Urethral stricture in female is a rare urological entity. It is defined as a fixed, symptomatic anatomical narrowing of the urethra that does not accommodate urethral instrumentation. The incidence is 0.1-1% in women with lower urinary tract voiding symptoms and 4-13% in women with bladder outlet obstruction. The presenting symptoms are weak stream, urgency, frequency, dysuria, hesitancy, urinary retention and recurrent UTIs. The most common location is in the distal third of the urethra or the urethral meatus. The etiology of female urethral stricture could be prolonged catheterization, repeated instrumentation or dilation, prior urogynecologic procedure, trauma, pelvic radiation, chronic cystitis and/or urethritis. Treatment options include urethral dilation, urethrotomy and urethroplasty. Both urethral dilation and urethrotomy have high recurrence rates, whereas success rates for urethroplasty range from 80-94%. Different female urethroplasty techniques have been described previously but there is no consensus on the optimal urethroplasty technique. Herein, we present a patient who underwent anterior vaginal wall flap or a “blandy” procedure for a distal urethral stricture.

A 52-year old nulliparous female presented with symptoms of urgency, frequency, dysuria and recurrent UTIs. She had previously tried urethral dilations, pelvic floor physical therapy and tamsulosin without resolution of her symptoms. On physical examination, the urethra was normal in appearance and no pelvic organ prolapse was visualized. The patient underwent video urodynamics where maximum urinary flow rate (Qmax) was 2 ml/sec and detrusor pressure at maximum flow rate (Pdet Qmax) was 130 cmH2O. Voided volume was 425ml and the post-void residual was 15ml. On fluoroscopy, a round bladder was noted with a dilated proximal urethra and a distal narrow urethral stricture.

The patient was placed in dorsal lithotomy position and the perineum was draped and prepped in a sterile fashion. Urethral sounds were used to determine the exact location of the distal portion of the stricture. After hydrodissection, an inverted-U shape vaginal incision was made. An anterior vaginal wall flap was developed and mobilized, taking care to dissect the periurethral fascia and pubovaginal fascia onto the flap to preserve the vascular pedicle and expose the urethra. The ventral aspect of the urethra was incised in the midline from the meatus until normal urethra was identified. In order to recreate the ventral portion of the urethra, the anterior vaginal wall flap was folded on itself. The tip of the U-flap was sutured to the proximal part of the opened urethra. The edges of the flap were further sutured to the edges of the urethra to create the ventral portion of the distal urethra. After reconstruction of the distal urethra and the meatus, the remaining base of the flap was sutured to the borders of the vaginal epithelium. A cystoscopy was performed at the conclusion of the procedure to ensure that the urethral suture line was well approximated with good hemostasis. A 22 French foley catheter was placed for 2 weeks. At the 12-week post-operative visit, the patient was urinating with good flow and was able to be sexually active without pain. On vaginal examination, there was no urethral tenderness and a 10-French straight catheter was passed without difficulty.

Distal urethroplasty with an anterior vaginal wall flap can be a feasible and effective treatment for female urethral strictures.