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Urethral Stricture

What is a urethral stricture?

A urethral stricture is a scar tissue that blocks the urethra. The urethra is the tube that drains from the bladder and allows you to pee (urinate). In men, the urethra passes through the center of the prostate and then down between the legs, through the scrotum and then out to the penis. In women, the urethra exits between the labia, between the vagina and the clitoris. A stricture can occur anywhere along the length of the urethra tube.

What does it feel like to have a urethral stricture?

A urethral stricture can cause slowing of the urinary stream such that it takes longer to empty the bladder prolonged urination. Most people can empty their bladder in 30 seconds. If you have a stricture, it can take more than a minute to empty the bladder. Other symptoms include frequent urination or having an urge to urinate right away – probably from not emptying the bladder very well during the previous urination.

How common is a urethral stricture?

Strictures occur in about 1% of all men. 99% of all strictures occur in men and 1% in women. This is likely because the female urethra is shorter and is protected inside the body.

What causes a urethral stricture?

Many strictures are caused by some injury to the urethra. This injury could be an accident, like a straddle injury which is where a man is hit between the legs, or it could be an internal injury like from a catheter. Prior surgery or radiation, sometimes for prostate cancer, can also cause strictures. Other strictures are caused by an autoimmune inflammatory disease called lichen sclerosus. Sometimes, we never find out what caused the stricture.

How do I find out if I have a urethral stricture?

If you have some of the symptoms listed above, then you should see your primary care provider or a urologist. They may check your urine for infection or may measure how fast you can pee and how well you empty your bladder. Once they rule out the more common causes of your symptoms, they may recommend evaluation for a stricture. A stricture is usually diagnosed by a cystoscopy (camera exam of the urethra). In this procedure a flexible camera about the size of a catheter is passed through the urethra in a urologist’s office; this takes only a minute or two. Once a stricture is detected then the next step is to measure how long and tight it is. A cystoscopy is not great for measuring length and diameter, so a urethrogram is done. A urethrogram is x-ray test that involves squirting an x-ray dye through the urethra and taking several images.

What are the treatments for urethral stricture?

Dilation: A wire is passed through the stricture using a camera and then either a balloon or a series of metal dilators are used to stretch the urethra to normal size. Scar tissue is brittle, so it doesn’t really stretch; instead, it develops cracks (or fissures). The hope is that healthy urethra tissue will grow in to fill these cracks. Short strictures that have not been treated before have a good chance of responding well to dilation – >50% of these men will still have an open urethra a year or two later. But men with strictures longer than 2cm (about 1 inch) or men who have a stricture that has recurred after prior treatments, have a low success rate with dilation.

Urethrotomy: A scope (camera) with a small knife (about the size of a Q-tip) on the end of it is used to make a few cuts in the scar tissue. Like with dilation, the hope is that these cuts will fill in with normal urethral tissue as the site heals. Success rates are similar to dilation.

Self-Dilation: One way to deal with the stricture without further surgery is to perform self-dilation at home. Once every other day, a person passes a catheter or inflatable balloon across the stricture to keep it open. By repeating this procedure frequently, you are encouraging the stricture to stay open, rather than re-dilating it from scratch every time. Therefore, this procedure is not as painful as you might imagine. Still, self-dilation isn’t for everybody. For those not interested in self-dilation, there are more invasive alternatives (see below).

Drug-coated balloon. The Optilume drug-coated balloon is a new option. The procedure is performed just like a regular balloon dilation but is more successful. The balloon is coated with paclitaxel which is a chemotherapy drug that fights scar tissue reformation. Just a like a regular dilation, it creates cracks in the scar; the paclitaxel dissolves into the tissue in these cracks. The concept is that by delaying scar tissue formation, it allows more time for normal urethral tissue to grow instead. Dr. Elliott was the lead investigator for the study that led to the FDA approval of this device and is an expert on its use. In that study, 127 men were randomized to receive either the Optilume or a plain balloon or urethrotomy.

 

Success rates at 1 year were 75% in the Optilume group compared to 27% in the control group. With those kinds of success rates, you might ask, “Why not do Optilume in everyone?” The answer is that it is only FDA-approved in certain situations. Also, for a few weeks after the procedure, Optilume results in more burning with urination and more blood in the urine than a plain balloon.

Urethroplasty. This is a plastic surgical reconstruction of the urethra, a procedure in which Dr. Elliott is an expert. There are many different ways to perform a urethroplasty, depending on the length and location of the stricture. But, essentially, through an incision about 4 inches long, a new urethral tube is constructed. If the stricture is short then we remove the stricture and sew the two healthy ends of the urethra together again. If the stricture is longer than 2 cm (about 1 inch) then we cannot remove the stricture and, instead, open the stricture and add to the circumference of the urethra in that area using a tissue graft from the inside of the cheek. The cheek tissue is very similar to the urethral tissue, so it performs very well. Success rates of urethroplasty are about 90%.

Surgery for urethral stricture

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