1. URETHRAL STRICTURE
FUNDAMENTALS/DIAGNOSIS
Presenter: Dr Nderitu
Supervisors: Dr Otele/Dr. Owilla

2. Outline
•Definition
•Background
•Anatomy of the Urethra
•Epidemiology
•Etiology
•Pathophysiology
•Clinical Evaluation
•Diagnostics

3. DEFINITION
•Abnormal narrowing of a segment of the Anterior
Urethra caused by progressive ischemic spongiofibrosis
and scarring of urethral mucosa.
•The term “stenosis” is used for the posterior urethra
due to a lack of spongiosus tissue i.e. Bladder Neck
Stenosis(BNS).
•Females; fixed anatomical narrowing resulting in
reduced urethral lumen calibre i.e. less than 14Fr.

4. BACKGROUND
• Documented in ancient literature in both Greek and
Egyptian periods as early as 300BC
• Riddled by superstitions in 11-15th centuries; amulets,
charms to protect against disease
• 1520; first recorded epidemic of gonorrhea, strictures
receive more attention
• Up until 18th century still no consensus on etiology of
strictures
• From 19th century, Astley Cooper guided 99% strictures
were gonorrheal and advances made in treatment including
anaesthesia, antisepsis
• Currently; financial burden, stigma, improved
understanding, diagnostics and treatments

5. RELEVANT ANATOMY
•Narrow fibromuscular tube, 18-25cm long, “S”
shaped in adult males.
•Approx 4cm long in women.
•Male Urethra has two parts: Anterior & Posterior
•Anterior Urethra – Glanular, Penile, Bulbar.
•Posterior Urethra – Membranous, Prostatic,
Bladder Neck.

7. ANATOMY
Bladder neck/Preprostatic Urethra
•From the urinary bladder to the prostate gland
•Length 0.5cm to 1.5cm
•Transitional epithelium

8. ANATOMY
Prostatic Urethra
•From bladder neck to membranous urethra
•Length 2.5cm to 4cm, widest part of urethra.
•Forms an angle of 45 degrees at its midpoint
•Transitional epithelium, smooth muscle (inner circular,
outer longitudinal)
•Urethral crest, seminal colliculus, prostatic utricle,
openings of prostatic and ejaculatory ducts

9. ANATOMY

10. ANATOMY
Membranous Urethra
•Shortest (1-1.5cm), narrowest
•Least mobile/distensible as is firmly attached to ischial
rami & inf. Pubic rami by attachments of EUS muscle
and Perineal membrane.
•Most susceptible to injury in Pelvic #
•Bulbourethral(Cowper’s) glands lie posterior,
urothelium changes to pseudostratified columnar
epithelium.

11. ANATOMY
Spongy Urethra
•Enclosed in Corpus Spongiosum in its entire length:
Bulbar, Penile, Glanular
•Length approx 15cm
•Wider at Bulb of penis & Fossa Navicularis.
•Pseudostratified columnar epithelium for majority
part till distal part, where it changes to Stratified
squamous epithelium.

12. ANATOMY

13. ANATOMY
Blood Supply
•Inferior Vesical Artery – bladder neck and prostatic
urethra.
•Bulbourethral Artery – membranous and bulbar
urethra.
•Deep Penile (cavernosal) Artery – Penile urethra.

14. ANATOMY
•Spongy urethra has a dual blood supply.
•Antegrade flow paired Bulbourethral arteries.
•Retrograde flow terminal branches of Dorsal Artery of
the Penis.
•Minor contribution small perforating branches of
Cavernosal arteries.
•Significance; allows for aggressive mobilization of the
spongiosum off of corporal bodies without
compromising blood supply to the urethra

16. Venous Drainage
•Superficial veins in dartos fascia coalesce to form single
superficial vein - superficial external pudendal vein -
greater saphenous vein. Drains skin of penis.
•5 to 8 small veins form retrocoronal plexus, coalesce to
form deep dorsal vein draining glans, mid&distal
corpora into DVC
•Cavernosal veins formed from coalescing of emissary
veins, draining proximal parts of spongiosum,
cavernosum and crural bodies into int. pudendal vein.

