It’s Not What You Think: The Story of Urethral Dilation in Women

“I have been getting my urethra dilated since I was a young woman in my 20’s,” said the 70 year old woman in front of me. “Why is that?” I asked. “Well, I had lots of infections after I got married, and the doctor said that my urethra was too small and needed to be stretched.” “Do you still get  infections?” “No, not in a long time but when I start to notice that my urine stream is slower, and I feel like I’m going to the bathroom a lot more frequently, I know I need to be dilated again.”

This is not an uncommon story. Urethral dilation has been utilized for a variety of female urinary complaints both irritative (urinary frequency, urgency and burning with urination) and obstructive (hesitancy to the start of urinary stream, weak urinary stream, straining to urinate and feeling of incomplete emptying). These symptoms

may indicate a urinary tract infection, but they are not specific for it. In other words, something else may be causing the bladder to feel irritated. If a

urinalysis and culture do not demonstrate bacteria, the symptoms are not caused by a bladder infection.

Urethral stricture is the diagnosis that is given to some women to explain the need for dilation, yet strictures are very rare in women who have not had urethral surgery or trauma such as a pelvic fracture. The overwhelming majority of women who claim a urethral stricture based on a prior history of urethral dilation do not have one. For many of these women the source of their urinary symptoms is multifactorial , and often a single source is not clear. We all tend to be better concrete thinkers than abstract ones; therefore, explanations for symptoms such as “urinary tract infection” or “urethral stricture or scar” are much easier to understand than the explanation of we don’t know what is producing the symptoms. I suspect that this is why these diagnoses are frequently used erroneously. Conditions that are common sources for urinary symptoms are dry vaginal tissues from loss of estrogen (atrophic vaginitis) or overactive bladder, and treatment is medical. These conditions can be improved or cured with treatments that do not require a painful and traumatic stretching of her urethra; furthermore, dilation of the urethra does nothing for them.

Urethral dilation is a procedure usually performed in the office. A woman’s urethra is progressively dilated with metal tubes until significant resistance is met and/ or the physician feels it is “stretched” enough. The rationale behind urethral dilation in women is that the stretching of the urethra will tear the small nerve endings in the urethra and neck of the bladder causing a temporary anesthesia in those areas, thereby reducing or eradicating their irritative bladder symptoms. In some cases women will achieve relief of their symptoms from urethral dilation, but at potential cost to the
health and integrity of their urethra. Ironically, chronic dilation of the urethra can cause progressive scarring of it due to repeated trauma.

I would like to say that urethral dilation is a relic of a bygone era in urology, and a reliable predictor of the age of the urologist; this is unfortunately not the case. A better approach is to evaluate the woman for correctable causes of her symptoms, and treat any identified. When no obvious source can be found, it is appropriate to offer symptomatic relief with medications and/or pelvic floor exercises and physical therapy. Since obstructive symptoms are less common, women with obstructive symptoms and certainly any who fail to respond to thoughtful and reasonable treatments may require a more invasive evaluation such as cystoscopy (to use a scope to look in the bladder) or urodynamics (see explanation under FYI section).

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