SU29.11 | Urethral Strictures — Summary & Reflection

KEY TAKEAWAYS

A urethral stricture is fibrous narrowing of the urethral lumen from spongiofibrosis — scarring of the lining and the surrounding corpus spongiosum — producing a rigid, non-distensible segment. It presents with obstructive voiding symptoms: a weak, splaying stream, hesitancy, straining, prolonged voiding and incomplete emptying, with complications of recurrent UTI, stones, retention, periurethral abscess, fistula and back-pressure renal change. Anatomically, the anterior urethra (penile + bulbar) is most affected and the bulbar urethra is the commonest site, while the posterior (membranous) urethra is distracted by pelvic fracture. Trauma is the major cause (straddle/perineal injury, pelvic fracture, and iatrogenic catheterisation/instrumentation/TURP), with inflammatory causes (post-urethritis, lichen sclerosus/BXO) and congenital/idiopathic cases making up the rest. Investigation centres on uroflowmetry (a low, flat-topped curve) and the retrograde urethrogram (± MCU), the key study that maps site, length and number. Management is length-driven: dilatation (temporising), DVIU for short (<1-2 cm) single bulbar strictures, and urethroplasty as the definitive option — excision and primary anastomosis for short bulbar strictures, buccal mucosa graft substitution for longer ones — with a suprapubic catheter for acute retention when the urethra cannot be passed. Counsel recurrence and long-term follow-up.

REFLECT

Recall a patient you have seen with poor urinary flow, or imagine clerking one in your next surgical or urology clinic. Did you ask about the character of the stream — whether it was weak and splayed — and did you take the trouble to ask about old perineal trauma, a past pelvic fracture, or previous catheterisation that the patient may have long forgotten? Consider how easily a young man's stricture could be mislabelled as prostatic obstruction and treated with tablets while his upper tracts came to harm. Reflect on the one piece of technique that is entirely in your own hands: gentle, well-lubricated catheterisation, never forced, because so many strictures are made by the instruments we ourselves pass. Finally, think through how you would explain to this patient why he needs a retrograde urethrogram before any operation, and why a short stricture and a long stricture lead to different procedures.