From the Guidelines
The next best step for a patient with urinary incontinence and a scarred, open proximal urethra is to refer them to a urologist for evaluation and likely surgical intervention, specifically a urethroplasty, as this approach directly addresses the urethral damage and incontinence issues simultaneously. This recommendation is based on the principle that surgical management is often necessary for patients with significant urethral scarring and incontinence, as conservative measures may not be sufficient to address the underlying anatomical issues [ 1 ].
Key Considerations
- The presence of a scarred, open proximal urethra indicates significant urethral damage, which may not be adequately addressed by conservative measures such as pelvic floor exercises or medications.
- Urethroplasty is a surgical procedure that aims to reconstruct the damaged urethra, which can help improve incontinence symptoms.
- Prior to surgery, a thorough assessment, including urodynamic studies and cystoscopy, is necessary to fully understand the extent of the urethral damage and the nature of the incontinence [ 1 ].
- The choice of surgical approach and technique may depend on the extent of the scarring and the patient's overall health status.
Surgical Options
- Urethroplasty may involve grafting tissue to rebuild the urethra, potentially using buccal mucosa (tissue from the inside of the cheek) or penile skin, depending on the extent of the scarring.
- Other surgical options, such as artificial urinary sphincter (AUS) placement, may be considered in certain cases, but urethroplasty is often the preferred approach for patients with significant urethral scarring [ 1 ].
Post-Surgical Care
- Close follow-up is necessary to monitor healing and assess improvement in continence after surgery.
- Patients should be counseled on the potential risks and benefits of surgery, as well as the importance of post-surgical follow-up care [ 1 ].
From the Research
Treatment Options for Urinary Incontinence
The next best step for a patient with urinary incontinence and a scarred, open proximal urethra can be determined by considering the following treatment options:
- Conservative therapy with education, fluid and food management, weight loss, timed voiding, and pelvic floor physical therapy 2
- Medical therapy, such as anticholinergic medication, for urgency incontinence 2, 3
- Devices, including condom catheters, penile clamps, urethral inserts, and pessaries, can be helpful in specific situations 2
- Surgical therapies, which vary depending on the type of incontinence, but are typically offered if conservative measures fail 2, 3, 4, 5
Surgical Interventions
Surgical interventions, such as:
- The polypropylene pubovaginal sling, which has been shown to be effective in treating women with complicated stress urinary incontinence, including those with a scarred, open proximal urethra 4
- Open retropubic colposuspension, which has been found to be an effective treatment modality for stress urinary incontinence, especially in the long term 5
- Radio frequency bladder neck suspension, which has been shown to be safe and effective for improving stress urinary incontinence in women, although longer follow-up is needed to assess the durability of results 6
Considerations
When considering the next best step for a patient with urinary incontinence and a scarred, open proximal urethra, it is essential to:
- Evaluate the patient's specific condition and medical history
- Consider the patient's goals and desired outcomes
- Discuss the potential benefits and risks of each treatment option
- Develop a personalized treatment plan that takes into account the patient's unique needs and circumstances 3