Urethral Strictures

Background

Urethral strictures are scars that obstruct urine flow resulting in difficulty with urination.  They can also cause urinary tract infections, painful ejaculation, acute urinary retention, hematuria and problems with urinary control.

 

Causes

Causes of urethral stricture include trauma, infections, surgery, radiation or catheterization although the exact cause may not always be apparent in all cases.  In some cases, a skin condition known as Lichen Sclerosis (LS) - also known as Balanitis Xerotica Obliterans (BXO) - can cause severe scarring of the urethral opening and may cause progressive scarring through the penile and bulbar urethra.

 

Diagnosis & Evaulation

The testing required to fully evaluate and treat urethral strictures includes an x-ray of the urethra (called a urethrogram) and looking inside the urethra with a small scope (cystoscopy).  Both are done as relatively quick outpatient procedures in the hospital.  The urethrogram is usually performed by a radiologist in the x-ray department.  In some cases, the urethrogram is done by your urologist.  Cystoscopy is performed by a urologist in the endoscopy or ambulatory care unit.

 

Treatment

There are several treatment options for urethral strictures.  They fall into 2 broad categories: endoscopic procedures and urethral reconstructive surgery.

Endoscopic (through a scope in the urethra) options include dilation, urethrotomy and stenting.  In addition to these procedures, some patients may benefit from passing a catheter through the urethra intermittently to keep there stricture from contracting.  Although the endoscopic options are relatively quick and non-invasive, they are almost never curative.  Furthermore, repetitive endoscopic procedures may lead to extension or progression of the stricture when it recurrs. 

Urethral stents are metallic mesh tubes that push out against the wall of the urethra.  They are rarely used due to inherent problems with stricture recurrence, stent encrustation (stone formation on the stent), chronic pain and migration.  Urethral stents are permanent and cannot be extracted without excising the portion of urethra in which they reside.  When strictures recur with a urethral stent in place (and they often do!) subsequent treatment is more difficult than if no stent is present.

Urethral reconstructive surgery, or urethroplasty, is the only "definitive" treatment option for urethral strictures.  Few Urologists perform these procedures as training in them is hard to come by.  Dr. Rapoport is one of a handful of Urologists in Canada with fellowship (subspecialty) training in urethral reconstruction and performs urethroplasty in addition to the other options above.  There are 2 general types of urethroplasty proceudres: primary anastamotic repairs and substitution repairs.  Primary anastamotic repairs involve excision of the stricture with reconnection of the healthy ends of urethra in a widened configuration.  Substitution urethroplasty involves tissue transfer techniques typically using buccal mucosa (inner cheek lining) grafts or genital skin flaps to build on to the stricture and increase its caliber.  When possible, anastamotic repairs are preferred as they are less complex and carry excellent durable success rates (>90%).  There are certain situations, usually when the stricture is too long, where substitution techniques are required.  These too carry excellent success rates (>80%).  Certain cases require a combination of techniques, typically when there are multiple severe strictures present.

Although urethroplasty is associated with the best chance of “cure”, it is surgery that requires an anesthetic, incision and catheterization for 7-21 days depending on the type of repair.  Most patients will be able to return to their usual daily activities about 2 weeks after urethroplasty.

 

 

 

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