Usually, the first thing patient will notice is difficulty or irregularities while urinating including slow and prolongating urinary flow, strain to void and feeling of incomplete bladder emptying. However, in some case, the urethral stricture can present directly with complications such as urinary infection, acute urinary retention or kidney failure. Regardless the clinical presentation, patients are advised to visit an urologist who will suggest the appropriate investigation to diagnose the disease.

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Cause of urethral strictures

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Among the different causes of urethral strictures, we acknowledge 6 main groups: trauma, infection, lichen sclerosus (balanitis xerotica obliterans-BXO), iatrogenic, congenital and idiopathic.

• Historically, urethral stricture was a sequela of gonococcal urethritis. To date, infection-induced strictures are mainly seen in patients with recurrent urinary tract infections or other sexually transmitted infections.

• Traumatic strictures are common and they occur after different types of trauma. Penile fracture is the traumatic rupture of the corpus cavernosum that may occur during intercourse. Occasionally, the pendulous urethra is involved hesitating in stricture formation. Perineal trauma is usually involving the bulbar urethra and it may cause a stricture in this segment. They occur more frequently after straddle injuries. In men, pelvic fractures are associated with urethral injury in 1.6% to 25% of cases. The membranous urethra and the bulbus-membranous junction are the commonest site of stenosis. In female, pelvic fractures can be associated with urethral injury causing stenosis of any tract of urethra. Pelvic fracture in female can also hesitate in bladder neck rupture when the injury occurs at the level of proximal urethra, or urethra-vaginal fistula when the injury occurs at the level of mid and distal urethra. 

• Lichen sclerosus is an inflammatory disease that can cause urethral strictures. Any segment of the anterior urethra can be involved. Conversely, the posterior urethra is usually not involved. The disease has typically a progressive evolution. In men, it presents frequently as a balanitis or phimosis, but frequently patients complain of poor flow and the urethrogram enhances the presence of a stricture involving the meatus or the fossa naviculars. If untreated, the disease might extend to the remaining parts of penile and bulbar urethra causing a pan-urethral stricture. In women, lichen sclerosus is diagnosed more frequently in postmenopause, but it can affect women at younger age. It has a predilection for the anogenital area, which in some cases can be seriously compromised (atrophy of the labia minora, phimosis, introital stenosis, etc.). Involvement of urethra is rare in female with anogenital lichen sclerosus. However, the presence of lichen sclerosus should be carefully assessed before planning any reconstructing surgery of the urethra because healing property of the tissues can be reduced. In these patients, the use of vaginal flaps for reconstruction is usually contraindicated, and buccal mucosal graft should be preferred.

• The term iatrogenic usually refers to stricture caused by catheter placement or after endoscopic procedures such as endoscopic prostatic resection (TURP, HoLep, TuLEP, Green laser, Etc), stone surgery (URS, RIRS, etc), or endoscopic bladder surgery (TURB, repeated cystoscopy, etc). Patients on repeated clean intermittent catheterization (CIC) are also at higher risk to develop urethral strictures. The commonest site for instrumentation-induced stricture is the bulbar urethra, but many times also the penile urethra can be involved. When the stricture occurs at the bulbo-membranous junction, close to the external sphincter, the surgery is challenging due to the risk of compromising the urinary continence of the patient.

• Urethral stricture is defined as congenital only if it is not due to infection-inflammation, it is of short-length, and it is not associated with history of urethral trauma or instrumentation. As by definition, congenital strictures are present since birth and they are typically diagnosed in children with recurrent urinary infections. In those cases where the stricture is not particularly severe, symptoms can be negligible, and the disease can go unnoticed until adulthood. Thus,  strictures can be classified as congenital in adults, only when others etiological factors have been excluded. Usually, patients complain of poor flow since they have memory. Congenital strictures are more common in men than women.

• When all the previous etiologies have been excluded, the stricture is usually classified as idiopathic.