To investigate the histopathological features of female urethral strictures (FUS) and their correlation with symptom severity, assessed by the American Urological Association Symptom Score (AUA-SS), and treatment outcomes.

This prospective single-arm cohort study was conducted from January 2024 to June 2025 at a tertiary care hospital. 
Women undergoing dorsal onlay buccal mucosal graft urethroplasty (DO-BMGU) for Female urethral stricture were included. Preoperative history, symptom score (AUA-SS) and number of dilations were recorded. Stricture-site tissues were analyzed using hematoxylin and Eosin, Masson’s Trichrome, and Verhoeff Van Gieson stains. Pathological scores were assigned based on fibrosis, inflammation, elastin fiber density, and epithelial changes. The pathological scores then correlated with symptom severity and outcomes.

22 patients (mean age 43.4 ± 5.5 years) underwent urethroplasty; seven (31.8%) had prior dilation. The mean preoperative AUA-SS was 17.2 ± 8.5, while the median pathological score was 8 (7-10). Failure occurred in four patients (18%). Failed cases showed significantly higher mean AUA-SS (30.25 ± 1.5 vs. 15.33 ± 6.99, p = 0.026) and pathological scores (12.25 ± 0.96 vs. 7.94 ± 1.43, p = 0.026). Histology revealed inflammation, epithelial erosion, fibroblast proliferation, and dense fibrosis in failed cases. Strong correlations were noted between failure and preoperative AUA-SS (r = 0.67) and pathological scores (r = 0.87). Prior dilation had no significant impact on outcomes.

Histopathological severity strongly correlates with symptom burden and failure in FUS. Higher pathological scores predict treatment failure, highlighting the importance of tissue-level assessment.

The study concluded that higher pathological scores were predictive of treatment failure, reflecting the severity of underlying histological changes. Similarly, elevated symptom scores were strongly associated with failure, indicating that more severe clinical symptoms align with poorer outcomes. A clinically significant correlation between symptom scores and pathological scores was identified, emphasizing the value of histopathological evaluation in predicting disease progression.

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Continence 19S (2026) 102621
DOI: 10.1016/j.cont.2026.102621