Urethral stenosis: definition, causes, symptoms, diagnosis and treatment

By Cristiano Antonino On Jun 16, 2023

The obstruction or narrowing of the urethra, the channel that allows urine to flow outwards, is called urethral stenosis

An uncommon disorder that can affect men and women of all ages and is not always easy to diagnose.

What is urethral stenosis?

Urethral stenosis is the reduction in the diameter of the urethra, i.e. the narrowing of the channel that carries urine from the bladder to the outside during the act of urination and which causes difficulty in the passage of fluid.

It is a disorder that occurs with scar tissue, i.e. a mass of tissue, around the wall of the urethra.

The greater the extent of the narrowing, the thinner the urethral canal becomes.

A cylindrical-shaped canal, the urethra starts from the bladder and ends outwards with a small opening (called the urinary meatus).

In men it passes through the penis to open at the tip of the glans, making a path of about 20 cm.

This is the same channel through which sperm passes after ejaculation.

In women, however, it is much shorter and ends in the vulva, located between the vaginal opening and the clitoris.

The causes of urethral stenosis can be several

The most common are:

Urinary infections that occur as a result of the transmission of sexually contracted infectious diseases, such as gonorrhoea and chlamydia. Another reason that can lead to an infection of the urethra is the prolonged use of a urinary catheter, or even inflammation of the prostate.
Trauma of the urethra, e.g. fractures or contusions resulting from falls from a horse or motorbike, can damage the canal. In this case, the healing of the lesion can take place with the affixing of scar tissue that narrows the urethral diameter, even to the point of completely occluding it.
Injuries resulting from invasive instrumental manoeuvres such as catheter placement, or following bladder, prostate or genital surgery.
Dermatological diseases: Lichen Sclerosus (also called Balanitis Xerotica Obliterans), an inflammatory disease affecting skin and mucous membranes. Although rare, it can affect male and female genital tissues, and the pathogenesis is autoimmune.
Tumours of the urethra that can narrow the canal. This is also uncommon, but must be taken into account.
Congenital defects: it may happen, in rare cases, to witness the birth of children with defects of the urethral canal.

Symptoms

The symptoms of urethral stenosis are manifold and manifest themselves in an aggravating manner, depending on the severity of the obstruction.

Mild discomfort may occur during urination that, if underestimated and not investigated in time, will gradually worsen.

Suspicion should arise if you begin to experience the sensation of not emptying your bladder completely following urination, pain when expelling urine, or notice a reduced or irregular jet (called a micturition), such as double or ‘splashing’.

It is important to consult your doctor immediately if you experience one or more of these “anomalies” because neglecting the problem could lead to serious problems throughout the genitourinary system, up to and including complete obstruction.

Specifically, we can summarise the disorders due to the presence of stenosis in

sensation of difficulty in passing urine
decreased flow with consequent thinner urine stream;
sense of incomplete emptying of the bladder, with the presence of pain in the suprapubic area, due to the effort;
stranguria, i.e. a burning sensation when urinating;
haematuria, i.e. presence of blood in the urine (reddish-coloured discharge of urine);
loss of blood outside of urination, called urethrorrhagia;
high frequency of urinary tract infections;
orchitis, inflammation of the testicles;
prostatitis, inflammation of the prostate.

In the most serious cases, if action is not taken immediately by consulting a doctor, acute retention of urine may occur, with inability to empty the bladder, stones in the bladder or urethra, which can degenerate into kidney failure.

Diagnosis

Should one or more worrying symptoms occur, it is a good idea to contact your doctor or urologist immediately.

In order to arrive at a precise diagnosis of urethral stenosis, various tests and functional tests are required, both to quantify the severity of the disorder and to investigate the underlying cause and then intervene with the most suitable therapy.

During the urological examination, the doctor collects the patient’s medical history in order to understand if the disorder may have been caused by trauma from a fall, or if it is a consequence of previous surgery.

The first routine tests are then carried out, such as urine analysis (with urine culture) and urethral swab.

These two tests are very useful for checking for the presence of a possible bacterial infection in progress, caused by gonorrhoea or chlamydia.

In this case, it may be sufficient to proceed with a suitable antibiotic therapy.

In doubtful cases, more extensive instrumental tests will be necessary.

Anterograde and retrograde urethrography

This is an X-ray test that allows the urethra and bladder to be visualised by introducing a contrast medium.

It can be bothersome and painful, but it is essential for the diagnosis of stenosis.

In any case, it should only be performed by experienced doctors.

