Another urologic condition we see and treat regularly is urethral strictures. A stricture is primarily a problem of the male urethra, or the tube that carries urine through the prostate and penis. A stricture is essentially a scar that limits urine flow. The male urethra has several distinct anatomic segments, and it is valuable to go over them here briefly. Technically speaking, the urethra starts at the bladder base or neck, and travels through the prostate as the prostatic urethra. The most common cause for prostatic urethral strictures would be previous radiation therapy for prostate cancer or previous TURP. Just beyond this point, in the area which includes the voluntary urinary sphincter, is the membranous urethra. This can also be narrowed or scarred by radiation therapy, but is most commonly injured as a result of pelvic trauma or pelvic fracture. Repair of the membranous urethra is complicated, often resulting in incontinence, and will not be discussed further here.
After the short membranous urethra comes what should be the widest portion of the male urethra called the bulbar urethra. Here is where the urethra changes course upwards to reach the penis. Men sit on their bulbar urethras, and it is this site which is most commonly strictured or scarred. Such patients are usually younger men, and a distinct cause of the stricture is usually elusive. The most common causes would be trauma from falling on one’s crotch, being kicked, or previous STD’s affecting the urethra such as chlamydia or gonorrhea.
The length of urethra that traverses most of the penis is called the penile urethra, or pendulous urethra, or sometimes the anterior urethra. Strictures here are less common, and may be associated with inflammatory conditions of the glans such as balanitis xerotica obliterans or lichen sclerosis. These are tough strictures to treat, often requiring more complicated reconstructive procedures, and can be recurrent if an underlying disease is present.
Finally, the area of the urethra just under the glans, just before the meatus, is called the fossa navicularis. Strictures in this area are seen often after a catheter or scope has been placed in a man’s urethra, for instance after a TURP. These strictures often respond to simple dilation, and if recurrent can easily be managed by self-dilation, although on rare occasion a reconstructive surgery is indicated.
Typically a patient with a urethral stricture will complain of a slow urinary stream, and a common telltale sign in a younger man is urinary dribbling after finishing at the toilet. An urinary infection may be what brings a stricture to light. It is often a progressive problem, and when suspected the diagnosis is made by cystoscopy, or looking into the urethra with a scope in the office. If a stricture is found, often it will be investigated by an x-ray called a retrograde urethrogram to determine its exact location and length. Based on the findings, several treatment options can be employed. The simplest is dilation of the stricture. This is always performed with a fossa navicularis stricture due to its ease and effectiveness, or a membraneous stricture as this may be the only way to open the channel without causing incontinence. Otherwise, we employ dilation very sparingly, as the recurrence rate after dilation is 80-90%, and each dilation can lengthen the stricture thus complicating its treatment. Our preferred approach for the initial presentation of a urethral stricture is to perform a minor procedure, under anesthesia, called a direct vision internal urethrotomy (DVIU). Here, there is still a high recurrence rate, but it is approximately 50%, and may be less traumatic to the urethra. The stricture is cut with a knife or laser using a scope. A patient will typically wear a urinary catheter for a few days after a DVIU, and should notice a dramatic improvement in their stream right away. Then, it is a function of being on the lookout for recurrence.
A: Bulbar urethral stricture. B: Initial incision of stricture. C: Completion of incision.
D: Stricture now open, urinary sphincter shown.
If a stricture does recur, more aggressive solutions will be offered. A patient can always choose to undergo another DVIU, or even dilation, but at this point such a patient must expect recurrence, even with DVIU. A more permanent solution is called a urethroplasty, a reconstructive procedure that Dr. Engel performs. An urethroplasty is a surgical repair of a stricture whereby the affected area is dissected and either fully excised with the good ends brought together with sutures (an anastomotic urethroplasty), or incised and the gap in the tubular urethra filled with tissue. Today, the preferred tissue to use is the lining of one’s cheek, called buccal mucosa. Over the years, many different tissue techniques have been used, including bladder mucosa, scrotal skin, foreskin, penile skin, and others. Buccal mucosa has largely replaced those tissues as the graft of choice.
For bulbar strictures less than 2cm, Dr. Engel prefers an anastomotic urethroplasty, whereas longer or anterior strictures will call for a graft. With a buccal mucosa urethroplasty, the patient will have stitches inside the side of their mouth, where the graft was taken. The feeling is similar to having bitten one’s cheek. Pain is not severe, and this site heals very rapidly. An urethroplasty will typically involve at least an overnight stay in the hospital, with a much longer period of catheterization while the urethra heals. With more work comes more reward, as depending on the location and severity of the stricture an urethroplasty can afford up to a 93% success rate with no recurrence.
Dr. Engel would be happy to see you if you suspect or have been diagnosed with a urethral stricture during an office consultation.