Urethral Stricture: Symptoms, Causes & Treatment

What Is Urethral Stricture?

Urethral stricture is a narrowing of the urethra (the tube that carries urine from the bladder out of the body) caused by scar tissue formation. This narrowing obstructs urine flow, causing difficulty urinating, weak stream, and incomplete bladder emptying. It primarily affects men and becomes more common with age.

The urethra is a thin tube that carries urine from the bladder to the outside of the body. In men, the urethra is approximately 20 centimeters long and also carries semen during ejaculation. When scar tissue forms in the urethral wall, it causes the urethra to narrow, restricting the flow of urine. This condition is called urethral stricture, also known as urethral stenosis.

Urethral stricture is a relatively common condition in men, affecting approximately 0.6% of men over 55 years of age. The incidence increases with age, partly because older men are more likely to have undergone medical procedures that can cause strictures, such as catheterization or prostate surgery. The condition is rare in women due to the shorter and more protected nature of the female urethra.

The severity of urethral stricture varies widely. Some men have mild narrowing that causes only minor inconvenience, while others develop severe obstruction that can lead to urinary retention (complete inability to urinate) and kidney damage. The location, length, and density of the scar tissue all influence symptoms and treatment options.

Anatomy of the Male Urethra

Understanding the anatomy of the urethra helps explain why strictures occur in different locations and why treatment approaches vary. The male urethra is divided into several segments, each with different characteristics and susceptibility to stricture formation:

• Prostatic urethra: Passes through the prostate gland; strictures here are often related to prostate surgery
• Membranous urethra: Short segment passing through the pelvic floor muscles; often damaged in pelvic fractures
• Bulbar urethra: Most common site for strictures; located in the perineum (area between scrotum and anus)
• Penile urethra: Runs through the length of the penis; strictures often result from catheter trauma or infections
• Fossa navicularis: Widened portion near the urethral opening; susceptible to inflammation-related strictures

The bulbar urethra is the most common location for strictures, accounting for approximately 50% of all cases. This is partly because it is the narrowest segment of the urethra and is vulnerable to both external trauma (straddle injuries) and internal trauma from catheters and instruments.

How Strictures Form

Urethral strictures develop when the normal urethral lining is damaged and replaced by scar tissue. This process, called fibrosis, can occur after any injury to the urethra, whether from trauma, infection, or medical procedures. The scar tissue that forms is less elastic than normal tissue and contracts over time, progressively narrowing the urethral channel.

The body's wound healing response plays a central role in stricture formation. When the urethral epithelium (inner lining) is damaged, inflammatory cells migrate to the area and initiate the healing process. In some individuals, this healing process produces excessive scar tissue that extends into the surrounding spongy tissue of the urethra. The resulting stricture may be short and thin (web-like) or long and dense, depending on the nature of the original injury.

What Causes Urethral Stricture?

Urethral stricture is caused by scar tissue formation from urethral trauma, medical procedures (catheters, cystoscopy), infections (especially gonorrhea), inflammatory conditions, or previous surgery. In approximately 30-40% of cases, no specific cause is identified (idiopathic stricture).

Understanding the cause of a urethral stricture is important for planning appropriate treatment and preventing recurrence. The causes can be broadly categorized into several groups, each with distinct characteristics and implications for management.

Iatrogenic Causes (Medical Procedures)

Medical procedures are now the most common cause of urethral stricture in developed countries, accounting for approximately 40-50% of all cases. This is partly because infectious causes have decreased with improved treatment of sexually transmitted infections, while the number of urological procedures has increased.

Urethral catheterization is the most common iatrogenic cause of stricture. Even a single catheterization can damage the urethral lining if performed traumatically or with an inappropriately sized catheter. Prolonged catheterization (more than 5-7 days) significantly increases the risk because the catheter can cause pressure necrosis of the urethral wall. Patients in intensive care units and those with spinal cord injuries are at particularly high risk due to frequent or long-term catheterization.

Transurethral procedures such as cystoscopy, transurethral resection of the prostate (TURP), and ureteroscopy can all cause urethral injury. The passage of instruments through the urethra, especially rigid instruments, can tear or abrade the delicate urethral lining. The risk is higher when multiple procedures are performed or when there is existing urethral pathology.

