Reconstructive and functional urology center

The occurrence of urethral strictures is more common in men due to their longer urethra. These strictures, which are contractions of the urethral space, can occur in any part of the urethra, from the bladder neck to the tip of the penis. They restrict or slow down the flow of urine, and in some cases, can cause complete blockage. Common causes of strictures include trauma or injury to the urethra, infections such as sexually transmitted diseases or other inflammatory conditions, damage resulting from surgery or other medical procedures involving the urethra, and conditions that lead to swelling or scarring of the urethral tissues.

Examples of conditions that can lead to strictures in the anterior urethra in men include falls or injuries to the perineum or scrotum, prostate surgery, procedures for treating or removing urinary stones, catheterization, or other interventions involving the urinary tract. However, in most cases, strictures cannot be attributed to a specific trauma or condition.

Injuries to the posterior urethra are usually caused by severe trauma with fractures of the pelvic bones. In these cases, the posterior urethra may be damaged or even detached from the fractured pelvic bones.

Other causes of obstruction in the posterior urethra include enlargement or obstruction of the prostate gland (prostate). Although these conditions are common, they are not considered "strictures" in the strict sense.

When there is a urethral stricture, it can cause a weakening of urine flow and sometimes even complete obstruction of urine flow. A patient with such a stricture may experience difficulty or pain during urination, split or spray urine stream, weak flow, or even dribbling. In some cases, infections or leakage of urine, penile swelling, and difficulties in urinary control may develop.

Over time, these conditions can also cause damage to the bladder and kidneys due to the effort and pressure required for urination against the stricture and the trapped urine in the bladder.

In addition to the patient's medical history and physical examination findings, the doctor may utilize various tests to diagnose a urethral stricture:

- Uroflowmetry, a test that measures urine flow, is performed by having the patient urinate into a computerized device that records an accurate graph of the urine flow rate throughout voiding.
- Transrectal ultrasound can help rule out other causes of voiding disturbances and evaluate whether residual urine remains in the bladder after voiding due to blockage at the urethral outlet.
- Cystourethroscopy (also known as cystoscopy) is performed using a thin optical fiber that is inserted through the urethral opening, allowing visual examination of the urethral space and any changes in the urethral structure.
- Retrograde urethrography or cystourethrography involves the injection of contrast material through the urethral opening into the bladder and capturing X-ray images during the voiding and filling of the bladder. This test helps assess the location and length of the urethral stricture and evaluate the extent of disruption it causes to urine flow.

By employing these tests, the doctor can gather valuable information about the urethral stricture, its location, and its impact on urine flow.

There are two main approaches to treating urethral strictures. The first approach is more conservative and involves dilation or endoscopic cutting of the strictures in the urethra, sometimes using a drug-coated balloon for dilation (Optilum) or a stent after dilation.

Dilation aims to stretch or tear the scar tissue in the narrowed area of the urethra to create a wider passage for urine. It can be performed using different devices, such as gradually increasing catheters or a small balloon that is inflated inside the strictured area, expanding the urethral region. Endoscopic cutting is performed using a special cystoscope that allows visualization of the stricture site, and a blade or energy source like a laser is used to cut the scar tissue. Both techniques aim to create a wider passage for urine through the urethra. In some cases, after dilation or cutting, the physician may decide to leave a catheter in the urethra for some time. Despite the difference in these conservative methods, their success rates are similar, ranging from 30% to 50% for long-term resolution of the stricture problem. In many cases, strictures recur due to the regrowth of scar tissue in the treated area, leading to re-narrowing of the urethral space. If strictures have been previously treated conservatively and recurred, further dilation may be performed.

Optilum balloon dilation:

Optimum is an innovative technique for urethral dilation. It involves using a drug-coated balloon, specifically coated with paclitaxel, for the dilation. When the balloon is inflated at the stricture site, the drug penetrates deep into the tissue, and this medication has the effect of reducing scar tissue development at the site. Clinical studies with medium-term follow-up (up to 3 years) have shown that the use of Optilum balloon dilation, in suitable cases, prevented significant stricture recurrence in 77% of cases, demonstrating a notable improvement compared to traditional dilation.

Stent placement:

Stent placement is an additional method for reducing the likelihood of recurrent strictures after conservative treatment in specific cases.

The second approach for treating urethral strictures, as opposed to the more conservative approaches mentioned in the previous paragraphs, involves performing a surgical procedure for repair or reconstruction of the urethra, also known as urethroplasty. In these surgeries, the damaged segment of the urethra is repaired using various techniques that involve removing the affected portion and reconnecting the healthy segments of the urethra. In cases where the damaged segment of the urethra is longer, and it is not feasible to excise the affected portion, the damaged urethra is repaired using grafts or tissue flaps from another location. Grafts are usually obtained from the buccal mucosa (inside the cheek) or, in some cases, using skin. Urethral reconstruction surgeries, although more complex than the previously mentioned methods, require advanced surgical skills and expertise from the physicians performing them. They can lead to sustained improvement in the condition and function of the treated area, often resulting in long-term healing. Therefore, when feasible, urethral reconstruction surgeries are considered preferable over simpler conservative treatments, which have a much lower chance of long-term success.

As mentioned, urethral strictures in women are much rarer than in men and can be caused by injury, catheterization or other medical devices, birth trauma, chronic inflammatory conditions, and sometimes for unclear reasons. Another specific reason for urethral strictures in women is routine surgeries performed to treat urinary incontinence (such as mesh or sling placement) in which the implanted sling is either too tight and externally obstructs the urethra or migrates from its intended position and penetrates into the urethral tube. Additional reasons that require urethral reconstruction surgeries in women are conditions such as urethral diverticula or urethral prolapse that affect the urethral lining. Therefore, although not strictly classified as urethral strictures, the surgical procedures for their treatment are very similar to those performed for urethral reconstruction due to strictures.