Urethral Stricture Treatment in Birmingham

What is a urethral stricture?

The urethra is the tube that carries urine from the bladder to the outside of the body. A urethral stricture develops when scar tissue causes part of this tube to become narrowed.

As the narrowing becomes tighter, it can restrict the flow of urine and make it increasingly difficult to empty the bladder. Some strictures remain stable for a long time, while others gradually worsen or return after treatment.

Urethral strictures are more common in men because the male urethra is longer. They can also occur in women, although the investigation and treatment pathway may be different.

Symptoms of a urethral stricture

Symptoms vary depending on the position, length and severity of the narrowing. They may include:

• A slow or weak urinary stream
• Taking longer than usual to pass urine
• Difficulty starting urination
• Needing to strain to pass urine
• Spraying or splitting of the urinary stream
• A feeling that the bladder has not emptied completely
• Dribbling after urination
• Pain or discomfort when passing urine
• Recurrent urinary tract infections
• Difficulty passing a catheter
• Complete inability to pass urine in more severe cases

These symptoms can also be caused by prostate enlargement, infection, bladder problems or other urinary conditions. Specialist assessment is therefore important before deciding on treatment.

What causes urethral strictures?

A stricture forms when the lining of the urethra is damaged and heals with excessive scar tissue. Possible causes include:

• Previous urinary catheterisation
• Previous cystoscopy or surgery through the urethra
• Surgery for prostate or urethral conditions
• Injury to the pelvis or perineum
• Previous infection or inflammation
• Sexually transmitted infection
• Radiotherapy or other prostate cancer treatments
• Previous hypospadias surgery
• Lichen sclerosus, sometimes known as BXO
• An unknown cause

In many patients, no definite cause can be identified.

How is a urethral stricture diagnosed?

Assessment usually begins with a careful discussion about your urinary symptoms, previous operations, catheterisation, infections and any earlier treatment for a stricture.

Tests may include:

Urine testing

A urine sample may be checked for infection, blood or other abnormalities.

Urinary flow test

You will be asked to pass urine into a flow meter. This measures the strength and pattern of your urinary stream.

Bladder scan

An ultrasound scan can measure how much urine remains in the bladder after you have finished urinating.

Flexible cystoscopy

A thin, flexible camera is passed gently through the urethra under local anaesthetic gel. This allows the narrowed area to be seen directly.

Urethrogram

A urethrogram is a specialised X-ray of the urethra. It helps show the exact position and length of the stricture and is particularly important when reconstructive surgery is being considered.

The investigation required will depend on your symptoms, previous treatment and whether a simple endoscopic procedure or a reconstructive operation is being considered. Current European guidance recommends urinary flow assessment and measurement of residual urine, with urethrography used to define strictures before reconstructive surgery.

Treatment options for urethral stricture disease

There is no single treatment that is suitable for every urethral stricture. The recommendation depends on:

• Where the stricture is located
• Its length and severity
• Whether it is the first occurrence or has returned
• The amount of surrounding scar tissue
• Previous dilatations or urethrotomies
• Your general health
• Your personal priorities and preferences

The main options are observation, urethral dilatation, optical urethrotomy, Optilume, intermittent self-dilatation and urethroplasty.

Observation and monitoring

A mild narrowing that is found incidentally and is not causing symptoms may not require immediate treatment. Monitoring may include reviewing symptoms, urinary flow and bladder emptying.

Treatment is usually recommended when the stricture causes troublesome symptoms, recurrent infection, incomplete bladder emptying, urinary retention or deterioration in urinary flow. Current European guidance advises against intervention for certain wide, incidental strictures that are not causing symptoms.

Urethral dilatation

Urethral dilatation stretches and widens the narrowed part of the urethra.

The procedure may be performed using smooth dilators of gradually increasing size or with a balloon. Local anaesthetic gel is commonly used, although some procedures are performed under general or spinal anaesthesia.

A camera examination may be performed at the same time. Some patients need a temporary urinary catheter afterwards.

