Urethra is a hollow tube, which connects the bladder to the external meatus in the penis. Narrowing of this urinary passage is called stricture.

This tube can get narrowed down or malformed during development process and lead to congenital strictures at birth. Strictures, which develop after birth, are called as Acquired strictures.

The common varieties of acquired strictures are

Traumatic – due to accident / injury to the perineum

Inflammatory – Due to urethral infection or due to sexually transmitted diseases

Post operative – Following surgeries to the urinary tract, especially after difficult dissections

Stricture formation is sequelae of either mal alignment of the urinary passage due to accidents or as a consequence of disease. Disease process causes inflammation of the tube called urethritis that causes swelling and narrowing of the passage. At first there is inflammation of the mucus membrane but very soon bacteria migrate to the submucus coat and to the various glands of the urethra. Here they remain incarcerated and cause repeated infections. Repeated infections cause the tissue to loose blood supply and become unhealthy leading to fibrosis. Combination of these events causes the urethra to loose its elasticity and smoothness that is necessary for urinary flow.

There are usually two types of strictures

Passable

Impassable

In passable strictures there is a small passage through which urine still flows out.

In Impassable strictures the passage is almost blocked and flow is only as dribbles or completely stopped.

Common sites of this stricture formation are in

Penile urethra (Portion of urethra in the penis)

Bulbar urethra (Portion of urethra just below the bladder)

CLINICAL FEATURES

There is ballooning of the urine passage proximal to the stricture and consequently there is increased pressure during voiding. This may lead to swelling of the bladder, ureters and kidneys, as all are continous structures.

Bladder is able to generate increased pressure during voiding and compensate for smaller strictures. Due to this despite having strictures men present late with the problem. One or combination of these symptoms is usually seen and the symptoms usually start when the narrowing is more than 50 – 60%.

Characteristics of urinary stream seen are

Is narrow, not projectile and often distorted.

Dribbling of urine in the end

Severe delay in initiating the urine flow

Feeling of incomplete evacuation

Frequency

Common modes of presentation are younger individuals with one or more of the following complaints

Acute retention of urine – Total inability to pass urine

Dull aching pain in the flanks

Periurethral abscess

Urethral fistula – abnormal opening of urine passage

Rupture of the bladder

Blood in urine – Hematuria

Infection of the bladder – Cystitis

Infection of the kidney – Pyelonephritis

Backpressure changes causing swelling in Bladder, ureter and kidneys

Swelling in the flanks

Some of the complications noted are

Total inability to pass urine

Blood in urine

Fever with infection in the kidneys

Kidney failure

In India the commonest cause for strictures are due to sexually transmitted diseases and hence proper precautions need to be taken for sexual activity with multiple partners.

Treatment

A simple blood test, ultrasound and an X-ray helps in detecting the problem. Cystoscopy (passing an instrument through urine passage to visualise urethra and bladder) will be necessary. Additional tests may be necessary if there are complications.

An X-ray with contrast to visualise the passage is able to

Provide accurate information on the location of the stricture

Extent or length of the stricture

Connectivity to the bladder

Proper management can cure the condition. If detected early as a passable stricture

Simple dilatation of the stricture with metal instrument may cure the condition

May require cystoscopic visualisation and cutting the stricture internally – Internal urtethrotomy

If it is a an impassable stricture

It may require open surgery either in one operation or two operations to correct the problem.

Several times in cases of emergency where there is total blockage to urinary passage an initial outlet to urine flow is created in the abdomen till such time a proper decision is made regarding the stricture and surgery.

Strictures are known for recurrence due to repeated infections and also fibrosis of the surrounding areas. It is necessary to follow your doctor’s advice carefully and maintain proper follow-up.

Self-Dilatation of strictures is recommended in difficult strictures to maintain the passage integrity and prevent recurrence.