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 to perform urethral reconstruction using autologous fascial or biological slings rather than synthetic materials.

Assessment and Diagnosis

When evaluating a patient with urinary incontinence and a scarred, open proximal urethra, it's essential to understand that this anatomical abnormality represents a complex case of stress urinary incontinence (SUI) with significant intrinsic sphincter deficiency. This is not a standard case of SUI and requires specialized management.

Key diagnostic considerations include:

• Confirmation of the urethral condition through cystourethroscopy to assess the extent of scarring and the condition of the proximal urethra
• Urodynamic testing to evaluate bladder function, as this is recommended for "non-index" patients with complex conditions 1
• Assessment of the degree of incontinence severity and impact on quality of life

Treatment Approach

Why Standard Approaches May Be Insufficient

Standard first-line treatments for SUI are unlikely to be effective in this scenario:

• Pelvic floor muscle training (PFMT) and behavioral therapy, while recommended as first-line for typical SUI 1, are unlikely to provide adequate continence with an open, scarred proximal urethra
• Standard mid-urethral slings may be ineffective due to the compromised urethral tissue

Recommended Surgical Approach

The AUA guidelines specifically address this type of complex situation, noting that in patients with compromised urethral tissue:

• Autologous fascial and alternative biological slings are the preferred options for treatment of concomitant stress incontinence in patients with scarred urethras 1
• Synthetic materials should be avoided as they "may place the patient at higher risk for subsequent urethral erosion, vaginal extrusion, urethrovaginal fistula and foreign body granuloma formation" 1

For urethral reconstruction specifically:

• Vaginal flap techniques are generally considered the best option for urethral reconstruction in women with post-traumatic urethral damage 2
• An autologous pubovaginal sling should be considered at the time of reconstruction to address the incontinence 2

Considerations for Specific Surgical Techniques

When planning the reconstruction:

1. Preoperative imaging: Use retrograde urethrography (RUG) with voiding cystourethrogram (VCUG) for proper surgical planning 1

2. Surgical options:

   • Vaginal wall flap reconstruction with autologous pubovaginal sling
   • Anterior or posterior bladder flap techniques (though vaginal approaches are generally preferred) 2
   • Consider a Martius flap to provide additional tissue support during reconstruction 2

3. Avoid synthetic materials: The scarred urethra significantly increases risk of complications with synthetic materials 1

Post-Surgical Management

Following reconstruction:

• Appropriate urinary drainage with urethral catheter is mandatory after surgical management 1
• Monitor for at least one year for complications including stricture formation, persistent incontinence, or voiding dysfunction 1
• Consider urodynamic studies post-treatment to assess functional outcomes, especially if there were concerns about bladder storage parameters 1

Alternative Options for Severe Cases

In cases where standard reconstruction may not be feasible:

1. Artificial urinary sphincter (AUS) may be considered in select patients with acceptable bladder storage parameters 1, though this has a limited role and carries risks of erosion, infection, and device malfunction (28% erosion/extrusion rate) 1

2. Bladder neck closure with concomitant bladder drainage as a last resort for refractory cases, though this is irreversible and has up to 25% risk of fistulization 1

Common Pitfalls to Avoid

1. Using synthetic mesh materials in a patient with compromised urethral tissue, which significantly increases risk of erosion and fistula formation

2. Undertreatment - Studies show that up to 71% of women with urinary incontinence do not receive active treatment within a year of identification 3

3. Inadequate preoperative imaging - Failure to properly assess the urethral defect can lead to suboptimal surgical planning

4. Overlooking patient quality of life - The degree of bother from symptoms should be a key consideration in determining treatment approach 1

By following this approach and prioritizing urethral reconstruction with autologous materials, patients with this complex condition have the best chance for improved continence and quality of life.