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

Next Best Step for Patient with Urinary Incontinence and Scarred, Open Proximal Urethra

For a patient with urinary incontinence and a scarred, open proximal urethra, the next best step is to perform urodynamic testing to evaluate the specific type and cause of incontinence before proceeding with surgical intervention. 1

Diagnostic Evaluation

The presence of a scarred, open proximal urethra represents a complex urological condition that requires thorough evaluation before treatment:

1. Urodynamic Testing:

   • Essential for non-index patients (those with complex presentations)
   • Particularly indicated for patients with:
     • History of prior anti-incontinence surgery
     • Prior pelvic organ prolapse surgery
     • Mismatch between subjective and objective measures
     • Significant voiding dysfunction 1

2. Cystoscopy:

   • Indicated in this case due to urethral abnormality (scarred, open proximal urethra)
   • Allows direct visualization of the urethral damage and assessment of bladder integrity 1

3. Imaging Studies:

   • Consider cross-sectional imaging (CT or MRI) to assess the proximal extent of urethral damage and any associated anatomical abnormalities 1

Treatment Algorithm

Step 1: Determine the Type and Severity of Incontinence

• Stress urinary incontinence (SUI) vs. urgency urinary incontinence (UUI) vs. mixed
• Evaluate the relationship between the scarred urethra and incontinence

Step 2: Consider Surgical Options Based on Findings

For a scarred, open proximal urethra with incontinence, surgical reconstruction is typically required:

1. Artificial Urinary Sphincter (AUS):

   • Recommended for severe stress incontinence with proximal urethral damage
   • Most effective option for patients with compromised urethral integrity 1

2. Urethral Reconstruction:

   • For patients with urethral stricture/scarring causing difficulty with voiding
   • Should be performed by experienced reconstructive surgeons 1

3. Fascial Pubovaginal Sling:

   • May be considered if the proximal urethra can be adequately supported 1

Step 3: Post-Reconstruction Management

• Monitor for at least one year for complications (stricture recurrence, erectile dysfunction, persistent incontinence) 1
• Consider pharmacologic management of any residual urgency symptoms with antimuscarinic medications like oxybutynin if appropriate 2

Important Considerations and Pitfalls

• Avoid Repeated Endoscopic Procedures: Multiple endoscopic interventions in patients with urethral scarring often lead to worsening of the condition and increased patient morbidity 1

• Treat Vesicourethral Anastomotic Stenosis First: If bladder neck contracture or vesicourethral anastomotic stenosis is present alongside the urethral scarring, this should be treated prior to addressing incontinence 1

• Realistic Expectations: Patients with complex urethral pathology may require multiple procedures to achieve optimal continence outcomes

• Consider Urinary Diversion: In cases where multiple reconstructive attempts have failed, urinary diversion may be considered as a last resort for patients with intractable incontinence who are appropriately motivated and counseled 1

The management of urinary incontinence with a scarred, open proximal urethra requires specialized urological expertise. Referral to a reconstructive urologist with experience in complex urethral pathology is strongly recommended to optimize outcomes and quality of life.