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Page 2 of 11 de Toledo et al. Plast Aesthet Res 2022;9:5 https://dx.doi.org/10.20517/2347-9264.2021.103

Keywords: Urethra, female urethral stricture, female urethroplasty, buccal mucosal graft, vaginal flap

INTRODUCTION
Bladder outlet obstruction (BOO) in women remains a challenging scenario. Care needs to be taken not to
confuse functional entities with anatomic to offer appropriate care to the patient. By far, more women with
obstructive symptoms will have a functional etiology. Within anatomic etiologies, female urethral stricture
[1]
(FUS) disease accounts for a considerable proportion ranging from 4% to 18% of women with BOO .
However, there is a generalized consensus that FUS is likely underdiagnosed due to the lack of well-
established diagnostic criteria and relatively nonspecific symptoms. Some studies report a higher incidence
[2]
of up to 8%-22.4% in women with obstructive symptoms . There is no single definition of FUS that exists,
nor an accepted descriptive nomogram. Some authors propose that a urethral lumen too narrow to admit a
17 Fr flexible cystoscope or that has the feel of scar tissue by cystoscopic haptic feedback is diagnostic for
stricture . In contrast, others opine that FUS should be defined as a fixed anatomical narrowing of the
[1]
urethra such that the lumen will not accommodate instrumentation without disruption of the urethral
mucosal lining . Uroflow can be helpful in trying to diagnose a FUS, although there is no consensus
[3]
regarding its cut-off values.

FUS somewhat mimics their male counterparts regarding etiology, with notable differences regarding
traumatic etiology. Almost every stricture can be attributed to 4 etiologies (in order of most to least
frequent): idiopathic, iatrogenic, inflammatory, or traumatic . There is a small proportion of rare etiologies,
[4]
which include: urethral tuberculosis, urethral carcinoma, locally advanced cervical carcinoma,
[5-7]
fibroepithelial polyps and infection . Within iatrogenic etiologies, the most common are: prior urethral
dilations, prior urethral diverticulectomy, sling insertion or excision, transvaginal fistula repair and/or
transurethral bladder surgery.

Evidence is overall poor for female urethral stricture management, and included here is a contemporary
[8]
literature review and a summary of the recently published European Guidelines . In this article, we will also
review our recommended workup and management of FUS, with a focus on options for surgical treatment.

DIAGNOSIS AND EVALUATION
The diagnosis of FUS requires a high index of clinical suspicion. A thorough investigation is essential for
diagnosis, to plan appropriate treatment, and to exclude differential diagnoses such as functional BOO,
urethral diverticulum or malignancy. It is very important to collect sufficient data regarding past medical
history, prior procedures, history of pelvic malignancies, radiation, etc. As mentioned above, FUS is often
underdiagnosed, and the lack of standardization about the diagnosis of BOO in women emphasizes that
BOO is often a clinical diagnosis . An adequate physical exam is also mandatory as it will give important
[9]
information about tissue quality, meatal stenosis, pelvic organ prolapse and/or concomitant lichen sclerosus
(LS). Faiena et al. state that physical examination with bimanual pelvic, vaginal and speculum
[10]
examinations are essential.

Patients with FUS have variable lower urinary tract symptoms (LUTS). As Kuo demonstrated, the
[11]
differential diagnosis of lower urinary tract dysfunction in women cannot be based on LUTS alone. Patients
with urethral stricture may be asymptomatic or present a variety of symptoms ranging from minor
discomfort to a wide spectrum of voiding and storage symptoms.