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 in management. 1
Assessment of the Urethral Condition
When evaluating a patient with urinary incontinence and a scarred, open proximal urethra, several key factors must be considered:
- The scarred, open proximal urethra represents a significant anatomical defect that will impact treatment selection
- This condition likely indicates sphincteric insufficiency (often called intrinsic sphincter deficiency)
- The scarring suggests previous trauma, surgery, or radiation that has compromised urethral integrity
Treatment Algorithm
First-Line Recommendation: Artificial Urinary Sphincter (AUS)
- Artificial Urinary Sphincter (AUS) - This is the gold standard treatment for patients with severe incontinence due to compromised urethral integrity 1
- Provides the best chance for continence in patients with significant anatomical defects
- Particularly indicated when there is a scarred, open proximal urethra
Important Considerations Before AUS Placement
- Complete urethral evaluation is mandatory before proceeding with AUS 1
- Review any previous operative reports to understand the nature and extent of prior interventions 1
- Treat any vesicourethral anastomotic stenosis or bladder neck contracture prior to incontinence surgery 1
- Cystourethroscopy should be performed to fully assess urethral and bladder pathology 1
Why AUS is Superior to Other Options
For patients with a scarred, open proximal urethra:
- Male slings are likely to have poor outcomes due to the compromised urethral condition 1
- Patients with scarred urethras have decreased success rates with male slings 1
- The AUS can be customized (cuff size, location, pressure) to accommodate the specific anatomical defect 1
Special Considerations
Contraindications to Synthetic Material
- Avoid synthetic mesh in patients with poor tissue quality or compromised wound healing 1
- If urethral injury occurs during the procedure, do not place synthetic mesh 1
Monitoring and Follow-up
- Monitor for complications (stricture formation, erectile dysfunction, incontinence) for at least one year following urethral injury 1
- Surveillance strategies with uroflowmetry, retrograde urethrogram, or cystoscopy are recommended 1
Potential Complications to Discuss with Patient
- Device infection (may require complete removal)
- Erosion
- Mechanical failure
- Need for revision surgery
- Persistent incontinence
Alternative Options if AUS is Not Feasible
If the patient is not a candidate for AUS due to medical contraindications or patient preference:
Urinary diversion may be considered in patients unable to obtain long-term quality of life with other treatments 1
- Options include ileal conduit or continent catheterizable pouch
- Should be reserved for cases where other options have failed
Urethral bulking agents may provide some temporary relief but are less effective for severe incontinence 1
Pitfalls to Avoid
- Avoid male slings in patients with scarred, open proximal urethra as they have poor success rates in this population 1
- Do not attempt endoscopic realignment with prolonged or heroic measures as this may increase injury severity 1
- Do not place synthetic mesh if there is poor tissue quality or compromised healing 1
- Avoid placing a mesh sling if the urethra is inadvertently injured during the procedure 1
The scarred, open proximal urethra represents a challenging clinical scenario that requires specialized management. The artificial urinary sphincter provides the best chance for restoration of continence in this anatomically compromised situation.