How common are urethral strictures after repeated urethral instrumentation compared with a single episode of trauma?
Executive summary
Repeated urethral instrumentation—through catheterization, multiple endoscopic procedures, or long-term clean intermittent catheterization—emerges in contemporary literature as a leading, and often more frequent, pathway to urethral stricture formation and recurrence than a single external traumatic episode in many care settings [1] [2] [3]. Severe single traumas (eg, pelvic fracture urethral distraction) still cause clinically important strictures with distinctive management challenges, but epidemiology and recurrence data show iatrogenic/repeated injury is a common and preventable driver of disease in developed-care contexts [4] [5].
1. Repeated instrumentation: a common and high-risk pathway
Modern reviews and guidelines identify iatrogenic causes—including repeated instrumentation, catheterization, and transurethral surgery—as a dominant etiology for urethral strictures in developed health systems, with one procedural group (transurethral resection) accounting for roughly 41% of iatrogenic strictures in some series, and clean intermittent catheterization linked to increased injury risk in patients requiring long-term CIC [1] [6] [3].
2. Numbers and recurrence: how often do strictures follow instrumentation?
Quantitative data vary by study and definition, but recurrence after endoscopic treatment (often following instrumentation) is substantial—one cohort reported an overall recurrence rate of 37% with a mean time to recurrence of about 4.5 months after optical urethrotomy—while guideline-cited cohorts following catheter-related urethral trauma reported up to 78% of a small referred group developing strictures, signalling that instrument-related injury commonly leads to stricture formation or exacerbation [7] [8].
3. Single traumatic events: less common but clinically distinct
Epidemiology shows that external blunt pelvic or perineal trauma is an important cause of urethral stricture, particularly posterior strictures after pelvic fracture, and remains the predominant cause in low-income regions where traffic injuries are frequent [1] [5]. However, contemporary series of anterior urethral strictures often find idiopathic and iatrogenic causes to outnumber traumatic ones, indicating single trauma is relatively less common in many datasets [4].
4. Outcomes differ by cause and prior interventions
Etiology matters for prognosis: trauma-associated and lichen sclerosus–related strictures can have poorer long-term outcomes after urethroplasty, and multiple prior interventions (ie, repeated instrumentation or failed repairs) worsen patency and increase recurrence risk; guideline panels emphasize that prior instrumentation is both a cause and a predictor of worse surgical outcomes [9] [1].
5. Practical takeaway and limits of the evidence
Taken together, the literature argues that repeated urethral instrumentation is at least as important—and in many developed-care cohorts more frequent—as a cause of urethral stricture and is strongly associated with recurrence, whereas a single episode of severe trauma produces a distinct subset of strictures with different anatomy and treatment implications [2] [4] [3]. These conclusions rely on heterogeneous data sources (cohort studies, guideline summaries, and single-center series) with variable follow-up, differing definitions of “recurrence,” and limited population-based incidence studies; where specific population-level incidence comparisons are not provided by the cited sources, that gap is acknowledged rather than asserted [7] [2].
6. Policy and clinical implications: prevent what is avoidable
Because many instrument-related strictures arise from modifiable practices—traumatic catheterization, repeated unnecessary dilations, oversized instruments or poor lubrication during endoscopy—guidelines and reviews stress prevention (avoid unnecessary catheterization and careful technique) and judicious use of repeated endoscopic interventions, particularly since repeated instrumentation both causes and complicates subsequent management [8] [4] [6].