About Ureteric Stricture

A ureteric stricture is a narrowing of the ureter, the tube that carries urine from the kidney to the bladder, which restricts or blocks urine flow.Ureteric Stricture is a common problem for males. The reason behind it is that males have a longer urethra. Ureteric Stricture is rarely an occurrence in females and children. Ureteric Stricture can occur at any age and at any point of the urethra, from tip to the bladder. Any such structure can restrict the flow of the urine and cause a lot of problems. Some of the reasons for Ureteric Stricture are:

Signs and Symptoms of Ureteric Stricture

• blood in urine or dark-colored urine
• bloody semen
• obstructed urine stream
• spraying urine stream
• pain while urinating
• abdominal pain
• urethral leaking
• UTIs in men
• swelling of the penis
• loss of bladder control

Causes of Ureteric Stricture

• Any Shock or Trauma to the Urethra or Ureter:
  • Mechanism: Physical injury to the ureter or nearby structures (like the urethra) can cause scarring that narrows the ureter. While your phrasing mentions “shock to the urethra,” trauma to the ureter itself is more directly relevant, though urethral injury can indirectly affect the urinary tract.
  • Examples: Blunt trauma (e.g., a car accident impacting the abdomen or pelvis), penetrating injuries (e.g., gunshot wounds), or even kidney stone passage that tears the ureter lining can trigger inflammation and scar tissue formation.
  • Process: After trauma, the body heals by laying down fibrous tissue. Excessive scarring contracts the ureter’s diameter, creating a stricture over weeks to months.
• Infection, Such as a Sexually Transmitted Disease (STD):
  • Mechanism: Chronic or severe infections can inflame the ureter, leading to scarring and narrowing. While STDs primarily affect the urethra, untreated cases can ascend to the upper urinary tract, including the ureter.
  • Specific STDs: Gonorrhea or chlamydia, if untreated, may spread beyond the urethra to cause pelvic inflammatory disease or ureteritis (ureter inflammation). Tuberculosis (less common in the West) can also affect the urinary tract, causing strictures via chronic inflammation.
  • Process: Repeated infection damages the ureter’s mucosal lining, prompting fibrosis. For example, a history of recurrent urethritis from an STD could indirectly contribute if inflammation reaches the ureteral junction.
• Damage from Surgery:
  • Mechanism: Surgical procedures near the ureter can inadvertently injure it, leading to scar tissue and stricture formation.
  • Common Scenarios:
    • Urologic Surgery: Procedures like ureteroscopy (for kidney stones) or lithotripsy can nick or perforate the ureter, especially if stones are large or jagged.
    • Pelvic Surgery: Gynecologic (e.g., hysterectomy), colorectal, or vascular surgeries risk accidental ureteral ligation, cutting, or thermal injury from cautery.
    • Post-Surgical Effects: Radiation therapy for pelvic cancers (e.g., prostate, cervical) can also cause delayed strictures by damaging ureteral tissue over time.
  • Process: Surgical trauma triggers an inflammatory response, and healing often involves collagen deposition. If excessive, this scars and stiffens the ureter, reducing its lumen.

Other Causes 

• Kidney Stones: Chronic stone passage or lodged stones can erode the ureter, causing strictures.
• Congenital Factors: Some are born with narrow ureters that worsen with age.
• Cancer: Tumors in or near the ureter (intrinsic or extrinsic) can compress or invade it, mimicking a stricture.

Ureteric Stricture Risk Factors

• History of Trauma: Past abdominal or pelvic injuries increase likelihood.
• Recurrent Infections: Frequent UTIs or STDs raise the risk of upper tract involvement.
• Prior Surgery: Recent or multiple pelvic/urologic procedures heighten exposure.
• Age and Gender: More common in adults with surgical or stone histories; no strong gender bias, though causes differ (e.g., gynecologic surgery in women).

Ureteric Stricture Complications

• Hydronephrosis: Blocked urine flow backs up into the kidney, causing swelling and potential damage.
• Infections: Stagnant urine above the stricture breeds bacteria, risking pyelonephritis or sepsis.
• Kidney Damage: Chronic obstruction can lead to atrophy or loss of kidney function.
• Pain: Flank or abdominal discomfort from pressure or stone-like symptoms.
• Stone Formation: Poor urine flow can crystallize minerals, worsening obstruction.

Ureteric Stricture Diagnosis

Physical Exam

• A doctor evaluates external signs like swelling, redness, or discharge around the urethral opening. They may palpate the urethra along the penis or perineum (in men) to feel for hardening or scar tissue. Urine flow rate might be observed—weak or interrupted flow can hint at a stricture. In men, the prostate may also be checked to rule out related issues.

Urethral Imaging (X-rays or Ultrasound)

• X-rays: Often paired with contrast dye (see retrograde urethrogram below) to visualize the urethra’s structure and pinpoint narrowing.
• Ultrasound: Uses sound waves to create images of the urethra and surrounding tissues. It’s non-invasive and can assess the stricture’s length, location, and severity, plus detect any associated abnormalities like bladder thickening from obstruction.

Urethroscopy (To See the Inside of the Urethra)

• A thin, flexible scope with a camera (cystoscope) is inserted into the urethra to directly visualize the stricture. This allows the doctor to see the degree of narrowing, inflammation, or scar tissue. It’s often done under local anesthesia and can also guide minor treatments like dilation during the procedure.

Retrograde Urethrogram

• A specialized X-ray where contrast dye is injected into the urethra through the tip of the penis. The dye outlines the urethra as it flows backward (retrograde), highlighting the stricture’s exact location, length, and tightness on the X-ray image. It’s considered the gold standard for diagnosing urethral strictures in men.

Additional Diagnostic Methods for Urethral Stricture

1. Urine Flow Studies (Uroflowmetry)

• Measures the speed and volume of urine flow. A slow or irregular flow pattern can suggest a stricture blocking normal urination, prompting further imaging or scoping.

2. Post-Void Residual (PVR) Measurement

• Uses ultrasound to check how much urine remains in the bladder after urination. A high residual volume might indicate obstruction from a stricture, as the bladder struggles to empty fully.

3. Urinalysis or Urine Culture

• Tests urine for signs of infection, blood, or inflammation, which can either cause or result from a stricture. Recurrent infections are common with urethral narrowing.

4. Cystourethrography (Voiding Cystourethrogram - VCUG)

• Similar to a retrograde urethrogram but done while the patient urinates after the bladder is filled with contrast dye. It shows how the stricture affects urine flow and can reveal issues in the bladder or upper urinary tract.

5. MRI or CT Scan (Rarely Used)

• In complex cases, advanced imaging like MRI or CT might be employed to assess surrounding tissues, especially if the stricture is linked to trauma, cancer, or pelvic injury. This is less common but useful for surgical planning.

Treatment for Ureteric Stricture

Ureteric Stricture cannot be treated with medication and other treatments are used for a successful recovery. At MASSH hospital we recommend different types of treatment for ureteric stricture depending upon the size of the stricture. We recommend the following ureteric stricture treatment:

• Holmium Laser Endoureterotomy : Holmium Laser Endoureterotomy is a minimally invasive endoscopic procedure using a holmium laser to cut and open a ureteral stricture, restoring urine flow from the kidney to the bladder.
• Ureteric reimplantation: Ureteric reimplantation is a surgery to reposition or re attach the ureter into the bladder to restore proper urine flow and prevent complications like reflux or obstruction.