What is the recommended treatment for a 65-year-old female with a urethral stricture?

Treatment of Urethral Stricture in a 65-Year-Old Female

For a 65-year-old female with urethral stricture, initial treatment should be urethral dilation or direct visual internal urethrotomy (DVIU) if the stricture is short (<2cm), while urethroplasty is recommended for longer strictures or after failed endoscopic management. 1

Diagnostic Approach

• Urethrocystoscopy is the most accurate diagnostic method to confirm urethral stricture
• Additional diagnostic tools include:
  • Retrograde urethrography
  • Voiding cystourethrography
  • Uroflowmetry
• Determine stricture length and location before planning treatment 1

Treatment Algorithm Based on Stricture Characteristics

For Short Strictures (<2cm)

1. First-line treatment: Urethral dilation or DVIU

   • Both techniques have similar success and complication rates (35-70% success)
   • Catheter can be safely removed within 72 hours post-procedure 1
   • Consider balloon dilation for elderly or medically unfit patients as it causes less trauma 2

2. Post-procedure management:

   • Catheterization for 24-72 hours
   • For patients not suitable for urethroplasty, consider intermittent self-catheterization to maintain urethral patency 1

For Longer Strictures (≥2cm) or Recurrent Strictures

1. Recommended treatment: Urethroplasty
   • Success rates of 90-95% compared to very low success with endoscopic management for longer strictures 1
   • Urethroplasty techniques for female patients include:
     • Vaginal inlay flap (simple technique with durable results) 3
     • Dorsal buccal mucosa graft (23% recurrence rate at mean 33 months follow-up) 4
     • Labial flaps (useful when vaginal tissue is compromised) 5

Important Considerations and Pitfalls

Pitfalls to Avoid

1. Repeated dilations: Multiple endoscopic treatments may:

   • Cause longer strictures
   • Increase complexity of subsequent urethroplasty
   • Have poor definitive success (>80% recurrence rate) 1

2. Failure to recognize stricture etiology:

   • Iatrogenic (e.g., difficult catheterization)
   • Trauma/straddle injury
   • Lichen sclerosus
   • Idiopathic 4, 5

Special Considerations

• For patients dependent on indwelling catheter or intermittent self-dilation, consider suprapubic cystostomy to promote "urethral rest" prior to definitive treatment 1
• Female urethral stricture is often under-recognized and inappropriately treated with repeated dilations despite poor outcomes 4
• Consider referral to a reconstructive urologist for recurrent strictures or when urethroplasty is indicated 1, 4

Monitoring and Follow-up

• Monitor for symptom improvement:
  • Improved urinary stream
  • Decreased post-void residual
  • Resolution of recurrent UTIs
• Cystoscopy can confirm absence of stricture recurrence
• Watch for complications:
  • Urinary tract infection
  • Bleeding
  • Urinary retention

Female urethral stricture is less common than male urethral stricture but causes significant morbidity when not properly treated. Early recognition and appropriate management can significantly improve quality of life and prevent complications such as recurrent UTIs, urinary retention, and renal impairment.