In the first phase, anterograde urethrography or cystourethrography, contrast medium is injected into the urethra through a small catheter.

This will visualise the entire anterior urethra and check for abnormalities.

The second phase, called retrograde or urinalysis, instead studies the entire urethra, including the posterior part up to the prostate.

The test is performed by completely filling the bladder with contrast medium.

When the bladder is full, the patient is asked to urinate.

During this operation, X-rays are taken to check for any narrowing along the canal.

Urethroscopy or cystoscopy

This test is very delicate and is carried out under local anaesthesia to avoid causing pain to the patient.

It is performed by introducing an instrument with a very small camera into the urethra.

The urethroscope provides the possibility to directly observe the urethral lumen and the condition of the urethral walls in order to detect abnormalities or lesions.

During cystoscopy it is also possible to perform a biopsy, i.e. to take a tissue sample for laboratory analysis.

Ultrasound of the urethra

At the same time as the retrograde urethrography, an ultrasound of the urethra is also performed, especially if the patient is male.

This non-invasive test is performed with a probe that can provide images to estimate the extent and severity of the stenosis.

If the patient is female, on the other hand, ultrasound of the urethra produces poor results.

Treatment of urethral stenosis

Once all the necessary tests have been performed and a precise diagnosis has been made, the urologist can decide which therapy to use.

The choice of the type of intervention certainly depends on personal factors such as the patient’s age and general clinical situation.

In addition, the case must be approached according to the characteristics of the stenosis: size, location and underlying cause.

In the presence of urethral stenosis of infectious origin, antibiotic therapy is imposed to treat the bacterial infection

It is important to know that the only way to solve the problem and return to normal function, in the case of other aetiologies, is surgery.

In the presence of recurrent urinary tract infections, serious difficulties in urinating and kidney problems, combined with severe and constant pain, surgery is necessary to avoid the inevitable worsening of the condition.

Surgery can be performed using various techniques, which will be evaluated according to the patient’s clinical picture. The two most effective and widely used methods are endoscopic urethrotomy and urethroplasty.

Endoscopic urethrotomy

For this procedure, the surgeon uses an endoscope, at the top of which a scalpel is mounted, which is introduced into the urethral meatus.

Arriving at the level of the narrowing, the scalpel cuts the tissue causing the narrowing, re-establishing the patency of the urethral canal.

To allow the tissue to heal while maintaining the correct opening, a Foley catheter with an inflatable end is introduced into the canal for a few days.

Urethroscopy has the advantage of being a fairly quick operation that does not require surgical cutting and has a good success rate for small stenoses.

If one is faced with an extensive stenosis, it is preferable to proceed with urethroplasty.

Urethroplasty

Urethroplasty is a surgical procedure consisting of an initial open microsurgical operation followed by an aesthetic reconstruction of the genitals through plastic surgery.

It is a rather long operation (several hours) and requires competent professionals, given the delicacy of the area involved.

The advantage, however, is the very high success rate and the definitive resolution of the problem.

Stenosis can be resolved, thanks to urethroplasty, in a single operation or in several surgical stages.

In the case of a single operation, the surgeon may intervene with

the anastomosis urethroplasty, in which the urethral canal is cut transversally and the damaged piece is removed, with subsequent suturing of the stumps;
urethroplasty with buccal mucosa, in which the canal is opened lengthwise and an addition of buccal mucosa (patch) is applied at the narrowing.

There are cases, however, in which the stenosis requires more than one operation, which will be performed at least six months apart.

In these situations, two types of operations can be performed:

Penile urethroplasty: the penis is completely opened and the damaged urethra removed, to be replaced by a portion of buccal mucosa. This, after a few months, will be moulded into a tubular shape and become the new urethral canal. In these cases, between operations, the patient will have to use a replacement meatus placed along the belly of the penis to urinate. Once the entire plastic reconstruction procedure is complete, the functionality of the urethra will return to its original state.
Urethroplasty in the bulbar urethra: the urethral canal is cut a few centimetres and left open, allowing the damaged tissue to heal spontaneously. After a few months, when healing is complete, it is closed again and the damaged urethra can resume normal function. In this case, during the transition period, the patient urinates through the perineostomy, an artificial opening placed between the anus and the scrotum.

Stenosis, a final type of operation to consider is ureteral stenting

This type of procedure is indicated especially for very elderly patients in whom it is not possible to intervene with the previous techniques.

Urethral stenting is an endoscopic technique, which consists of introducing a small tube (called a stent) at the point where the deformation is present, in order to keep the canal open.

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