In men, the urethra is a tube that carries urine from the bladder, and semen from the ejaculatory ducts, out of the body. From the bladder, it goes through the prostate, the external sphincter (the muscle that helps you remain continent), the perineum (the area between scrotum and anus) and the penis

A urethral stricture is a narrowing caused by scarring of the inner layer of the urethra and the surrounding corpus spongiosum. Strictures can range from less than 1cm long to those that extend the entire length of the urethra. They can occur at any point along the urethra but are most often seen in the bulbar region (region behind the scrotum).

The most likely cause depends on the site of the stricture. Broadly, the commonest reasons are:

• Idiopathic- cause unknown

• Inflammatory- caused by the infection or inflammation in the urethra, e.g. sexually transmitted infections (STIs) e.g. gonorrhoea, chronic inflammation e.g. lichen sclerosis (LS) also known as balanitis xerotica obliterans (BXO)

• Traumatic- caused by injury to the urethra, e.g. a fall astride the cross-bar of a bicycle and other crushing pelvic trauma

• Iatrogenic- caused by medical intervention, e.g. repeated urological procedures that involve the passage of instruments along the urethra, urethral catheterization, radiotherapy, or surgery to adjacent organs

• Congenital- Inherited conditions e.g. hypospadias (or as a result of previous surgery to correct hypospadias)

With minor strictures, you may not have any symptoms. With tighter strictures, you may experience one or more of the following:

• Poor urinary flow and need to strain to pass urine

• Spraying or splitting of the urinary stream

• Dribbling of urine after urination

• Needing to pass urine often (urinary frequency)

• Urinary tract infections

• Reduced force of ejaculation and low ejaculate volume

• Pain on passing urine

A stricture can act like a “bottleneck” which prevents complete bladder emptying. This can cause you to retain urine in your bladder after you pass urine, which can result in bladder, prostate, or kidney infections, and lead to the formation of stones. All these conditions can cause long-term bladder damage and kidney failure.

• Stricture may be suspected if you have a reduced urinary flow rate or your bladder does not empty completely on an ultrasound scan after you have passed urine.

• Stricture may be diagnosed by:

• RGU-MCU (urethrogram) – an X ray performed using contrast medium (dye) put into your urethra to show the anatomy

• Failure to pass catheter or telescope- during investigation of urinary symptoms, especially when the stricture is close to the bladder

• Ultrasound scan

• MRI scan

A urethrogram is an X ray that shows the anatomy of the urethra (done after the urine culture report has been obtained as sterile). We place a very fine catheter inside the tip of the penis and use it to inject a dye that shows up on X ray. This procedure is done under intravenous antibiotic coverage.

Under local anaesthesia, we pass a plastic or metal dilator into your urethra to stretch the narrow area. Afterward, we may teach you to pass a similar dilator or “slippery” catheter into your urethra (intermittent self dilatation). There is a relatively high risk that the stricture will return using this method, so your urologist may need to repeat the dilatation from time to time.

Many types of treatment are available, ranging from conservative or minimally invasive procedures, right through to complex reconstructive operations.

The type of treatment we recommend depends on several factors:

• Your preference as the patient
• The site and length of your stricture
• The cause of your stricture
• Any previous treatments you have received for your stricture
• Your general health

Under anaesthesia, we pass a telescope through the urethra to cut the stricture. This opens but does not remove the scar tissue causing the narrowing. You will usually need a catheter for atleast 3 days after the procedure. You will be asked to return later, as an outpatient, to have the catheter removed.

If you are having an optical urethrotomy for the first time, there is almost 19% risk of stricture recurrence, so it may need to be repeated. If your stricture has recurred after a previous urethrotomy, the risk of further recurrence is higher.

Urethroplasty has a much higher success rate in curing symptoms and preventing the stricture from returning than most other forms of treatment. It requires a longer anaesthesia time; it is a complex open surgery. The type of procedure needed can vary a lot depeneding on the site, length and the tightness of the stricture but, in general terms, the following approaches are most commonly used.

Anastomotic Urethroplasty- If your stricture is short, we cut out the narrowed area and join the heathy ends together again

Augmentation buccal mucosa graft urethroplasty- If your stricture is longer, we cut open the narrowed area and use a piece of your cheek lining (buccal mucosa) as a graft to widen the stricture.

Augmented anastomotic buccal mucosa graft urethroplasty- For long, tight strictures, we cut out the diseased area, join the health ends together, and use a buccal mucosal graft as well to widen the urethra.

These procedures need an incision in your perineum (between your anus and scrotum), 2-3 days hospital stay, a catheter in your bladder for 2-3 weeks. Generally, absorbable sutures are used, which do not require removal.

This involves two operations several months apart and is most often used for strictures of the penile urethra. In the first stage, we make a cut on the under-surface of your penis, open the urethra and remove all diseased tissue. We use a piece of buccal mucosa (cheek mucosa) as a graft and fix it in, leaving the graft itself exposed. After this, your new urethral meatus (external opening) will be further back on the underside of your penis than it was before the procedure. We perform the second stage several months later, once the graft has picked up a new blood supply. We roll the graft into a tube to reconstruct the urethra, and put a catheter into the bladder for two to three weeks.

If you have multiple medical problems or you wish to avoid complex treatment, we may recommend putting in a long-term catheter. This can be put into your bladder through the abdomen wall above the pubic bone (a supra-pubic catheter). Catheters can cause irritation of the bladder, urinary infections, and bladder stones. Long term catheters need to be changed every 6-10 weeks.

This is a procedure to “short circuit” the diseased urethra by bringing it out to the skin surface in the perineum (between the back of the scrotum and the anus). It is less complex than urethroplasty and may be considered if you have extensive stricture disease where reconstructive surgery might not be technically possible, or if you wish to avoid further surgery. After this, you will need to sit down to pass urine. You will also ejaculate through this opening (not through your penis).

Most of the patients have a good outcome after treatment for a urethral stricture. You may not need any further treatments in the future.

In some cases, you may need a few sessions of urethral dilatation in the immediate post-operative year.

It is not always possible to prevent urethral stricture. Since STDs are one cause, using protection during sexual contact can prevent some cases. However, injuries and other medical conditions associated with urethral stricture can’t always be avoided. It’s important to see a doctor right away if you are experiencing symptoms of urethral stricture. Treating the problem quickly is the best way to avoid serious complications.