permanent cure after one procedure; best in short bulbar strictures; poor for long, penile or recurrent strictures; bleeding, infection |
| Intermittent self-dilatation | The patient passes a soft hydrophilic catheter regularly | After urethrotomy to delay recurrence; men unfit for or unwilling to have urethroplasty | Lifelong |
| Anastomotic urethroplasty (excision and primary anastomosis) | Scar segment excised; spatulated ends joined without tension | Short bulbar strictures; post-traumatic strictures; pelvic fracture distraction injury (delayed repair at 3–6 months) | Success about 90%; not possible in the penile urethra |
| Substitution urethroplasty | Urethra opened and patched with a graft or flap; buccal (cheek) mucosa is preferred, also penile skin | Long or penile strictures, BXO | Success about 80% at 10 years; buccal mucosa is tough, used to being wet, plentiful (about 6–7 cm per cheek), low donor morbidity |
| Perineal urethrostomy | Urethra brought out in the perineum | Complex failures, unfit patients | Patient voids sitting |
| Meatotomy / meatoplasty | Meatus opened | Meatal stenosis | — |
The usual sequence is urethrotomy first for a new short (non-traumatic) bulbar stricture, and urethroplasty for recurrent strictures or those after trauma. Repeating urethrotomy many times makes later repair harder.
Strictures recur. Each failed urethrotomy lowers the chance of success with the next, so recurrent strictures should go to urethroplasty, not repeated cutting.
Stricture with acute retention
- A tight stricture may not allow even a fine catheter. Do not force a catheter (risk of false passage, bleeding, sepsis).
- Suprapubic catheterisation is the safe choice; definitive treatment follows electively.
- An experienced urologist may dilate the stricture or do an urgent urethrotomy.
Pelvic fracture urethral injury
- Clues: blood at the meatus, inability to void, high-riding prostate on DRE, perineal and scrotal bruising.
- Retrograde urethrogram confirms the injury.
- Initial management: suprapubic catheter (ultrasound guided if needed) once the patient is resuscitated.
- If there is no blood at the meatus but uncertainty, one gentle attempt with a soft catheter by an experienced doctor is acceptable; if it fails, stop and do a urethrogram.
- Definitive: delayed anastomotic urethroplasty at about 3–6 months.
- Late problems: erectile dysfunction, incontinence (if the bladder neck is also damaged), recurrent stricture.
Straddle (bulbar) injury
- Fall astride a beam or bicycle bar crushes the bulbar urethra against the pubis.
- Perineal butterfly bruising; blood at the meatus.
- If Buck's fascia is torn, urine and blood extravasate deep to Colles' fascia into the scrotum, penis and lower abdominal wall, but not the thighs (Colles' fascia fuses with the fascia lata).
- Suprapubic diversion; drain extravasation; later urethroplasty if a stricture forms.
Female urethral stricture
Uncommon; follows trauma, surgery or radiotherapy. Female urethra is about 2–3 cm long. Treated by dilatation or urethroplasty.
Expect: the commonest site (bulbar), causes (gonorrhoea, catheters and TURP, BXO, straddle and pelvic fracture trauma), the straddle versus pelvic-fracture level, the flat plateau flow curve, the retrograde urethrogram as the key test, suprapubic catheter for retention or urethral injury, optical urethrotomy at 12 o'clock with about 50% cure, urethroplasty for recurrent and traumatic strictures with about 90% success for anastomotic repair, buccal mucosa grafts, and complications such as UTI, stones, fistula (watering-can perineum) and false passage.
Quick revision
- Stricture = scar of urethra and spongiosum; commonest in the bulbar urethra.
- Causes: inflammatory (gonococcal, BXO), trauma (straddle → bulbar; pelvic fracture → membranous), iatrogenic (catheters, TURP).
- Young man, poor stream, dribble → think stricture.
- Flow: long flat plateau; key test: retrograde urethrogram.
- Retention: suprapubic catheter; never force a urethral catheter.
- New short bulbar: optical urethrotomy (~50% cure).
- Recurrent or traumatic: urethroplasty (anastomotic ~90%; buccal graft for long).
- Commonest complication: UTI.
Written by The House Job from standard references (Bailey & Love; Kumar and Clark's Clinical Medicine).
FAQ
Where do urethral strictures most often occur?
In the bulbar urethra. This is the usual site after gonococcal urethritis, straddle injury and many idiopathic strictures.
What is the best test to show a urethral stricture?
A retrograde (ascending) urethrogram, often combined with a micturating study, which shows the site, length and number of strictures.
How is a man in retention from a tight stricture treated?
With a suprapubic catheter. Forcing a urethral catheter risks a false passage and bleeding; the stricture is treated electively later.
When is urethroplasty preferred to urethrotomy?
For strictures that recur after urethrotomy, strictures after trauma including pelvic fracture, and long or penile strictures, where urethroplasty gives far better long-term results.