•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
•Females; fixed anatomical narrowing resulting in
reduced urethral lumen calibre i.e. less than 14Fr.
• 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
• From 19th century, Astley Cooper guided 99% strictures
were gonorrheal and advances made in treatment including
• 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,
•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,
•Urethral crest, seminal colliculus, prostatic utricle,
openings of prostatic and ejaculatory ducts
•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
•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
•Spongy urethra has a dual blood supply.
•Antegrade flow paired Bulbourethral arteries.
•Retrograde flow terminal branches of Dorsal Artery of
•Minor contribution small perforating branches of
•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.
19. 2. CLASSIFICATION BY STRICTURE TIGHTNESS
Category Description Urethral Lumen
0 Normal Urethra on
Above 18Fr -
but > 16Fr
2 Low Grade
11Fr-15Fr Low Grade
3 High Grade/Flow
4Fr-10Fr High Grade
4 Nearly Obliterative
1Fr-3Fr High Grade
No urethral lumen,
•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
•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
•Local studies in KNH, Bulbar 60.1%, Membranous
22.6%, Penile 13.7%, and Panurethral 3.6% (Otele et
•Most common cause in adult males.
•32% to 79% cases of stricture in well-resourced
Endoscopic procedures e.g TURP
•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
•78% of catheter-related trauma developed urethral
•Injuries occur during insertion or period catheter
remains in situ.
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
•Post catheterization strictures are long,
irregular, located at the penoscrotal
•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
•common surgery done at any age. 23% overall
complication rate with neonates/children more
•Presents as meatal stenosis with obstructive
symptoms rare but frequency, weak stream, dysuria
Failed hypospadias repair
•Also presents with obstructive symptoms, fistula
30. EXTERNAL TRAUMA
•Most common cause in the developing world.
•Occurs as: straddle injury, penetrating vs blunt perineal
•Incidences; sports, road traffic accidents, combat,
•15% cases of penile fracture will cause urethral
•1.5 to 10% of pelvic fractures will cause PFUIs.
31. EXTERNAL TRAUMA
•Corpus spongiosum is crashed against inferior pubic
•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.
•Gonococcal vs Nongonococcal Urethritis.
•Previously was the most common cause of
•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.
•Penetration through intercellular spaces of epithelium.
•Inflammation of subepithelium, recruitment of PMNLs.
•Periglandular (Littre’s) inflammation and microabscess
•Blockage of Littre’s ducts with phagocytes and
•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.
•A.Mundy et al…BJUI
•Caused by Lichen Sclerosus (LS); chronic inflammatory
condition of unknown etiology, occur at any age, affect
any cutaneous area but with predilection for anogenital
•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
•More common in uncircumcised men.
•Belsante M.J et al..2015
•34% of penile urethral strictures are idiopathic.
•63% of bulbar urethral strictures are idiopathic.
•May be due to unrecognised trauma to perineum
•Congenital urethral stricture is due to failure of
canalization of the cloacal membrane (6th to 7th
•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
•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,
•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
•Abdomen – palpable bladder, SPC in situ/scar.
•Meatus – blood at the external urethral meatus in
trauma, position and size, check for scarring of
•Palpate anterior urethra – depth & density of scar
•Presence of perineal or penile fistulae i.e. watering
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
•Hip assessment – lithotomy position.
46. ‘Watering Can’ Perineum
•Urine leak through multiple urethrocutaneous fistula at
•Caused by long standing, fulminant, purulent,
inflammation>> pressure on friable tissue>> urine
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
•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
•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.
•Inject 20 – 30mls of 60% iodine based contrast
through the catheter into urethra under flouroscopy
•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.
56. ‘Watering Can’
Long segment of
involving the bulbar
of Littre’s and
•Sonourethrography provides 3D assessment of anterior
•Gives information on degree of spongiofibrosis.
•More accurate than RCUG at diagnosis of anterior urethra
stricture location and length, 94% sensitivity.
•Lower sensitivity in Bulbar urethral strictures.
•Need for urethral distention requiring anesthesia to get
more accurate images
•Gives an accurate visual detection of stricture.
•Can be done in office setting.
•Detects narrowing of lumen before changes in
•Rules out stricture as a cause of obstruction.
•Assess for bladder pathology and BM stricture better
•Better than VCUG+RCUG in identifying fistulae, false
passages and calculi.
•Can be combined with an intervention
•Greater anatomical detail.
•Used to assess PFUIs and posterior urethral stenosis
•Gives more info on diverticula, fistulae, tumor and
•More accurate than RCUG in detecting stricture length.
•Sensitivity 100%, specificity 91.7%
•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%.
•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
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.
Other pathologies (fistula, tumors, calculi)
Level of spongiofibrosis
• 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
• Abdeen et al,…(2022). Urethral Strictures, Stat Pearls, NCBI
• EAU Guidelines 2020
• Campbell & Walsh, 11th Edition.
66. THANK YOU!!!
• To the supervisors for guidance.
• To the audience for listening/contributing.