18. 1. CLASSIFICATION BY LOCATION
1) ANTERIOR URETHRA
• Meatal Stricture
• Penile Stricture
• Bulbar Stricture
• Penobulbar Stricture
• Multifocal Stricture
• Panurethral Stricture
2) POSTERIOR URETHRA
• Membranous Stricture
• Bladder Neck Stenosis

19. 2. CLASSIFICATION BY STRICTURE TIGHTNESS
Category Description Urethral Lumen
(Fr)
Degree
0 Normal Urethra on
Imaging
Above 18Fr -
1 Subclinical
Strictures
Urethral narrowing
but > 16Fr
Low Grade
2 Low Grade
strictures
11Fr-15Fr Low Grade
3 High Grade/Flow
significant
Strictures
4Fr-10Fr High Grade
4 Nearly Obliterative
Strictures
1Fr-3Fr High Grade
5 Obliterative
Strictures
No urethral lumen,
0Fr
High Grade

20. EPIDEMIOLOGY
Incidence
•229 to 627 per 100,000 males typically older men, >55yrs
(Santucci et al..2007)
•No longer a disease of older men only. (Mugalo et
al..2013) average age 42.7yrs (>50% btwn 20-49yrs)
•Young men 200/100,000 males. (Abdeen et al…2022)
•Women above 64yrs age, female urethral stricture(FUS)
occurs in up to 5.4% of women with refractory LUTs (EAU
Guidelines 2020)

21. EPIDEMIOLOGY
•Anterior urethra is most frequently affected (92.2%),
particularly the bulbar urethra (46.9%).
•Bulbar urethra 46.9%, Penile 30.5%, Combined
(penobulbar) 9.9%, Panurethral 4.9% (Abdeen et
al…2022)
•Local studies in KNH, Bulbar 60.1%, Membranous
22.6%, Penile 13.7%, and Panurethral 3.6% (Otele et
al…2020)

22. ETIOLOGY
ETIOLOGY DEVELOPED COUNTRIES LOCAL
IDIOPATHIC 41% 10.7%
IATROGENIC 35% 17.3%
EXTERNAL TRAUMA 19% 60.7%
INFECTIVE 0.9% 10.7%
INFLAMMATORY <5% 0.6%

23. IATROGENIC
•Most common cause in adult males.
•32% to 79% cases of stricture in well-resourced
setting.
•Due to:
Catheterization
Endoscopic procedures e.g TURP
Prostatectomy
Radiotherapy

24. IATROGENIC
•Urethral catheterization accounts for 11.2% to 16.3% of
all urethral strictures (EAU…2020)
•Long indwelling catheter >3weeks had 8.7% chance of
developing stricture, <3weeks had 3.4% of developing
stricture.
•78% of catheter-related trauma developed urethral
stricture
•Injuries occur during insertion or period catheter
remains in situ.

25. IATROGENIC
•During insertion
70.3% is due to balloon inflation in lumen
20.7% false passage by catheter tip
•Post instrumentation strictures are short,
well defined, located at bulbomembranous
jxn.
•Post catheterization strictures are long,
irregular, located at the penoscrotal
junction.

26. IATROGENIC
TURP
•4.5% to 13% of patients post-TURP develop urethral
strictures, while 0.3% to 9.7% post-TURP develop BNS.
•Most common site is: Bulbomembranous urethra
junction and Fossa navicularis.
•Inadequate lubrication, repetitive “in & out”
movement, monopolar current leak due to inadequate
insulation, prostatic inflammation, long operative TURP
time >60min.

