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Initial workup should include uroflow and post-void residual (PVR). While there are no specific cutoffs for
uroflowmetry or PVR volumes, a curve that reaches a plateau, flow less than 12 to 15 mL/s, or PVRs > 100,
[12]
may suggest obstruction . Cystourethroscopy can be useful, although a smaller diameter pediatric scope
may be necessary. This can yield information about the stricture itself, bladder health, and any concomitant
pathology. Urethral calibration with bougie-à-boule can be very helpful in understanding the caliber of the
stricture and having an objective measurement prior to undergoing surgical management, although
Kalra et al. found that we should not rely on urethral calibration only given that a good caliber of the
[13]
urethra (14 Fr) is not sufficient enough to rule out a significant obstruction due to FUS.

Unlike male patients, retrograde urethrography and voiding cystourethrography (VCUG) do not play a
central role in the diagnosis and evaluation of FUS. It can often be challenging to distinguish between a
primary bladder neck obstruction, a urethral sphincter obstruction, a pelvic floor obstruction, or a urethral
stricture itself. If done, we recommend positioning the patient in an A-P fashion and relying more heavily
on the voiding film. Urethrography can help determine the position of the stricture within the urethra
(proximal, mid, distal, or panurethral).

Finally, a urodynamic study (UDS) will show a classic high pressure low flow pattern. Although there is no
consensus regarding cut-off values for FUS, West et al. suggest that detrusor contraction at a maximum of
[14]
> 25 cm H O, with a flow < 12 cc/s, could be diagnostic of BOO, and the nomogram proposed by Blaivas
2
and Groutz may be utilized to confirm obstruction. It is recommended to add fluoroscopy and do a
[15]
video-UDS to maximize the data a UDS offers. Since female detrusor pressure values are highly variable, it
was not until urodynamic data was fused with fluoroscopic imaging that conclusions could be drawn on
functional and anatomic criteria . A pelvic MRI may be helpful in some cases, particularly if there is
[16]
[4]
suspicion of pelvic organ prolapse or additional pathology such as malignancy. Sarin et al. summarize that
calibration of < 14 F (most commonly used cut-off value by authors), evidence of BOO on urodynamics,
and visualization of narrowing on urethroscopy or VCUG may be diagnostic of FUS.

SURGICAL TECHNIQUE
Conservative management
Minimally invasive treatment for FUS remains the most popular among urologists. Both urethral dilation
(UD) and direct vision internal urethrotomy are the available conservative options. According to a 2006
British Survey, 69% of urologists were still regularly practicing UD ; these practice patterns may have
[17]
changed over the past 15 years favoring surgical intervention. Furthermore, a majority of urologists believe
that the first intervention for female urethral stricture should be urethral dilatation , a treatment option
[18]
supported by recent guidelines .
[8]
[19]
Although easy to do and relatively low risk, judicious use of UD is advised. Santucci et al. reported that
only 40 patients out of a population of 1.2 million with urethral stricture had undergone reconstructive
surgery. This not only resulted in deterioration of patients’ health and quality of life but also resulted in
increased health costs with $61 million/year spent on female urethral dilation.

Data are limited to retrospective series, small patient populations without adequate long-term follow-up.
UD overall success is noted to be between 47%-49% [4,20] , with success defined as the lack of need for further
intervention. These numbers parallel what is seen in male patients as well regarding endoscopic
management of urethral strictures. Mean time to failure with UD was 12 months . In our practice, we
[21]
follow the same principle as in male patients with no more than one attempt of UD per patient given the
[23]
poor outcomes of repeated dilations (30%), unless the patient is not a surgical candidate . Spilotros et al.
[22]