Prostate cancer treatment including radical prostatectomy and radiation therapy can lead to strictures at the bladder neck or anastomotic site. These strictures are particularly challenging to treat because of the disrupted anatomy and scarring from the cancer treatment.

Traumatic Causes

Urethral trauma is a significant cause of stricture, particularly in younger men. The type and location of the stricture depend on the mechanism of injury.

Pelvic fractures associated with high-energy trauma (motor vehicle accidents, falls from height) can cause complete disruption of the membranous urethra. These injuries occur because the membranous urethra is relatively fixed where it passes through the pelvic floor, and the shearing forces of a pelvic fracture can tear it apart. Posterior urethral strictures resulting from pelvic fractures are among the most challenging to treat.

Straddle injuries occur when a blunt force compresses the bulbar urethra against the pubic bone, typically from falls onto a bicycle crossbar, fence, or similar object. These injuries cause direct contusion to the urethral wall, leading to scar formation. The bulbar urethra is particularly vulnerable because it is the only segment of the urethra that lies outside the protection of the bony pelvis.

Penile fracture and other direct penile trauma can damage the penile urethra, leading to stricture formation at the site of injury. Sexual activity-related injuries, though relatively uncommon, can also cause urethral trauma.

Infectious Causes

Historically, infections were the leading cause of urethral stricture, but improved treatment of sexually transmitted infections has significantly reduced their contribution in developed countries. However, infectious strictures remain common in developing regions.

Gonorrhea was once the most common cause of urethral stricture. The infection causes severe urethritis (inflammation of the urethra) that can lead to extensive scarring. Gonorrheal strictures are often long and involve multiple segments of the urethra, making them difficult to treat. Although less common today, gonorrhea remains an important cause of stricture, particularly when infections go untreated or are inadequately treated.

Non-specific urethritis from other sexually transmitted pathogens, including chlamydia, can also cause strictures, though less commonly than gonorrhea. Recurrent urinary tract infections have also been associated with stricture formation, though the relationship is less clear.

Inflammatory Conditions

Lichen sclerosus (formerly called balanitis xerotica obliterans or BXO) is a chronic inflammatory skin condition that can affect the genital area, including the urethra. When it involves the urethra, it causes progressive scarring that often starts at the urethral meatus (opening) and extends proximally. Lichen sclerosus-related strictures are particularly challenging because the underlying condition continues to cause inflammation and scarring even after treatment.

Idiopathic Strictures

In approximately 30-40% of urethral strictures, no specific cause can be identified despite careful history-taking. These are called idiopathic strictures. Some researchers believe that many of these cases result from unrecognized childhood trauma, subclinical infections, or minor urethral injuries that the patient doesn't remember. Idiopathic strictures are most commonly found in the bulbar urethra.

What Are the Symptoms of Urethral Stricture?

The main symptoms of urethral stricture include a weak or slow urine stream, difficulty starting urination (hesitancy), straining to urinate, incomplete bladder emptying, frequent urination, spraying of the urine stream, recurrent urinary tract infections, and in severe cases, complete urinary retention requiring emergency treatment.

The symptoms of urethral stricture result from obstruction of urine flow through the narrowed urethra. Symptoms typically develop gradually and may worsen over months to years as the stricture progresses. Many men initially attribute their symptoms to aging and delay seeking medical attention, which can lead to complications.

Obstructive Voiding Symptoms

The hallmark symptoms of urethral stricture relate to difficulty emptying the bladder. A weak or slow urine stream is often the first symptom noticed. Men may describe their stream as "not as strong as it used to be" or taking longer to empty their bladder than previously. The stream may gradually weaken over time as the stricture progresses.

Hesitancy, or difficulty starting urination, occurs because the bladder muscle must generate higher pressure to overcome the obstruction. Men with strictures often need to wait several seconds before urine flow begins, even when they feel a strong urge to urinate. This can be particularly problematic in public restrooms.

Straining to urinate is another common symptom. Men may need to push with their abdominal muscles to initiate or maintain urine flow. This compensatory mechanism helps overcome the obstruction but can lead to problems over time, including hemorrhoids and hernias.

Incomplete bladder emptying results when the bladder cannot fully empty against the obstruction. Men may feel that their bladder is never completely empty and may need to return to the bathroom shortly after urinating. This residual urine also increases the risk of urinary tract infections.

