URETHRAL STRICTURES

What is the urethra?

The urethra is the tube or channel that carries urine from the bladder to the tip of the penis. The tube runs through the prostate gland and the bottom of the penis before emerging at the end of the penis.

What is a urethral stricture?

A urethral stricture is a narrowing of the lining of the urethra.

On this X-ray, called a retrograde urethrogram, dye is injected into the urethra, which looks like a tube and appears dark gray. The stricture is the sharp narrowing in the tube where the arrow is located.

If you look inside the urethra (with a cystoscope) you would see an abrupt narrowing in the lining of the urethra. This is a picture of someone who was diagnosed with a urethral stricture. This narrowing is the urethral stricture and the arrow points to it.

What causes urethral strictures? How did I get a urethral stricture?

Typical causes of a urethral stricture include trauma, either from an injury, such as a car or bike accident, complications from a medical procedure such as a urethral catheter placement or from prostate surgery. Occasionally, an infection of the urethra or gonorrhea (a sexually transmitted disease) can cause this, but in many cases the cause of the stricture is unknown.

What are the symptoms of a urethral stricture?

The most common symptoms of a urethral stricture are related to problems urinating. Typically you might have a very slow urinary stream, need to push to urinate, not completely empty your bladder and feel like you have to urinate again after urinating or have urinary frequency and strong urges to urinate. Other symptoms include pain, bleeding and a fear of urinating.

What kind of problems can a urethral stricture cause?

A urethral stricture can cause permanent bladder damage, recurrent urinary tract infections, blood in the urine, backup of urine to the kidneys and kidney damage. It is also very uncomfortable for patients and makes patients think about urinating often and fear having to go to the bathroom.

How do you diagnose a urethral stricture? What kind of evaluation will I need?

Usually patients present with suspicious urinary symptoms and difficulty urinating. The urologist might seen a slow urinary flow on a machine that tests or see a high residual urine in the bladder after urination. The gold standard for diagnosis is a cystoscopy where a small scope is used to look inside the urethra under local anesthesia. A retograde urethrogram is an x-ray study where contrast dye is placed in the urethra to mark out its borders and find the location and length of the stricture is also very helpful to evaluate the stricture.

What are the treatment option for a urethral stricture?

The treatment options for a urethral stricture include:

watching and closely monitoring the stricture called active surveillance
dilating or stretching the stricture
incising the stricture through a cystoscope called a urethrotomy
placing a metal stent in the stricture called a UroLume
surgical reconstruction of the urethra, also called urethroplasty

What is the best treatment for a urethral stricture?

For patients who have light, filmy, short strictures without a lot of scar tissue in the urethral sponge (called spongiofibrosis) active surveillance, urethral dilation or a endoscopic incision of the urethra may be an option.

For patients who have had a recurrent stricture or a dense or long stricture and who are in good health, a urethral reconstruction, also called a urethroplasty, is usually the best option, but only in the hands of a highly skilled surgeon.

What exactly is a urethroplasty?

A urethroplasty is an operation done in the hospital under anesthesia to reconstruct the urethra. It fixes the underlying problem of urethral strictures, the spongiofibrosis and,in most patients, permanently cures correct the stricture.

It usually does this in one of two ways. Either by:

excising, or removing a section of the urethra that contains the spongiofibrosis and the stricture, (called an end-to-end urethroplasty).
by bringing new tissue, such as a graft from the mouth, called a buccal mucosal graft, or a flap of skin to help reshape urethra. Typically, for long complex strictures a flap or graft is necessary; and for short strictures excision of the diseased segment is enough.

The surgery itself is complex and delicate, and requires a urologic surgeon with extensive experience in this for best outcomes. Patients typically stay in the hospital for 1 to 2 days and have a urinary catheter in for 2-3 weeks after the surgery. Post-operatively patients often experience dramatic and long-lasting improvement in their urinary symptoms.

This drawing shows a typical 'end-to-end' urethroplasty where the stricture and spongiofibrosis is cut out and the urethra is put back together.

Then why would you do a urethroplasty?

