Urethral Stricture

By Nick Peplow·Gender-affirming surgery coordinator

Last reviewed 27 September 2026· How this site is researched

A urethral stricture is a narrowing of the urethra caused by scar tissue, so urine has to squeeze through a smaller channel. After metoidioplasty or phalloplasty with urethral lengthening, it's one of the two urethral complications, paired with fistula, and the two often turn up together. If your urethra wasn't lengthened, this page doesn't apply.

Why it happens

Every join between two pieces of urethra heals with scar, and scar contracts. If it contracts far enough, the channel narrows. The usual site is the join where the new urethra meets your original one, near the base. The second is the opening at the tip (the meatus), which can tighten as it heals. A phalloplasty urethra built in two sections has a second join along the shaft, so one more place for it. A thin blood supply to the flap, a nearby fistula or infection, and tissue closed under tension all raise the odds.

How common it is

Common rather than rare. As the fistula page explains, published figures lump the two together and vary too much to quote. One thing is consistent and worth planning for: a treated stricture has a real chance of narrowing again, so a second procedure is a possibility rather than a failure. Your surgeon's own stricture rate, quoted separately from their fistula rate, is the number to plan around.

When it shows up

Later than a fistula, as a rule. Fistulas tend to appear in the weeks after the catheter comes out; strictures creep in over months, often from around month three. Most are picked up in the first year, often on a follow-up flow test. Late ones years after surgery happen too, so any change in how you pee is worth reporting however long it's been.

What it feels like

• A stream that weakens over days or weeks, so gradually you adjust without noticing
• Having to strain or push to start, or to keep going
• A spraying, split or twisting stream that had settled and has come back
• Dribbling after you've finished, or taking much longer to empty
• Feeling you haven't emptied fully, and needing to go again soon after
• Repeated urinary infections
• A new fistula opening upstream, because the blocked urine forces its way out

Spraying and dribbling in the first weeks after the catheter comes out are normal and usually settle as swelling goes down. What points to a stricture is a stream that was fine and then got worse. Dribbling can also come from a diverticulum, a small pouch in the urethra that traps urine, which the urethral lengthening page describes.

A stricture that closes off completely means you can't pass urine at all. That's acute retention, and it's an emergency.

When to call and when to go to hospital

Contact your surgeon's team within a few days if:

• Your stream has got noticeably weaker or thinner
• You're straining, dribbling or can't seem to empty
• You've had two or more urinary infections since surgery
• A fistula has appeared or reopened

Call the same day if you have burning, cloudy or smelly urine with a temperature. Infection behind a narrowing gets worse faster.

Go to an emergency department, or call an ambulance, if:

• You can't pass urine at all, or only drops, and your lower belly is swelling and painful
• You have a fever with pain in your back or side below the ribs, which can mean infection has reached the kidneys
• You feel confused, faint or have a racing heart alongside a fever

Don't sit through retention overnight hoping it'll ease. The bladder needs draining. Because the new urethra may not take a catheter easily, and a forced attempt can tear it, the usual answer is a suprapubic catheter, placed through the lower belly straight into the bladder. Tell the staff you've had urethral lengthening, and ask them to contact your surgical team or the on-call urologist before anything is passed up the urethra. The most useful thing I've seen people carry is the operation summary from their surgeon, on paper and on their phone. An emergency doctor who has never seen a lengthened urethra can then see exactly what was built and where the joins are.

How it's diagnosed

Your surgeon or a urologist will usually start with a flow test, peeing into a machine that measures how fast the stream runs, and a bladder scan to see how much is left behind afterwards. If those point to a narrowing, they look at the urethra directly, with a thin camera (a cystoscopy) or an X-ray with dye run through it (a urethrogram). That shows where the narrowing is, how long it is and how scarred the tissue around it looks. Those three things decide the treatment.

Treatment options

Dilation. Stretching the narrowing with gradually larger instruments, often in clinic under local anaesthetic. It gives quick relief, but a stricture that's been stretched tends to tighten again, often within months. Some people are taught to pass a catheter themselves on a schedule to keep it open, which works as long-term management for some. That is taught by a urologist, with the kit supplied, and never improvised. The dilation glossary entry has more.

Urethrotomy. Cutting the scar from the inside through a scope, with a small blade or laser, under anaesthetic. Good short-term relief, high recurrence for longer or repeat strictures, and most urologists try it once at most, because repeated cutting makes the scar worse.

Urethroplasty. Open surgical repair. For a short stricture the narrowed piece is cut out and the ends rejoined. For a longer one the urethra is opened along its length and widened with a graft, usually lining from inside the cheek (buccal mucosa), which is tough, hairless and used to being wet. Some repairs are done in two stages months apart, with the urethra left open in between. This has the best long-term results of the three, at the cost of a bigger operation, a catheter for a couple of weeks, and a sore mouth for about a week. Surgeons usually wait until the tissue has settled, often several months after the original operation.

Perineal urethrostomy. After repeated failures, or when someone decides they've had enough, the urethra can be brought out to a permanent opening behind the scrotum. You sit to pee, but reliably and without more surgery, and the phallus stays as it is. The people I've seen take this route mostly describe relief rather than defeat, and it's worth knowing the option exists before you commit to lengthening.

Cost and planning

A stricture revision is billed like a fistula repair, toward the lower end of the separate-stage prices on the urethral lengthening page, with its own US insurance authorisation or a return trip abroad. Ask before you book whether dilation and revision are in the quote.

Living with it

Until the definitive fix, most people get by with dilation, sitting to pee, plenty of fluids and getting infections treated early rather than riding them out. Keep a rough note of your stream (how long a pee takes, whether you strain, whether it sprays), because a gradual change is the earliest warning and the hardest to notice from the inside. For the wider shape of bottom surgery recovery see bottom surgery recovery, and for complications that drag on, mental health.

This is general information, not medical advice. Which treatment suits your stricture is a decision for your surgeon or urologist.