27. IATROGENIC
Prostatectomy
•Differing degrees-narrow anastomosis/lack of
mucosal apposition.
•Occurs at bladder neck.
•Independent predictors v patient-related
factors(smoking, DM, obesity).
•Open vs Robotic 7.5%: 2.1%

28. IATROGENIC
Radiation
•stricture occurs at the bulbomembranous urethra.
•associated with delayed presentation.
•associated with ischemic necrosis at site of
radiation.
•??data for EBRT v brachytherapy

29. IATROGENIC
Circumcision
•common surgery done at any age. 23% overall
complication rate with neonates/children more
commonly affected.
•Presents as meatal stenosis with obstructive
symptoms rare but frequency, weak stream, dysuria
Failed hypospadias repair
•Also presents with obstructive symptoms, fistula
formation

30. EXTERNAL TRAUMA
•Most common cause in the developing world.
•Occurs as: straddle injury, penetrating vs blunt perineal
injury
•Incidences; sports, road traffic accidents, combat,
sexual intercourse.
•15% cases of penile fracture will cause urethral
stricture.
•1.5 to 10% of pelvic fractures will cause PFUIs.

31. EXTERNAL TRAUMA
•Corpus spongiosum is crashed against inferior pubic
rami.
•Often goes unrecognized until presentation of voiding
symptoms. Some reports of presentation of
obstruction in 10-15yr old straddle injuries
•Bulbomembranous junction primarily involved.
•Adults – distal to BM jxn, bulbar urethra.
•Children – proximal to BM jxn, prostatic urethra.

34. INFECTIVE
•Gonococcal vs Nongonococcal Urethritis.
•Previously was the most common cause of
strictures.
•Nowadays 0.9% to 3.7% stricture cases are infective
due to safe sex practices, advent of HIV/AIDS
increased level of sex education, improved
diagnosis, availability of antimicrobials.
•Associated with multifocal strictures.

35. Pathophysiology
•Penetration through intercellular spaces of epithelium.
•Inflammation of subepithelium, recruitment of PMNLs.
•Periglandular (Littre’s) inflammation and microabscess
formation.
•Blockage of Littre’s ducts with phagocytes and
desquamated cells.
•Rupture of abscess into urethra(sinuses) or corpora
bodies and skin(fistulae).
•Exposure of subepithelium, stratified squamous
metaplasia of epithelium.
•Fibrosis and sclerosis of underlying epithelium.
•Stricture formation.
•A.Mundy et al…BJUI

36. NON-GONOCOCCAL URETHRITIS
•Chlamydia trachomatis
•Ureaplasma urealyticum
•Trichomonas vaginalis
•Mycoplasma genitalium

37. INFLAMMATORY
•Caused by Lichen Sclerosus (LS); chronic inflammatory
condition of unknown etiology, occur at any age, affect
any cutaneous area but with predilection for anogenital
region.
•20% involves urethra. Starts from meatus to advance
proximally. Doesn’t involve posterior urethra.
•LS is the most common cause of pan urethral stricture.
•Age - men (3rd to 4th decade), women (5th to 6th
decade).
•More common in uncircumcised men.
•Belsante M.J et al..2015

38. IDIOPATHIC
•34% of penile urethral strictures are idiopathic.
•63% of bulbar urethral strictures are idiopathic.
•May be due to unrecognised trauma to perineum
years back

39. RARE CAUSES
•TB
•Lymphogranuloma venereum
•Parasitic- Schistosomiasis
•Fungal- Actinomycotic mycetoma
•Reiters syndrome
•Vitiligo

40. CONGENITAL
•Congenital urethral stricture is due to failure of
canalization of the cloacal membrane (6th to 7th
week gestation).
•Stricture occurs distal to EUS.
•Presents with diurnal enuresis, UTIs, straining, VUR.
•VCUG will show focal narrowing of bulbar urethra,
while RCUG will show normal penile urethra.