Advantages of urethral dilatation

• It does not require a cut in the skin
• It is usually performed as a day case
• Recovery is generally quicker than after reconstructive surgery
• It can improve urinary flow promptly
• It may be suitable for a short, simple stricture

Limitations of urethral dilatation

Dilatation stretches the scar but does not remove it. The narrowing may therefore return, particularly if the stricture is long, dense, located in the penile urethra or has already been treated several times.

Dilatation and optical urethrotomy have broadly similar long-term patency outcomes. They work best in carefully selected patients with a first-time, single, short narrowing in the bulbar urethra. Repeated procedures are less likely to provide lasting control and may make the stricture more complex.

Optical urethrotomy

Optical urethrotomy, also called direct vision internal urethrotomy or DVIU, is a telescopic procedure used to open a urethral stricture.

A small telescope is passed through the urethra. The surgeon identifies the scarred area and makes an internal incision through the narrowing. There are no external cuts or stitches.

A urinary catheter is usually left in place for a short period while the area settles. The precise duration depends on the stricture and the procedure performed.

Who may benefit from optical urethrotomy?

Optical urethrotomy may be considered for:

• A first-time stricture
• A single stricture
• A short narrowing, generally less than 2 cm
• A non-completely blocked stricture in the bulbar urethra
• A short, thin recurrence following previous bulbar urethroplasty

It is less effective for long strictures, penile strictures or strictures that have repeatedly returned.

Possible side effects

Temporary burning, discomfort and a small amount of blood in the urine are common after endoscopic treatment. Other possible complications include urinary infection, recurrence of the stricture, difficulty passing urine, creation of an abnormal passage and, less commonly, effects on erections.

Endoscopic treatment is less invasive than urethroplasty, but it does not usually remove the underlying scar. Patients should therefore understand that further treatment may be required if the narrowing returns.

Optilume drug-coated balloon treatment

Optilume is a minimally invasive balloon treatment for selected recurrent urethral strictures.

The balloon is coated with paclitaxel, a medication intended to reduce the regrowth of scar tissue. When the balloon is inflated, it widens the narrowed part of the urethra and delivers the medication directly to the treated area.

Who may be suitable for Optilume?

Optilume is not suitable for every urethral stricture. It is principally considered for selected patients with a recurrent, short bulbar urethral stricture who have already undergone previous endoscopic treatment.

Current European guidance recommends drug-coated balloon dilatation for a recurrent bulbar stricture shorter than 3 cm after at least two previous endoscopic treatments, particularly when the patient is not suitable for or does not wish to undergo urethroplasty. NICE has issued HealthTech guidance supporting its use for recurrent bulbar strictures under defined circumstances, with continued collection of comparative outcome information.

Potential benefits

• No external surgical incision
• Usually performed as a day case
• Shorter recovery than urethroplasty
• May delay or reduce the need for further intervention
• A potential option for patients wishing to avoid open reconstruction

Important limitations

Optilume is not a replacement for urethroplasty in every patient. Long, complex, penile or completely blocked strictures may require a different approach.

Patients must also receive specific advice about paclitaxel and reproductive precautions. Temporary barrier contraception and avoidance of fathering a child for a defined period may be recommended. The treating team will provide instructions based on the current product guidance and individual circumstances.

Clean intermittent self-dilatation

Clean intermittent self-dilatation, also called intermittent self-dilatation or ISD, involves regularly passing a smooth, lubricated catheter through the narrowed area to help keep it open.

It may be recommended after urethral dilatation or optical urethrotomy, particularly when the stricture is likely to return and urethroplasty is not suitable or is not currently being pursued.

What does self-dilatation involve?

A specialist nurse or trained healthcare professional teaches the technique. You are shown:

• Which catheter to use
• How far it should be inserted
• How to maintain clean technique
• How often to perform the dilatation
• What to do if the catheter will not pass
• When to contact the clinical team

The frequency varies considerably. Some patients initially perform self-dilatation more often and then reduce the frequency. Others may only need it weekly. The schedule should always be agreed with the treating team.

