Urethral Strictures, Male

Author: Angelo E Gousse, MD, Professor of Urology and Gynecology, Director of Urology
Residency Program, University of Miami School of Medicine; Director, Urodynamics
Laboratory, Miami Veterans Affairs Medical Center
Coauthor(s): Daniel J Caruso, MD, MBA, Clinical Instructor, Division of Female Urology,
Voiding Dysfunction, and Pelvic Floor Reconstruction, Department of Urology, University of
Miami/Jackson Health Systems; Richard A Santucci, MD, FACS, Chief of Urology, Detroit
Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic
Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction;
Clinical Professor of Urology, Michigan State College of Medicine; Joshua A Broghammer,
MD, Resident Physician, Department of Urology, Wayne State University; Jon Timothy Posey,
MD, Staff Physician, Department of Urology, University of Miami School of Medicine
Contributor Information and Disclosures
Updated: Jun 24, 2009
Urethral strictures arise from various causes and can result in a range of manifestations, from an
asymptomatic presentation to severe discomfort secondary to urinary retention. Establishing
effective drainage of the urinary bladder can be challenging, and a thorough understanding of
urethral anatomy and urologic technology is essential. Consultation with a urologist should be
obtained for any patient presenting to the emergency department with urinary retention
secondary to urethral stricture disease.
Urethral strictures. Cross-sectional diagram of the penis.
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Urethral strictures. Schematic of penile anatomy.

History of the Procedure

Urethral stricture disease has been cited as long ago as ancient Greek writings that reported
establishing bladder drainage with the passage of various catheters. Historically, the treatment
consisted of urethral dilation with sounds. Hamilton Russell described the first surgical
procedure for repair of a urethral stricture in 1914. In contemporary times, several surgical
options are available.

Problem

Urethral strictures can result from inflammatory, ischemic, or traumatic processes. These
processes lead to scar tissue formation; scar tissue contracts and reduces the caliber of the
urethral lumen, causing resistance to the antegrade flow of urine.
The term urethral stricture generally refers to the anterior urethra and is secondary to
scarring in the spongy erectile tissue of the corpus spongiosum.
A posterior urethral stricture is due to a fibrotic process that narrows the bladder neck and
usually results from a distraction injury secondary to trauma or surgery, such as radical
prostatectomy. The focus of this article is anterior urethral stricture disease.

Etiology
The most common causes of urethral stricture today are traumatic or iatrogenic. Less-common
causes include inflammatory or infectious, malignant, and congenital. Infectious urethral
strictures are secondary typically to gonococcal urethritis, which remains common in certain
high-risk populations.

Pathophysiology

Urethral strictures occur after an injury to the urothelium or corpus spongiosum causes
scar tissue to form.
A congenital stricture results from inadequate fusion of the anterior and posterior urethra,
is short in length, and is not associated with an inflammatory process. This is an
extremely rare cause.

Presentation
The most common presentation includes obstructive voiding symptoms, urinary retention, or
urinary tract infections. Obstructive voiding symptoms are characterized by a decreased force of
stream, incomplete emptying of the bladder, urinary terminal dribbling, and urinary
intermittency. These symptoms are progressive in many patients.

Indications
Surgical treatment of urethral stricture disease is indicated when the patient has severe voiding
symptoms, bladder calculi, increased postvoid residual, or urinary tract infection or when
conservative management fails.

Relevant Anatomy

The urethra is divided into anterior and posterior segments. The anterior urethra (from
distal to proximal) includes the meatus, fossa navicularis, penile or pendulous urethra,
and bulbar urethra. The posterior urethra (from distal to proximal) includes the
membranous urethra and the prostatic urethra.
The urethra lies within the corpus spongiosum, beginning at the level of the bulbous
urethra and extending distally through the length of the penile urethra. The bulbar urethra
begins at the root of the penis and ends at the urogenital diaphragm. The penile urethra
has a more central position within the corpus spongiosum in contrast to the bulbous
urethra, which is more dorsally positioned.
The membranous urethra involves the segment extending from the urogenital diaphragm
to the verumontanum.

The prostatic urethra extends proximally from the verumontanum to the bladder neck.
The soft-tissue layers of the penis, from external to internal, include the skin, superficial
(dartos) fascia, deep (Buck) fascia, and the tunica albuginea surrounding the corpora
cavernosa and corpus spongiosum.

The superficial vascular supply to the penis comes from the external pudendal vessels,
which arise from the femoral vessels. The external pudendal vessels give rise to the
superficial dorsal penile vessels that run dorsolaterally and ventrolaterally along the
penile shaft, providing a rich vascular supply to the dartos fascia and skin. The deep
penile structures receive their arterial supply from the common penile artery, which arises
from the internal pudendal artery. The common penile artery gives off several branches,
including the bulbourethral, cavernosal, and deep dorsal penile arteries. The corpus
spongiosum receives a dual blood supply via anastomoses between dorsal and urethral
artery branches in the glans.

The scrotum receives its vascular supply via branches from both the external and internal
pudendal arteries.

Contraindications

Urinary tract infections should be adequately treated prior to treatment.

Malignancy should be ruled out with an endoscopic biopsy.