From the Guidelines
The next step for this 48-year-old woman with persistent urinary incontinence after urethral diverticulum repair should be referral to a urogynecologist or urologist for consideration of surgical intervention, specifically a mid-urethral sling procedure. Her clinical presentation strongly suggests stress urinary incontinence (SUI) as evidenced by the positive cough stress test 1. The failed response to antimuscarinic therapy is not surprising, as these medications target overactive bladder symptoms rather than SUI. The normal post-void residual of 35 mL indicates adequate bladder emptying, and the negative urinalysis rules out infection as a cause of her symptoms. The urine pooling in the vaginal vault may indicate a vesicovaginal fistula or recurrent diverticulum that requires evaluation. Before surgery, urodynamic testing would be beneficial to confirm the diagnosis and rule out detrusor overactivity or mixed incontinence 1. Pelvic floor physical therapy could be initiated while awaiting specialist evaluation, focusing on Kegel exercises to strengthen the pelvic floor muscles. The persistence of symptoms three months post-repair suggests either an anatomical issue related to the previous surgery or underlying stress incontinence that was masked by the diverticulum and has now become apparent following repair. Key considerations in managing this patient include:
- Differential diagnosis to distinguish SUI from other forms of urinary incontinence, as treatment approaches differ 1
- The role of pelvic floor muscle training as a first-line management strategy for SUI, with potential for symptom improvement 1
- The importance of evaluating for associated abnormalities, such as urethral diverticula or bladder-neck/urethral hypermobility, which may impact management decisions 1
From the Research
Next Steps for Urinary Incontinence Treatment
Given the patient's persistent urinary incontinence despite antimuscarinic therapy, with a positive cough stress test and urine pooling in the vaginal vault, the next steps in management should consider the following options:
- Re-evaluation of the patient's condition to determine the underlying cause of incontinence, as the presence of a urethral diverticulum may require further investigation 2.
- Consideration of alternative or additional pharmacological therapies, such as beta-adrenoceptor agonists or other agents that target novel therapeutic targets, as current antimuscarinic therapy has shown limited efficacy in this patient 3, 4.
- Exploration of non-pharmacological interventions, including behavioral therapy, pelvic floor exercises, or other conservative management strategies, which may be used in conjunction with pharmacological therapy 2.
- Discussion of surgical options, as the patient has already undergone urethral diverticulum repair and may require further surgical intervention to address ongoing incontinence, with approximately 200 different surgical procedures available for stress urinary incontinence 2.
- Investigation of emerging treatments for urinary incontinence, such as autologous muscle-derived cell therapy or agents that act on novel targets, which may offer alternative therapeutic options for this patient 5.
Considerations for Treatment Selection
When selecting the next step in treatment, it is essential to consider the patient's individual needs and preferences, as well as the potential benefits and risks associated with each option 2, 4. The patient's positive cough stress test and urine pooling in the vaginal vault suggest that stress urinary incontinence may be a contributing factor, and treatment should be tailored to address this specific condition 2. Additionally, the patient's post-void residual volume of 35 and negative urinalysis results should be taken into account when determining the most appropriate course of treatment 3, 6.