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

Next Best Step for Patient with Urinary Incontinence and Scarred, Open Proximal Urethra

For a patient with urinary incontinence and a scarred, open proximal urethra, the next best step is to consider an artificial urinary sphincter (AUS) as the primary surgical intervention rather than a synthetic mesh sling. 1

Assessment and Diagnostic Considerations

Before proceeding with any intervention, a thorough evaluation is essential:

1. Cystourethroscopy: Mandatory to fully assess the urethral and bladder pathology, particularly the extent of scarring and the condition of the proximal urethra 1

2. Urodynamic testing: Should be performed to:

   • Differentiate between stress and urgency incontinence
   • Assess bladder contractility
   • Evaluate for any bladder outlet dysfunction 1

3. Assessment of tissue quality: The scarred, open proximal urethra indicates poor tissue quality, which significantly impacts treatment selection 1

Treatment Algorithm

1. Surgical Approach Selection

The presence of a scarred, open proximal urethra creates specific challenges that guide treatment selection:

• AVOID synthetic mesh slings: Guidelines explicitly state that mesh should not be used in patients with poor tissue quality, significant scarring, or when there is risk for poor wound healing 1

• CONSIDER artificial urinary sphincter (AUS): This is the preferred option for patients with severe incontinence and compromised urethral tissue 1

• ALTERNATIVE options if AUS is not feasible:

  • Autologous fascial sling
  • Biological (non-synthetic) slings 1
  • Urinary diversion in severe cases with multiple failed treatments 1

2. Rationale for AUS Selection

• Fixed, immobile urethra: The scarred proximal urethra likely represents what guidelines refer to as "intrinsic sphincter deficiency" with a fixed, immobile urethra 1

• Severity of condition: Open proximal urethra suggests a severe anatomical defect that requires more definitive management than what can be achieved with less invasive options 1

• Avoiding complications: Using synthetic materials in a scarred urethra significantly increases risks of:

  • Urethral erosion
  • Vaginal extrusion
  • Urethrovaginal fistula
  • Foreign body granuloma formation 1

Important Considerations and Caveats

1. Pre-surgical preparation:

   • Any urethral strictures or bladder neck contractures must be treated before incontinence surgery 1
   • Ensure optimal tissue health before proceeding with any surgical intervention

2. Patient counseling:

   • Discuss realistic expectations regarding continence outcomes
   • Explain potential complications including device malfunction, infection, and erosion
   • Review the need for long-term follow-up and possible device adjustments 1

3. Technical considerations:

   • Proper cuff sizing is critical in the scarred urethra
   • Consider proximal placement of the cuff where tissue quality may be better
   • In severe cases, tandem cuff placement may be necessary 1

4. Follow-up requirements:

   • Monitor for at least one year for complications 1
   • Assess for device function, erosion, and continence outcomes

Special Situations

• If urethral reconstruction is needed: Consider vaginal flap techniques for reconstruction before placement of continence device 2

• If patient has concomitant urgency symptoms: Address mixed incontinence with combination therapy including anticholinergics if appropriate 1

• If patient is not a surgical candidate: Consider conservative management with absorbent products and intermittent catheterization, though this should be considered a last resort given the impact on quality of life 1, 3

The scarred, open proximal urethra represents a challenging clinical scenario that requires specialized surgical expertise. While conservative approaches may be attempted initially, the anatomical defect described strongly suggests the need for definitive surgical management with an artificial urinary sphincter or autologous sling rather than synthetic mesh options.