Treatment Options for Urethral Stricture

There are three main treatment options for urethral stricture disease: dilation, internal urethrotomy, and open urethroplasty.

In this article, you will find a straightforward explanation of how each method works, along with its advantages and disadvantages. The most suitable treatment depends on the location, length, cause of the stricture, and how many previous treatments you have had.

The Difference Between the Three Methods at a Glance

In the simplest terms:

• Dilation stretches the narrowed area open.

• Internal urethrotomy opens the stricture by cutting it from the inside.

• Urethroplasty surgically repairs or reconstructs the diseased section.

The first two methods are “closed” or endoscopic procedures and usually provide temporary relief. Urethroplasty, on the other hand, is an open surgical procedure and offers the most durable solution.

1. Urethral Dilation

Closed / Endoscopic procedure

How is it performed?

The narrowed section is gently widened using progressively larger dilators or a balloon. The urethra is not cut; it is opened by stretching the narrowed area.

Success rate after the first procedure: approximately 30–60%

Success rates may be higher in short, first-time bulbar strictures.

Advantages

• It is the simplest and least invasive option.

• It is quick and recovery is usually fast.

• It can be repeated in an outpatient setting when necessary.

Disadvantages

• In many patients, the stricture returns over time.

• It is not considered a permanent solution and usually provides temporary relief.

• Success rates decrease significantly after repeated procedures.

2. Internal Urethrotomy

Closed / Endoscopic procedure

How is it performed?

An endoscope is used to reach the narrowed area, which is then opened from inside with a small blade. It is usually performed under spinal or general anesthesia, and a catheter is placed for a short period afterward.

Success rate after the first procedure: approximately 30–60%

Long-term success after repeat procedures: approximately 0–40%

Advantages

• It is minimally invasive and does not leave an external incision or scar.

• It can be a reasonable first option for short, first-time bulbar strictures.

• The procedure and recovery period are relatively short.

Disadvantages

• The stricture frequently recurs, and success rates drop substantially when the procedure is repeated.

• Repeating the same procedure several times is generally not recommended.

• It is ineffective for long strictures.

3. Open Urethroplasty

Open surgery / Durable solution

How is it performed?

The diseased narrowed section is surgically repaired. There are two main types:

• Anastomotic urethroplasty: the diseased segment is removed and the healthy ends are joined together.

• Graft urethroplasty: a graft, most commonly tissue taken from the inside of the mouth (buccal mucosa), is used to reconstruct the urethra.

Long-term success rate: approximately 80–95%

Advantages

• It is the most durable treatment option with the highest success rate.

• It can provide a long-term solution in a single operation, with a lower recurrence rate.

• It is the most effective option for long, recurrent, or endoscopic-treatment-resistant strictures.

Disadvantages

• It is a larger operation, with a longer hospital stay and catheter duration.

• The catheter usually remains in place for 3–4 weeks.

• Recovery takes longer compared with endoscopic procedures.

• In rare cases, temporary side effects such as erectile dysfunction or urinary incontinence may occur.

Two Important Rules

Anastomotic urethroplasty is used only for trauma-related strictures

Anastomotic urethroplasty, in which the diseased segment is completely removed and the two healthy ends are sewn together, is particularly preferred for short, nearly obliterative bulbar strictures caused by trauma, such as a perineal injury or pelvic fracture.

The European Association of Urology (EAU) Guidelines also recommend this method primarily for short trauma-related strictures.

For non-traumatic strictures, non-transecting repair or graft urethroplasty is generally preferred because these techniques may reduce the risk of erectile dysfunction and other complications.

Dilation and internal urethrotomy are not used for penile urethral strictures

Internal urethrotomy and dilation are not recommended for strictures located in the penile urethra.

There are two main reasons:

• The success rates of these endoscopic procedures are very low in the penile urethra, and the stricture almost always returns.

• Cutting procedures in this area may damage structures involved in erectile function and increase the risk of permanent erectile dysfunction.

