Urethral Strictures

7. DISEASE MANAGEMENT IN FEMALES

7.1. Signs and symptoms of female urethral strictures

The symptoms of female urethral strictures are non-specific and therefore generally non-diagnostic. Female urethral stricture presents with mixed filling and voiding symptoms with frequency in 63%, urgency in 55%, incomplete emptying in 36%, poor flow in 32%, urinary incontinence in 31% (stress, urge or mixed), strain void in 21.5%, UTI in 20.5%, nocturia in 20.5% and dysuria in 20%. It very rarely presents with urethral pain (2.7%), terminal dribble (2%), haematuria (1.6%) or renal failure (0.5%) (see supplementary Table S7.1).

There is often a significant delay in diagnosis of FUS from time of development of symptoms with mean delays of 4.3-12 years described (range 1-30 years) [137].

7.2. Diagnosis of female urethral strictures

Twenty-four studies detail investigations leading to a diagnosis of FUS (see supplementary Table S7.2). In all cases a full history was taken, and a detailed pelvic examination was performed to assess for prolapse, masses, scars and vulval dermatological disorders such as LS, lichen planus or vulvo-vaginal atrophy. Flow rate and US PVR assessment was evaluated in nineteen (75%) and eighteen (71%) studies, respectively. Lateral VCUG was performed routinely in sixteen studies (63%) and as required in one study (4%). Cystourethroscopy was performed routinely in fourteen studies (54%) and as required in two studies (8%). Urodynamics (UDS) were performed routinely in four studies (17%) and as required in seven studies (30%) whilst video-urodynamics (VUDS) were performed routinely in three studies (13%) and urethral calibration also in four studies (13%). Pelvic MRI was performed as required in four series (17%) whilst transrectal US (TRUS) and renal US were each performed routinely in two series (8%) and intravenous urography (IVU) in ten (4%).

Flow rate and PVR assessment make inherent sense as initial non-invasive screening tools and allow for simple monitoring of effect of treatment. Voiding cystourethrography and/or VUDS will permit diagnosis of BOO [23,474], visualisation of ballooning above the proximal end of the FUS [135], and delineation of alternate or co-existent diagnoses such as detrusor overactivity (DO) and SUI [128], although VCUG, VUDS and UDS require the ability to insert a 6 Fr catheter and may not be possible without preliminary urethral dilatation in all cases of FUS [475]. Likewise, passage of a cystourethroscopy will require a preliminary dilation in the majority of cases even when a paediatric uretero-renoscope is utilised [126]. Cystourethroscopy will allow for formal identification of the distal end of the FUS and will also allow for exclusion of a functional cause of BOO [135]. Magnetic resonance imaging is performed mainly to exclude alternate pathology such as urethral diverticulum and urethral carcinoma and also allows assessment of the degree of urethral fibrosis associated with FUS [475]. Proponents of TRUS utilise it in lieu of MRI and also for visualisation of the dilated urethra above the proximal end of the FUS. Recent gel-infused USS has been assessed and found to more accurate means of diagnosing stricture and associated spongiofibrosis than cystoscopy and videourodynamics in a small preliminary study (n=8) [476].

7.3. Treatment of female urethral strictures

7.3.1. Minimally invasive techniques for treatment of female urethral strictures

Several minimally invasive treatments have been reported; these include urethrotomy, dilatation, meatotomy and meatoplasty. Meatotomy and meatoplasty are essentially the same procedure in the female urethra and the term ‘meatoplasty’ will be used throughout this document.

7.3.1.1. Urethrotomy for treatment of female urethral strictures

No papers were found detailing the use and outcomes of urethrotomy specifically for the management of FUS. Internal urethrotomy or dilation was used by Massey and Abrams [477] to treat a variety of pathologies, including FUS, causing symptoms of obstructed voiding, and resulted in symptomatic improvement in 80% of patients. As this study included women with a variety of complaints and did not assess urodynamic parameters, the results in the patient subset with true urethral stricture are unclear. If utilised, urethrotomy in the female urethra involves incisions at three, nine and occasionally twelve o’clock [477].