41. CLINICAL MANIFESTATION
•LUTs most common presentation – 54.3%
•In LUTs, weak stream(49%), incomplete
emptying(27%) and frequency(20%) are the most
common.
•Acute Urinary Retention – 22.3%
•Recurrent UTIs – 6.1%
•Difficult catheterization – 4.8%

42. CLINICAL MANIFESTATION
•Genitourinary pain (22.9%-71%).
•Others: Spraying (9%), Haematuria (3.1-5%),
Urgency (14%), Incontinence (1-4%).
•Previous Hx of instrumentation.
•Previous Hx of urethral surgeries i.e. TURP,
urethroplasty, RP.
•Prior Hx of pelvic trauma.
•Prior Hx of Urethritis.

43. CLINICAL MANIFESTATION
•Sexual function – erectile and ejaculatory function
should be known before surgery.
•Chronic illnesses – DM, immunosuppression
•Smoking history – chewing of tobacco or betel
leaves, impaired integrity of oral mucosa incase
BMG is required.

44. PHYSICAL EXAM
•General examination
•Abdomen – palpable bladder, SPC in situ/scar.
•Meatus – blood at the external urethral meatus in
trauma, position and size, check for scarring of
Lichen Sclerosus.
•Palpate anterior urethra – depth & density of scar
tissue.
•Presence of perineal or penile fistulae i.e. watering
can perineum

45. PHYSICAL EXAM
•DRE – rule out prostatic obstruction, high riding
prostate in trauma.
•Assess for suitability of oral mucosa.
•BMI – obese pts are at high risk for leg
compartment syndrome
•Hip assessment – lithotomy position.

46. ‘Watering Can’ Perineum
•Urine leak through multiple urethrocutaneous fistula at
the perineum.
•Caused by long standing, fulminant, purulent,
inflammation>> pressure on friable tissue>> urine
extravasation.

47. INVESTIGATIONS
Baseline Investigations
•Urinalysis - Pus cells, presence of nitrites.
•Urine for MCS
•Gram staining - Gram negative, oxidase positive
Diplococci suggests Gonococcal infection
•UECs.
•FBC

48. IMAGING
1)VCUG & RCUG
•Voiding and Retrograde cystourethrogram.
•VCUG for visualizing the posterior urethra.
•RCUG for visualizing the anterior urethra.
•Modality of choice for Urethral stricture diagnosis.
•Sensitivity 91%, Specificity 72% (EAU Guidelines
2020)

49. IMAGING
•RCUG & VCUG should show
a) Location of stricture.
b) Length of stricture.
c) Stricture Number (multifocal)
d) Caliber of stricture (partial/complete).
e) Other urethral pathology i.e. fistula, foreign
bodies.

50. Procedure
•Informed consent
•Take a scout film with the patient lying supine
(assess bony structures and calculi).
•Clean the urethral meatus in a sterile fashion
•Place 8/10Fr catheter tip in fossa navicularis, inflate
balloon with 1.0 - 2mls sterile water.
•Position patient in steep oblique lateral position
with penis on proximal thigh in moderate traction.

51. Procedure
•Inject 20 – 30mls of 60% iodine based contrast
through the catheter into urethra under flouroscopy
guidance.
•Spot radiographs taken under visual confirmation of
bladder filling or stricture end point.
•VCUG bladder filled with contrast media via SPC,
spot radiographs taken during voiding.

52. Procedure

53. RADIOLOGICAL ANATOMY

54. PHASES OF MCUG
1. Scout Film - assess bony structures (pelvic #, spine
defects), calculi, foreign objects.
2. Filling Phase – seconds within flow of contrast.
assess bladder filling, wall thickening, trabeculation
and diverticula.
3. Voiding Phase - assess presence of VUR, posterior
urethral valves, posterior urethra stenosis.
4. Postvoid film - assess postvoid residual volume,
urine extravasation and VUR.
5. Retrograde Film - assess urethra distal to stricture,
opacifications of Littre’s glands, fistulae.