Spraying or splitting of the urine stream occurs when urine is forced through a narrow, irregular stricture. Instead of a single, well-directed stream, urine may spray in multiple directions, making it difficult to aim and creating hygiene problems.

Dribbling after urination is common because urine pools behind the stricture and slowly drains after the main stream has stopped. Men may notice wet spots on their clothing after urinating.

Irritative Voiding Symptoms

In addition to obstructive symptoms, urethral strictures often cause irritative symptoms related to bladder dysfunction.

Increased frequency of urination occurs because the bladder cannot empty completely. The residual urine reduces the functional capacity of the bladder, so it fills to the point of discomfort more quickly. Men may need to urinate every 1-2 hours during the day.

Urgency, a sudden strong need to urinate, develops as the bladder muscle becomes overactive in response to chronic obstruction. This can lead to episodes of urge incontinence if the bathroom cannot be reached in time.

Nocturia, the need to wake up at night to urinate, is common. Men with strictures may wake 2-4 times per night, significantly disrupting sleep quality and overall health.

Complications and Warning Signs

Recurrent urinary tract infections are a common complication of urethral stricture. The stagnant residual urine provides an ideal environment for bacterial growth. Symptoms include painful urination, cloudy or foul-smelling urine, fever, and lower abdominal pain. Recurrent UTIs should prompt evaluation for possible stricture.

Urinary retention is a serious complication that requires emergency treatment. In acute retention, the patient is suddenly unable to urinate despite a full bladder, causing severe lower abdominal pain. This constitutes a medical emergency requiring immediate bladder drainage. Chronic retention develops more gradually and may cause less dramatic symptoms despite dangerously high residual volumes.

How Is Urethral Stricture Diagnosed?

Urethral stricture is diagnosed through medical history, physical examination, and diagnostic tests including uroflowmetry (urine flow measurement), retrograde urethrography (X-ray with contrast dye), cystourethroscopy (camera examination), and ultrasound. These tests determine the stricture's location, length, and severity to guide treatment planning.

Accurate diagnosis of urethral stricture requires a systematic approach combining patient history, physical examination, and specialized diagnostic tests. The goals of evaluation are to confirm the presence of a stricture, determine its location and length, assess its severity, and identify the underlying cause when possible.

Medical History

A detailed medical history provides important clues to the diagnosis. The physician will ask about the nature and duration of urinary symptoms, any previous urological procedures or catheterizations, history of urethral trauma or pelvic fractures, sexually transmitted infections, and previous treatments for urethral problems.

The timing and progression of symptoms help differentiate stricture from other causes of urinary obstruction such as benign prostatic hyperplasia (BPH). Stricture symptoms tend to develop over months to years, whereas BPH symptoms are more commonly associated with older age and may fluctuate.

Physical Examination

Physical examination includes assessment of the external genitalia, feeling along the urethra for areas of scarring or induration, and a digital rectal examination to assess the prostate. The urethral meatus (opening) is examined for narrowing or signs of lichen sclerosus. In some cases, areas of scarring can be felt along the penile urethra.

Uroflowmetry

Uroflowmetry is a non-invasive test that measures the rate and pattern of urine flow. The patient urinates into a specialized toilet that records the flow rate over time. A normal maximum flow rate is typically greater than 15 mL/second, while men with significant strictures often have maximum flow rates below 10 mL/second.

The flow pattern also provides useful information. A normal flow curve rises quickly to a peak and then gradually decreases. In stricture disease, the curve is typically flattened and prolonged, sometimes described as a "plateau" pattern. However, uroflowmetry cannot determine the cause of reduced flow or the location of obstruction, so additional tests are needed.

Post-Void Residual Measurement

After uroflowmetry, the amount of urine remaining in the bladder is measured, typically using ultrasound. A post-void residual (PVR) greater than 50-100 mL suggests significant obstruction or bladder dysfunction. Very high residual volumes (greater than 300-400 mL) indicate severe obstruction and increase the risk of complications.

Retrograde Urethrography

Retrograde urethrography (RUG) is the gold standard imaging test for urethral stricture. Contrast dye is injected into the urethra through a small catheter at the urethral meatus, and X-ray images are taken as the dye flows backward (retrograde) through the urethra. This shows the location, length, and caliber of any strictures.