For this reason, the EAU Guidelines clearly do not recommend urethrotomy for penile strictures.

The appropriate treatment for penile urethral strictures is usually graft urethroplasty.

Anastomotic repair may only be considered in very selected trauma-related penile strictures shorter than 1 cm.

Which Treatment Is Right for Me?

The decision is based on several factors rather than a single rule:

• Short, first-time bulbar stricture: Dilation or internal urethrotomy may be reasonable first options.

• Long stricture (2 cm or longer): Endoscopic methods are usually insufficient, and urethroplasty is recommended from the outset.

• Recurrent stricture after failed endoscopic treatment: Rather than repeating the same procedure, urethroplasty is recommended. Endoscopic treatment should generally not be repeated more than twice.

• Penile urethral stricture: Dilation and urethrotomy are not used; graft urethroplasty is preferred.

• Short trauma-related stricture: Anastomotic urethroplasty is usually the most appropriate option.

Summary

Dilation and internal urethrotomy are simple, quick, and minimally invasive procedures. However, they do not usually provide a permanent solution, especially in long, recurrent, or penile urethral strictures.

Open urethroplasty is a larger operation, but it offers the highest and most durable success rate. The right treatment should be determined together with your urologist based on the specific characteristics of your stricture.

Frequently Asked Questions

Can a urethral stricture heal on its own?

No. A urethral stricture is scar tissue that forms inside the urinary channel and does not open on its own. Without treatment, urinary flow may become increasingly difficult, and problems such as urinary tract infections or incomplete bladder emptying can develop. If you have symptoms, it is important to see a urologist.

What is the best treatment option?

There is no single best treatment for everyone. The appropriate option depends on the location, length, cause of the stricture, and how many previous treatments you have had.

Endoscopic methods may be considered for short, first-time bulbar strictures. For long, recurrent, or penile strictures, open urethroplasty usually provides the most durable solution.

How many times can internal urethrotomy or dilation be repeated?

These endoscopic methods are generally not recommended to be repeated over and over after the first failure. The likelihood of success drops significantly with each repeat procedure.

Guidelines generally recommend moving to open urethroplasty, if suitable, rather than performing more than two repeat endoscopic treatments.

Why are cutting or dilation procedures not used for penile urethral strictures?

Because success rates for dilation and internal urethrotomy are very low in this area, and the stricture almost always returns.

In addition, cutting procedures may damage structures involved in erectile function and increase the risk of permanent erectile dysfunction. Therefore, graft urethroplasty is usually the preferred treatment for penile urethral strictures.

Can anastomotic urethroplasty be performed for every stricture?

No. This technique is mainly suitable for short, nearly obliterative bulbar strictures caused by trauma, such as a perineal injury or pelvic fracture.

For non-traumatic or long strictures, graft urethroplasty or non-transecting repair is generally preferred.

How long does recovery take after urethroplasty?

Hospital stay is usually a few days. After surgery, you will typically have a catheter for around 3–4 weeks.

Before removing the catheter, healing is often checked with imaging, such as a urethrogram. Return to normal daily activities depends on the catheter period and your overall recovery.

Can the stricture recur after treatment?

The risk of recurrence depends on the treatment method.

Recurrence is common after endoscopic procedures such as dilation and internal urethrotomy. Open urethroplasty has a much higher long-term success rate, approximately 80–95%, and a lower recurrence risk. However, regular follow-up remains important after every treatment.

Will surgery affect sexual function?

Erectile dysfunction may occur after urethroplasty, but it is usually temporary and generally improves within a few months. The risk of permanent dysfunction is low.

In trauma-related cases, there may already be an existing risk related to the original injury. It is helpful to discuss any concerns in detail with your urologist before surgery.

What follow-up checks are needed after treatment?

Follow-up is usually recommended at 3, 6, and 12 months.

During follow-up visits, urinary flow rate testing (uroflowmetry) is performed and symptoms are reviewed. Imaging or cystoscopy may be requested if necessary. A decrease in urinary flow may be an early sign of recurrence.