Introduction
Stenosis of the urethra can be defined as a reduction in the size, more or less extended, of the urethral canal. It is a relatively common condition among men with a prevalence of 229-627 per 100,000 inhabitants or 0.6% of the population at risk in Cameroun.1 It remains a major urological challenge worldwide, particularly in low-resource settings where diagnostic delays and limited therapeutic options lead to severe complications and permanent disability.2 In Western countries, iatrogenic causes predominate because of the widespread use of endoscopic procedures.3 In contrast, African studies have historically reported infectious etiologies, particularly gonococcal urethritis, as the leading cause.4 However, this pattern is shifting as road traffic accidents increase and health care-associated catheter injuries persist.5 In the Democratic Republic of the Congo (DRC), and particularly in South Kivu Province, published epidemiological data on urethral stricture remain limited; where no national data on the prevalence and burden of the disease exists. With multiple wars in eastern DRC there was no public investment in health system and there’s no insurance; therefore, patient have to pay from their pockets contributing in delay on presentation and limited access to some investigation. This study therefore aimed to determine the hospital frequency of urethral stricture at the General Referral Hospital of Panzi, and to describe the sociodemographic and clinical characteristics, etiologies, and anatomical site of the stricture, as well as the treatments received and in-hospital outcomes of affected patients.
Methods
Study design and setting
This cross-sectional study was conducted at the Department of Surgery of General Referral Hospital of Panzi, Bukavu, Democratic Republic of the Congo in April 2023. The hospital is a level 4 hospital with 450 beds and serves as a major referral center for a population of over 1,700,000 in Bukavu. The Department of Surgery is staffed by one specialist in urology.
Study population
All patients admitted with a confirmed diagnosis of urethral stricture between January 1, 2020, and December 31, 2022, were eligible. Inclusion criteria were diagnosis confirmed by retrograde urethrogram (RUG) or Direct Vision Internal Urethrotomy (DVIU) and complete hospital records. Patients with incomplete files and no urethral strictures confirmed were excluded (6 excluded for missing files, 3 diagnosed not operated).
Data collection
Data were extracted from surgical protocol books, ward registries, and individual patient medical files. Collected variables included sociodemographic, clinical, laboratory investigation and imaging, surgical and pharmacological treatment and outcome. All patients meeting the inclusion criteria were included and no sample was taken from the population. Data were abstracted by a single investigator and verified by a second investigator with a third investigator resolving any disagreements. Discrepancies between source documents (protocol books, registries, and files) were resolved by re-examining all three sources. Missing data were present for several variables, with “not performed” or “not specified” categories documented in the medical records.
Statistical analysis
Data were entered into Microsoft Excel 2016 and analyzed using SPSS version 25.0. Descriptive statistics (frequencies, percentages, means) were calculated. Frequencies (n) and percentages (%) were calculated for all categorical variables. 95% confidence intervals were calculated for key proportions using the Wilson score method. No formal comparative or subgroup analyses were planned or performed in this study. The study was designed as a descriptive epidemiological study to characterize the frequency, etiologies, clinical presentations, and treatment outcomes of urethral strictures at a single referral hospital. The sample size (n=37) precluded meaningful subgroup analyses or multivariable modeling, and the study was not powered to detect differences between groups. Given the descriptive nature of this study, no formal methods for confounding control were employed. The study was not designed to test associations or to estimate causal effects; rather, it aimed to describe the epidemiological, clinical, and therapeutic profiles of urethral strictures in a resource-limited setting. No sensitivity analyses were performed.
Ethical considerations
The study was approved by the COMITÉ INSTITUTIONNEL D’ÉTHIQUE DE LA SANTÉ (CIES) institutional review board. Patient confidentiality was maintained by anonymizing all data. The reference number is N° Réf : UCB/CIES/NC/022/2023. The approval by the ethics committee was obtained the 6th April prior to data collection. The ethics committee in Université Catholique de Bukavu was the one in charge of all research approval in South Kivu before the war in 2025.
Results
During the study period, 298 patients were admitted to the urology unit. Of these, 37 (12.4%) had a confirmed diagnosis of urethral stricture and met inclusion criteria and all of them were male. The annual distribution was: 12 cases (32.4%) in 2020, 11 (29.7%) in 2021, and 14 (37.8%) in 2022. The mean age was 28 years, and the 16–30 years age group was the largest, accounting for 43.2% (n = 16), (SD: 14.2; median: 26.0 years; IQR: 18.0–38.0; range: 16–62 years). Most patients resided outside Bukavu city (62.2%, n = 23). Occupations included merchants (27.0%, n = 10), students (18.9%, n=7), farmers (18.9% each, n = 7), and drivers (8.1%, n = 3) (Table 1).
