The urethra is the water pipe that carries urine from the bladder, out of the body. In men, it runs from the bladder, through the prostate, through the perineum (the area between the scrotum and anus), through the bulbar urethra, and then through the penis to the tip (external urethral meatus).
Urethral stricture disease is a narrowing of the urethra (water pipe) that mostly affects men and usually occurs near the bladder end of the urethra (bulbar urethral stricture disease), but it can also affect the urethra within the penis (penile urethral stricture disease) or the tip (meatal stenosis).
Normally urine is carried freely from the bladder when you want to pass urine. If there is a narrowing or stricture, this affects a man’s ability to urinate. Urologist Nikesh Thiruchelvam tells us what causes urethral strictures and what can be done to treat it.
What causes urethral stricture?
The main causes for bulbar urethral stricture disease (near bladder) are:
- Medical examination or treatment (Iatrogenic); such as during urological procedures that involve passing instruments along the urethra, like urethral catheterisation. This makes up 35% of cases.
- 10% of cases are caused by chronic inflammation due to sexually transmitted diseases such as gonorrhoea or from a condition called lichen sclerosis.
- 15% of cases are caused by trauma. Injury to the urethra can occur from simply falling onto the cross-bar of a bicycle.
- 40% of cases are idiopathic, which means that the cause is unknown.
The main causes of penile urethral stricture disease fall into the same categories but with different prevalence rates.
- 40% are iatrogenic, caused by medical intervention
- 40% are caused due to inflammation
- 5% of cases are caused due to trauma
- 15% have no known cause
This area of the water pipe may also be affected by congenital conditions such as hypospadias or as a result of previous surgery to correct hypospadias, whereby the opening at the tip of the penis is in an unusual location, usually somewhere along the underside of the penis.
What are the symptoms of urethral stricture disease?
Most men experience the following:
- A change in the waterworks such as poor flow, spraying or dribbling when passing urine
- The need the urinate more frequently
- The urgent need to urinate
- Discomfort on passing urine
- Urinary tract infections
- Blood in the urine or semen
- Reduced ejaculation force and volume
If left untreated, urethral strictures can cause risks of urinary retention (inability to pass urine), urinary tract infections and bladder failure.
How is urethral stricture diagnosed?
A stricture may be diagnosed in a number of different ways.
- Upon physical examination.
- Failure to pass a telescope or catheter up the urethra.
- With a flow rate test, where urine is passed into a machine that measures the speed and volume of the urine.
- Using a urethrogram- an X-ray that uses a contrast medium (dye) to view the urethra.
- With an ultrasound scan of the urethra.
How is urethral stricture treated?
There are a number of treatment options.
If you don’t have many symptoms and you are prepared to undertake the risks of not treating the stricture, observation is a possibility. Further options involve surgery. The type of surgery depends on patient preference, the site and length of the stricture, the cause of the stricture and any previous treatment received.
Under anaesthetic, the stricture can be cut open (optical urethrotomy) or dilated ( urethral dilatation) using special instruments. Usually, a catheter needs to be used for a few days after the procedure to help with urination. Some men are taught to self-dilate the urethra after the procedure. These procedures have a high chance of the stricture recurring.
The only curative option is a urethroplasty. The type of urethroplasty used depends on the length and site of the stricture.
For bulbar strictures:
- An anastomotic bulbar urethroplasty can be used. The narrowed area of the water pipe is cut out and the healthy ends of the water pipe are re-joined.
- An augmentation buccal mucosa graft urethroplasty can be done if the stricture is longer. A narrowed area is cut open and a piece of cheek lining is used to make a free graft. Tissue taken from the cheek will develop a new blood supply when placed into the affected area of the urethra, helping it to widen.
These procedures all need an incision into the perineum (between the anus and scrotum). Usually, an overnight stay in hospital and a urethral catheter in your bladder for 2 or 3 weeks is required.
To treat penile or meatal strictures:
A two-stage penile urethroplasty is carried out. A cut is made on the under-surface of the penis, the urethra is opened and the diseased tissue is removed. Cheek lining is used as a graft and fixed in place with stitches. The skin of the penis is stitched back to the edges of the graft, leaving the graft exposed. The patient will then have a new opening for their water pipe. An overnight hospital stay is required and a catheter will be needed for 3 weeks. Three months later, once the graft has picked up a new blood supply, the urethra is reconstructed and the skin of the penis closed over it.
Alternatively, for both bulbar and penile urethral stricture disease, one option is a perineal urethrostomy. In this operation, a small hole is created in the surface of the skin in the perineum (between the scrotum and anus) where the urethra empties out into, allowing urine to drain through his opening. Ejaculation will also happen through this opening rather than through the tip of the penis. Other long-term options include a long-term urethral catheter or suprapubic catheter (especially if you have multiple medical problems). Catheters can be convenient but can also cause urinary tract infections, bladder spasms and bladder stone formation and need to be changed every 3 months.