A urethral stricture, or urethral narrowing, is a narrowing of the urethra (urethral passage) that can be congenital or acquired and is usually treated surgically. Predominantly men are affected by true urethral strictures.
What is a urethral stricture?
A congenital or acquired narrowing of the urethra is called a urethral stricture. In this context, urethral strictures caused by scarring narrowing must be differentiated from stenoses (constrictions) due to benign prostatic hyperplasia (enlarged prostate). Most commonly, strictures are localized in the prostatic, membranous, bulbar, or penile urethra and in the navicular fossa. Due to the stenosis of the urethra, complete emptying of the bladder is only possible to a limited extent. This leads to an increased susceptibility to urinary tract infections, which in pronounced courses can lead to a backflow of urine into the kidneys and thus to damage to the kidneys. A urethral stricture manifests itself symptomatically in the form of a weakened urine stream, which may be deformed like a watering can, twisted or divided, and an “after-drip” after micturition (urination). Similarly, pain during micturition, at the penis or vagina, and in the perineal area are characteristic of urethral strictures.
Causes
Urethral strictures can generally be differentiated between acquired and congenital stenoses. Congenital stenoses include malformations of the external genitalia such as hypospadias, in which the urethra is not protected by the erectile tissue. Acquired urethral strictures are mainly caused by injuries resulting from accidents (straddle trauma, pelvic fractures) or manipulations or surgical interventions on the urethra. In particular, endoscopic interventions via the urethra (anastomotic stenosis after radical surgery on the prostate, urinary bladder endoscopy) and long-term bladder catheters are risk factors for urethral stenosis. In addition, bacterial urethral infections (urethritis, gonorrhea), pathologic connective tissue changes (balanitis xerotica obliterans, lichen sclerosus), and tumors in the urethra and surrounding structures can cause urethral strictures.
Symptoms, complaints, and signs
A urethral stricture interferes with complete emptying of the bladder. Although there is a constant urge to urinate, the urinary stream is very weak. Sometimes the stream also splits or twists. There is often post urinary dribbling. Due to the backed-up urine, there is often pain when urinating. In addition, incomplete emptying of the bladder leaves residual urine in the bladder. This increases the risk of urinary tract infections. As a result, it is not uncommon for a bladder infection to develop, which aggravates the pain and burning sensation when urinating and at the same time leads to a nighttime urge to urinate. At times, the urine is red in color. Chronic overstretching of the bladder also damages the bladder muscles. In severe forms of urethral stricture, complete urinary retention may occur. The bladder fills up and can no longer be emptied. There is only an involuntary dribbling, which is caused by a so-called overflow. The overfull bladder causes severe and unbearable pain. It is a medical emergency that must be treated immediately. Prolonged retention of urine can lead to kidney failure, and in men, prostatitis or inflammation of the epididymis can also develop. A serious complication is the expansion of a urinary tract infection to a life-threatening urosepsis (blood poisoning), which often manifests itself with states of confusion, fever and eventually even circulatory shock.
Diagnosis and course
A urethral stricture is diagnosed on the basis of characteristic symptoms in the course of the patient’s medical history. The diagnosis is confirmed by measuring the flow and pressure of urine during micturition. Microhematuria (blood in the urine), which can be detected microscopically or with the help of the Sangur test, also indicates a urethral stricture. Sonography can also be used to determine possible residual urine after micturition, changes in the bladder, urethra and kidneys, and bladder wall thickness. An X-ray with contrast medium (retrograde urethrography) can localize the stricture and determine its extent.Any ambiguities can be finally resolved by endoscopy of the urethra (urethroscopy). In general, urethral stricture has a good prognosis. To avoid long-term complications such as kidney damage or complete urinary retention, the stricture should be diagnosed and treated early.
Complications
In most cases, urethral stricture occurs almost exclusively in men. Due to the narrowing of the urethra, various symptoms may occur. The urinary stream is weakened by the disease and urination is thus only possible to a limited extent, so that the affected person usually has to visit the toilet more often. It is not uncommon for urethral stricture to lead to cystitis. This is associated with severe and stabbing pain and extremely restricts the patient’s quality of life. Likewise, there is pain and other discomfort during urination. This is usually associated with a strong burning sensation. Due to the pain during urination, most patients also experience psychological discomfort and irritability. Less fluid is intentionally accepted in order to avoid this pain. As a result, dehydration may develop. Treatment of urethral stricture is performed by surgical intervention and does not cause any particular discomfort or complications. After the surgery, there is also no discomfort and the pain subsides. A possible tumor can also be removed without complications. Life expectancy is not affected or decreased by urethral stricture.
When should you see a doctor?