Is self-dilatation a cure?

Self-dilatation does not remove the scar and is not considered a permanent cure. Its purpose is to stabilise the narrowing, maintain urinary flow and reduce the likelihood of needing repeated operations.

It can reduce recurrence after dilatation or urethrotomy, but some patients find long-term self-dilatation inconvenient, uncomfortable or intrusive. The benefits and effect on quality of life should therefore be discussed openly.

Possible problems

These may include:

• Mild discomfort or stinging
• A small amount of bleeding
• Urinary tract infection
• Difficulty passing the catheter
• Trauma to the urethra
• Creation of a false passage if excessive force is used
• Anxiety or difficulty continuing the treatment long term

The catheter should never be forced. Patients should seek advice if it will not pass, if there is significant bleeding, worsening pain, fever or symptoms of infection.

Self-dilatation and self-catheterisation

Self-dilatation is performed mainly to keep a narrowed section of urethra open. Clean intermittent self-catheterisation is usually performed to empty the bladder. The equipment and technique may appear similar, but the clinical purpose is different.

Urethroplasty

Urethroplasty is reconstructive surgery to repair the narrowed section of urethra. It is generally the most durable treatment for longer, complex or recurrent strictures.

Depending on the length and position of the narrowing, surgery may involve:

Excision and re-joining

A short, severely scarred section is removed and the healthy ends of the urethra are joined together.

Graft urethroplasty

The narrowed urethra is opened and widened using a graft. This is commonly taken from the lining of the inside of the cheek, known as buccal mucosa.

Staged reconstruction

Complex strictures may require more than one operation. This is more likely after previous hypospadias surgery, extensive scarring, lichen sclerosus or several unsuccessful earlier procedures.

When is urethroplasty considered?

Urethroplasty may be recommended for:

• A long urethral stricture
• A penile urethral stricture
• A dense or nearly complete narrowing
• A stricture that has returned after dilatation or urethrotomy
• A complex stricture following injury, surgery or inflammation
• A patient seeking a more durable alternative to repeated endoscopic procedures

A catheter is normally required for several weeks after surgery while the repair heals. A urethrogram may be performed before catheter removal. Recovery is longer than after dilatation or urethrotomy, but urethroplasty generally offers the best prospect of lasting urethral patency in appropriately selected patients.

Possible risks of urethroplasty

These depend on the position and complexity of the repair but may include:

• Bleeding or infection
• Wound discomfort
• Temporary discomfort from the catheter
• Recurrence of the stricture
• Urine leakage from the repair
• Mouth discomfort if a cheek graft is used
• Changes in ejaculation or erections
• Penile shortening or curvature in selected complex repairs
• Need for further surgery

When specialist reconstruction is indicated, Mr Shahzad can explain the findings and arrange referral to an appropriate reconstructive urethral surgery service.

Which treatment is right for me?

The least invasive treatment is not always the best long-term treatment, and the most extensive treatment is not necessary for every patient.

For a first-time, short bulbar stricture, dilatation or optical urethrotomy may be reasonable. For a suitable recurrent short bulbar stricture, Optilume may provide another minimally invasive option. For longer, penile, dense or repeatedly recurrent strictures, urethroplasty may offer a better prospect of durable control.

Repeated dilatations or urethrotomies should not automatically continue without reviewing the overall treatment strategy. Current guidance advises against repeated endoscopic treatment when urethroplasty is a realistic option because repeated procedures may increase the complexity of the scar.

Recovery and follow-up

Recovery depends on the procedure performed.

After dilatation, optical urethrotomy or Optilume, many patients return home the same day. Mild burning, urinary frequency and a small amount of blood may occur temporarily. A catheter may be required for several days.

Recovery from urethroplasty takes longer. Physical activity is restricted while the repair heals, and the catheter usually remains in place for several weeks.