7.3.1.2. Urethral dilatation for treatment of female urethral strictures

With this treatment, the urethra is dilated to between 24 Fr and 41 Fr. Some patients will continue with ISD. Romman et al., 2012 [478] and Popat & Zimmern [475] also described suture plication of bleeding areas of the meatus if required post-urethral dilatation.

Four studies described the results after twelve to 59 months follow-up of, in total, 183 patients having dilatation only. Patency rates ranges from 7.5-51% (see Table 7.1) [128,129,475,478]. In another four studies that included, in total, 31 patients that continued to perform ISD, stabilisation of the stricture with “patency” was obtained in 37.3-100% of cases at twelve to 21 months of follow-up (see Table 7.1) [13,133,136,479].

New onset SUI (1.4%) and other complications are very rare after dilation (see supplementary Table S7.3). Due to the low complication rate, the minimally invasive nature of the technique and the reasonable success rate, it is acceptable to start with urethral dilation as a first-line treatment for an uncomplicated FUS. If the stricture recurs then repeat urethral dilatation is unlikely to be curative.

7.3.1.3. Meatoplasty for treatment of female urethral strictures

Meatal stenosis is extremely rare, with only 2/58 (3%) of females evaluated for voiding dysfunction found to have true meatal stenosis [480]. Only one meatoplasty paper contains more than five patients and has been included for analysis (see supplementary Table S7.4) The patency rate of meatoplasty in girls in this paper is excellent with 96% of the 50 girls in Heising’s series having a successful outcome with no reported side effects at twelve months. Forty-eight of 50 patients experienced resolution of their recurrent UTIs and improved voiding symptoms one year after meatoplasty [481]. There was no incontinence or other acute complications reported. For short meatal strictures, meatoplasty is the first-line treatment option.

7.3.2. Urethroplasty for treatment of female urethral strictures

Twenty-five papers report the outcomes of urethroplasty for FUS disease in 253 patients in total after the scope search of the Panel. The Panel have analysed the outcomes of these urethroplasty according to flap or graft type as: vaginal graft, vaginal flap, labial/vestibular graft, labial/vestibular flap and buccal or lingual graft. In female urethroplasty, a dorsal approach is via a stricturotomy at twelve o’clock, a ventral approach is via a stricturotomy at six o’clock and circumferential is a full circumference reconstruction.

7.3.2.1. Vaginal graft augmentation urethroplasty for treatment of female urethral strictures

There were five studies reporting vaginal graft urethroplasty containing 72 patients. All 72 vaginal graft urethroplasties were performed via a dorsal approach in women with a mean/median age of 47.5-60.6 years (range 28-79). At a mean/median follow-up time of 8.5-24.65 months (range 6-36) following vaginal graft urethroplasty 59 (82% range 73-94%) of patients had no recurrent stricture. No complications and no new onset urinary incontinence were reported. Mean/median flow rate (with range) improved from 6.2-8.23 mls/s (2.2-10.2) to 16.64-27.6 ml/s (12-32.7) whilst mean/median PVR (with range) reduced from mean/median
113.2-187.1 mls (44-420) to mean/median 20-90.31 mls (0-122).

See supplementary Table S7.5 for further information.

7.3.2.2. Vaginal flap augmentation urethroplasty for treatment of female urethral strictures

Vaginal flap urethroplasty was reported in 150 women and was always via a ventral approach, utilising an inverted U vaginal flap inlay in seven studies (n=96) [127,128,131,482,483], a lateral C vaginal flap in three studies (n=58) [125,133,137] and one vaginal island flap urethroplasty in one patient [131]. At a mean/median follow-up time of 12- 80.7 months (range 3-198), patency rates of 67-100% were reported (Table 7.1). Eight (5.3%) patients had a simultaneous pubo-vaginal sling (PVS), four (2.7%) had a simultaneous Martius fat pad flap interposition and one (0.7%) had a simultaneous excision of urethral diverticulum. Fourtheen (9.3%) patients developed new onset UI, and fourtheen (9.3%) developed other acute complications including UTI and intravaginal direction of the urinary stream.

See supplementary Table S7.6 for further information.

