What is the next step for managing urinary incontinence due to a scarred open urethra?

Management of Urinary Incontinence with Scarred Open Urethra

For urinary incontinence due to a scarred open urethra, delayed urethroplasty is the recommended treatment after initial urinary drainage is established. 1

Initial Assessment and Management

1. Establish urinary drainage immediately

   • Suprapubic catheter placement is preferred in cases with scarred open urethra 1
   • Avoid urethral catheterization if possible to prevent further trauma to the damaged urethra

2. Diagnostic evaluation

   • Urethrography should be performed to assess the extent of urethral damage
   • Repeat urethrography every two weeks to monitor healing progress 1
   • Cystoscopy may be needed to evaluate the extent of scarring and urethral patency

Definitive Management Algorithm

Step 1: Conservative Management (Initial Approach)

• Establish urinary drainage via suprapubic catheter
• Allow initial healing and reduction of inflammation
• Attempt endoscopic realignment if anatomically feasible 1

Step 2: Surgical Planning

• If endoscopic realignment fails, plan for delayed urethroplasty 1
• Optimal timing: within 14 days of injury if no other contraindications exist
• In cases with associated pelvic fractures, postpone definitive surgery until after healing of pelvic ring injuries 1

Step 3: Surgical Intervention

• For anterior urethral scarring:

  • Urethroplasty with graft or flap is indicated for large defects (>2-3 cm in bulbar urethra, >1.5 cm in penile urethra) 1

• For posterior urethral scarring:

  • Anastomotic posterior urethroplasty is the procedure of choice 2
  • The "gold triad" for successful outcome includes:
    1. Complete excision of scarred tissues
    2. Fixation of healthy mucosa of the two urethral ends
    3. Creation of a tension-free anastomosis 2

• For complex cases with multiple prior failures:

  • Consider artificial urinary sphincter (AUS) placement 1
  • In patients with recurrent erosions, small intestinal submucosa (SIS) urethral wrap with AUS placement may be considered 3
  • Modified bulbar urethral sling procedure is an alternative for patients with sphincteric incontinence 4

Special Considerations

• Prior radiation exposure: Higher risk of procedure failure (80%) when using urethral wraps 3

• Multiple previous AUS failures: These represent a challenging population with limited options. Consider:

  • Small intestinal submucosa urethral wrap with AUS placement 3
  • Counsel patients about expected risks including temporary urinary retention

• Post-prostatectomy patients:

  • Artificial urinary sphincter is preferred over male slings for patients with stress urinary incontinence after radiotherapy 1
  • Patients should be counseled that AUS will likely lose effectiveness over time (24% failure at 5 years, 50% at 10 years) 1

Follow-up Care

• CT scan with delayed phase imaging or urethrogram/urethroscopy for follow-up of urethral repairs 1
• Monitor for complications:
  • Recurrent stricture
  • Persistent incontinence
  • Erosion or infection of implanted devices
  • Urinary retention

Pitfalls and Caveats

1. Device infection/erosion: If an AUS device becomes infected, it should not be replaced for at least three months to allow infection clearance 1

2. Urethral cuff erosion: The AUS should be explanted with urethral catheter left in place for several weeks to allow healing 1

3. Persistent incontinence after AUS: Evaluate for device malfunction, inadequate cycling, or urethral atrophy 1

4. Post-radiation patients: Higher failure rates for reconstructive procedures; counsel patients accordingly 3

5. Temporary urinary retention: Common after urethral wrap procedures; patients should be prepared for this possibility 3