A man in his thirties notices his stream isn't what it was. It takes longer to start, sprays rather than flows, and he finds himself pushing. He assumes it's stress, or ageing, or something that will settle. It doesn't.
Eventually he sees a doctor, is told it might be his prostate, and is given a tablet that does nothing. The reason it does nothing is that his prostate is fine. The problem is scar tissue in the urethra.
What a stricture actually is
The urethra is the tube carrying urine from the bladder out through the penis. When its lining is injured — by trauma, infection, or an instrument passed through it — it heals with scar tissue. Scar tissue contracts. The tube narrows.
The critical difference from prostate enlargement: a stricture is scarring within the wall of the tube itself. Prostate enlargement squeezes the urethra from outside. That distinction determines everything about treatment, which is why drugs that relax the prostate have no effect on a stricture — there is nothing there for them to relax.
Why it gets mistaken for a prostate problem
Both produce the same complaints — weak stream, hesitancy, straining, incomplete emptying. So the symptoms alone don't separate them.
What should raise suspicion of a stricture:
- Age. Strictures affect men of any age, including their twenties and thirties. Significant prostate enlargement in a 32-year-old is rare; a stricture is not.
- A spraying or forked stream, or one that deviates — quite characteristic.
- A relevant history — catheterisation, previous endoscopic surgery, straddle injury, or past infection.
- No response to alpha-blockers. If a tablet for a supposed prostate problem changes nothing, question the diagnosis rather than adding another drug.
A man under 50 with a weak stream should have a stricture actively excluded, not assumed to have early prostate enlargement. A simple flow test and examination point the way quickly.
Symptoms
- Weak, slow or spraying stream — usually the first sign
- Straining, hesitancy, prolonged voiding
- Incomplete emptying, and going again soon after
- Post-void dribbling
- Recurrent urinary infections
- Pain or burning on passing urine
- In severe cases, complete inability to pass urine — a medical emergency
Symptoms typically progress slowly over months or years, which is exactly why men adapt and delay.
What causes it
Iatrogenic — caused by medical procedures. The commonest cause today. Catheterisation, particularly prolonged or traumatic; endoscopic surgery such as TURP; previous urethral instrumentation.
Trauma. Straddle injuries — falling onto a bar, a bicycle crossbar, the edge of a wall — and pelvic fractures from road traffic accidents, which can disrupt the urethra completely.
Infection. Historically gonorrhoea was a leading cause; less common now, but still seen.
Lichen sclerosus (BXO), an inflammatory skin condition affecting the glans and urethral opening.
Idiopathic. A substantial proportion have no identifiable cause.
How it's diagnosed
Uroflowmetry. You pass urine into a machine that plots flow rate. A stricture typically produces a characteristic flat, plateau-shaped curve — quite different from the pattern of prostate obstruction. A useful, quick, non-invasive first test.
Post-void residual by ultrasound.
Retrograde urethrogram (RGU). Contrast is injected at the tip of the urethra and X-rays taken. This shows exactly where the narrowing is and, importantly, how long it is — the single most important factor in choosing treatment.
Urethroscopy. Direct visual inspection with a fine flexible telescope.
Ultrasound of the urethra in selected cases, to assess the depth of scarring.
The dilatation cycle — and why it fails
This is the part most patients are not told, and it matters enormously.
The two endoscopic treatments — dilatation (stretching the narrowing) and direct vision internal urethrotomy, DVIU (cutting it from inside) — are quick, done through the urethra, and offer fast relief.
But neither removes the scar. They stretch or cut it, and it heals — by scarring again. Often with a longer, denser stricture than before.
The numbers make the point plainly. A first DVIU for a short bulbar stricture is a reasonable attempt. But repeat endoscopic procedures have success rates below 20%, and repeated instrumentation is associated with the stricture progressing and becoming harder to reconstruct later. Guidance is explicit that repeat endoscopic treatment should not be offered as an alternative to reconstruction.
Meanwhile, comparative data show that men who undergo urethroplasty have around a 48% lower risk of needing further intervention, with recurrence roughly 19% after urethroplasty versus 39% after urethrotomy.
So a man having his fourth dilatation is not receiving conservative management. He is on a treadmill that is making the definitive operation progressively more difficult.
If you have had more than one dilatation or urethrotomy for the same stricture, that is the moment to ask for a referral to someone who performs urethroplasty — and to ask specifically why reconstruction is not being offered.
Urethroplasty
Open reconstructive surgery to remove or repair the scarred segment. Broadly two approaches:
Excision and primary anastomosis. For short strictures, typically under about 2 cm in the bulbar urethra. The scarred segment is cut out and the healthy ends joined. Success rates are high and durable.
Substitution urethroplasty. For longer strictures, the narrowed segment is widened using a graft — most commonly buccal mucosa taken from inside the cheek. It suits the job well because it is thin, tough, used to a wet environment and heals quickly, and the donor site inside the mouth recovers within a couple of weeks.
Success rates consistently exceed 85% in appropriately selected patients, with benefit sustained on long-term follow-up. Recovery involves a catheter for two to three weeks, and an X-ray before it is removed to confirm healing.
It is a bigger operation than a dilatation. It is also, for most strictures, the one that ends the problem rather than postponing it.
Frequently asked questions
How is a stricture different from prostate enlargement?
A stricture is scar tissue inside the urethra; prostate enlargement squeezes it from outside. Strictures affect men of any age, including their twenties. Prostate drugs don't help a stricture.
Does dilatation cure it?
Rarely. It stretches the scar, which heals by scarring again. One attempt is reasonable for a short bulbar stricture; repeated attempts have low success and make later reconstruction harder.
Will urethroplasty affect erections?
Temporary changes in sensation or erectile function can occur and usually settle within months. Permanent problems are uncommon in experienced hands, and should be discussed specifically before surgery.
Can a stricture damage the kidneys?
Yes, if neglected. Long-standing obstruction thickens the bladder and can eventually raise pressure in the kidneys, alongside infection, bladder stones and retention.
Can it come back after urethroplasty?
Recurrence is possible but much less likely than after endoscopic treatment. Most recurrences appear within the first two years, which is why follow-up with flow testing is standard.
Medically reviewed by Dr. Navdeep Garg, MCh (Urology), FEBU. This article is general information about urological conditions and does not constitute medical advice. Treatment decisions depend on individual assessment. For any medical concern, please consult a qualified physician.