Urethral Stenosis

Urethral stenosis, also called urethral stricture, is a narrowing of the tube that carries urine out of your body. This narrowing makes it difficult and sometimes painful to urinate, and without treatment, it can lead to serious complications affecting your bladder and kidneys.

Table of contents

• What is urethral stenosis?
• Associated anatomy
• How common is urethral stenosis?
• What causes urethral stenosis?
• Signs and symptoms
• How is urethral stenosis diagnosed?
• Treatment options
• Possible complications
• When to contact a healthcare provider

urethral stricture, urethral stricture disease

What is urethral stenosis?

Urethral stenosis is an abnormal narrowing of the urethra — the tube through which urine leaves your body from the bladder^[1]. This narrowing is typically caused by scar tissue that develops in the urethra, making it more difficult for urine to flow^[1].

In people with a penis, the urethra runs from the bladder to the opening at the tip of the penis. In people with a vagina, the urethra runs from the bladder to the front of the vagina^[1]. The male urethra is much longer, typically 8 to 9 inches (about 20 centimeters), while in females the urethra is about 1.5 inches (3 to 4 centimeters) long^[3].

The condition can develop gradually, leading to slowly increasing discomfort while urinating, or it may appear suddenly and require immediate medical care^[1].

• Urethra
• Bladder
• Kidneys
• Prostate (in males)

Types based on location

The male urethra is divided into two main portions. The anterior urethra extends from the external urethral opening at the tip of the penis to the distal membranous urethra. The posterior urethra extends from the distal membranous urethra to the bladder neck^[4].

Strictures can develop anywhere along the length of the urethra but are most often found in the bulbar urethra^[4]. Posterior urethral stenosis is a specific type that affects the uppermost part of the urethra closest to the bladder^[3].

How common is urethral stenosis?

Urethral strictures affect about 1% of people who have a penis^[1]. The condition is much more common in males than in females because the male urethra is significantly longer^[2][3]. Urethral strictures are rare in women, resulting in limited guidelines for their diagnosis and treatment^[4].

The condition becomes more common in people with a penis who are older than 55^[1].

What causes urethral stenosis?

The most common causes of urethral stenosis are chronic (long-term) inflammation or an injury that causes scar tissue to form. This scar tissue causes the urethra to become narrow, which makes it more difficult for urine to flow^[1].

Scar tissue can gradually form from several factors:

• An injury to the penis, scrotum, or pelvic area, including pelvic fractures that damage the urethra^[1][3]
• Infections, particularly sexually transmitted infections (STIs) such as chlamydia and gonorrhea^[1]
• Placement of urinary catheters or surgical instruments in the urethra during surgery or other medical procedures^[1][2]
• Urethral or prostate cancer^[1][2]
• Radiation therapy for prostate cancer or other pelvic conditions^[1][3]
• Surgery for an enlarged prostate, including transurethral resection of the prostate (TURP)^[3]
• A skin condition called lichen sclerosus, which causes patchy, discolored, thin skin that often affects the genital area^[2]

Sometimes the inflammation or injury to the urethra happens long before you notice a urethral stricture. In other cases, the stricture develops soon after a urethral injury^[1]. In some rare cases, posterior urethral stenosis is present at birth (congenital)^[3]. Often the cause is unknown^[2].

Signs and symptoms

The most common sign of urethral stenosis is a weak or slow urine stream^[1][2]. Symptoms may include:

• Straining to urinate^[1]
• Pain while urinating (dysuria)^[1][3]
• Spraying of the urine stream^[2]
• Frequent urination or feeling the need to urinate more often^[2]
• Bladder not emptying completely, or feeling like you haven’t fully emptied your bladder^[1][2]
• Urinary tract infection (UTI)^[1][3]
• Inflammation in the prostate gland (prostatitis)^[1]
• Dark urine or blood in the urine (hematuria)^[3]
• Abdominal pain^[3]
• Blood in the semen^[2]

Most people can urinate with a urethral stricture, but it may be uncomfortable or painful. You may not feel like you’re able to empty your bladder completely^[1]. The severity of symptoms depends on how narrow the urethra has become.

How is urethral stenosis diagnosed?

Contact a healthcare provider if you have a slow or weak urine stream^[1]. A healthcare provider will review your medical history, ask about your symptoms, and conduct a physical exam^[3]. A physical exam may reveal a decreased urinary stream, discharge from the urethra, an enlarged bladder, enlarged or tender lymph nodes, or other abnormalities^[11].