7.3.2.3. Labial/vestibular graft augmentation urethroplasty for treatment of female urethral strictures

There were four papers detailing the outcomes of 42 patients having labial or vestibular graft urethroplasty (see supplementary Table S7.7); fifteen had ventral labial minora graft [132,139,484] and thirteen had dorsal labia minora graft [136] and fourtheen had dorsal labia majora graft. At a mean follow-up of 18 to 24 months, patency rates of 75-86% were reported with ventral grafting whilst this was 100% with dorsal grafting at twelve to ninetheen month’s follow-up (Table 7.1). One (2.4%) ventral graft patient developed an UTI post-surgery. There were no other complications (including UI). Post void residual volume reduced from 141.9 +/- 44.2 mls to 24.5 +/- 2-.9 ms post dorsal onlay labial minora graft urethroplasty.

7.3.2.4. Labial/vestibular flap urethroplasty for treatment of female urethral strictures

There were two papers detailing the outcomes of twenty-one patients having labial/vestibular flap urethroplasty: seventeen had a dorsal vestibular flap [16], whilst twelve had a dorsal labia minora flap [485]. At a mean/median follow-up of 24 months the two ventral flap patients (100%) remained stricture-free whilst fifteen (88%) dorsal flap patients remained stricture-free at a mean of twelve months follow-up (Table 7.1 and supplementary Table S7.8). There were no adverse short- or long-term effects reported in either group.

7.3.2.5. Buccal and lingual mucosal graft augmentation urethroplasty for treatment of female urethral strictures

There were eleven papers detailing the outcomes of 234 patients, all treated with BMG except in the series of Sharma et al., who used lingual mucosa graft (LMG) in fifteen patients at the dorsal urethra [126]; 44 patients with dorsal onlay oral (buccal or lingual) mucosa graft (DOOMG) [126-128,131,134,474,486-488]; 27 with ventral onlay BMG (VOBMG) [127,135,489,490]. The outcome of circumferential BMG urethroplasty in two patients were only detailed in one paper [127]. At a mean/median follow-up of six to 33 months, 62.5-100% of DOOMG urethroplasty patients were stricture-free whilst 92-100% of VOBMG patients were stricture-free at a mean of six to 24.5 months follow-up. Both circumferential BMG patients were stricture-free at a mean of 21 months follow-up (Table 7.1). Twenty-four (10.7%) DOOMG patients suffered a low-grade short-term adverse effect and no patients in any subgroup developed new onset UI. No patients developed acute complications or new onset stress urinary incontinence following VOBMG urethroplasty or circumferential BMG urethroplasty (although this was only performed in two patients). Mean/median flow rate improved from 5.0-12.5 ml/s (range 3-11.2) to 12.1-28 ml/s (range 14-37) and mean/median PVR reduced from 101-270 mls (range 90-200) to 6.5-122.6 mls following DOBMG. Likewise mean/median flow rate improved from 5.1-7.6 ml/s (range 3-11.2) to 18-29.2 ml/s (range 5-33.4) whilst mean/median post void residual reduced from 100-149 ml (range 0-300) to 15-59.2 ml (range 0-360 mls) following VOBMG. The flow rate and post void residual changes following circumferential BMG urethroplasty have not been detailed as this technique was performed in two patients only and the outcomes detailed in the describing paper are not specific to this technique.

One prospective randomized trial compared VOBMG with DOBMG and found equivalent stricture free rates and improvements in maximum flow rate, post void residual and sexual function. However, there were only twelve patients in each group and follow-up was limited to six months [491].

For further information see supplementary Tables S7.9, S7.10 and S7.11.

7.3.2.6. Anastomotic urethroplasty

Anastomotic urethroplasty has only been described in two cases in the literature – both in women with very short mid-urethral stricture and both of whom were stricture-free at four and 24-months follow-up respectively. None of them suffered from UI post-operatively [127,496] (see supplementary Table S7.12).

Table 7.1: Summary of available evidence on treatment of female urethral strictures

• FU = follow-up; ISD = intermittent self-dilatation; N = number of patients; UI= urinary incontinence.
• * Patent urethra NOT stricture free as ISC or urethral dilatation continues.

Figure 7.1: Women with refractory frequency, urgency, poor flow and incomplete emptying

ISC = intermittent self-catheterisation; MRI = magnetic resonance imaging; VUDS = video-urodynamics.