Urethral strictures in women are very uncommon, with a prevalence of 3-8%.1 The paucity of these strictures in women lends to the absence of standardized guidelines for diagnosis and treatment. Women with urethral strictures often present with a wide range of lower urinary symptoms, which makes diagnosis difficult.2 In this article, we describe the etiology, current diagnoses, and treatments for urethral strictures in women based on current literature.
Urethral strictures in women can be from multiple etiologies, including iatrogenic causes, chronic cystitis and urethritis, and trauma. We found that the most common etiology is iatrogenic, due to previous vaginal and urethral surgeries. Although there are many symptoms associated with urethral strictures in women, the most common are slow stream, recurrent urinary tract infections, urethral pain, and obstruction. It is imperative to obtain a detailed history and thorough physical exam, including that of the vaginal vault when there is even the slightest suspicion of a urethral stricture.
Clinically, important signs associated with urethral strictures in women include anuria, difficulty placing a urethral catheter, and decreased flow on uroflowmetry. Cystourethroscopy and imaging techniques, such as voiding cystourethrography, can confirm the presence and location of strictures. MRI and other three-dimensional imaging modalities such as CT urethrography are adjunct tools that can evaluate for presence of a urethral stricture.
When considering treatment options, it is important to consider several key factors including location of the stricture, stricture length, length of the healthy proximal urethra, bladder integrity, and surgeon experience. First line minimally invasive treatment generally consists of urethral dilation and urethrotomy, though the latter is rarely found reported in the literature. Importantly, urethral dilation can cause and worsen urethral strictures, and its overall success rate is less than 50%. Moreover, performing repeated dilations for recurrent strictures has an even lower success rate of 27%.3
Urethroplasty, a more definitive treatment option, on the other hand, has success rates ranging between 80-94% among all techniques including vaginal flaps, labial flaps, and buccal mucosal grafts.4 In fact, in one series, urethroplasty was successful in 100% of urethral strictures when done in women with stricture recurrence after urethral dilation.5 Vaginal flaps, labial flaps and buccal mucosa graft repairs (dorsal or ventral) have all had high success rates.6 Buccal mucosal grafts have gained the most traction as preferred grafting material and are associated with the highest success.
There is a need for guidelines for the diagnosis and management of female urethral strictures. Though many are treated with urethral dilation, this does not offer long-term durability, while urethroplasty procedures have increased in recent years as a means of definitive treatment.
Written by: Nikan K. Namiri, Nnenaya Agochukwu-Mmonu, Sudarshan Srirangapatanam, Benjamin N. Breyer,Department of Urology, University of California, San Francisco, San Francisco, California, USA.
References:
- Carr LK, Webster GD. Bladder outlet obstruction in women. Urol Clin North Am. 1996;23(3):385–91.
- Spilotros M, Malde S, Solomon E, Grewal M, Mukhtar BM, Pakzad M, et al. Female urethral stricture: a contemporary series. World J Urol. 2017;35(6):991–5.
- Romman AN, Alhalabi F, Zimmern PE. Distal intramural urethral pathology in women. J Urol. 2012;188(4):1218–23.
- Osman NI, Mangera A, Chapple CR. A systematic review of surgical techniques used in the treatment of female urethral stricture. Eur Urol. 2013;64(6):965–73.
- Blaivas JG, Santos JA, Tsui JF, Deibert CM, Rutman MP, Purohit RS, et al. Management of urethral stricture in women. J Urol. 2012;188(5):1778–82.
- Gormley EA. Vaginal flap urethroplasty for female urethral stricture disease. Neurourol Urodyn. 2010;29(Suppl 1):S42–5.