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 a patient with urinary incontinence and a scarred, open proximal urethra, the next best step is delayed urethroplasty with urinary diversion via suprapubic catheter placement until definitive repair. 1

Initial Assessment and Management

1. Urinary Drainage

   • Immediate urinary drainage should be established to prevent further complications
   • Options include:
     • Suprapubic catheter (preferred in cases with scarred proximal urethra)
     • Urethral catheter (if possible without causing further damage)

2. Diagnostic Evaluation

   • Urethrography should be performed to assess the extent of urethral damage 1
   • CT urography with nephrographic and excretory phases if concomitant upper tract injury is suspected 1

Management Algorithm

Step 1: Establish Urinary Drainage

• Place a suprapubic catheter for immediate urinary diversion
• This provides drainage while avoiding further trauma to the damaged urethra

Step 2: Plan for Delayed Reconstruction

• Delayed urethroplasty is strongly recommended over repeated endoscopic procedures 1
• Timing considerations:
  • Allow 3-6 months after initial injury for tissue healing 1
  • Ensure patient is medically stable for surgery
  • Allow pelvic hematoma to resolve if associated with pelvic trauma

Step 3: Surgical Approach Selection

For proximal urethral injury with scarring:

• Anastomotic urethroplasty is typically required
• Techniques to gain urethral length may include:
  • Mobilization of the bulbar urethra
  • Crural separation
  • Inferior pubectomy (in severe cases)
  • Supracrural rerouting (in severe cases)

Important Considerations

Avoid Common Pitfalls

• Avoid immediate repair attempts in traumatic posterior urethral injuries as these are associated with high rates of erectile dysfunction and urinary incontinence 1
• Avoid repeated endoscopic procedures (including dilations) as they increase patient morbidity and may delay definitive reconstruction 1
• Avoid genital skin for reconstruction if lichen sclerosus is suspected as a cause 1

Special Circumstances

• If the patient is hemodynamically unstable, focus on stabilization first with temporary drainage measures 1
• In female patients with urethral damage, vaginal flaps are usually the best option for reconstruction 2
• Consider placement of an autologous pubovaginal sling at the time of reconstruction if sphincteric incontinence is present 2

Follow-up

• Monitor for symptomatic recurrence after urethroplasty 1
• Diagnostic tests to detect stricture recurrence should include one or more of:
  • Urethrocystoscopy
  • Ultrasound urethrography
  • Retrograde urethrography

This approach prioritizes establishing proper urinary drainage while planning for definitive repair that will address both the anatomical defect and the functional issue of incontinence, ultimately improving the patient's quality of life and reducing morbidity.