Urethral Stricture

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Bulbar Stricture

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Failed Penile Flap

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Urethroplasty

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Urethral Obliteration

Posterior Urethroplasty

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What is a urethral stricture?

A urethral stricture is when a portion of the urethra is abnormally narrowed. The urethra is the tube that carries urine from the bladder out the tip of the penis, and the narrowing of the urethra results in difficulty with urination, and can lead to urine infections, prostatitis, bladder damage, and even kidney failure if left untreated. Fortunately, there is a curative surgical treatment that resolves all symptoms of the disease.

Do you think you have a urethral stricture?

The first thing you will notice is difficulty or irregularities while urinating. Some specific symptoms to look out for include a slow prolonged urinary stream, straining to urinate, and/or a feeling of incomplete bladder emptying. However, in order to have a diagnosis, it is best to visit a urologist who will perform a test to diagnose the disease, called a cystoscopy. Once the cystoscopy confirms the diagnosis, X-ray imaging is the next step to determine the exact length, location, and severity of the stricture.

After learning the exact details of the disease, treatment options can then be discussed. Common treatment methods include A urethral stricture dilation technique, an internal incision called a direct vision internal urethrotomy or DVIU, and an open repair of the urethral stricture, called a urethroplasty. Of all of these treatment options, a properly performed urethroplasty has the highest success rate, however, a urethral stricture dilation and DVIU are still viable options.

Have you been diagnosed and want to be cured?

Whether you have been diagnosed with a urethral stricture or not, we can help. Some of our patients come to us because they suspect something is wrong based on having a slow urinary stream or other symptoms, and they want to be properly and gently evaluated. However, approximately 90% of our patients come in already with a diagnosis, either because they are referred to us or seek our care without a referral. Most of these patients come to us because they have tried and failed multiple treatments (usually dilation or internal urethrotomy) at different urology centers. However, these urology centers usually do not get appropriate diagnostic imaging or tell the patient that they can be cured with up to a 98+% cure rate with a single surgery. Instead of suffering from recurrent procedures that only offer temporary relief, surgery can provide a permanent fix. We recently published this data in the Urology Practice Journal, an official publication of the American Urological Association, as part of our efforts to educate Urologists about the importance of patients being made aware that urethroplasty is usually the best treatment option.

Urology Practice Journal paper authored by Joel Gelman, M.D. and Rachel Quinn, M.D.

Are you being told you 'need' to have a dilation or internal urethrotomy?

If a urologist or other medical professional is telling you that you “need” to have a dilation or internal urethrotomy, they are mistaken or misguided. No one ‘needs’ to be treated with dilation or urethrotomy, with possible need to then catheterize themselves to keep the stricture open. Instead, if you have been diagnosed with a stricture of your urethra, before considering which treatment to pursue, a proper urethral X-ray imaging called a retrograde urethrogram RUG (not just a scope test) is indicated to determine the length of the urethral stricture.

If after imaging, it is determined that the stricture is longer than 1/2-3/4 of an inch, or if you had a single dilation or incision and the stricture came back, open repair called urethroplasty is the proper standard of care.

How to use this website to learn about urethral stricture evaluation and treatment

This website provides patients with all they need to know about urethral stricture disease. If you look towards your left, you will see sub-sections discussing all aspects of the disease. The first section explains details about the normal urethra using our own illustrations, which can ultimately prove very helpful. If you know the different parts of the urethra and basic anatomy you can better understand certain terminology associated with the disease. For example, perhaps you were told you have a “bulbar urethral stricture”. This section will explain what is meant by “bulbar urethra stricture” and how to treat a “bulbar urethra stricture”.

Why do I have a urethral stricture?

The next section on causes and symptoms not only will explain why certain men develop the disease, but also some of the potentially dangerous side effects. While a slow urinary stream is a very common symptom, the most worrisome things that can happen in men with improperly treated strictures is that they can get progressive bladder and even kidney damage. That is why it is absolutely essential to get treatment as soon as possible, avoiding hazardous side effects to the bladder and kidneys.

How is a urethral stricture diagnosed?

The most common way to diagnose the disease is for a urologist to look up your urethra with a flexible telescope called a cystoscope. The cystoscope enables the urologist to identify exactly where the urethra becomes narrow, allowing them to make a fairly accurate diagnosis.

Flexible cystoscope

Pinpoint urethral stricture

This test is easily performed by Urologists as cystoscopy is as basic to General Urology practice as the use of a stethoscope is to a Cardiologist. However, the main limitation with this test is that it is unable to determine the length and exact location of the stricture. That detailed information requires X-ray urethral imaging (called a retrograde urethrogram or RUG, and a voiding cystourethrogram for VCUG). This imaging, to be done properly, requires specific expertise and equipment.

Cone shaped adaptor to form a seal at opening of urethra

X-ray image of a stricture in the urethra.

Retrograde urethrogram

The cutting-edge X-ray imaging at our Center is performed using a specific technique modified by Dr. Gelman. This technology allows us to gently provide high-resolution images that accurately determine the strictures length, location, and severity. The picture on the left shows a cone-shaped adaptor being used to gently form a seal at the opening of the urethra. This plastic adaptor used to be commercially available but was discontinued, so we developed a better surgical grade stainless steel adaptor. This is now commercially available by CS Surgical and called the Gelman adaptor. This specific technique, first used by Dr. Gelman in 1997, is now illustrated in Campbell-Walsh Urology, the major Textbook in Urology. The film on the right is a retrograde urethrogram in a patient with a long urethral stricture. The image clearly documents the limitations of a cystoscope, as it is only able to see a small portion of the stricture. When looking through the small opening, the Urologist would see a wider area just beyond the narrowed urethra and could mistakenly think this was a short urethral stricture. However, as shown, there is additional stricture farther in, and the only way to obtain this detail is by performing urethral imaging. The section on diagnostic evaluation will provide detailed information on how we image the urethra.

