From the Guidelines
The next best step for a patient with urinary incontinence and a scarred, open proximal urethra would be surgical intervention with an artificial urinary sphincter (AUS) implantation. This procedure involves placing a cuff around the bulbar urethra, a pressure-regulating balloon in the retropubic space, and a control pump in the scrotum. The AUS effectively addresses the anatomical defect by providing mechanical closure of the urethra to prevent urinary leakage, as recommended by the AUA/SUFU guideline 1.
Before proceeding with surgery, the patient should undergo comprehensive urodynamic testing to confirm the diagnosis of sphincteric deficiency and rule out detrusor overactivity or other contributing factors, as suggested by the guideline 1. Additionally, the patient should be counseled about potential complications including device infection, erosion, and mechanical failure, which may require revision surgery. The patient should also be informed that the artificial urinary sphincter will likely lose effectiveness over time and reoperations are common, with failure rates of approximately 24% at 5 years and 50% at 10 years 1.
Some key considerations before surgery include:
- Cystourethroscopy to assess for urethral and bladder pathology that may affect outcomes of surgery 1
- Urodynamic testing to facilitate diagnosis or counseling, particularly if the clinician is unsure if sphincteric or bladder dysfunction is the cause of incontinence 1
- Patient counseling on the risks, benefits, and expectations of different treatments using the shared decision-making model 1
Alternative options like male slings may be considered for mild to moderate incontinence, but the AUS remains the gold standard for severe incontinence, particularly with anatomical defects like a scarred, open proximal urethra. The AUS is preferred over male slings or adjustable balloons in men with stress urinary incontinence after primary, adjuvant, or salvage radiotherapy 1.
From the Research
Next Best Step for Patient with Urinary Incontinence and Scarred, Open Proximal Urethra
- The patient's condition involves urinary incontinence and a scarred, open proximal urethra, which may require a comprehensive evaluation to determine the best course of treatment 2, 3.
- Urodynamic tests can be used to investigate people with urinary incontinence or other urinary symptoms to make an objective diagnosis 4, 5.
- These tests can help identify the underlying cause of incontinence and guide treatment decisions, including the use of conservative measures, medical therapy, devices, or surgery 3, 6.
- Conservative therapy, such as education, fluid and food management, weight loss, timed voiding, and pelvic floor physical therapy, can be effective in managing incontinence 3.
- Medical therapy, including anticholinergic medication, may be used to treat urgency incontinence, while devices like condom catheters, penile clamps, urethral inserts, and pessaries can be helpful in specific situations 3.
- Surgical therapies vary depending on the type of incontinence and are typically offered if conservative measures fail 2, 3.
- Urodynamic investigations can change clinical decision-making, but there is some evidence that this may not result in better outcomes in terms of urinary incontinence rates after treatment 4, 5.
Considerations for Treatment
- The choice of treatment will depend on the underlying cause of incontinence, the severity of symptoms, and the patient's overall health and preferences 2, 3.
- A thorough evaluation, including urodynamic tests, can help determine the best course of treatment for the patient 4, 5.
- The patient's scarred, open proximal urethra may require special consideration in the treatment plan, and a multidisciplinary approach may be necessary to achieve optimal outcomes 6.