Dysuria was the most common presenting symptom (48.6%), followed by urinary retention (40.5%, n = 15) and urinary incontinence (10.8%). A history of sexually transmitted infections (STIs) was reported by 35.1% of patients, prior prostate adenectomy by 27.0%, pelvic trauma by 18.9%, and previous urethral stricture by 16.2%. Unknown causes were most frequent (43.2%), followed by infectious causes (35.1%) and traumatic causes (21.6%). Urinalysis was positive for infection in 45.9%. Pelvic radiography revealed fractures in 6 patients. Retrograde urethrogram (RUG) was performed in 70.2% and confirmed stricture in all cases. Urethroscopy was performed in 27.0%, also confirming stricture in all (Table 2). The bulbar urethra was the most common stricture site (35.1%), followed by membranous (24.3%), penile (13.5%), and prostatic (8.1%). The site was not specified in 18.9% (Table 2).
The most common surgical procedure was DVIU, performed in 48.6%. Urethroplasty was performed in 27.0%, urethral dilation in 13.5%, and combined DVIU plus urethroplasty in 10.8%. Postoperatively, 34 patients (91.9%, 34/37) received antibiotics and analgesics alone; the remaining 3 (8.1%, 3/37) additionally received an alpha-blocker for prostatic involvement (Table 2). In-hospital complications included urinary tract infection (5.4%, 2/37), recurrence (inability to void after catheter removal) (2.7%, 1/37), and erectile dysfunction (patient reporting new onset of difficulty in achieving erection) (2.7%, 1/37). Hospital stay was ≤21 days in 56.8% (21/37), 22–42 days in 21.6% (8/37), and ≥43 days in 21.6% (8/37) (Table 2). DVIU is typically performed as a day-case or requires only 1–2 days of hospitalization in high-resource settings, the median hospital stay in our series was 21 days (IQR: 14–42), with 43.2% of patients staying ≥22 days and 21.6% staying ≥43 days.
Discussion
This study aimed to determine the epidemiological, clinical, and therapeutic profiles of urethral strictures at General Referral Hospital of Panzi in Bukavu, eastern DRC, over a three-year period from January 2020 to December 2022. The 12.4% frequency observed in our series is directly comparable to the 10.8% reported by Diarra and colleagues in Mali, as both studies used operated urological admissions as the denominator. The substantially lower frequency (2.6%) reported in some West African series likely reflects, at least in part, the use of a broader denominator (all urological consultations or admissions) rather than surgical admissions alone. Differences in healthcare access, diagnostic capacity, and prevalence of risk factors (untreated STIs, catheter-related injuries, road traffic accidents) between regions may also contribute, but denominator definition is a key methodological factor that must be acknowledged before attributing differences to clinical or epidemiological factors.
Demographics and clinical presentation
The mean age of patients in this study was 28 years, with patients aged 15 years or younger representing 13.5% of cases, those aged 16–30 years accounting for the largest proportion (43.2%), those aged 31–40 years for 10.8%, and those older than 40 years for 32.4%. Median (IQR) 26.0 (18.0–38.0) years This age distribution differs slightly from that reported by Ngandu et al in Mbuji-Mayi, where the most represented age group was 26–43 years (52.7%).6 Dysuria was the most common presenting symptom, reported by 48.6% of patients, followed by urinary retention in 40.5% and urinary incontinence in 10.8%. In developed countries, most patients are present with lower urinary tract symptoms (54.3%) alone, and retention is uncommon at initial presentation.7 In our series, referral to a tertiary center, which selects for more advanced disease and inflates the retention proportion (40.5%).
Diagnostic modalities in a resource-limited setting
Retrograde urethrogram (RUG) was the most frequently used imaging modality, performed in 70.2% of patients, and confirmed stricture in all cases where it was conducted. In our series, RUG demonstrated that the bulbar urethra was the most common stricture site, involved in 35.1% of patients, followed by the membranous (24.3%), penile (13.5%), and prostatic (8.1%) urethra. The predilection for the bulbar urethra is consistent with anatomical vulnerability: this segment is fixed in position, lacks surrounding protective structures, and is subjected to compressive forces during straddle injuries.8,9 7 patients had a pelvic trauma history but only 6 radiograph were reported, it appears pelvic radiography was performed selectively on clinical suspicion.
Treatment outcomes
DVIU was the most common surgical procedure, performed in 48.6% of patients. Because follow-up after discharge was not available, longer-term outcomes of DVIU in this series could not be assessed. The in-hospital window is far shorter than the interval over which DVIU failure typically manifests. Urethroplasty was performed in 27.0% of patients. Unlike DVIU, which is palliative and does not remove the underlying scar tissue, urethroplasty involves excising the stricture and reconstructing the urethra using various techniques, including end-to-end anastomosis or substitution urethroplasty with buccal mucosa or skin grafts. While urethroplasty offers higher long-term success rates (typically 85–95% in specialized centers),10,11 it is technically more demanding, requires longer operative time, has a higher complication rate, and necessitates a longer hospital stay. The series published up to the moment do not clarify which of both options, free grafts or penile skin flaps guarantees better results, leaving the choice, in general terms to the experience and preferences of the surgeon.12 Urethral dilation, used in 13.5% of patients, is the oldest and simplest treatment method, involving progressive stretching of the stricture using graduated bougies or sounds. The length of the stricture was not recorded in the patients’ file and what guided the choice of the procedure; therefore, we could only report what was done without providing the rationale. Hospital stay varied considerably, with 56.8% of patients discharged within 21 days, while 21.6% stayed between 22 and 42 days, and another 21.6% remained hospitalized for 43 days or longer.
