Introduction and Objective

Providers historically practiced urethral dilation for numerous symptoms which did not represent an indication for urethral dilation. One of the most common problems affecting females of any age is that of recurrent UTIs, or a symptom complex of chronic urethritis where patients describe bothersome urinary frequency, burning, suprapubic discomfort, dissatisfaction with their voiding pattern, pelvic floor dysfunction, or urgency. Historically this has been very challenging to treat. Numerous different approaches in management have been tried, including prolonged antibiotic courses, urethral suppositories, bladder instillations, and even surgical procedures with minimal improvement in symptoms, which eventually led to the emergence of female urethral dilations. Historically, urethral dilation in women has been a commonly practiced procedure for managing bothersome urinary symptoms and recurrent UTIs.¹ However, its efficacy has been questioned due to the rarity of female urethral strictures and the lack of scientific evidence supporting its use.^2,3 Despite the lack of scientific backing to support its practice, many women who have previously had the procedure done demand it due to their perceived improvement in symptoms. Providers as well may feel inclined to perform these dilations in order to feel as if something was being done about bothersome symptoms. This article represents a historical review of female urethral dilation, shedding light on its origins, evolution, and current status in modern-day practice patterns.

Methods

A literature review was performed using PubMed to evaluate the history of female urethral dilation. Search terms included “female urethral dilation,” “female urethral stricture,” and “female urethral incision.” Archived articles in The Journal of Urology^® as well as urological textbooks were reviewed to obtain historical information and references.

Results

The practice initially began in 1923 when Stevens concluded that a urethral meatus of small caliber could be responsible for this symptom complex of recurrent UTIs or chronic urethritis.¹ In 1936, Stevens advised urethral meatotomy using a scalpel to maintain a caliber of 30F or larger, otherwise recurring infections would be inevitable.¹ In 1956, Davis reiterated the thesis that obstruction from a narrow urethra was the causative factor and advocated for dilating the urethra to at least 45F using the Otis urethrotome to cut the entire length of the urethra.¹ However, the profession was hesitant to accept this advice due to the fear of incontinence. Over the next 10 years, the practice underwent many modifications to refine the technique, trying to identify the exact location where to incise and how long to incise the urethra (Figure 1). In 1961, individuals began performing these dilations and incisions primarily in young girls who fit this symptom complex.¹ Keitzer used the Otis urethrotome in children to incise the bladder neck and extended his incision half an inch distally into the urethra.¹ Eventually, Keitzer and Benavent modified their practice to incise the entire length of the urethra using the rationale that the entire length of the female urethra corresponded to the same embryological origins as the male prostatic urethra, which may have increased amounts of fibroelastic elements needing to be incised.¹

Two years later, in 1963, Lyon theorized that a contraction ring in the distal urethra of little girls was the cause of persistent urinary tract infections and advised “over dilatation” to avulse this ring.¹ Kerr modified this technique and used the Otis urethrotome with Otis bulbs to incise this contraction ring.¹

Figure 2 highlights the use of the Otis bulbs. These were used to calibrate the urethra and to identify the site of narrowing. As shown in Figure 3, a scaled Foley catheter was used to measure the length of the urethra. The Otis urethrotome was then used to incise the narrowed segment within the urethra, as shown in Figure 4. An example of a technique of urethral dilation is highlighted in Figure 5. The Otis urethrotome was used to incise the upper half of the urethra as shown at the 3, 9, and 12 o’clock positions. A lower incision was not used to minimize the risks of vesicovaginal or urethrovaginal fistula. The Otis bulb was then repassed to ensure the urethral caliber was adequate.

These procedures became so commonplace that series reporting results in as many as 800 women were read at the national AUA meeting in 1967.¹ However, this practice was scrutinized and lost scientific backing due to complications of de novo urinary incontinence. As further investigations were made into the management of this urethral pain complex, more favorable outcomes originated with less invasive approaches, as stated in the updated recurrent UTI guidelines advocating for the use of other modalities such as cranberry prophylaxis and estrogen therapy.⁴ In fact, the last reference to using urethral dilation without a urethral stricture was in 1970.¹

Interestingly, despite the lack of data to support its use, Medicare reimbursement still shows high utilization and cost expenditures. As shown in the Table, almost $70 million in Medicare was spent in 2000 despite only ∼40 documented cases of female urethral stricture.⁵ Despite the rarity of female urethral strictures, those with a diagnosis of “female urethral stricture” have ∼$4000 greater health care costs annually than those without this diagnosis.⁵ The workup for these patients is costly, including repeated imaging studies, such as retrograde urethrograms, and numerous office visits.

Table. Expenditures for Female Urethral Stricture and Share of Costs by Site of Service

Abbreviations: ER, emergency room
Source: NAMCS, NHAMCS, HCUP, Medical Expenditure Panel Survey, 1994, 1996, 1998, 2000. Reprinted with permission from Santucci et al, J Urol. 2008;180(5):2068-2075.⁵

Work by several others has shown that the finding a true female urethral stricture is rare, indicating that much of these costs and health care burdens may be unnecessary.^5-14 Given the discrepancy between the rate of female urethral strictures and high utilization and cost expenditures for the practice of urethral dilation, Lemack et al investigated the actual practice of urologists. They provided questionnaires regarding urologists’ perceptions of its indications, efficacy, and need for repeated dilations.¹⁵ Interestingly, when surveying urologists, those who completed residency after 1989 rarely performed urethral dilation when compared to their predecessors, who find it a useful practice, suggesting a need for updated guideline statements and better education of patients as well as providers to limit its use.¹⁵

Conclusions

A wide variety of treatment modalities have been used to manage recurrent UTIs and irritative lower urinary tract symptoms. Female urethral dilation was common despite the rarity of a female urethral stricture. Urinary incontinence and a better understanding of bladder function have decreased the support for female urethral dilation, putting into question its practice. Evidence-based medicine supports medical management, vaginal estrogen, and pelvic floor physical therapy more favorably. One would hope that this practice would go into extinction; however, Medicare data still show high utilization. Perhaps updated guideline statements and better education of patients that have had prior dilations will help in debunking this practice.