Urethral stricture

The male urethra, a complex and segmented structure, is divided into two main sections: the anterior urethra and the posterior urethra. These segments differ in their anatomy, vascularization, and susceptibility to injury.

The posterior urethra comprises the prostatic urethra (passing through the prostate) and the membranous urethra (passing through the pelvic floor). The anterior urethra, also known as the spongy urethra, is surrounded by the spongy body of the penis. It is subdivided into two parts: the bulbar urethra, located between the membranous urethra and the penoscrotal angle, and the penile urethra, which extends to the urethral meatus.

This structure directly influences the location of strictures and how they occur. Thus, posterior strictures are often secondary to pelvic trauma, while anterior strictures most often occur as a result of inflammation or medical instrumentation.

The clinical signs of urethral stricture vary and depend on the severity of the narrowing, its location, and its progression. The most common symptom is a weak urine stream, often accompanied by prolonged urination, a feeling of incomplete bladder emptying, or a frequent urge to urinate.

Other symptoms include a “watering can” or bifid urinary stream, hematuria (blood in the urine), pain during urination (dysuria), or recurrent urinary tract infections. In some cases, acute urinary retention is a sudden symptom that requires emergency treatment. Stenosis can also cause perineal or pelvic pain and, eventually, impaired sexual function, particularly through a decrease in ejaculatory flow.

In some patients, symptoms may be absent or very subtle, especially in cases of gradual adaptation of the detrusor muscle, making diagnosis more difficult.

Urethral stricture results from a process of scar tissue formation that leads to narrowing of the canal. This fibrosis phenomenon can be caused by various mechanisms.
Trauma, whether iatrogenic or accidental, is among the most common causes. Medical procedures involving the introduction of instruments into the urethra—such as endoscopies and transurethral surgeries—are largely implicated. This type of injury is referred to as iatrogenic stricture. In a significant proportion of cases, the origin of the stricture remains idiopathic, i.e., without a clearly identifiable cause.
Direct trauma, such as perineal impact or pelvic fracture, can also induce urethral fibrosis, particularly in the bulbar or posterior urethra.
Sexually transmitted infections, although less common today in developed countries, continue to play an important pathogenic role, as do certain chronic inflammatory skin conditions such as lichen sclerosus, which is responsible for meatal or penile stenosis.

Certain medical histories or procedures significantly increase the risk of urethral stricture. The primary risk factor is male gender, as the anatomical length of the male urethra makes it more vulnerable to trauma and instrumental procedures.
The use of urinary catheters, especially over long periods or repeatedly, is another well-documented risk factor. The same applies to surgical procedures involving the prostate, bladder, or urethra.
In addition, patients who have suffered a pelvic fracture, perineal injury, or pelvic radiation for cancer have a significantly higher incidence of urethral strictures. Finally, inflammatory skin diseases, such as lichen sclerosus, are responsible for chronic strictures that are sometimes extensive and difficult to treat

The diagnosis of urethral stricture is based on a rigorous clinical approach, supplemented by targeted tests. The doctor begins by taking a detailed medical history, looking for symptoms of urinary obstruction (weak stream, two-stage urination, dysuria), a history of trauma, or previous urological procedures. A physical examination can help to check for any hard or painful areas along the urethra.
Several additional tests may then be recommended:

These tests allow the doctor to determine the location, size, and severity of the stricture in order to recommend the most appropriate treatment.

The treatment of urethral stricture depends on several factors: the severity of symptoms, the length of the narrowing, and its location. There is no single treatment: each case is assessed individually by a urologist.

In mild cases, or when the stricture is short, the doctor may first suggest a minimally invasive treatment, such as dilation. This involves gently widening the urethra with special probes, which are inserted gradually. This procedure is often performed under local anesthesia. 

Another common treatment is internal urethrotomy, an endoscopic procedure in which a small camera is inserted into the urethra, allowing the surgeon to cut the narrowed area with a very fine blade. It is a quick procedure, but as with dilation, the risk of recurrence is high, affecting around 1 in 2 patients. 

A third, minimally invasive treatment has recently emerged, with a reported success rate of 58% at 5 years. This is Optilume® paclitaxel-coated balloon urethral dilation, which works by mechanically dilating the narrowed urethra while delivering a locally applied antiproliferative drug that prevents recurrence by inhibiting the formation of scar tissue.

For complex, longer, or recurrent strictures after initial dilation or internal urethrotomy, a surgical procedure called urethroplasty is recommended. This involves removing the narrowed segment and reconstructing the urethra, sometimes using a graft taken from the foreskin or inside the mouth (buccal mucosa). This treatment is more invasive, but offers the best long-term results with a success rate of over 85% in the hands of surgeons experienced in this field.

In much rarer cases, if no intervention is possible or desired, iterative self-calibration or an indwelling catheter may be offered to keep the urethra open. These solutions are reserved for very specific situations. Furthermore, urethral stents are no longer recommended for the treatment of urethral strictures.

If left untreated, urethral stricture can progress and cause complications. As urine can no longer flow properly, pressure builds up in the bladder, which can lead to acute urinary retention. This is a medical emergency: the person can no longer urinate, which can damage the kidneys and often requires the rapid insertion of a suprapubic catheter.
In the longer term, chronic obstruction can lead to recurrent urinary tract infections, pelvic pain, and even urinary stones. Severe or recurrent stricture can also cause sexual dysfunction, such as a decrease in semen flow.
In addition, repeated dilations or partial endoscopic treatments can make the stricture more difficult to treat later on, increasing its length or complexity. For this reason, after an initial failure of treatment with dilation or internal urethrotomy, reconstructive surgery should be recommended immediately

The appearance of abnormal urinary symptoms justifies a medical consultation. A gradual decrease in urinary flow, a feeling of incomplete emptying, blood in the urine, persistent dysuria, or episodes of urinary tract infection should be cause for concern.

People who have previously had urethral stricture should also consult a doctor at the first signs of recurrence, even if they are mild. Regular follow-up with a urologist is recommended after any conservative or surgical treatment.

Hôpital de La Tour offers personalized care for patients suffering from urethral stricture. Thanks to the expertise of Dr. Fenner Vanessa, an FMH-certified urologist specializing in reconstructive urology for men and women, the hospital offers advanced therapeutic solutions including Optilume® balloon dilation and urethroplasty, tailored to the nature and complexity of each case. Dr. Fenner has been recognized for many years as a reference in the surgical field in Switzerland, with an annual volume of complex urethral reconstructive surgery that is among the highest in the country