Urethral Stricture: When the Flow Keeps Narrowing

A man in his thirties or forties notices it takes longer to start, the stream is weaker than it was, and sometimes it sprays. He assumes it is a prostate problem, because that is what he has heard about.

In a man under 50, it usually is not. The prostate rarely causes obstruction before the mid-fifties. A stricture does, at any age.

What is a urethral stricture?

The urethra is the tube carrying urine from the bladder out through the penis. When part of it is injured or inflamed, it heals with scar tissue — and scar tissue contracts. The passage narrows, and the flow drops.

It behaves exactly like a kink in a hosepipe: the pressure behind rises, the stream out weakens, and the bladder has to work progressively harder.

What does it feel like?

• Weak stream, often the first change noticed
• Spraying or splitting of the stream — quite characteristic of a stricture
• Straining to start or maintain flow
• Feeling of not emptying fully
• Dribbling after finishing
• Repeated urinary infections
• Discomfort or pain on passing urine

The stream that splits or sprays is the detail that most often points to a stricture rather than the prostate.

What causes it?

• Trauma — a straddle injury (falling astride a bicycle crossbar, a wall, a bar) or a pelvic fracture
• Instrumentation — previous catheterisation, endoscopic surgery, or a prolonged catheter after another operation
• Infection — including sexually transmitted infections, particularly untreated ones
• Lichen sclerosus — an inflammatory skin condition affecting the genital skin
• Idiopathic — no identifiable cause, which is a meaningful proportion

How is it diagnosed?

• Uroflowmetry — measures the stream objectively. A stricture typically produces a characteristic flat, plateau-shaped curve rather than a normal bell.
• Retrograde urethrogram (RGU) — a contrast X-ray of the urethra. This is the key test, because it shows exactly where the narrowing is and how long it is. Both determine the treatment.
• Ultrasound — to check post-void residual urine and the state of the kidneys.
• Cystoscopy — direct inspection where needed.

Why dilatation stops working

This is the part worth understanding before agreeing to anything.

Dilatation stretches the narrowed segment. Internal urethrotomy (DVIU) cuts it from inside with an endoscope. Both are quick, both are done through the natural passage with no external cut, and both give immediate relief.

Both also have a high recurrence rate. Neither removes the scar — one stretches it, the other cuts it, and scar tissue re-forms as it heals. A first urethrotomy may hold for a while. A second rarely does, and the odds worsen with each attempt.

There is a further problem. Each repeated procedure tends to lengthen the scarred segment. A short stricture that could have been cured by removing it and rejoining the healthy ends can, after several years of repeat dilatations, become a long one needing a graft. The easy treatment repeatedly applied makes the definitive treatment harder.

Endoscopic treatment is reasonable once, for a short, first-time stricture. Being offered it for a third time is a reason to ask about reconstruction instead.

Urethroplasty — the repair that lasts

Open reconstruction of the urethra, and the only treatment that reliably cures a stricture. Two broad approaches:

Excision and primary anastomosis — the narrowed segment is removed entirely and the healthy ends joined. Suited to short strictures, typically under 2 cm. Success rates are excellent, above 90 percent in appropriate cases.

Substitution urethroplasty — the urethra is widened using a graft, most commonly buccal mucosa taken from the inside of the cheek. Cheek lining suits this well: it is used to a wet environment, takes readily, and the donor site heals within a couple of weeks. Used for longer strictures.

A catheter stays in for two to three weeks afterwards, and an X-ray confirms healing before it comes out. Long-term success is generally above 85 percent.

It is a bigger operation than a dilatation. It is also, for most men, the one that ends the cycle.

When to see a urologist in Uppal

Come in if you have a weak or spraying stream, if you are under 50 with flow problems, if you have had repeated urinary infections, if you have been dilated more than once, or if you have been told you have a stricture and want to know whether reconstruction is an option for you.

Dr. Srikanth Munna consults in urology and andrology at UNO Super Speciality Clinics, Uppal, Monday to Saturday, 6–9 PM, and treats urethral stricture including urethroplasty.

Bring any previous urethrogram films, uroflowmetry reports, and details of any dilatation or urethrotomy you have had, with dates. The history of what has already been done shapes the recommendation as much as the current scan does.