Sexual violence is a major public health problem. On average, there are 463,634 victims of rape and sexual assault each year in the United States, of which 90% are female. Despite the high incidence, it often goes unreported and untreated, leading to long-term biopsychosocial aftereffects. Victims can suffer from impaired social relationships, psychiatric disorders, suicidal thoughts, and genitourinary disorders.
Sexual abuse survivors have a significantly higher incidence of genitourinary dysfunction symptoms, including stress and urge incontinence. Depending on the nature of the assault, the victim can suffer from physical consequences as well, such as strictures and genital deformation.
Urethral stricture is a rare pathology in the female population, accounting for 0,08 - 5,4% of women with obstructive voiding. Traumatic etiology accounts for 16% of FUS, mainly after pelvic fracture. The percentage of FUS after sexual trauma is unknown.
Post-traumatic FUS usually presents as a challenging pathology that requires urethral reconstruction, and evidence regarding the surgical approach is scarce. The technique of choice varies largely based on stricture anatomy, patient comorbidities, and surgeon preference. 
The purpose of the video is to present a rare case of complex surgery of genitourinary tract reconstruction, in a woman with long-term incontinence as sequelae of chronic sexual assault.

We present a 47-year-old premenopausal female who sought medical care with a complaint of urinary incontinence and severe vulvar deformation for the past seven years.
She had a history of chronic sexual abuse, including vulvar cutting and one untreated genital soft tissue infection after a human bite, leading to severe vulvar and urethral deformation. The aspect of the genitalia had a heavy negative impact on her self-esteem and sexual life.
An attempt at surgical correction of the urethral stricture was performed two years after the episode, unsuccessfully. 
Physical examination revealed complex vulvar and vaginal fibrous cicatricial alterations with no evidence of pelvic organ prolapse. 
The urodynamics evaluation was impaired due to continuous urinary loss after an infusion of 80mL, and pad testing revealed a urinary loss of 800g. Pelvic magnetic resonance evidenced a short urethra (1,6 cm) with fibrous tissue on its anterodorsal aspect.
We proposed dorsal Urethroplasty with buccal mucosa graft, autologous retropubic sling, and nymphoplasty in a single procedure. Before the incision, endoscopic evaluation of the stricture was made with a 6-Fr ureteroscope and evidenced a short, thin, and pale urethra. Augmentation urethroplasty was chosen due to the endoscopic and MRI aspect of predominantly dorsal fibrous tissue, alongside the abundant donor site mucosa. The option for an autologous sling was justified by the history of trauma and previous vaginal and urethral surgical manipulation, with a higher risk of adverse effects of a synthetic tape. The vulvoplalsty was performed using 5-0 monocryl intradermal suture. The procedure is described step-by-step in the video.

The final urethral length was 3 cm, and there were no complications. The patient was discharged on the first postoperative day, and the indwelling urinary catheter was removed 3 weeks later.
After a 90-day follow-up, the patient is no longer incontinent and had no voiding complaints or other urinary complaints. She reported a major increase in self-esteem and sexual well-being.
There were no complaints regarding the donor site.

Buccal mucosa dorsal urethroplasty is a feasible technique and can be done concomitantly to stress urinary incontinence correction. An autologous sling should be preferred to diminish the risk of infection.
Sexual violence is a major social and health problem. Governmental and public health programs should raise awareness, encourage reports, punish offenders, and prevent new assaults.

Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, National Crime Victimization Survey, 2019 (2020).
Davila GW, Bernier F, Franco J, Kopka SL. Bladder dysfunction in sexual abuse survivors. J Urol. 2003 Aug;170(2 Pt 1):476-9. doi: 10.1097/01.ju.0000070439.49457.d9. PMID: 12853803.
Riechardt S, Waterloos M, Lumen N, Campos-Juanatey F, Dimitropoulos K, Martins FE, Osman NI, Barratt R, Chan G, Esperto F, Ploumidis A, Verla W, Greenwell T. European Association of Urology Guidelines on Urethral Stricture Disease Part 3: Management of Strictures in Females and Transgender Patients. Eur Urol Focus. 2022 Sep;8(5):1469-1475. doi: 10.1016/j.euf.2021.07.013. Epub 2021 Aug 13. PMID: 34393082.

Continence 12S (2024) 101400
DOI: 10.1016/j.cont.2024.101400