Because data has definitively shown that it provides the best long-term cure rates for patients with urethral strictures. In expert hands it is clearly the best option if you want your problem fixed permanently. It can be safely done and recovery tends to be relatively quick with minimal pain in the large majority of patients.

What if I have a stricture from radiation?

Radiation induced urethral strictures can be a very difficult problem to treat because of the potentially devastating effects of the radiation on your tissue around the urethra. Sometimes the strictures are accompanied by a fistula which is even more difficult to treat. There is no consensus among reconstructive urologists on how best to treat this issue. We have had good success using a combination of a buccal graft (from the mouth) and a muscle from the inner thigh, called a gracilis muscle flap, to correct this problem while preserving erectile function and urinary continence and minimum consequences to functionality.

Why do urethral strictures come back?

If you took a cross-section of the urethra it would look like a donut. The 'crumbly' filling of the donut is the urethral sponge and the inner hole of the donut is where urine is carried and where is where the stricture occurs. In the case of a urethral stricture the urethral sponge gets scarred in a process called spongiofibrosis. If a stricture recurs after treatment, it is usually because underlying spongiofibrosis or scar tissue prevents the stricture from healing properly by preventing healthy nutrients from reaching the lining of the urethra.

Why do other doctors recommend a urethral dilation or a endoscopic urethral incision (urethrotomy)?

Most urologists are not comfortable, experienced, or trained to do complex urethral reconstructive surgery and fall back on the easier, quicker option of dilation or incising the stricture. In addition, many urologists are simply not aware of the excellent results from urethroplasty.

What not do urethral dilations or urethrotomy first?

After one failed dilation or incision, there is nearly a 100% recurrence rate -- that means that almost all dilations after a stricture recurrence fail to last. Furthermore each dilation or incision will worsen the extent of spongiofibrosis which in turn makes the strictures when they do recur more dense, longer and decreases the cure rate of definitive surgery.

The following graph demonstrates the likelihood of success from a urethral dilation.

from The Journal of Urology: Volume 160(2) August 1998 pp 356-358

The data and other supporting data suggests that eventually most dilations fail for recurrent strictures.

What is the success rate of the UroLume for urethral strictures?

UroLume was popular about a decade ago and has fallen out of favor among many urologists who are knowledgeable about stricture disease. We do not think this is a good option in the large majority of patients. Only in patients who are too sick to undergo a definitive procedure and have a short life expectancy, is UroLume a good option. In large part this is because the failure rate is very high and when failure does occur a urethral recurrence can be difficult to treat and the UroLume is difficult to remove. A subsequent urethral reconstructive surgery to definitively fix the problem becomes more difficult if you have a UroLume in place. If your doctor advises you to get a UroLume, get a second opinion!

I have an urethral stricture, What should I do?

First, learn as much as you can about your options. Second, find a urologist who is expert and experienced in reconstructive surgery and urethral stricture disease. Be sure to ask the doctor if he is an expert; if not, ask him to recommend someone who is. A generalist urologist may not know about the best options for you; there is nothing to lose and much to gain by getting a second opinion.

Your best chance for a cure is the first time you get treated, but this often requires an operation under general anesthesia. If you are too unhealthy and do not want to undergo surgery, management with dilations would be ok, but if you want to cure your problem, surgery is usually necessary.

Is the New York City Urology experienced with strictures?

We have one of the world's busiest reconstructive practices specializing in both male and female reconstruction. We have combined experience of over 30 years successfully treating cases other urologists have given up on and have the rare combination of efficacy of cutting edge techniques with the reassurance of experience. We evaluate and treat not only those with straightforward 'run-of-the mill' strictures but also complex strictures such as those that occupy the entire length of the urethra, strictures caused by radiation and recurrent strictures after Urolume insertion, and even urethral strictures in women. We have pioneered techniques to deal with radiation strictures, female strictures and have also utilized state-of-the-art technology such as robotic surgery to revolutionize treatment of complex strictures. We often see patients referred by other urologists who come to us as a last resort and we offer the best chance of definitive cure for these difficult to treat patients. But remember, the best chance for cure is the first operation and New York City Urology may offer you your best chance to cure this problem.