Follow-up may include:

• Review of urinary symptoms
• Urinary flow testing
• Bladder scan
• Urine testing
• Cystoscopy or urethrogram when required
• Discussion of self-dilatation where appropriate

Patients should report any gradual weakening of urinary flow because this may be an early sign that the stricture is returning.

Need urgent help?

Seek urgent medical attention if you:

• Cannot pass urine
• Develop fever or feel acutely unwell with urinary symptoms
• Have severe or increasing pain
• Develop heavy bleeding or pass large blood clots
• Have a catheter that stops draining
• Develop marked swelling or discharge after an operation

Depending on the severity of the symptoms, contact NHS 111, your GP, an urgent treatment centre, A&E or the emergency services.

Private urethral stricture assessment in Birmingham

Mr Syed Ali Shahzad provides consultant-led assessment for patients with weak urinary flow, difficulty passing urine, recurrent strictures and other urethral symptoms across Birmingham, Worcestershire and the West Midlands.

The consultation focuses on identifying the position and severity of the narrowing and discussing the relative benefits, limitations and recovery associated with each treatment.

Urethral stricture treatment pathway

Symptoms reviewed

• Weak, slow or spraying urinary stream
• Straining or difficulty starting urination
• Incomplete bladder emptying
• Recurrent urinary infection
• Previous urethral treatment
• Difficulty passing a catheter

Tests considered

Urine testing

• Urinary flow assessment
• Post-void bladder scan
• Flexible cystoscopy
• Urethrogram where appropriate

Treatment options discussed

• Observation for selected mild strictures
• Urethral dilatation
• Optical urethrotomy
• Optilume for suitable recurrent strictures
• Clean intermittent self-dilatation
• Referral for urethroplasty when appropriate

Consultant-led decision making

Mr Shahzad will explain what the investigations show, whether treatment is needed and which option is most appropriate for your particular type of stricture. Treatment decisions are based on anatomy, previous procedures, general health and personal preference.

Common questions

Can a urethral stricture heal on its own?

Scar tissue does not usually disappear without treatment. A mild narrowing may remain stable and can sometimes be monitored, but a symptomatic or worsening stricture usually requires active management.

Is urethral dilatation painful?

Local anaesthetic gel is used, and some procedures are performed under general or spinal anaesthesia. Mild discomfort, burning and temporary bleeding may occur afterwards.

Is optical urethrotomy the same as dilatation?

No. Dilatation stretches the narrowing, while optical urethrotomy makes an internal incision through the scar. Both are endoscopic procedures and neither removes all of the underlying scar tissue. Their long-term outcomes are broadly similar in appropriately selected short strictures.

How many times can dilatation or urethrotomy be repeated?

A repeat procedure may occasionally be reasonable, but repeated cycles are unlikely to provide permanent control. When a stricture continues to return, Optilume or urethroplasty should be discussed rather than continuing repeated procedures automatically.

Is Optilume better than ordinary dilatation?

Optilume combines balloon dilatation with delivery of medication intended to reduce scar regrowth. It may provide better control for selected recurrent short bulbar strictures, but it is not suitable for all strictures and does not replace urethroplasty in complex disease.

Will I need to perform self-dilatation?

Not everyone needs self-dilatation. It may be recommended after dilatation or urethrotomy when there is a significant risk of recurrence and definitive reconstruction is not being performed.

How long is self-dilatation continued?

The duration varies. Some patients use it for a defined period, while others require longer-term treatment. Stopping may allow the narrowing to recur, so changes should be discussed with the treating team.

Is urethroplasty a major operation?

Urethroplasty is more involved than endoscopic treatment and requires a longer recovery and temporary catheter. However, it generally provides the most durable treatment for longer or recurrent strictures.

Do I need a GP referral?

Self-pay patients can usually request a private consultation directly. Insured patients should check whether their insurer requires a GP referral or prior authorisation.

Where are appointments available?

Private appointments are available across Birmingham, Worcestershire and the West Midlands, subject to hospital and clinic availability.