Female urethral dilatation (bougierung): a case report
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Primary bladder neck obstruction is a rare clinical entity, reported to be responsible for 2.7–8% of lower urinary tract symptoms. It can lead to various urinary storage and voiding symptoms. The mainstay of treatment of female urethral strictures is urethral dilatation. Despite the long history of this method, it is unclear how far the female urethra should be dilated in correlation with residual urine volume.
A 79-year-old Caucasian woman presented to our institute with urgency (12–15 times/day), nocturia (3 times/night), and reoccurring urinary tract infections. A physical examination revealed no anatomical malformation in her genital organs, 150 mL post-void urine retention, and a significant narrowing in the mid-segment of the urethra (4 mm). After informed consent, our patient underwent urethral dilatation ranging from Ch9 (3 mm) to Ch39 (13 mm), and reported no symptoms at the 4-week follow-up, with no post-void residual urine.
The relatively low (around 50%) success rate of urethral dilatation might be improved by the utilization of wider dilatators, and the relaxation of the pubourethral ligament, achieved by a gentle downward saggital push during the intervention, although long-term studies with a large number of participants are necessary to prove our hypothesis.
KeywordsPrimary bladder neck obstruction Urethral dilatation Bougierung Bladder outlet obstruction
Charrier (1 mm = 3 Ch)
Female urethral stricture
Lower urinary tract symptom
Primary bladder neck obstruction
Pelvic organ prolapse quantification
Maximum flow rate
Urinary tract infection
Primary bladder neck obstruction (PBNO) is a rare clinical entity, which can occur both in men and women, and is described as the bladder neck failing to open adequately during voiding, leading to increased striated sphincter activity or obstruction of urinary flow in the absence of another anatomic obstruction, like genitourinary prolapse in women . It is a relatively uncommon reason of lower urinary tract symptoms (LUTS), causing storage symptoms (frequency, urgency, urge incontinence, nocturia) and voiding symptoms (decreased force of stream, hesitancy, incomplete emptying), although in this condition the variety of symptoms may be present simultaneously in several combinations. Although the true prevalence of PBNO is not clear and little is known about the etiology, previous urinary tract infections (UTIs), trauma, or prior surgeries of the urethra are suggested to play a role in the pathogenesis of the condition . The diagnosis is based on urodynamic findings, characterized by relative high-pressure, low-flow voiding (cut points for the obstruction of 15 mL/s or less for maximum flow rate [Qmax] and greater than 20 cm H2O for detrusor pressure at maximum flow), as described by Nitti et al. ;, however, radiographic evidence of obstruction at the bladder neck with relaxation of the striated sphincter and no evidence of distal obstruction is also necessary . For its management, several approaches exist, although to date there has been no consensus as to the best care. Among the surgical modalities, urethral dilatation is considered to be the traditional method, although there is no available guideline on how wide the urethra should be dilated in correlation with urethral stricture level, or residual urine volume. Despite the majority of the available literature reporting dilatation until charrier (Ch) 30 (10 mm), we report a case of a patient whose symptomatic urinary retention (150 ml for 1 year) was successfully eliminated by urethral dilatation of Ch 39 (13 mm), without urethral injury. The following case report is rare, as it provides information about an advanced degree of urethral dilation together with successful elimination of residual urine and no urethral injury in the long term.
Here, we present a case of a patient with female urethral stricture (FUS) with storage and urinary symptoms (150 mL post-void residual urine preoperatively), which was successfully treated with extreme urethral dilation (Ch39). Urethral dilation is the benchmark of the management of FUS, however, available data on the method in the current literature is limited. Although the majority of available literature describes female urethral dilation until Ch 30 (10 mm) , based on our unpublished results and observations, this was found to be less effective, therefore we decided to proceed further with the dilation. The advantage of this method is that it is easy to carry out, and has been reported to have low intra-and postoperative complication rate, and can be performed in a 1-day surgery setting with low medical costs. The disadvantage of the approach includes potential complications during the intervention, such as urethral microrupture, which can lead to a UTI, therefore we suggest intraoperative combined antibiotic prophylaxis. We also recommend a gentle saggital downward push of the dilatators during penetrance of the urethra in order to ease and relax the pubourethral ligament, as described by Petros and Ulmsted , and to facilitate the urine outflow. A weak point of the method is that limited information is currently available on the effectiveness rate. While Romman et al. reported 51% success rate, Smith et al. published 57% success rate during follow-up of 21 months [6, 7]. Other surgical options include vaginal, or labial flaps, and also vaginal and oral mucosa grafts . Vaginal flaps first described in 1989 by Blavas et al. . These techniques use “U” or “C-shaped” vaginal flaps to reconstruct the urethra, and were reported to have a success rate of 80–100% [10, 11]. Another therapy option would be vaginal graft urethroplasty, which has, based on the limited available data, a success rate ranging from 75 to 100% during a mean follow-up between 15 and 24 months [12, 13, 14]. Use of buccal or lingual mucosa grafts are also looking to be a promising surgical approach to treat FUS, but missing long-term data, and studies with a large number of participants are currently missing.
According to the literature, urethral dilatation remains the cornerstone of PBNO treatment, despite its success rate. We believe that urethral dilatation should not be terminated at Ch30, and the urethra should be and can be further dilated until 13 mm. Since we only present a single case, long-term studies with a large number of participants are necessary to confirm our theory, as well as a correlation analysis between the post-void urine volume and the gauge of the dilation.
We thank the medical assistants, station and operating room nurses working at the Vivantes Humboldt Clinic, Berlin, Germany, for their help and dedicated contribution toward the study and our patient. The publications was supported from the project EFOP-3.6.1.-16-2016-00004 Comprehensive Development for Implementing Smart Specialization Strategies at the University of Pécs.
The current study received no funding.
Availability of data and materials
The data that support the findings of this study is available from the corresponding author upon reasonable request.
BF performed the operation and wrote the manuscript. MS participated in study design and carried out the control examination. Both authors read and approved the final manuscript.
Ethics approval and consent to participate
The study was approved by the Regional Research Ethics Committee and the patient gave informed consent.
Consent for publication
Written informed consents were obtained from the patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The corresponding author receives financial support from the Hungarian Academy of Sciences (MTA), Budapest, Hungary. The other authors have no conflict of interest.
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