The test is typically combined with voiding cystourethrography (VCUG), where the patient urinates after the bladder has been filled with contrast. This shows the urethra from above the stricture and helps assess the functional significance of the narrowing.

Cystourethroscopy

Cystourethroscopy involves passing a small camera through the urethra to directly visualize the stricture. This allows assessment of the stricture's appearance, the health of the surrounding urethral tissue, and any associated conditions. It can be performed with a flexible or rigid scope, typically under local anesthesia.

Direct visualization provides information that imaging cannot, such as the presence of inflammation, the appearance of the urethral lining, and the density of scar tissue. However, the scope may not be able to pass through tight strictures, limiting evaluation of the proximal urethra.

Ultrasound

Urethral ultrasound is increasingly used to assess strictures, particularly to measure the length and depth of scarring (spongiofibrosis). This information helps plan surgical treatment. Ultrasound is also useful for measuring post-void residual urine and assessing the kidneys for signs of obstruction (hydronephrosis).

What Are the Treatment Options for Urethral Stricture?

Treatment options for urethral stricture include urethral dilation (stretching), urethrotomy (endoscopic incision), and urethroplasty (surgical reconstruction). While dilation and urethrotomy are less invasive, they have high recurrence rates (50-70%). Urethroplasty offers the best long-term success (85-95%) and is recommended for most strictures that have recurred after simpler treatments.

The goal of treatment is to restore normal urine flow and prevent complications. Treatment selection depends on stricture characteristics (location, length, density, cause), patient factors (age, health status, previous treatments), and individual preferences. The urologist will discuss the pros and cons of each option to help the patient make an informed decision.

Urethral Dilation

Urethral dilation is the oldest and simplest treatment for urethral stricture. It involves gradually stretching the stricture using progressively larger dilators passed through the urethra. The procedure can be performed in the office with local anesthesia or in the operating room under sedation.

Several types of dilators are used, including metal sounds (solid rods), filiform and followers (thin, flexible guides followed by larger dilators), and balloon dilators. The choice depends on stricture characteristics and physician preference.

Dilation provides immediate improvement in symptoms for most patients. However, the stricture almost always recurs because dilation tears the scar tissue rather than removing it, and the healing process creates more scar. Success rates at 2 years are only 30-50%, and repeated dilations may worsen the stricture over time.

Dilation is most appropriate as an initial treatment for short, thin strictures, or for patients who cannot undergo more definitive treatment. Some patients with recurrent strictures learn to perform self-dilation at home using specialized catheters, which can maintain patency and delay the need for further procedures.

Direct Vision Internal Urethrotomy (DVIU)

Urethrotomy involves cutting open the stricture using a special knife passed through an endoscope. The procedure is performed under anesthesia with direct visualization of the stricture. The cut is typically made at the 12 o'clock position to avoid important structures underneath the urethra.

Like dilation, urethrotomy provides immediate symptom relief but has high recurrence rates. The cut through the scar tissue heals by forming more scar, often recreating the stricture. Long-term success rates are similar to dilation at 30-50%, and there is little evidence that urethrotomy is superior to dilation for most strictures.

Urethrotomy is most successful for short strictures (less than 1-2 cm) in the bulbar urethra that have not been previously treated. For longer strictures or those that have recurred after previous treatment, urethrotomy is unlikely to provide lasting benefit and may make subsequent surgical repair more difficult.

Urethroplasty

Urethroplasty is surgical reconstruction of the urethra and is the definitive treatment for urethral stricture. Unlike dilation and urethrotomy, which simply open the stricture temporarily, urethroplasty removes or bypasses the scarred tissue and reconstructs the urethra using healthy tissue. Success rates range from 85-95% depending on the type of reconstruction and stricture characteristics.

Several surgical techniques are available:

Excision and primary anastomosis (EPA) is used for short strictures (typically less than 2-3 cm in the bulbar urethra). The scarred segment is completely removed, and the healthy ends of the urethra are sewn together. This technique has the highest success rates (over 90%) because it completely eliminates the diseased tissue.

Substitution urethroplasty is used for longer strictures where excision would create too much tension. Additional tissue is used to widen or replace the narrowed segment. The most common tissue used is buccal mucosa (tissue from the inside of the cheek), which has properties similar to urethral lining and tolerates the moist urethral environment well. Other options include skin grafts and penile skin flaps.

