Urethral stricture in boys: a weak stream and straining

What is a urethral stricture?

The urethra is the tube that carries urine from the bladder out of the body. When scar tissue forms in its wall, the tube narrows and urine cannot flow freely. This is called a urethral stricture.

Strictures are rare in children. The narrowing can be anywhere along the tube: inside the penis, behind the scrotum or close to the bladder.

A urethral stricture is not the same as meatal stenosis: in meatal stenosis only the opening at the tip of the penis is narrow, while a stricture narrows the tube further inside.

Causes

• Previous surgery or procedures. This is the most common cause. Most of these boys have had hypospadias repair in the past. A urinary catheter can also cause narrowing.
• Injury. A damaged urethra heals with a scar.
• Congenital stricture. This term is used when there has been no previous procedure, injury or infection.
• Inflammation and infection. These are less common causes.

After hypospadias repair, strictures are more common in severe (proximal) forms. Complications can appear soon after surgery or years later. This is why these boys are followed for a long time.

Symptoms

• a thin, weak or interrupted stream,
• straining to pee, spending a long time on the toilet,
• the bladder not emptying fully,
• repeated urinary tract infections,
• daytime or nighttime wetting, pain when peeing,
• sometimes blood in the urine.

Parents often notice that the stream is weaker than before and that their son spends a long time on the toilet. If after hypospadias repair the urine comes out in a thin trickle or the underside of the penis balloons while he pees, have him checked by a doctor.

Diagnosis

• Uroflowmetry. Your son pees into a special device that records the speed and shape of the stream. Then the urine left in the bladder is measured with ultrasound. This is a simple first step, but a normal result does not fully rule out a stricture.
• Contrast X-ray. Contrast is put into the urethra and images are taken while it fills and while he pees. The site and length of the narrowing can be seen. A voiding cystourethrogram is part of this study.
• Endoscopy. Under anesthesia, the urethra is examined with a thin camera (cystoscopy).

Treatment

Treatment depends on where the narrowing is, how long it is and what caused it.

• Endoscopic treatment. The tube is stretched or cut from the inside under direct vision (urethrotomy). This is less invasive, but in children the narrowing often comes back. Repeat cutting works even less well, so doctors try not to repeat it again and again.
• Open repair (urethroplasty). For a short stricture, the narrowed part is removed and the healthy ends are stitched together. For a long stricture, the tube is widened with tissue from the inside of the cheek (a graft) or a local skin flap. In studies, open repair lasted much better than endoscopic treatment.

The choice of method is discussed for each child individually. After surgery, the stream is checked with uroflowmetry.

When to see a doctor

If the stream has become weaker, your son strains or he has frequent infections, book a routine appointment. If he cannot pee at all, his lower belly is swollen and painful, or he has a fever along with a weak stream, seek urgent care without waiting for an appointment.

Boys who have had hypospadias repair should come to follow-up visits even when there are no complaints.