Treatment options including dilation, direct vision internal urethrotomy (DVIU) and urethroplasty

Urethral X-ray imaging will reveal either a short or long stricture of the urethra, excluding men who have a severed urethra from a pelvic fracture, which requires a different evaluation. The best choice for treatment will depend on the length of the stricture, as well as if there was any prior treatment. For short strictures with no prior treatment most Urologists may choose to perform a procedure called a direct vision internal urethrotomy or DVIU. A DVIU is a procedure in which the Urologist dilates or cuts open the narrow urethra internally, providing some temporary relief of symptoms but does not offer a long lasting cure, making it an ineffective treatment option. To learn more, read the section on urethral dilation and urethrotomy, which will discuss these options. However, the most successful option is a urethroplasty. A urethroplasty is an open repair of the urethra, and detailed information about urethroplasty can be found in the urethroplasty section

Refer to the above simplified decision tree algorithm to learn about additional treatment options. An additional treatment for short strictures is an anastomotic urethroplasty, and for other potential issues, a substitution urethroplasty may be best.

Anastomotic Urethroplasty

Substitution Urethroplasty

Anastomotic urethroplasty, also called excision and primary anastomosis, is a procedure in which the troublesome section is removed and the healthy ends of the urethra are re-connected. Since the urethra has a bit of elasticity and ability to stretch, after a section is removed the healthy sections can be successfully re-connected. An anastomotic urethroplasty is most typically performed when the urethra under the scrotum, known as the bulbar urethra, has been injured by a straddle injury trauma. To learn more about this type of surgery, read the section on bulbar strictures.

Since anastomotic urethroplasty requires removing a portion of the urethra, when strictures are longer this procedure is no longer possible. In these cases, instead of removing the troublesome section we instead widen it. We open up the problem area and add substitute tissue to the narrow urethra to make the narrow urethra wider. This is called tissue transfer or substitution urethroplasty. We recently published our results with anastomotic and substitution urethroplasty, and our technical early success rate was 100% with anastomotic urethroplasty and 97.3% with substitution urethroplasty (short bulbar strictures), with the highest reported short and long term success rates.

There are a few different causes for longer strictures. One cause is an inflammatory condition that affects the penis skin and urethra called Lichen Sclerosus = Lichen Sclerosis, also known as Balanitis Xerotica Obliterans or BXO. Other causes include prior failed surgeries or complications stemming from the treatment of incomplete development of the urethra (called hypospadias).

Pelvic Fracture Urethral Injuries

A pelvic bone fracture is a very serious injury that can have a number of ramifications, including the possibility of a torn urethra. When the pelvic bone is fractured during an accident, in some rare instances the urethra can be torn or completely severed. If this occurs, it is important to take immediate action. Emergency management includes the placement of a bladder drainage tube. The drainage tube, called a suprapubic tube, allows the bladder to empty to prevent any further issues or damage. The repair of a damaged torn urethra from a pelvic fracture is called a posterior urethroplasty and is discussed in our pelvic fracture urethral injury section.

Meatotomy and Perineal Urethrostomy

When there is a urethral stricture just around the area of the tip of the penis, there may be a different treatment that can prove more effective. The treatment is called meatotomy and is a simple surgery to snip open the narrow tip of the penis.

Another alternative treatment method is the perineal urethrostomy. In cases where there is a very long stricture after prior surgery, the patient may desire the simplest and most straightforward way to relieve the blockage. Instead of making the narrow urethra wider in these situations, a perineal urethrostomy connects the urethra to the skin under the scrotum. This allows the urine to exit prior to the blockage, but the downside is that the urine no longer will exit at the tip of the penis. This means that patients will have to sit down to urinate moving forward. These 2 options for specific situations are discussed in the meatotomy and perineal urethrostomy sections.

What is the Right Treatment Option for Me?

Many of our patients tell us that in the past their urologist told them that they “needed” or “required” urethral dilations or internal incisions. That is not how we do things at the Center for Reconstructive Urology. We believe that for a patient to make a correct and informed treatment choice, there first must be a very specific diagnosis. Once the diagnosis is made, the patient should be informed of all treatment options, including the risks, benefits, and expected outcome of each option. The section on making the right choice reviews our approach to decision making.

Surgery Complications and Prevention

Many of our patients are worried about the potential risks of surgery. While it is true that no surgery is without risk, there are certainly substantial risks to not having surgery. The key to making a decision as to whether surgery is the best option for you is if the likely benefits of surgery outweigh the risks. The complications and prevention section outlines the risks of surgery, factors that increase and decrease the risk of complications, and tips to prevent a recurrence.

Our Results and Outcomes

Men from 45 different states and 27 different countries have traveled to the Center for Reconstructive Urology for treatment. As more surgeons are attempting these complex surgeries, we are seeing more patients coming to us to re-do surgeries that were performed without the needed expertise and precision. We have a 20+ year history of providing success rates as high as 99+% for certain surgeries along with a very low complication rate. Our results are presented at regional, national, and international scientific meetings and published in international peer-reviewed Journals. In this section, we discuss the different definitions of success and provide detailed information regarding how we obtain outcomes data.

If you are interested in learning more, click on “Videos”. This will take you to a section with additional information, including firsthand testimonials detailing experiences of actual patients. Should you wish to read about the experiences of our patients who have submitted ratings-reviews to independent websites, you can click here to read our reviews.