Staged urethroplasty is used for the most complex strictures, particularly those involving the entire penile urethra or associated with lichen sclerosus. The urethra is opened and laid flat in the first stage, then reconstructed into a tube in a second operation 6-12 months later. While requiring two procedures, this approach provides the best results for difficult strictures.

Urethroplasty is typically performed under general or regional anesthesia and requires a hospital stay of 1-2 days. A catheter is left in place for 2-3 weeks while the reconstruction heals. Most patients return to normal activities within 4-6 weeks.

Urethral Stents

Urethral stents are metal mesh tubes placed inside the stricture to hold it open. They were developed as an alternative to repeated dilation but have largely fallen out of favor due to high complication rates including migration, encrustation, and pain. Stents may still be considered for elderly patients with limited life expectancy who are not candidates for surgery.

Choosing the Right Treatment

The optimal treatment depends on multiple factors that should be discussed with a urologist experienced in stricture management:

• Stricture length: Short strictures (under 1-2 cm) may respond to dilation or urethrotomy; longer strictures benefit from urethroplasty
• Stricture location: Bulbar strictures have the best outcomes with any treatment; penile and posterior strictures are more challenging
• Previous treatment: Strictures that recur after dilation/urethrotomy are unlikely to respond to repeat procedures
• Underlying cause: Lichen sclerosus-related strictures require special surgical techniques
• Patient factors: Age, overall health, ability to undergo anesthesia, and personal preferences

What Is Recovery Like After Treatment?

Recovery after urethral stricture treatment varies by procedure. Dilation and urethrotomy have minimal recovery with return to normal activities within 1-2 days. Urethroplasty requires 2-3 weeks with a catheter and 4-6 weeks before full activity. Most patients notice improved urinary symptoms immediately after catheter removal.

Understanding what to expect during recovery helps patients plan appropriately and recognize potential problems early. Recovery varies significantly depending on the type of treatment received.

After Dilation or Urethrotomy

These minimally invasive procedures typically require minimal recovery. Most patients go home the same day and can return to normal activities within 1-2 days. Some discomfort with urination and mild bleeding are common for the first few days. Patients should drink plenty of fluids to maintain good urine output and help flush the urethra.

Follow-up typically includes a repeat uroflowmetry at 4-6 weeks to assess the result. Some urologists recommend periodic self-dilation to maintain patency, which patients can learn to do at home.

After Urethroplasty

Recovery from urethroplasty is more involved but leads to better long-term outcomes. Immediately after surgery, patients have a catheter that drains urine while the reconstruction heals. The catheter typically remains in place for 2-3 weeks depending on the type of repair. During this time, patients should avoid strenuous activity but can perform light activities and return to sedentary work.

Catheter removal is performed in the office, often after a special X-ray (voiding cystourethrogram) confirms the repair has healed. Most patients notice immediate improvement in their urinary stream after catheter removal, though some temporary swelling may affect flow in the first few weeks.

Full recovery takes approximately 6-8 weeks. During this time, patients should avoid heavy lifting, vigorous exercise, and sexual activity. Most patients can drive after 1-2 weeks and return to desk work within 2-3 weeks. Physical labor may require 6-8 weeks off.

If buccal mucosa (cheek tissue) was used for the repair, there will also be some discomfort in the mouth that typically resolves within 1-2 weeks. Patients can eat normally but should avoid spicy or acidic foods initially.

Long-Term Follow-Up

Regardless of treatment type, long-term follow-up is important to detect recurrence early. Recurrence is most common in the first 2 years after treatment but can occur later. Follow-up typically includes:

• Uroflowmetry at 3, 6, and 12 months, then annually
• Assessment of urinary symptoms at each visit
• Repeat imaging if flow rates decline or symptoms recur

Patients should contact their urologist if they notice a return of their original symptoms, as early intervention for recurrence may improve outcomes.

What Complications Can Urethral Stricture Cause?

Untreated urethral stricture can lead to serious complications including complete urinary retention (emergency), recurrent urinary tract infections, bladder dysfunction and damage, kidney damage (hydronephrosis), bladder stones, and in rare cases, kidney failure. Early treatment prevents these complications.

Understanding potential complications emphasizes the importance of timely diagnosis and treatment. While many men live with mild stricture symptoms without significant problems, progressive obstruction can cause serious and sometimes irreversible damage.

