When (and Why) Strictures Happen


Urethral strictures can occur as a result of radiation treatment for prostate and rectal cancers, surgery for prostate cancer or an enlarged prostate, or trauma to the perineum or genitals. The symptoms of a urethral stricture include straining to pass urine, slowed urine flow, feelings of incomplete emptying, urinary incontinence, and eventually urinary retention. Over time, urethral strictures can lead to poor bladder emptying, resulting in urinary tract infections, bladder stones, and, eventually, irreversible bladder and kidney damage.

Incidence of Urethral Stricture Disease

Urethral strictures most commonly develop one to three years after radiation therapy. (1) However, for many patients, the diagnosis is delayed for several years because the worsening of urinary symptoms is a slow and progressive process. The reported incidence of urethral stricture disease after radiation therapy varies widely within the medical literature. The incidence of urethral strictures after brachytherapy range from 0 to 10.2 percent within 23 to 63 months of follow-up. (2), (3), (4), (5), (6) Similar rates of urethral stricture are reported in several series of high-dose-rate brachytherapy, with stricture rates of 7 to 8 percent at five-year follow-up. (7), (8) The reported incidence of urethral stricture after external beam radiotherapy (EBRT) increases, depending on length of follow-up, with an incidence of less than 7 percent with five years of follow-up, and increasing to 10 to 18 percent when the patient is followed for as long as ten years. (5), (9), (10) (11), (12) In the CaPSURE™ database, urethral stricture rates by radiation modality were as follows: brachytherapy (1.8 percent), EBRT (1.7 percent), and combination RT (5.2 percent) with a median follow-up of 2.7 years. (13)

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Leading-Edge Treatment Alternatives

At Memorial Sloan Kettering, we evaluate and treat urethral stricture disease that results from radiation therapy, surgery, or traumatic injury. The recommended initial treatment options include minimally invasive techniques such as dilation, direct vision internal urethrotomy, or laser urethrotomy.  Surgical urethral reconstruction, or urethroplasty, is available for patients who develop recurrent urethral strictures after a previous unsuccessful endoscopic surgery. A urethroplasty involves removing the scarred tissue and reconnecting the healthy tissue of the urethra by anastomosis. For longer segments of urethral scarring, a graft can be used to re-create a healthy urethra and restore urinary function.

Success rates of urethroplasty vary, based on the cause and the severity of the stricture. For patients who received radiation therapy for prostate cancer, success rates reported in the literature range from 70 to 89 percent. (14), (15) For patients who develop strictures as a result of prior surgery or trauma, success rates after surgical repair can be as high as 95 percent.

Urinary control may be affected in patients with urethral strictures, resulting in urinary incontinence. In this situation, an artificial urinary sphincter can be placed after urethroplasty to safely restore urinary control and to allow the patient to return to an active and even athletic lifestyle. The AMS 800TM artificial urinary sphincter was developed in the 1970s and has been implanted in more than 150,000 prostatectomy patients with excellent long-term outcomes. (16), (17) Recent clinical series have demonstrated this sphincter’s effectiveness in patients who were previously treated with radiation therapy or urethral surgery. (18), (19)

For all patients with urethral stricture disease, early diagnosis can help to prevent damage to the bladder and kidneys. Physicians and their patients should fully discuss all therapeutic options available to determine the solution that best fits each patient’s goals.

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  1. Herschorn S, Elliott S, Coburn M, et al. SIU/ICUD Consultation on Urethral Strictures: Posterior urethral stenosis after treatment of prostate cancer. Urology. 2014;83(3 Suppl):S59-70.
  2. Allen ZA, Merrick GS, Butler WM, et al. Detailed urethral dosimetry in the evaluation of prostate brachytherapy-related urinary morbidity. Int J Radiat Oncol Biol Phys. 2005;62(4):981-7.
  3. Leapman MS, Stock RG, Stone NN, et al. Findings at cystoscopy performed for cause after prostate brachytherapy. Urology. 2014;83(6):1350-5.
  4. Merrick GS, Butler WM, Wallner KE, et al. Risk factors for the development of prostate brachytherapy related urethral strictures. J Urol. 2006;175(4):1376-80.
  5. Zelefsky MJ, Levin EJ, Hunt M, et al. Incidence of late rectal and urinary toxicities after three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys. 2008;70(4):1124-9.
  6. Zelefsky MJ, Yamada Y, Cohen GN, et al. Five-year outcome of intraoperative conformal permanent I-125 interstitial implantation for patients with clinically localized prostate cancer. Int J Radiat Oncol Biol Phys. 2007;67(1):65-70.
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  9. McDonald AM, Baker CB, Popple RA, et al. Increased radiation dose heterogeneity within the prostate predisposes to urethral strictures in patients receiving moderately hypofractionated prostate radiation therapy. Pract Radiat Oncol. 2015.
  10. Lawton CA, Bae K, Pilepich M, et al. Long-term treatment sequelae after external beam irradiation with or without hormonal manipulation for adenocarcinoma of the prostate: analysis of radiation therapy oncology group studies 85-31, 86-10, and 92-02. Int J Radiat Oncol Biol Phys. 2008;70(2):437-41.
  11. Gardner BG, Zietman AL, Shipley WU, et al. Late normal tissue sequelae in the second decade after high dose radiation therapy with combined photons and conformal protons for locally advanced prostate cancer. J Urol. 2002;167(1):123-6.
  12. Chism DB, Horwitz EM, Hanlon AL et al. Late morbidity profiles in prostate cancer patients treated to 79-84 Gy by a simple four-field coplanar beam arrangement. Int J Radiat Oncol Biol Phys. 2003;55(1):71-7.
  13. Elliott SP, Meng MV, Elkin EP, et al. Incidence of urethral stricture after primary treatment for prostate cancer: data From CaPSURE. J Urol. 2007;178(2):529-34.
  14. Glass AS, McAninch JW, Zaid UB, Cinman NM, Breyer BN. Urethroplasty after radiation therapy for prostate cancer. Urology. 2012;79(6):1402-
  15. Hofer MD, Zhao LC, Morey AF, et al. Outcomes after urethroplasty for radiotherapy induced bulbomembranous urethral stricture disease. J Urol. 2014;191(5):1307-12.
  16. Haab F, Trockman BA, Zimmern PE, Leach GE. Quality of life and continence assessment of the artificial urinary sphincter in men with minimum 3.5 years of followup. J Urol. 1997;158(2):435-9.
  17. Litwiller SE, Kim KB, Fone PD, White RW, Stone AR. Post-prostatectomy incontinence and the artificial urinary sphincter: a long-term study of patient satisfaction and criteria for success. J Urol. 1996;156(6):1975-80.
  18. Brant WO, Erickson BA, Elliott SP, et al. Risk factors for erosion of artificial urinary sphincters: a multicenter prospective study. Urology. 2014;84(4):934-8.
  19. McGeady JB, McAninch JW, Truesdale MD, Blaschko SD, Kenfield S, Breyer BN. Artificial urinary sphincter placement in compromised urethras and survival: a comparison of virgin, radiated and reoperative cases. J Urol. 2014;192(6):1756-61.