Urethral stricture: symptoms, causes, tests and treatment options in the UK

The urethra is the tube that carries urine from the bladder out of the body. BAUS explains that in men it also carries semen. It passes through the prostate, the external sphincter muscle, the perineum and the penis, and urologists divide it into six regions with the bulbar urethra, in the perineum, being the most commonly affected.

A urethral stricture is a narrowing caused by scarring. BAUS says strictures can range from less than 1 cm long to those that extend the entire length of the urethra. Because the scar tissue is firm and does not stretch, the urine stream is restricted.

The information on this page draws mainly on BAUS patient leaflets, which describe strictures in men. Women can also have narrowing of the urethra; this is less common and is assessed by specialist teams.

BAUS says the most likely cause depends on the site of the stricture, and groups the commonest causes into five broad categories. In many people no cause is found.

• Idiopathic: the cause is unknown.

• Inflammatory: infection or inflammation in the urethra, such as sexually transmitted infections (for example gonorrhoea), or chronic inflammation such as lichen sclerosus (also called balanitis xerotica obliterans).

• Traumatic: injury to the urethra, such as a fall astride the crossbar of a bicycle, or pelvic trauma with pelvic fracture.

• Iatrogenic: caused by medical intervention, such as repeated urological procedures passing instruments along the urethra, catheterisation, or radiotherapy or surgery to nearby organs.

• Congenital: inherited conditions such as hypospadias, or as a result of previous surgery to correct hypospadias.

BAUS says that with minor strictures you may not have any symptoms. With tighter strictures you may experience one or more of the following: poor urinary flow and needing to strain to pass urine, spraying or splitting of the stream, dribbling after urination, needing to pass urine often, urinary tract infections, reduced force of ejaculation and low ejaculate volume, and pain on passing urine.

BAUS explains that a stricture can prevent complete bladder emptying. Urine left in the bladder can result in bladder, prostate or kidney infections and lead to stones, and rarely long-term bladder damage and kidney failure. This is why a stricture that is causing symptoms or retention should be assessed rather than ignored.

If you cannot pass urine at all, or have severe pain in the lower tummy with a bladder you cannot empty, seek urgent medical help through NHS 111 or A&E, as this is acute urinary retention and needs prompt treatment.

BAUS says a stricture may be suspected if you have a reduced urinary flow rate or if your bladder does not empty completely on an ultrasound scan after you have passed urine. It may be diagnosed by examination, particularly if the narrowing is visible at the tip of the penis; by failure to pass a telescope or catheter during investigation of urinary symptoms; by a urethrogram, an X-ray using contrast dye put into the urethra to show its anatomy; or by ultrasound or MRI scan.

Some urologists prefer a urethral ultrasound, which BAUS says can show the extent of scarring around the urethra more clearly. Mapping the length and position of the stricture is important because it determines which treatments are likely to work.

BAUS says many types of treatment are available, ranging from conservative or minimally invasive procedures to complex reconstructive operations. The goal is to relieve symptoms and, if possible, reduce the risk of the stricture returning. The choice depends on your preference, the site and length of the stricture, its cause, previous treatments and your general health.

BAUS describes endoscopic treatments as usually done as a day case without cuts in the skin, with a general or spinal anaesthetic, and with a temporary bladder catheter for one to ten days afterwards in some cases. Risks it lists include burning or bleeding when passing urine and urinary tract infection needing antibiotics, each between 1 in 2 and 1 in 10, and recurrence of the stricture, also between 1 in 2 and 1 in 10. Some people are taught to pass a catheter or dilator themselves to keep the urethra open.

Urethroplasty, according to BAUS, is a longer operation with a higher risk of side effects than dilatation or urethrotomy. Bulbar procedures need an incision in the perineum, a 1 or 2 day hospital stay, a catheter for 2 to 3 weeks and 4 to 6 weeks off work. Penile strictures may need a staged repair with two or more operations at least three months apart. Your urologist will advise whether your surgery should be done in a specialist unit in another hospital or region.

On the NHS, a GP usually arranges initial tests and refers to urology. BAUS says endoscopic treatments are available at every urological unit in the UK, whereas complex reconstructive urethroplasty is concentrated in specialist centres.

Private urology consultations are available for people who want to be seen earlier or choose a surgeon. Whichever route you use, it is reasonable to ask how many urethroplasties the surgeon performs, what the plan is if the stricture returns and who will follow you up and for how long.