Conclusion
Urethral stricture imposes a substantial burden on young men in eastern DRC, accounting for 12.4% of urological admissions, yet the high proportion of unknown etiologies (43.2%) and the rising frequency of prior prostate surgery (27.0%) suggest that both diagnostic limitations and iatrogenic causes are under-recognized. The finding that 40.5% of patients presented with urinary retention and that one in five required hospitalization exceeding 42 days points to advanced disease and significant delays in care compounded by limited diagnostic capacity and healthcare access. One in-hospital recurrence was recorded (2.7%); as follow-up after discharge was not available, this figure does not represent the long-term recurrence rate. These findings underscore an urgent need to establish a structured follow-up pathway, improve diagnostic capacity, and systematically document iatrogenic risk.
Strengths and Limitations
This study provides first description of the hospital-level profile of urethral stricture in South Kivu, consecutive inclusion of all operated cases over three years and data collected directly from primary source documents. The sample size was however relatively small, with only 37 patients included, which limits statistical power for subgroup analyses and multivariate modeling, and may not capture rare complications or outcomes. Validated instruments were not used to assess patient outcomes such as quality of life, sexual function, and long-term satisfaction. In addition, outcomes were recorded only during hospitalization, as post-discharge follow-up data were not available. These findings can reasonably be extrapolated to resource-limited settings and conflict-affected zone but not to stable and rich countries where etiologies, diagnostic modalities and therapeutic possibilities might be significantly different. Selection bias arises from excluding non-operated patients (not captured) and requiring complete records, meaning the reported frequency is conditioned on surgical admission and adequate documentation, so the true population burden is likely underestimated. Information/misclassification bias is inherent in retrospective record abstraction, evidenced by 43.2% unknown etiology and high proportions of “not performed” diagnostic categories (RUG 29.7%, urethroscopy 73.0%, pelvic X-ray 83.8%), suggesting that the “unknown” category largely reflects documentation gaps rather than true idiopathic disease. Single-center referral bias operates because the study is conducted at one tertiary hospital in a conflict-affected region with no insurance and out-of-pocket payment, selecting for more advanced disease; the 40.5% retention rate far exceeding the 23.4% reported in developed-country referral cohorts (Rourke & Hickle, 2012) reflects referral/ascertainment bias rather than population-level severity, and milder cases managed locally never enter the cohort. No culture/antibiogram data were reported as they were lacking in the records. No assessment of inter-abstractor reliability was performed, as data were abstracted by a single investigator with unspecified “verification,” precluding quantification of abstraction error. The absence of a comparison group means no causal or comparative inference is possible, and all findings are descriptive and hypothesis-generating only.
Recommendations
Based on these findings, several measures are recommended to strengthen the diagnosis and management of urethral stricture. First, a standardised urethral stricture proforma should be introduced to systematically capture stricture length and site, catheter status, serum creatinine, and procedural detail, reducing the documentation gaps identified in this series. Second, a structured follow-up clinic should be established at 3, 6, and 12 months after treatment, incorporating uroflowmetry or, at minimum, a basic voiding assessment, to capture longer-term outcomes that fall outside the in-hospital window examined here. Third, given the likely iatrogenic burden suggested by the high proportion of prior prostate adenectomy and unknown etiology, catheterization and open-prostatectomy practices should be audited to identify and reduce preventable causes of stricture. Fourth, a clear care pathway and referral or training route for urethroplasty should be developed, given its higher long-term success rate relative to DVIU and the current reliance on individual surgeon experience and preference in selecting treatment. Finally, the drivers of prolonged hospital stay, which exceeded 42 days in more than one-fifth of patients, warrant further investigation, as this likely reflects delays in diagnosis and treatment access rather than the procedure itself.
Ethical Approval
The study was approved by the COMITÉ INSTITUTIONNEL D’ÉTHIQUE DE LA SANTÉ (CIES) institutional review board (N° Réf : UCB/CIES/NC/022/2023)
Informed Consent
Being a retrospective study, informed consent was waived. No patients’ privacy was violated, the study complies with the law in Eastern DRC and no individual-level cell in the table permits re-identification in a small single-center series.
Data Availability
Deidentified data are available at Referral Hospital of Panzi and can be accessed upon reasonable request and in compliance with necessary ethical and institutional approvals.
Conflict of Interest
None
Funding
None