What is the next best step for a patient with urinary incontinence and a scarred, open proximal urethra (urethral stricture)?

From the Guidelines

The next best step for a patient with urinary incontinence and a scarred, open proximal urethra is surgical reconstruction with an artificial urinary sphincter (AUS) implantation. This recommendation is based on the most recent and highest quality study available, which suggests that AUS is the preferred treatment for patients with stress urinary incontinence after prostate treatment, especially in cases with urethral scarring 1. The AUS effectively addresses incontinence by providing mechanical closure of the urethra that the patient can control.

Before proceeding with surgery, a complete urodynamic evaluation should be performed to confirm the diagnosis of sphincteric insufficiency and rule out detrusor overactivity or other contributing factors. The patient should be counseled about potential complications including device infection, erosion, mechanical failure, and the possible need for revision surgery, as the failure rate of AUS increases with time, with failure rates of approximately 24% at 5 years and 50% at 10 years 1.

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

• The presence of a scarred, open proximal urethra makes the AUS particularly appropriate as it can provide circumferential compression despite urethral scarring.
• Alternatives such as male slings may be considered for mild to moderate incontinence, but are not recommended given the lack of compelling evidence of their effectiveness in this subgroup 1.
• Other potential treatments for incontinence after prostate treatment should be considered investigational, and patients should be counseled accordingly 1.
• Postoperatively, the device is typically left deactivated for 4-6 weeks to allow healing, and patients require instruction on proper operation of the pump mechanism for voiding.

Overall, the AUS is a highly effective treatment option for patients with urinary incontinence and a scarred, open proximal urethra, and should be considered the next best step in management.

From the Research

Treatment Options for Urinary Incontinence with Urethral Stricture

The patient's condition of urinary incontinence with a scarred, open proximal urethra (urethral stricture) requires careful consideration of treatment options. The following are potential next steps:

• Conservative measures:
  • Lifestyle modifications, such as decreasing caffeine intake and engaging in physical activity to strengthen pelvic floor muscles 2
  • Pelvic floor physical therapy to help with urge and stress incontinence 3, 2
• Medical therapy:
  • Anticholinergic medications for urge incontinence, although their use may be limited due to adverse effects 4, 3
  • Beta-3 adrenergic agonists as an alternative to anticholinergic drugs for urge incontinence 2
• Surgical interventions:
  • The polypropylene pubovaginal sling has been shown to be an effective treatment for women with complicated stress urinary incontinence, including those with a scarred, wide open, proximal urethra 5
  • Other surgical options, such as midurethral slings, may also be considered for stress incontinence 2

Considerations for Urethral Stricture

The presence of a urethral stricture may affect the choice of treatment. For example:

• The polypropylene pubovaginal sling has been used successfully in patients with a scarred, wide open, proximal urethra 5
• Other treatments, such as catheterization or targeting the source of obstruction, may be necessary to address the urethral stricture itself 2