Urology treats urinary tract diseases in all genders and male reproductive issues, covering the kidneys, bladder, prostate, urethra, from infections to complex cancers.
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The clinical presentation of urethral stricture disease is primarily defined by the obstructive nature of the condition. However, the onset is often insidious. Because the narrowing of the urethral lumen occurs gradually over months or even years, patients frequently adapt subconsciously to the diminishing flow. This phenomenon often delays the pursuit of medical attention until the stricture has progressed significantly, sometimes to a critical point.
The hallmark symptom of a urethral stricture is a reduction in the force and caliber of the urinary stream. Patients often describe a weak stream that takes a progressively longer time to empty the bladder. The stream may be thin, resembling a wire, or it may be splayed. Spraying or splitting of the urinary stream is a classic sign, resulting from the turbulence created as urine is forced at high pressure through the irregular, narrowed segment of the urethra. This spraying can be unpredictable, causing significant hygiene issues and social embarrassment for the patient.
In addition to a weak stream, patients often experience hesitancy, which is a delay in the initiation of urination. They may have to wait for several seconds or minutes at the toilet for the stream to start. Straining to void is also common; patients often engage their abdominal muscles (Valsalva maneuver) to assist the bladder in expelling urine, a process that should normally be passive and effortless once initiated.
As the bladder compensates for the chronic obstruction, secondary irritative symptoms may develop. These include urinary frequency, requiring the patient to urinate often during the day, and nocturia, necessitating multiple trips to the bathroom at night to void. Urgency, the sudden and compelling need to void that is difficult to defer, is also a frequent complaint. These symptoms arise because the bladder muscle becomes hypertrophied, less compliant, and irritable from the increased workload.
Post-void dribbling is another distressing symptom where small amounts of urine leak out after the patient has finished voiding and dressed. This occurs because urine gets trapped behind the stricture or in the dilated segment of the urethra proximal to the narrowing and is released by gravity or movement after the main stream has ceased.
In severe cases, the stricture can lead to acute urinary retention, a medical emergency where the patient is unable to pass any urine despite a full and painful bladder. This often precipitates the diagnosis. Other complications that may serve as the initial presentation include recurrent urinary tract infections, prostatitis, or epididymitis, caused by the reflux of stagnant, infected urine into the prostate and reproductive ducts due to high voiding pressures.
Trauma is a leading cause of urethral stricture disease, particularly in younger populations. The mechanism of injury typically dictates the location and severity of the stricture. Straddle injuries are a specific type of blunt force trauma that frequently results in bulbar urethral strictures. These occur when an individual falls forcefully onto a narrow object, such as a bicycle crossbar, a fence, a ladder rung, or the edge of a bathtub. The force of the impact crushes the bulbar urethra against the undersurface of the pubic bone. While the immediate injury might result in some bruising or minor bleeding from the meatus, the healing process triggers inflammation and fibrosis that manifests as a symptomatic stricture months or years later.
Pelvic fractures, often resulting from high-velocity motor vehicle accidents or industrial crush injuries, are associated with posterior urethral injuries. In these devastating events, the urethra is often sheared off at the junction of the prostate and the membranous urethra due to the massive disruption of the pelvic ring. This results in a distraction defect rather than a simple narrowing, leading to complete obliteration of the urinary channel and requiring complex reconstructive surgery.
Iatrogenic causes, or those resulting from medical procedures, have become the most common etiology of urethral strictures in the developed world. This increase correlates with the widespread use of transurethral diagnostic and therapeutic interventions in modern medicine.
The passage of instruments through the urethra, such as cystoscopes, resectoscopes for prostate surgery (TURP), or ureteroscopes for kidney stone removal, can cause mechanical trauma to the delicate urethral mucosa. Even with proper lubrication and technique, friction and micro-tears can occur, particularly if the urethra is narrow or the instrument is large.
Indwelling urinary catheters are another significant source of iatrogenic strictures. Catheters can cause strictures through pressure necrosis, particularly if they are too large or if there is traction on the catheter. Prolonged catheterization can lead to ischemia at the urethral meatus or the penoscrotal junction, areas where the urethra is naturally narrower or curved. The material of the catheter (latex vs. silicone) may also induce an inflammatory reaction in susceptible individuals. Traumatic insertion of a catheter, specifically the inflation of the retention balloon within the urethra rather than the bladder, is a preventable cause of severe strictures.
Infectious urethritis remains a cause of stricture disease, although its prevalence has decreased in developed nations with effective antibiotic therapy. Gonococcal urethritis, caused by Neisseria gonorrhoeae, was historically the primary cause of multi-segment strictures. These strictures are often complex, involving long segments of the anterior urethra. Non-gonococcal urethritis, such as that caused by Chlamydia trachomatis, can also lead to scarring, though less frequently.
A specific and particularly challenging inflammatory condition is Lichen Sclerosus, also known as Balanitis Xerotica Obliterans (BXO) when involving the genitalia. This chronic, progressive skin disease typically affects the glans penis and prepuce, causing whitish, atrophic plaques. It can aggressively invade the urethra, causing dense, long-segment strictures that usually begin at the meatus and extend proximally down the penile urethra. Lichen Sclerosus is considered an autoimmune or inflammatory condition, and strictures of this etiology have a high rate of recurrence and require specific tissue transfer techniques for repair.
In a significant proportion of cases, termed idiopathic, no specific cause can be identified despite a thorough evaluation. These strictures are most commonly found in the bulbar urethra of young to middle-aged men. It is hypothesized that they may result from unrecognized minor trauma in childhood (e.g., bicycle riding) or a congenital predisposition that makes the urethral tissue more susceptible to fibrosis over time. Despite the lack of a clear precipitating event, the histological characteristics of the scar tissue are identical to those of traumatic strictures, involving dense collagen deposition.
Radiation therapy for the treatment of pelvic malignancies, such as prostate, bladder, or rectal cancer, can cause collateral damage to the urethra. Radiation induces a process called endarteritis obliterans, which thickens and closes off the small blood vessels supplying the tissue. This leads to chronic ischemia (lack of blood supply) of the urethral tissue, resulting in scarring and stricture formation. These strictures often present years after the radiation treatment and are notoriously difficult to manage due to the poor quality and vascularity of the tissue, often requiring complex reconstruction with grafts or flaps.
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Spraying happens because the scar tissue makes the opening of the urethra irregular, stiff, and narrow. As urine is forced through this uneven gap under pressure, the fluid dynamics change, and the stream becomes turbulent instead of flowing smoothly, causing it to fan out or split into multiple streams.
Yes, untreated or severe sexually transmitted infections, particularly gonorrhea, can cause significant inflammation in the urethra. If not treated promptly, this inflammation leads to the formation of scar tissue that narrows the urethra, a condition that can present symptoms years after the infection has cleared.
A straddle injury occurs when a person falls and strikes their perineum, the area between the scrotum and anus, on a hard object like a bike bar, fence, or bathtub edge. This crushes the bulbar urethra against the pelvic bone and is a very common cause of strictures in men.
Catheters can irritate the lining of the urethra. If a catheter is too large, inserted traumatically, or left in place for a long time, it can put pressure on the urethral wall, cutting off blood flow. This ischemic damage heals with scar tissue, which can form a stricture.
Lichen Sclerosus is a chronic skin condition that causes white, patchy, thin scars on the skin of the penis and foreskin. It can spread into the urethra, causing very dense and difficult-to-treat strictures. It is not an infection but an inflammatory disease that requires long-term management.
Urethral stricture is a common issue worldwide, causing trouble with urination. Thanks to new medical imaging, diagnosing this problem has gotten much better. CT scans
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