What is urethral stricture?
The urethra is the “pipe” that carries urine from the bladder to the outside of the body through the penis. Throughout its entire journey, the urethra can narrow (stenosis or stricture) and creates a blockage in the normal passage of urine. This clinically translates into difficulty urinating, weak stream, pain, persistent dribbling when finishing urinating, infections or simply discomfort when passing urine.
If this situation of obstruction to the passage of urine continues over time, chronically, the urine can return to the bladder again, then to the ureters (the tubes that carry urine from the kidneys to the bladder) and finally to the kidneys. This situation facilitates infections and can cause chronic damage to the bladder and kidneys. Each stenosis is different and so is each patient; Therefore, it is important to correctly diagnose stenosis and know how to properly assess the risks in each individual patient.
¿Which are the causes of urethral stricture?
It is really not clear at all what exactly causes the narrowing (stricture) of the urethra. It is known that the underlying cause of this narrowing is a fibrosis process known as “spongiofibrosis,” so called because what becomes fibrous is the tissue that surrounds the urethra, known as “spongy tissue.” Although the molecular processes that trigger this spongiofibrosis are not known, what is known is that certain situations facilitate this process and are associated with the development of urethral strictures.
Some of the situations or factors that increase the risk of developing a urethral stricture are:
- Procedures in which an endoscopic instrument is used through the urethra.
- Bladder catheterization.
- Repeated sexually transmitted infections (STDs) or urethritis (infections in the urethra).
- Lichen sclerosus (a skin condition that, when it affects the glans or penis, can also narrow the urethra).
- Trauma to the pelvic and perineal area.
- Stenosis that occurs at birth (congenital) is very rare
Even so, the most common cause is IDIOPATHIC (unknown) and the majority of patients will not associate their stenosis with any of these causes.
Our research group at the Virgen de las Nieves University Hospital actively participates in research on the causes of urethral stricture and carries out various studies to clarify the mechanisms that trigger this problem. We recently published results about this topic in the prestigious Journal of Urology. *(https://pubmed.ncbi.nlm.nih.gov/35913438/)
¿ Which are the symptoms of urethral stricture?
The most frequent:
- Very slow urine flow or doing it like a sprinkler.
- Pain or difficulty urinating.
- Strong urge to urinate and urination very frequently.
Less common:
- Discharge through urethra.
- Dark or bloody urine
- Loss of control of urine, with leaks or dripping.
- Urgency with inability to hold back the urge to urinate.
- Pain in the lower abdomen.
- Feeling of inability to empty the bladder.
¿How do I diagnose urethral stricture?
If there is a suspicion of a urethral stricture, a series of tests should be requested to assess the size, location and risks entailed by the presence of the stricture.
These tests include:
– USS-PROMS validated questionnaire: t is the initial test to assess the symptoms of stenosis. This is a series of questions to objectively assess the intensity of the most common symptoms of urethral stricture. Our research group carried out a study to validate the Spanish version of this questionnaire (https://pubmed.ncbi.nlm.nih.gov/26877070/).
You can access the pdf version of the questionnaire from this link (pdf USS-PROMS).
– Uroflowmetry: it is a simple test. It consists of urinating normally into a container that has a built-in urinary flow meter. The result is a curve with some parameters (Qmax, Qmed, flow time, shape of the curve). The most used is Qmax (maximum flow). It is useful to rule out other causes of weak stream or urination difficulty such as prostate hyperplasia.
– Ultrasound: It is a simple examination that is performed in the consultation. It allows us to assess the characteristics of the bladder and the possible involvement of the kidneys. It also allows us to observe whether the patient is able to completely empty the bladder or not (post-micturition residue).
– VCUG (serial voiding cystourethrography): This is a radiological examination in which contrast is introduced through a thin probe through the urethra. The idea is to observe how said contrast behaves inside the urethra and see if it gets “stuck” in some “narrow” point. X-rays are taken while the contrast is being introduced and then the patient is asked to “urinate” the contrast to see if it gets stuck again at any point. It serves to assess the size and location of the stenosis and also allows assessing the presence of vesicoureteral reflux towards the kidneys
(These images show, marked in blue, the appearance of two different types of stenosis in a VCUG)
These images show, marked in blue, the appearance of two different types of stenosis in a VCUG.
– Urethroscopy: It consists of the introduction of an endoscopic camera through the urethra. We usually perform it in the consultation itself with a single-use, disposable device. It is very useful to establish with absolute certainty the presence or absence of the stenosis and assess its caliber. It also allows the prostate and bladder to be assessed. It is performed with a local anesthetic gel, which is introduced through the urethra, and is an examination that is generally very well tolerated. With all these tests, we can establish a correct diagnosis of the stenosis and begin to choose, together with the patient, the most optimal treatment to solve it.
¿How do I treat urethral stricture?
There are a wide variety of therapeutic options to solve urethral stricture. It’s important to know:
- There is no medical treatment (oral) that can solve the stenosis)
- The solution to stenosis involves surgery and, roughly speaking, it can be done in two ways:
- Endoscopically (internal urethrotomy or dilation balloon Optilume)
- Open surgery (urethroplasty)
¿What is an internal urethrotomy?
It is a relatively simple endoscopic surgical procedure. In the operating room and under anesthesia, an instrument with a camera is introduced and cuts are made in the narrow urethral segment to “widen” or expand its caliber. After this, a urinary catheter is left in place for 3 days. The patient is normally discharged within 24 hours. These cuts in the stricture can be made with a cold knife or with a laser. Although it initially seemed that the laser would change clinical practice in this scenario, the truth is that neither of the two forms (knife or laser) have proven to be better than the other. That is why there is no clear recommendation in this regard. Although it is a simple technique with few complications, the long-term success rate is low and its indication is increasingly limited. It is mainly used in very short and flexible strictures as initial treatment.
* REMEMBER: Urethral stricture is a rare problem. Its treatment must be carried out by an experienced expert capable of facing all possible scenarios during surgery. Choosing the best treatment for a urethral stricture must be made taking into account ALL the circumstances of the stricture and the patient. It should be a process guided by your urologist’s recommendations and decided by consensus between both (urologist and patient).
¿What is dilation balloon Optilume®?
It is a relatively simple endoscopic procedure. In the operating room and under anesthesia, an instrument with a camera is introduced and we use a ballon to widen the stricture. This ballon is covered with a substance (placlitaxel) which reduces the chance of stricture recurrence.
*REMEMBER: Urethral stricture is a rare problem. Its treatment must be carried out by an experienced expert capable of facing all possible scenarios during surgery. Choosing the best treatment for a urethral stricture must be made taking into account ALL the circumstances of the stricture and the patient. It should be a process guided by your urologist’s recommendations and decided by consensus between both (urologist and patient).
¿What is an urethroplasty?
Urethroplasty is the name given to a surgery that is performed on the urethra and that tries to solve a problem in it. There are countless urethroplasty techniques, but they all have in common the objective of trying to correct the stricture and return a normal caliber to the urethra. On this page we will explain the most common urethroplasty techniques and what you can expect from them.
* REMEMBER: Urethral stricture is a rare problem. Its treatment must be carried out by an experienced expert capable of facing all possible scenarios during surgery. Choosing the best treatment for a urethral stricture must be made taking into account ALL the circumstances of the stricture and the patient. It should be a process guided by your urologist’s recommendations and decided by consensus between both (urologist and patient).