Tests that may be ordered include:

• Urinalysis and urine culture: Tests to look for infection, blood, or other abnormalities in the urine^[3][7]
• Urinary flow test (uroflowmetry): This measures the flow rate and pattern of urine during urination^[7]
• Post-void residual (PVR) volume: An ultrasound of the bladder to measure how much urine remains after urination^[7]
• Retrograde urethrogram (RUG): This test uses X-ray images with contrast dye to visualize the urethra and identify any narrowing or blockages^[3][7]
• Voiding cystourethrogram (VCUG): X-rays taken while you urinate to better outline the level of stricture^[3]
• Cystoscopy: A procedure using a thin, flexible tube with a camera (cystoscope) inserted into the urethra to visually inspect the inside of the urethra and bladder^[3][7]
• Urethral ultrasound: This shows how long the stricture is^[7]
• Pelvic ultrasound or MRI scan: To look at the pelvic area and assess involvement with the condition^[7]

Treatment options

There are no medications available that can treat urethral stenosis^[3][11]. Treatment options depend on the location and length of the stricture, how much scar tissue exists, and the severity of symptoms^[3][7].

Non-surgical approaches

For some people, the stricture may not be severe enough or bothersome, and doing nothing may be the best option^[19]. This strategy may also be adopted for people with significant medical illnesses that place them at greater risk for surgery. In some cases, a person may be taught to perform self-catheterization to slow the rate of narrowing from the stricture^[19].

Minimally invasive procedures

• Urethral dilation: A procedure that uses increasingly larger tubes (dilators) or a balloon inserted into the urethra to widen the narrowed area^[3][7]. This may be an outpatient procedure and can be a choice for treating recurrent urethral strictures^[7].
• Drug-coated balloon dilation: A newer minimally invasive option that uses a balloon coated with special medication. The balloon is inserted and opened to dilate the urethra and deliver medicine to the area to help prevent the stricture from reforming^[9][11].
• Urethrotomy: A minimally invasive procedure in which a small incision is made in the narrowed portion of the urethra to widen it^[7].

A urinary catheter is typically placed for a couple of days after these procedures^[19].

Surgical procedures

Urethroplasty is a surgical procedure to reconstruct or repair the narrowed portion of the urethra^[7]. For strictures close to the bladder, surgeons can often remove the scar tissue and reconnect the urethra^[9]. If the stricture is long or closer to the penis tip, surgeons may need to use tissue from other parts of the body to rebuild the urethra^[9].

Tissue may be taken from the penis skin or from the inside of the cheek. Using tissue from inside the cheek has been shown to be more successful in reconstructing the urethra and is well tolerated by most patients^[9]. Most patients do not need to stay overnight after this procedure^[9].

At experienced centers, stricture surgery has a long-term success rate of more than 95%. For very complex repairs involving long segments of the urethra, the success rate is about 85% to 90%^[19].

Emergency treatment

In acute cases when you cannot pass urine, a suprapubic catheter may be placed. This is an emergency treatment that allows the bladder to drain through the abdomen^[11].

Possible complications

If you have a severe urethral stricture, you may suddenly not be able to urinate at all. This is called acute urinary retention and is a medical emergency^[1]. Without treatment, urine can back up your urinary system and cause complications including:

• One or both kidneys to swell (hydronephrosis)^[1]
• Kidneys to stop working (kidney failure)^[1]
• Regular urinary tract infections^[3]
• Permanent bladder damage^[3]
• Urine backing up into the kidneys from the bladder (vesicoureteral reflux)^[3]
• Kidney damage^[3]
• Prostate infection^[3]

Without treatment, posterior urethral stenosis may get worse over time and cause these serious complications^[3]. It is important to have a urethral stricture treated because permanent injury to the bladder and kidneys may occur if it is not^[6].

When to contact a healthcare provider

Seek medical help quickly if you feel like you have to urinate but can’t^[1]. Contact a healthcare provider if you have a slow or weak urine stream or any other symptoms of urethral stenosis^[1].

Patients with obstructive urinary symptoms who do not respond to standard therapy, such as men treated with alpha-blockers for benign prostatic hyperplasia, should be suspected of having a possible urethral stricture^[4].