By: Shrijan Timalsina, Samir Ghimire For-Dr - UMSD, DR - RJ Urosurgery Surgery Department

URETHRAL
STRICTURE
S
By: Shrijan Timalsina,Samir
Ghimire
For- Dr.UMSD, Dr.RJ
Urosurgery
Surgery Department
HIGHLIGHTS
1) Anatomy of urethra
2) Causes and pathogenesis
3) Clinical Features and Complications
4) Investigations
5) Management
ANATOMY OF MALE URETHRA
OF THE PENIS.
PARTS - DIVIDED INTO 4 PARTS

A) PRE-PROSTATIC (INTRAMURAL)-
VARIES LENGTH AND DIAMETER
B) PROSTATIC - (3CM LONG AND 8MM
BREADTH)
C) MEMBRANOUS (2CM LONG AND
5MM BREADTH)
D) SPONGY (15CM LONG AND 4MM
BREADTH)
TOTAL LENGTH - 18 TO 20CM

 LAYERS OF  SPHINCTERS OF URETHRA - 2
in numbers
URETHRA - 3
layers (from
A) Internal Sphincters
inside-outside)
- anatomical existence is
questionable.
A) Mucous - involuntary and surrounded by
Membrane internal urethral orifices.
B) External Sphincter
B) Submucous - derived from sphincter urethrae
Coat muscle
- voluntary in nature
-Veromontanum in prostatic
C) Muscularis Coat urethra-landmark in TURP.Injury
can lead to Urinary incontinence.
Blood supply
 Arterial supply-  Venous drainage-
Prostatic branches of Prostatic venous plexus
inferior vesical and drain Intramural and
middle rectal arteries prostatic urethra.
supply Intramural and Veins accompany
Prostatic urethra. arteries for membranous
Membranous and Penile and penile urethra.
urethra supplied by
branches of dorsal artery
of penis.
Lympatic and Nerve Supply
 Lymphat  Nerve Supply-
ics- Proximal Male urethra-Prostatic plexus(Pelvic
plexus which is an extension to Inferior
Internal
hypogastric plexus)It has mixed
iliac lymph sympathetic,parasympathetic and visceral afferent
nodes. fibers.
Deep Distal Male urethra-Membranous part
inguinal autonomic(efferent) supply from prostatic nerve
lymph plexus; Sympathetic supply via lumbar splanchnic
nerves; Parasympathetic supply via pelvic
nodes. splanchnic nerves.Penile part somatic supply via
External dorsal nerve of penis, a branch of pudendal nerve.
iliac nodes
URETHRAL
STRICTURE
Urethral stricture refers to
any narrowing of the urethra
for any reason whether or not
it actually impacts the flow of
urine out of the bladder.
CAUSES
OF
URETHRAL
STRICTURES
A) Trauma
a)Rupture of bulbar urethra

- blow to perineum, usually fall on projecting objects.
Eg cycling accidents, loose manhole covers etc.
CF- Perineal bruises ,hematoma(butterfly distribution)
Urinary retention and bleeding at urethral meatus
b) Rupture of Membranous urethra
- Ruptured while passing over bony ring during pelvis
fractures and may be asscociated with extraperitoneal rupture
of bladder.
Eg: Pubic rami fracture resulting from car accident.
Landing on one leg after falling from height.
Clinical examination-On DRE high riding prostate
observed.
B) Instrumentation / C) Inflammation (more in penile)
Iatrogenic - (more in a) Gonorrheal urethritis (less
bulbar urethra) common due to ABx)
Cause-Trauma, Infection,
b) Non specific urethritis
Pressure necrosis
(non gonococcal urethritis)
- 40% are Chlamydia
- Indwelling catheter 
trochomatis
causes mechanical trauma
to acutely inflamed urethra - Ureaplasma urealytica
- 50% cases are unknown
- Urethral endoscopy organism
c)Balanitis xerotica
- Surgeries-Transurethral obliterans-Lichen sclerosus
prostatectomy, Radical Stricture produced are
prostatectomy typically long and hard to
treat.
PATHOPHYSIOLOGY
 Incidence of post inflammatory stricture decreasing
due to effective antibiotic treatment.Commonly seen
on bulbar urethra.
 Balanitis xerotica obliterans-Rare chronic
inflammatory dermatosis in which fibrosis occurs
resulting into phimosis.
 Post instrumentation-Catheter,endoscopy.Some
surgeons prefer urethrotomy before transurethral
prostatectomy.
 Injury to spongy tissue  Healing by fibrosis -urine
flow further causes inflammation  more fibrosis.
CLINICAL FEATURES
 SYMPTOMS
- Asymptomatic (accidental finding)
- Lower abdominal pain
- Difficulty starting urine flow
- Painful urination (dysuria)
- Decreased urinary flow rate.
- Incomplete emptying of bladder
- Dribbling of urine
 Acute retention
 Features of UTI
Examination-Well established stricture may be palpable along the

