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

Management of Urinary Incontinence in Scarred Open Urethra

For urinary incontinence due to a scarred open urethra, delayed urethroplasty is the recommended next step after establishing adequate urinary drainage. 1

Initial Assessment and Management

1. Establish urinary drainage immediately

   • Suprapubic catheter placement is preferred in cases with scarred open urethra 1
   • Avoid prolonged attempts at urethral catheterization which may worsen injury 1

2. Diagnostic evaluation

   • Perform urethrography to assess the extent of urethral damage 1
   • Urethrography should be repeated every two weeks to monitor healing 1

Definitive Management Algorithm

Step 1: Determine the location and extent of urethral scarring

• Anterior urethral scarring:

  • Initial conservative management with urinary drainage
  • Trial of endoscopic realignment should be attempted
  • If endoscopic approach fails, proceed to urethroplasty 1

• Posterior urethral scarring:

  • Initial conservative management with urinary drainage
  • Endoscopic realignment may be attempted in hemodynamically stable patients
  • If unsuccessful, plan for delayed urethroplasty 1

Step 2: Surgical Planning for Urethroplasty

The timing of urethroplasty depends on several factors:

• For anterior urethral scarring: Delayed urethroplasty after 3 months is recommended 1
• For posterior urethral scarring: Urethroplasty should be performed preferably within 14 days from injury if no pelvic fractures are present 1
• If associated with pelvic fractures: Postpone definitive surgery until after healing of pelvic ring injuries 1

Step 3: Urethroplasty Technique Selection

• For defects <2.5 cm: Perineal approach with mobilization of bulbar urethra 2
• For defects >2.5 cm: Elaborated perineal or perineo-abdominal transpubic procedure 2
• Key surgical principles (the "gold triad"):
  1. Complete excision of scarred tissues
  2. Fixation of healthy mucosa of the two urethral ends
  3. Creation of a tension-free anastomosis 2

Special Considerations

• For complex cases with multiple prior failures: Consider small intestinal submucosa urethral wrap at the time of artificial urinary sphincter placement as a salvage option 3

• For cases with bladder neck scarring: Skin graft to restore elasticity at the "zone of critical elasticity" may be necessary to prevent continued incontinence 4

• Monitoring for complications: Follow patients for at least one year after urethral injury to monitor for stricture formation, erectile dysfunction, and incontinence 1

Pitfalls to Avoid

1. Prolonged endoscopic realignment attempts can increase injury severity and long-term sequelae 1

2. Immediate operative intervention to repair or debride injured urethra is contraindicated in straddle injuries due to the indistinct nature of injury borders 1

3. Radiation history significantly reduces success rates of reconstructive procedures (80% failure rate in patients with prior radiation) 3

4. Inadequate follow-up: Stricture formation after urethral injury is very high, requiring surveillance with uroflowmetry, retrograde urethrogram and/or cystoscopy 1

5. Ignoring the need for specialized expertise: Complex urethral reconstruction should be performed by surgeons with expertise in urethral surgery 1

Remember that urethral strictures are a common complication after urethral trauma (45% of strictures are iatrogenic), and if left untreated can lead to serious long-term complications including impaired renal function 5.