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

Management of Urinary Incontinence with Scarred, Open Proximal Urethra

For patients with urinary incontinence and a scarred, open proximal urethra, delayed urethroplasty is the next best step to restore urinary continence and improve quality of life. 1

Assessment and Initial Management

When evaluating a patient with urinary incontinence and a scarred, open proximal urethra, the following approach is recommended:

1. Establish urinary drainage immediately

   • Suprapubic catheter placement is preferred over repeated attempts at urethral catheterization 1
   • Avoid multiple urethral catheterization attempts which can worsen injury and increase scarring 1

2. Diagnostic evaluation

   • Urethrography to assess the extent of urethral damage 1
   • Cystoscopy (antegrade if necessary) to evaluate the proximal urethra and bladder neck 1
   • Consider pelvic CT or MRI to assess:
     • Proximal extent of injury
     • Degree of urethral malalignment
     • Length of the defect 1

Definitive Management

Timing of Reconstruction

Delayed urethroplasty is strongly preferred over endoscopic procedures for urethral reconstruction in this scenario 1. The optimal timing for definitive reconstruction should be:

• After major injuries have stabilized
• When the patient can be safely positioned for urethroplasty
• Usually within 3-6 months after the initial trauma 1
• Avoid premature intervention which may increase complications

Surgical Approach

The surgical approach depends on the location and extent of the urethral injury:

1. For posterior urethral injuries:

   • Anastomotic reconstruction through a perineal approach
   • Excision of scar tissue and wide spatulation of the anastomosis
   • Techniques to gain urethral length may include:
     • Mobilization of the bulbar urethra
     • Crural separation
     • Inferior pubectomy (if necessary)
     • Supracrural rerouting (if necessary) 1

2. For complex urethral reconstruction:

   • Referral to a center with expertise in urologic reconstruction is recommended 1
   • Consider vaginal flaps for female urethral reconstruction when applicable 2

Important Considerations and Pitfalls

Avoid These Common Mistakes

1. Repeated endoscopic procedures

   • Not successful in the majority of cases
   • Increase patient morbidity
   • Delay time to definitive reconstruction 1

2. Premature reconstruction

   • Attempting reconstruction before stabilization of other injuries
   • Failure to allow adequate time for resolution of acute inflammation 1

3. Inadequate follow-up

   • Patients should be monitored for complications (stricture formation, erectile dysfunction, incontinence) for at least one year following urethral injury 1

Special Considerations

• In patients with lichen sclerosus, avoid using genital skin for reconstruction 1
• For patients requiring chronic self-catheterization, early urethroplasty can achieve outcomes comparable to those without neurogenic bladder 1
• Consider placing a suprapubic tube if the patient requires orthopedic fixation of pelvic fractures 1

Monitoring and Follow-up

After urethroplasty, patients should be monitored for:

• Symptomatic recurrence
• Development of urethral strictures
• Persistent incontinence

Diagnostic tests to detect recurrence may include:

• Urethrocystoscopy
• Ultrasound urethrography
• Retrograde urethrogram 1

Monitoring should continue for at least one year following the urethral injury, as most complications develop within this timeframe 1.