Female urethral stricture (FUS) is rare and generally managed endoscopically. We have assessed the history, imaging and urodynamic and stricture characteristics of all women having urethroplasty for recurrent symptomatic FUS.

A retrospective review of 107 consecutive women (median age 50 years, range 25-78) with recurrent or refractory FUS having urethroplasty since June 2012 by 3 surgeons in 2 countries with a median follow up of 31 months, range 6-112 was conducted.  
Data was analysed for stricture aetiology, presenting symptoms, previous stricture treatment, stricture length, stricture site and type of urethroplasty.
Statistical analysis was performed with the Students T Test and Mann-Whitney U Test. Statistical significance was determined as P<0.05.

The commonest causes of FUS are, idiopathic in 53(51.4%), iatrogenic in 41 (38.3%), skin disorders in 4 (3.7%), radiotherapy in 3 (2.8%), inflammation in 3 (2.8%) and external trauma in 1 (0.93%). 
Median duration of symptoms was 60 months (range 24-456). The commonest symptoms were poor flow in 98 (91.6%), straining to void in 88 (82.2%), incomplete emptying in 77 (72%), frequency in 76 (71%) and urgency in 64(59.8). 
The women had had a median of 5 previous urethral dilatations (range 0-33). 50(46.7%) had been performing ISC for a median of 48 months (range 1-144) and 41(82%) found it painful. 4 (3.7%) had an SPC in situ.
Pre-operative MRI pelvis was performed in 72 (67.2%) and revealed a concentrically thickened urethra in 51(70.8%), an absent/fibrotic urethra in 7(9.7 %), urethral diverticulum in 4 (5.6%), paraurethral cysts in 1 (1.4%), normal post urethral diverticulum excision appearance in 1 (1.4%) and no abnormalities in 8 (11.1%). 
Pre-operative VUDS were performed pre-operatively in 57(90%) and revealed bladder outflow obstruction (BOO) in 56(98%), detrusor overactivity in 22(39%) and stress urinary incontinence in 7(12%). Preoperatively median Qmax was 5 mls/s (range 0-24), median Pdet Q max was 70 cmH2O (range 0-165) and median Solomon-Greenwell BOOIf was 51.4 (range -24.2-156.2) (where BOOIf>5 =>50% chance of BOO). Median stricture length was 2.0cm (range 0.5-4.0cm) and the commonest sites were mid-distal in 20(32%) and distal in 19 (30%). 
53(84%) had ventral onlay buccal mucosal graft urethroplasty, 6(10%) had ventral vaginal flap urethroplasty, 2(3%) had ventral onlay labial minora flap urethroplasty and 1(1.5%) had a ventral vaginal graft urethroplasty – with stricture free status in 55(87%) at last follow-up

Poor flow secondary to urodynamic BOO is present in almost all women with FUS. The majority will also have irritative LUTS, recurrent UTIs and urethral pain. Definitive treatment with urethroplasty is significantly delayed whilst endoscopic management is possibly overused.

FUS should be suspected in all women with poor flow and irritative LUTS and urethroplasty considered earlier.