Acute Urinary Retention

Complete inability to urinate is a medical emergency that requires immediate treatment. It can occur suddenly when a marginal stricture becomes critically narrow, often triggered by cold weather, alcohol, medications, or infection. The bladder distends with urine, causing severe pain and potentially damaging the bladder muscle.

Emergency treatment involves draining the bladder, either by passing a small catheter through the stricture or by placing a suprapubic tube (catheter inserted through the abdominal wall directly into the bladder). Once the acute situation is stabilized, definitive treatment of the stricture can be planned.

Recurrent Urinary Tract Infections

Incomplete bladder emptying creates a reservoir of stagnant urine that promotes bacterial growth. Recurrent UTIs can cause significant symptoms including painful urination, urgency, fever, and general malaise. Chronic infections can also worsen bladder and kidney function over time. If UTIs keep recurring despite appropriate antibiotic treatment, evaluation for underlying stricture is warranted.

Bladder Dysfunction

Chronic obstruction forces the bladder to work harder to empty. Over time, the bladder muscle thickens (hypertrophy) to generate higher pressures. Eventually, the muscle may become unable to maintain these high pressures, leading to progressive decline in bladder function. In advanced cases, the bladder becomes permanently damaged and unable to contract effectively even after the obstruction is relieved. This is called bladder decompensation.

Kidney Damage

Severe obstruction can cause back-pressure on the kidneys, leading to hydronephrosis (swelling of the kidney). Chronic hydronephrosis can permanently damage the kidney tissue and impair kidney function. In rare cases of bilateral hydronephrosis or in patients with a single kidney, complete obstruction can lead to kidney failure, a life-threatening condition requiring dialysis.

Bladder Stones

Stagnant urine promotes the formation of bladder stones. These can cause additional symptoms including pain, blood in urine, and recurrent infections. Bladder stones require removal and are a sign that the underlying stricture needs treatment.

Can Urethral Stricture Be Prevented?

While not all urethral strictures can be prevented, risk can be reduced by using gentle catheterization techniques, avoiding unnecessary instrumentation, promptly treating urinary tract and sexually transmitted infections, practicing safe sex, and wearing protective equipment during activities with risk of perineal injury.

Prevention strategies focus on minimizing urethral trauma and infection, the two main causes of stricture formation.

Safe Medical Practices

Healthcare providers can reduce iatrogenic strictures by using appropriate catheter sizes, ensuring adequate lubrication during catheterization, avoiding traumatic insertion, and minimizing the duration of catheterization when possible. For patients requiring long-term catheterization, suprapubic catheters (inserted through the abdominal wall) may reduce urethral trauma compared to urethral catheters.

Infection Prevention

Preventing sexually transmitted infections through safe sex practices reduces the risk of infectious urethritis and subsequent stricture. Prompt treatment of urinary tract infections and sexually transmitted infections also limits urethral damage.

Trauma Prevention

Wearing protective equipment during sports and activities with risk of perineal injury can prevent traumatic strictures. Bicycle seats should be properly adjusted, and cyclists who experience perineal numbness should consider different seat designs.

For Patients with Existing Strictures

Patients who have been treated for urethral stricture should maintain regular follow-up to detect recurrence early. Self-dilation programs, when recommended by the urologist, may help maintain patency after treatment. Staying well-hydrated and avoiding conditions that predispose to urinary tract infections may also help.

When Should You See a Doctor?

See a doctor if you experience a persistently weak urine stream, difficulty starting urination, need to strain to urinate, feel your bladder doesn't empty completely, have recurrent urinary infections, or notice blood in your urine. Seek emergency care immediately if you cannot urinate at all or have severe pain.

Many men with urethral stricture delay seeking medical attention, attributing their symptoms to aging or assuming nothing can be done. However, early diagnosis and treatment prevent complications and improve outcomes.

Symptoms Requiring Routine Evaluation

• Weak or slow urine stream that persists or worsens
• Difficulty starting urination
• Need to strain or push to urinate
• Feeling that the bladder doesn't empty completely
• Frequent urination, especially waking multiple times at night
• Spraying or splitting of the urine stream
• Recurrent urinary tract infections
• Visible blood in urine

Emergency Symptoms