What is the recommended treatment for a urethral stricture in a female?

Treatment of Urethral Stricture in Females

For female urethral strictures, initial management should include urethral dilation or direct visual internal urethrotomy (DVIU), with urethroplasty reserved for recurrent cases or strictures >2cm in length. While most available evidence focuses on male urethral strictures, similar principles can be applied to female patients with appropriate anatomical considerations.

Initial Diagnostic Approach

• Suspect urethral stricture in females presenting with:
  • Decreased urinary stream
  • Incomplete bladder emptying
  • Dysuria
  • Recurrent UTIs
  • Elevated post-void residual
• Confirm diagnosis with:
  • Urethrocystoscopy (most accurate diagnostic method)
  • Retrograde urethrography
  • Voiding cystourethrography
  • Uroflowmetry (peak flow <12 mL/second suggests obstruction)

Treatment Algorithm

First-Line Treatment

• Short strictures (<2cm):
  • Urethral dilation or DVIU
  • Success rates range from 35-70% 1
  • Both techniques have similar success and complication rates 1
  • Catheter can be safely removed within 72 hours post-procedure 1

For Recurrent Strictures

• After failed dilation/DVIU:
  • Urethroplasty is recommended due to high recurrence rates (>80%) with repeat endoscopic procedures 1
  • For recurrent bulbar strictures <3cm, consider drug-coated balloon dilation (83.2% freedom from intervention at 1 year vs 21.7% with standard DVIU/dilation) 1

Based on Stricture Length

• Short strictures (<2cm):
  • Initial dilation or DVIU
• Longer strictures (≥2cm):
  • Urethroplasty is preferred due to very low success rates with endoscopic management 1
  • Success rates of urethroplasty range from 90-95% 1

Urethroplasty Options for Females

Several techniques have been described for female urethral stricture repair:

1. Vaginal flap urethroplasty:

   • Success rate of approximately 91% at mean follow-up of 32 months 2
   • Simple technique involving incision of posterior aspect of stricture and advancement of vaginal inlay flap 3
   • Provides durable results with low complication rates 3

2. Labial flap urethroplasty:

   • Uses easily accessible, wet, hairless, and elastic tissue 4
   • May be limited by conditions like lichen sclerosus or vaginal atrophy 4

3. Oral mucosal graft urethroplasty:

   • Success rate of approximately 94% at mean follow-up of 15 months 2
   • Particularly useful for more severe strictures requiring augmentation 4
   • Can be placed in ventral or dorsal approaches, similar to male techniques 4

Important Considerations

• Repeated endoscopic treatments may cause longer strictures and increase complexity of subsequent urethroplasty 1
• For patients not suitable for urethroplasty, consider self-catheterization after DVIU to maintain temporary urethral patency 1
• Patients dependent on indwelling urethral catheter or intermittent self-dilation may benefit from suprapubic cystostomy to promote "urethral rest" prior to definitive treatment 5

Potential Complications

• Persistent irritative symptoms, particularly urge, may occur despite technically successful repair 3
• Difficulties with catheterization may persist in some patients 3
• No reported cases of stress urinary incontinence following vaginal flap urethroplasty 3

Female urethral stricture is relatively uncommon compared to male urethral stricture, which explains the limited high-quality evidence specific to female patients. Treatment principles derived from male urethral stricture management can be applied with appropriate anatomical considerations, with urethroplasty showing significantly better long-term outcomes than repeated dilations.