55. GC URETHRAL
STRICTURE
Gonococcal bulbar
urethral long beaded
segment stricture.
Opacifications of
Littre’s glands shown
by arrow head.
Periurethral cavity
at distal bulbar
urethra.

56. ‘Watering Can’
Perineum
Long segment of
irregular stricture
involving the bulbar
urethra and
membranous urethra
with extensive
fistulous tracts
Multiple opacities
of Littre’s and
Cowper’s glands.

57. URETHRAL
TRAUMA
 Posterior urethral
rupture invoving
the membranous
urethra, urogenital
diaphragm and
distal bulbar.
 Contrast
extravasation
around
membranous
urethra region.
 Pubic rami #s

58. COMBINED VCUG +
RCUG
Shows both ends of
the bulbar urethral
stricture.
Length can also be
estimated.

59. U/S
•Sonourethrography provides 3D assessment of anterior
urethral strictures.
•Gives information on degree of spongiofibrosis.
•More accurate than RCUG at diagnosis of anterior urethra
stricture location and length, 94% sensitivity.
•Low cost.
Limitations
•Lower sensitivity in Bulbar urethral strictures.
•Operator dependency
•Need for urethral distention requiring anesthesia to get
more accurate images

60. CYSTOURETHROSCOPY
•Gives an accurate visual detection of stricture.
•Can be done in office setting.
•Detects narrowing of lumen before changes in
symptoms.
•Rules out stricture as a cause of obstruction.
•Assess for bladder pathology and BM stricture better
than RCUG+VCUG.
•Better than VCUG+RCUG in identifying fistulae, false
passages and calculi.
•Can be combined with an intervention

61. CYSTOURETHROSCOPY
Limitations
•Cannot assess stricture length.
•May need regional anesthesia if
complex/complicated/chronic.
•Availability of small caliber urethroscopes, i.e. 6.5Fr
& 4.5Fr. for high-grade strictures

62. MRI
•Greater anatomical detail.
•Used to assess PFUIs and posterior urethral stenosis
post radiation.
•Gives more info on diverticula, fistulae, tumor and
stone presence.
•More accurate than RCUG in detecting stricture length.
•Sensitivity 100%, specificity 91.7%
Limitations
•Expensive
•Time consuming

63. UROFLOWMETRY
•Reduced maximum flow rate with prolonged plateau is
characteristic of obstruction by stricture.
•Qmax < 10ml/s is diagnostic of reduced flow rate
(normal men >15ml/s, women 18-30 ml/s).
•Sensitivity 80-81%, specificity 77-78%.
Uses
•Detecting recurrence of strictures after urethroplasty
together with RCUG i.e. uroflowmetry at 3 month
intervals, RCUG at 3 & 12 month intervals.
•Combined with U/S PVR to identify emergent need for
bladder drainage.

64. STRICTURE DESCRIPTION
• Upon evaluation the following should come out clearly:
Etiology of stricture
Location of stricture
Length of stricture
Number of stricture i.e. multifocal
Panurethral or not.
Partial/completely obliterated
Other pathologies (fistula, tumors, calculi)
Level of spongiofibrosis

65. REFERENCES
• Santucci et al..(2007) Male Urethral Stricture disease. AUA, The
Journal of Urology
• Mundy A et al..(2010). Urethral Strictures. BJUI
• Mugalo et al..(2013). Aetiology of Urethral strictures at MTRH.
Annals of African Surgery
• Belsante M.J et al..(2015). The contemporary management of
urethral strictures in men resulting from lichen sclerosus
• Otele et al,…(2020). Efficacy of Revision Urethroplasty in the
treatment of Recurrent Urethral strictures in KNH. Bali Medical
Journal
• Abdeen et al,…(2022). Urethral Strictures, Stat Pearls, NCBI
Journal.
• EAU Guidelines 2020
• Campbell & Walsh, 11th Edition.

66. THANK YOU!!!
• To the supervisors for guidance.
• To the audience for listening/contributing.