Urethral stricture is an abnormal narrowing of the urethra caused by fibrosis and scarring from injury, infection, or inflammation. It occurs more often in males due to their longer urethra. Clinical features include dysuria, weak urine stream, urinary retention, and urinary tract infections. Management involves temporary measures like catheterization or definitive treatments like dilation, urethrotomy, or open urethroplasty depending on the location and severity of the stricture. Complications can include recurrent strictures, infections, fistulas, and renal impairment if left untreated.

1. Urethral Stricture
By Olagundoye Olaoluwa

2. Outline
• Introduction
• Anatomy of the urethra
• Aetiology
• Pathogenesis
• Clinical features
• Investigations
• Differential diagnosis
• Management
• Complications
• Conclusion
• References

3. Introduction
• Urethral stricture is an abnormal narrowing or loss of
distensibility of any part of the urethra due to fibrosis
(scar formation) in or around the urethra which can
lead to partial or total obstruction to the flow of urine
through the urethra.
• Urethral stricture could be a result of injury, infection
or inflammation of the urethra.
• Urethral stricture occurs when the urethra heals by
proliferation of fibroblasts which later contract to form
a scar.

4. Introduction
• Urethral strictures are seen more often in males
than females because the males have longer
urethras which are thus more susceptible to injury .
• Urethral stricture is the commonest cause of
urinary retention in tropical Africa.
• Urethral stricture can be seen in any part of the
urethra

5. Anatomy of the Urethra
• The urethra is a vessel transporting urine from the
bladder to external environment during micturition.
• The urethra originates from the neck of the bladder to
the external urethral meatus and has 2 sphincters
• Internal urethral sphincer (smooth muscle)
• External urethral sphincter (skeletal muscle)
• The course of the male and female urethras are different:
• Male Urethra: It is 15-20cm long and also provides an exit
for semen. It has 2 angles:
• Prepubic angle
• Infrapubic angle

6. Anatomy of the Urethra
• The male urethra is divided into 4 parts
i. Pre-prostatic (intramural)
ii. Prostatic
iii. Membranous
iv. Spongy- subdivided into
• Bulbous and
• Pendulous
• Female Urethra: Relatively short (4cm) hence it is
more prone to infection.
• It is located anteriorly to the vagina and posteriorly to
the clitoris.

7. Anatomy of the Urethra

10. Aetiology
• Urethral stritcure can be caused by the following:
a. Congenital:
Pin-hole meatus
Non-meatal stricture
b. Traumatic:
External trauma
Urethral instrumentation
Foreign body or urethral calculus
Douching in women
c. Postoperative:
Transurethral surgical procedures
Vaginal repair

11. Aetiology
d. Inflammatory:
Acute or chronic gonorrhoea
Non-specific urethritis
Tuberculous urethritis
Schistosomiasis

12. Pathogenesis
• Urethral stricture is due to fibrosis of the urethra or its
surrounding structures.
• When the urethra gets injured due to any of the
factors previously listed, the fibroblasts proliferate
laying down scar tissue and eventually contract to
form scars.
• These scars are what are known as strictures and may
partially or totally obstruct the urethra.
• Most strictures (60-70%) occur in the bulbous urethra
followed by the pendulous urethra and the glandular
urethra.

13. Pathogenesis
• Urethral stricture can result in:
• Dilatation of urethra proximal to the stricture
• Compensatory hypertrophy of the bladder musculature
• Vesicoureteral reflux resulting in hydroureters and
hydronephrosis
• Urine retention increasing risk of infections such as
periurethral abscess (rupture of which can lead to
urinary fistulas), prostatitis, cystitis and pyelonephritis.

14. Clinical features
• Dysuria
• Spraying of urine stream
• Increased frequency of micturition
• Abdominal pain
• Urethral discharge
• Hesitancy
• Dribbling
• Acute or chronic urinary retention
• Extravasation of urine
• Uraemia

15. Clinical features
• On examination, the following may be found
• Periurethral induration
• Periurethral abscess
• Perineal urinary fistula
• Visible/palpable bladder

16. Investigation
1. Peak Urine Flow Rate (PFR)
2. Post void residual urine
3. Urinalysis
4. Tests for renal impairment
5. Imaging
Urethrosonography, plain pelvic abdominal x-rays,
retrograde urethrogram and voiding cystourethrogram,
abdominal ultrasound
6. Instrumental examination
7. Urethroscopy

18. Secondary to non gonococcal
urethritis
Bulbar stricture

19. • Penile urethral stricture

20. Differential diagnosis
• Benign prostatic hyperplasia
• Prostatic carcinoma
• Bladder carcinoma

21. Complications
• Urinary tract infections
• Urethral or vesical calculi
• Urinary retention
• Extravasation of urine
• Urinary fistulae
• Infertility
• Carcinoma

22. Management
• Urethral structures can be managed in two ways:
• Temporary measures
• Specific measures

23. Management
• Temporary measures: These are done as emergency
treatments and also when definitive surgery can't be
done at that moment
i. Urinary retention: Suprapubic cystostomy
ii. Extravasation of urine: Suprapubic cystostomy
iii. Watering can scrotum (perineal urinary fistula):
Suprapubic cystostomy
iv. Uraemia: Suprapubic cystostomy

24. Management
• Specific measures:
Dilatation: Often palliative and can also be curative.
It is done using a bougie at intervals e.g 2 weeks, 1
month, 3 months or 6 months. It is indicated for
passable incomplete strictures.
• Complications include bleeding, clot retention,
urethral rupture, infections, endotoxic shock and
rupture of prostate in patients with prostatic
enlargement.

25. Management
Endoscopic direct vision internal urethrotomy:
Involves incision of the stricture under direct vision
using a urethrotome.
• Indicated for uncomplicated impassable strictures
and not used in cases complicated by fistulae,
extensive fibrosis or calculi
• It is advisable to splint the urethra using a catheter
for 2-7 days or more for difficult cases
• Complications include bleeding, clot retention,
extravasation of irrigation fluid and infections

26. Management
Urethroplasty: This is an open plastic repair of the
urethra.
• Indicated for patients with failed conservative
measures, urethral stricture with extensive
spongiofibrosis, periurethral abscess, very long
complete strictures.
• The urethroplasty done depends on the location of the
stricture within the urethra:
• External meatus-
• meatotomy
• meatoplasty

27. Management
• Anterior urethra-
• Excision and end-to-end anastomosis
• Two stage urethroplasty
• Skin island flap implantation
• Free graft urethroplasty
• Posterior urethra-
• Anastomotic urethroplasty
• Quartey's or Jordan's vascularized penile/scrotal hairless flap
• Inverted U-shaped scrotal flap operation

28. Conclusion
• Urethral stricture develops as result of injury to the
urethra leading to fibrosis and obstruction to flow
of urine through the ureter
• It is commoner in males than in females
• Urethral stricture can result in urinary retention,
infection, periurethral abscess, perineal urinary
fistula, extravasation of urine

29. Reference
• Baja's Principles and Practice of Surgery
• Urethra strictures by Ramayya Pramila