A 54-year-old woman presented with constant pressure in the bladder and what she described as incomplete bladder emptying. She was having progressive worsening of urinary frequency and urgency that had been episodic but was now more persistent. She had been seen by numerous clinicians over the years for similar complaints and had been treated many times for presumed urinary tract infections. More recently, in the absence of infection, she was treated with pelvic floor physical therapy and overactive bladder medications.
On further questioning, she reported a slow urinary stream. She thought that at some point in her thirties, she had also complained of bladder pressure and slow urinary stream and had a urethral dilation. She recalled that the procedure was painful.
Physical examination showed no significant pelvic organ prolapse, no stress incontinence, and no significant periurethral masses. The meatus was orthotopic in position. There was no mass on bimanual examination. Rectal examination was normal. Pelvic floor muscles were globally shortened and mildly tender.
Urinalysis was negative. Noninvasive uroflow showed a prolonged voiding pattern and a maximum flow rate of 12 mL/s. Post-void residual volume was 150 mL. Videourodynamics showed normal detrusor function during filling, with a bladder capacity of 425 mL. The patient voided 275 mL with a Qmax of 36 cm H2O and a flow rate of 9 mL/s. EMG recording showed a mild increase in activity during voiding, but there was some straining during the void, suggesting a guarding reflex. The fluoroscopic images showed a narrowing in the midurethral area with some proximal urethral dilation (Figure 1).
To confirm the diagnosis of a urethral stricture, a translabial ultrasound was performed. This confirmed a midurethral stricture about 2-cm long with periurethral fibrosis (Figure 2).
After receiving counseling about treatment options, the patient underwent a buccal mucosal dorsal onlay urethroplasty. The buccal graft harvest site healed well, and the urethral catheter was left in place for 10 days before a successful voiding trial. Postoperatively, the flow rate was 20 mL/s and post-void residual volume was 32 mL.
One-year postoperatively, the patient has improvement in bladder pressure, frequency, and urgency and has no sensation of incomplete emptying. She is infection free and continues to empty her bladder well.
Lower urinary tract symptoms are highly prevalent in women due to myriad underlying etiologies. Urinary symptoms may be nonspecific, and therefore the clinical manifestations of some conditions can overlap considerably. Very often, treatment of symptoms begins with empiric therapy. Prior to our evaluation, this patient had been treated empirically for infection and overactive bladder. But years of therapy resulting in little improvement raised the suspicion that the appropriate untreated cause still needed to be addressed.
The patient was evaluated thoughtfully, first confirming that there really was incomplete bladder emptying, as evidenced by an elevated post-void residual volume. The results of the noninvasive urine flow test were suggestive of obstruction, so further testing was warranted. Urodynamics and, more specifically, videourodynamics, are very useful where the mechanism of incomplete bladder emptying is not clear. Pressure flow data can suggest obstruction, and the fluoroscopic images can help confirm the location. It can be difficult to visualize the entire length of the urethra (or the length of the narrowing). A further limitation of the fluoroscopic imaging is the cause of narrowing.
In this case, the possibility of dysfunctional voiding (pelvic floor dysfunction) could be entertained. Because there was no known underlying neurological disease, this was not a case of detrusor sphincter dyssynergia. The history of prior dilation suggested urethral stricture, and the evaluation confirmed its presence.
Very often, the diagnosis of stricture is not entertained when clinicians try to figure out the underlying cause of urinary symptoms in women. This may be secondary to efforts over the last many years to rethink the role of female urethral dilation. Historically, most urethral dilations were performed on women who did not truly have a stricture but, rather, had symptoms secondary to pelvic floor dysfunction. The dilation of the female urethra may have transiently improved the pelvic floor muscle tightness, but more often it caused trauma to the urethra. In the current case, our patient’s stricture was either present at the time of the dilation and had recurred or, more likely, had developed as a result of trauma from the dilation. In either case, she now had developed a true anatomic urethral stricture. Although female stricture is rare, it is critical to identify the stricture to avoid continued years of mistreatment, prolonged symptoms, and frustration.
To identify a stricture in women, one needs a high suspicion. Endoscopy often inadvertently dilates the stricture and, as mentioned, fluoroscopy can show narrowing but lacks specificity for stricture. A diagnostic procedure that NYU Langone’s Center for Female Pelvic Medicine recently pioneered is translabial ultrasound to identify stricture. This procedure not only confirmed the diagnosis but was very useful in surgical planning.1
A procedure that has become invaluable for managing female urethral stricture is the dorsal onlay urethroplasty. My colleagues and I presented the NYU Langone Health series on this technique at the International Continence Society 2018 Philadelphia Scientific Programme.2 This surgical technique can be used for many urethral reconstructions and was considered the most appropriate approach for the midurethral stricture in the current case (Figure 3). As described above, the patient did well with the repair, with no significant postoperative issues.
This case addresses multiple aspects of female pelvic medicine: the history of urethral dilation, our growing understanding of bladder outlet obstruction in women, the techniques used to diagnose voiding phase dysfunction in women, and state-of-the-art surgical procedures.