Urethral stricture does not heal itself, so the condition must always be treated by a doctor. It can be combated only by surgical intervention. Since urethral stricture is usually congenital, the symptoms appear at a very young age. Those affected suffer from a very weak urinary stream. Urine continues to remain in the bladder, so that those affected have to visit the toilet relatively frequently. In the case of these complaints, an examination should be carried out. Furthermore, frequent inflammations of the bladder also indicate a urethral stricture. These are accompanied by pain or a burning sensation when urinating. If a urethral stricture is suspected, a urologist should be consulted. This doctor can usually perform the treatment, which does not lead to any particular complications. The symptoms will be completely relieved. Since especially men are very often affected by this disease, they should see a doctor when the symptoms appear.
Treatment and therapy
As a rule, urethral stricture is treated surgically. In principle, two surgical procedures are available for this purpose, the choice of which depends on the type and extent of the stenosis and the general health of the affected person. In the so-called urethrotomy (urethral slit), a urethrotome is inserted into the urethra either blindly (urethrotomy according to Otis) or under visual control (urethrotomy according to Sachse) and the urethra is slit through an incision in the area of the stricture. Subsequently, to avoid complications (especially with a urethrotomy according to Sachse), a bladder catheter is placed and left in place for several days. To reduce the risk of recurrence, a gel containing cortisone can be injected into the affected urethra through this catheter. If the surgical method does not lead to the desired success, if recurrences occur repeatedly or if there are protracted strictures, oral mucoplasty is usually indicated. In this oral mucoplasty, the urethra is opened over the stricture and a piece of oral mucosa (from the lower lip or cheek) of corresponding size and length is sutured in. A bladder catheter is then placed for about eight days to splint and keep the urethra open, and an abdominal catheter is placed for bladder emptying. If urethrography can demonstrate problem-free and complete bladder emptying, the abdominal wall catheter is removed (after about three weeks). In the case of strictures up to two centimeters in length, the narrowed section can be surgically removed and the ends of the urethra sutured. If the stricture is due to a tumor, the therapeutic measures for urethral stricture depend on the tumor treatment.
Outlook and prognosis
The prospect of cure depends largely on the time of diagnosis.In principle, the earlier a urethral structure is treated, the more favorable the outcome. In addition, the degree of narrowing also plays a role in the chances of success. The lower it is, the more likely a symptom-free life can be achieved. Statistically speaking, bulbar cock tube stricture has the best prognosis, with a cure rate of 50 percent. The problem is that in many cases the stricture recurs. Even then, patients and physicians must act quickly. However, with recurrent interventions after the initial treatment, the chance of healing decreases. In the long run, quality of life suffers. Urinary retention attacks the kidneys. Complete loss of kidney function may occur after years. Sometimes renewed interventions have a negative effect on everyday life. Individuals urinate significantly reduced amounts and complain frequently of burning and inflammation. Overall, a differentiated picture emerges: If the initial intervention takes place at an early stage, patients usually remain symptom-free for the rest of their lives. Other patients, however, have to be treated again. The chances of complete recovery can be rated as mixed.
Prevention
Urethral stricture can be prevented by avoiding triggering factors. For example, infections of the urethra should be treated early and consistently or prevented by appropriate protective measures (gonorrhea) to avoid urethral strictures.
Follow-up
In most cases of urethral stricture, the measures of aftercare are severely limited. Here, the affected person is primarily dependent on a quick diagnosis with the subsequent treatment, so that complications or other complaints do not arise. The earlier the disease is detected and treated, the better the further course of the disease usually is. Since urethral stricture cannot heal itself, the patient should consult a doctor at the first symptoms and complaints of urethral stricture. In most cases, this disease is treated by a minor surgical intervention. In any case, the patient should rest and take care of his body after such an operation. Efforts or stressful activities should also be avoided in order not to put unnecessary strain on the body. The disease does not reduce the life expectancy of the affected person, if it is recognized and treated in time. Since urethral stricture can also cause psychological upsets or depression, support and care from one’s family or friends is very important. However, in case of serious psychological upsets, a doctor should always be consulted.
What you can do yourself
If a urethral stricture has been diagnosed, those affected can take some measures themselves to alleviate the discomfort and promote the healing process. First, it is important to cure any accompanying symptoms such as cystitis or urinary retention. This applies by keeping warm in bed and wearing sufficiently warm clothing. A healthy and balanced diet can contribute to recovery. If the symptoms are severe, the individual symptoms should be clarified by a doctor and, if necessary, treated with medication. After surgery on the urethra, rest and bed rest apply. Patients should take a sick leave for at least one week and refrain from strenuous physical activities during this time. In addition, the surgical wound must be cared for according to the doctor’s instructions so that no wound healing disorders occur or scars remain. If any discomfort reappears after the treatment, it is best to talk to the doctor in charge. It is possible that another operation will have to be performed or that the urethral stricture is due to a serious cause that has not yet been identified. Lastly, it is important to avoid another urethral stricture. This can be achieved by treating urethral infections early and consistently. Ideally, infections are prevented by appropriate protective measures.