line of urethra due to scarring
C\F in Trauma cases
 HISTORY
- was patient having full bladder at the time of incidence?
 has pt passed urine or not?
 O\E
- blood in the meatus?
- any bruise in the perineum?
- is bladder palpable?
- any lower abd mass developing?
- Swelling of the penis n scrotum
- in PR examination, prostate palpable in normal position or its
replaced by boggy mass, as it happens after rupture of posterior
urethra?
TRIAD OF URETHRAL INJURY
1) Retention of Urine
2) Blood from meatus
3) bruise in perineum
In case of anterior urethral injury, no

need for active immediate surgical
intervention if there are features of
blood from external meatus or penile
bruises UNLESS THERE IS SIGN OF
URINE RETENTION.
COMPLICATIONS OF STRICTURES
1)Recurrent UTI
2) Retention of urine(acute or
chronic)
3) B\L ureterohydronephrosis
4)Bladder Calculi
5)Renal failure
Rare-
1) Urethral diverticulum
2) Peri urethral abscess
INVESTIGATIONS
) Urine analysis
) Urine culture and antibiotic

sensitivity
) Uroflowmetry-Prolonged urinary
flow rate and pleateau shaped.
Approximately 10 cc of
an iodine contrast
) Ascending
material is slowly urethrogram
injected in the urethra
via the catheter. Then,
radiographic pictures
are taken under
fluoroscopy to assess
any obstruction or
impairment to the flow
of the contrast material
that can suggest
urethral stricture. This
test provides useful
information about the
location, extent, and size
of any narrowing in the
urethra.
) Anterograde
cystourethrogram
 can only be done if there is a suprapubic

catheter in place. Iodine contrast is then
injected into the bladder via the catheter and its
flow out of the urethra is radiographed under
fluoroscopy.
) X-Ray Pelvis (in trauma cases)
) Post Void residual volume
) CT and MRI
- most valuable as an adjunctive tool in
patients with the complex anatomical
derangements such as congenital
anomalies, posterior (or
bulbomembranous) urethral injuries, and
with urethral or periurethral tumors.
)Urethroscpoy-Allows stricture to view as a
circumferential scar
TREATMENT
Changed
considerably over
last 20yrs.
A) Immediate
B) Late
A)IMMDEIATE
) Urethral catheter
- soft, small caliber WITHOUT
FORCE.
) Supra Pubic catheter
- either placed with aid of sharp introducer inside catheter. Or

are depend on insertion of trocar to deliver an introducing
sheath into bladder so that a Suprapubic catheter can be placed
- when bladder is full, it is felt abdominally due to acute
retention
B) LATE
) Urethral Dilatation
Less commonly done
nowadays.
- drawback is that its blind
procedure so stricture can
be worse by creating a
false passage
- its useful in elderly
patients with short length
stricture that recur
infrequently and related to
continence mechanism
eg.bladder neck stricture
following radical
) Endoscopic Urethrotomy
(Internal urethrotomy)
- Suitable for <1 cm length and

strictures in bulbar urethra.
- stricture usually cut at 12
o'clock position.
- A Foley catheter (urinary
catheter) is then inserted and
kept in place for a few days while
urethral incision is healing.
- Success rate in single setting is
about 50%
- Complications-bleeding and
infection
) Urethroplasty
- Controversy still present regarding
time of surgical reconstruction in
cases of trauma to urethra. Early
repair means within 72 hours and
late means after 2-3 months.
- In case of urethral trauma delayed
anastomotic urethroplasty
- urethroplasty reserved for cases when
recurrence of stricture following
endoscopic urethrotomy.
-involves excision of stenosed length of
urethra and reanastomosis in short
length cases.
- Grafts from bucal mucosa, urinary
bladder etc are also used.
RISK FACTORS
FOR RECURRENCE
 Longer than 1cm length

 Foley catheterization for
longer durations
References:
 Love and Bailey 26th Edition
 Moore’s Clinical Anatomy 7th Edition
THANK YOU

By: Shrijan Timalsina, Samir Ghimire For-Dr - UMSD, DR - RJ Urosurgery Surgery Department

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By: Shrijan Timalsina, Samir Ghimire For-Dr - UMSD, DR - RJ Urosurgery Surgery Department

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URETHRAL

PARTS - DIVIDED INTO 4 PARTS

TOTAL LENGTH - 18 TO 20CM

a)Rupture of bulbar urethra

Examination-Well established stricture may be palpable along the

In case of anterior urethral injury, no

) Urine culture and antibiotic

 can only be done if there is a suprapubic

) Post Void residual volume

- either placed with aid of sharp introducer inside catheter. Or

- Suitable for <1 cm length and

 Longer than 1cm length

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