What is the next step in managing a 48-year-old woman's urinary incontinence, with a positive cough stress test and pooling of urine in the vaginal vault, 3 months after urethral diverticulectomy, despite a trial of antimuscarinics (anticholinergics)?

From the Guidelines

The next step in managing this 48-year-old woman's urinary incontinence is to consider surgical intervention, specifically a midurethral sling procedure. Given her positive cough stress test, pooling of urine in the vaginal vault, and failure of antimuscarinic therapy, she has clear evidence of stress urinary incontinence that has persisted after her urethral diverticulectomy. Before proceeding with surgery, a complete urodynamic evaluation should be performed to confirm the diagnosis and rule out any other contributing factors such as detrusor overactivity or incomplete bladder emptying. The midurethral sling procedure, which involves placing a synthetic mesh tape under the midurethra to provide support during increases in intra-abdominal pressure, has a success rate of approximately 80-90% for stress urinary incontinence, as supported by the most recent guidelines 1.

Some key points to consider in the management of this patient include:

• The importance of a thorough evaluation to confirm the diagnosis and rule out other contributing factors
• The consideration of alternative surgical options, such as urethral bulking agents or autologous fascial slings, if synthetic material is contraindicated
• The need for counseling about potential complications, including voiding dysfunction, mesh erosion, pain, and infection
• The role of pelvic floor physical therapy as an adjunctive treatment both before and after surgery to optimize outcomes

The recommendation for a midurethral sling procedure is based on the clear failure of conservative management and the presence of anatomic stress incontinence following her diverticulectomy, which suggests a persistent urethral support defect that would benefit from surgical correction, as discussed in recent reviews 1. Additionally, the American Urological Association (AUA) and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) guidelines support the use of midurethral slings as a treatment option for stress urinary incontinence 1.

From the Research

Next Steps in Managing Urinary Incontinence

The patient in question has undergone a urethral diverticulectomy and is experiencing urinary incontinence despite a trial of antimuscarinics. Given the positive cough stress test and pooling of urine in the vaginal vault, the next step should focus on addressing the stress urinary incontinence (SUI).

• The patient's symptoms and history suggest that conservative measures have been attempted, and the focus should now be on more invasive options for managing SUI.
• Studies such as 2 and 3 suggest that surgical interventions for SUI can be effective, especially when conservative measures fail.
• Options for surgical intervention include midurethral slings and autologous fascial slings, as mentioned in 4 and 5.
• Given the patient's specific situation, with persistent SUI after urethral diverticulectomy, a midurethral sling (option D) could be considered as a next step, as it is a common and effective procedure for SUI.
• Another option could be an autologous fascial sling (option E), which is also mentioned in the literature as an effective treatment for SUI, especially in cases where other procedures have failed or are not suitable.
• Cystoscopy (option A) might be considered to rule out other causes of incontinence or to assess the urethra, but it is not directly addressing the SUI.
• Cystoscopy with retrograde pyelograms (option B) and urethral catheter (option C) are not the primary next steps for managing SUI in this context.

Considerations for Surgical Intervention

• The decision for surgical intervention should be based on the severity of symptoms, the impact on the patient's quality of life, and the failure of conservative measures.
• As noted in 6, surgical repair of urethral diverticula can have excellent results, but complications such as urethrovaginal fistula, UI, and urethral stricture can occur.
• The patient's history of urethral diverticulectomy and current symptoms of SUI should be carefully considered when choosing the next step in management, with a focus on procedures that directly address SUI, such as midurethral slings or autologous fascial slings, as supported by 2, 4, and 5.