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, an artificial urinary sphincter (AUS) is the recommended next best step as it provides the most effective management for this complex anatomical situation. 1

Initial Assessment and Characterization

Before proceeding with any intervention, proper characterization of the incontinence is essential:

1. Confirm stress urinary incontinence (SUI) through history, physical examination, and if needed, ancillary testing 1
2. Perform cystourethroscopy to assess the scarred, open proximal urethra and rule out other urethral/bladder pathology 1
3. Evaluate severity of incontinence (mild, moderate, severe) as this impacts treatment selection 1

Treatment Algorithm for Scarred, Open Proximal Urethra

First-line Recommendation:

• Artificial Urinary Sphincter (AUS) placement is the preferred surgical option for patients with scarred urethral tissue 1
  • AUS is specifically indicated for complex anatomical situations including scarred urethral tissue
  • Male slings have decreased success rates in patients with urethral scarring or open proximal urethra 1

Important Considerations:

1. Pre-surgical Management:

   • Any vesicourethral anastomotic stenosis or bladder neck contracture must be treated before incontinence surgery 1
   • Ensure proper urinary drainage while planning definitive treatment 1

2. Patient Counseling:

   • Inform patient that AUS will likely lose effectiveness over time (24% failure at 5 years, 50% at 10 years) 1
   • Reoperations are common and should be anticipated 1
   • Set appropriate expectations (one thin pad/day is a realistic goal) 1

3. Contraindications to Consider:

   • Active urinary tract infection
   • Untreated bladder neck contracture
   • Inability to operate the device

Alternative Options (If AUS is Contraindicated)

1. Male Slings - Not recommended as first-line for scarred urethra but may be considered with appropriate counseling about lower success rates 1

2. Urethral Bulking Agents - Should be avoided as efficacy is low and cure is rare, especially with scarred tissue 1

   • "Patients should be counseled that efficacy is low and cure is rare with urethral bulking agents" 1

3. Urinary Diversion - Consider only in cases where other options have failed repeatedly or are contraindicated 1

   • Reserved for patients unable to obtain long-term quality of life with other interventions 1

Pitfalls and Caveats

• Avoid male slings in patients with scarred urethral tissue as they have significantly lower success rates 1

• Do not delay treatment beyond 6 months if incontinence is severe or not improving with conservative measures 1

• Beware of concomitant conditions that may affect surgical outcomes:

  • Untreated bladder neck contractures
  • Vesicourethral anastomotic stenosis
  • Detrusor instability

• Post-AUS placement complications to monitor for:

  • Infection requiring device removal
  • Urethral erosion
  • Mechanical failure
  • Recurrent incontinence due to urethral atrophy 1

In summary, for a patient with urinary incontinence and a scarred, open proximal urethra, artificial urinary sphincter placement represents the gold standard treatment with the highest likelihood of improving quality of life and reducing morbidity associated with incontinence.