What is the next step in managing a 48-year-old woman's urinary incontinence after urethral diverticulectomy with a positive cough stress test and normal PVR?

Management of Post-Urethral Diverticulectomy Urinary Incontinence

The next step in managing this 48-year-old woman with persistent urinary incontinence after urethral diverticulectomy is to perform a midurethral sling procedure, as she has clear evidence of stress urinary incontinence that has failed conservative management. 1

Clinical Assessment and Diagnosis

This patient presents with:

• Failed trial of antimuscarinics
• Positive cough stress test
• Pooling of urine in the vaginal vault
• Normal post-void residual (35mL)
• Negative urinalysis

These findings strongly indicate stress urinary incontinence (SUI) following urethral diverticulectomy, which is a known complication occurring in approximately 13-15% of patients post-procedure 2. The positive cough stress test with normal PVR and negative urinalysis confirms uncomplicated SUI.

Treatment Algorithm

1. First-line treatment (already attempted):

   • Pelvic floor muscle training (PFMT) is typically first-line for SUI 3, 1
   • Antimuscarinics have already failed in this patient

2. Surgical management (recommended next step):

   • Midurethral sling is the gold standard for SUI with success rates of 51-88% 1
   • For post-diverticulectomy SUI specifically, an autologous pubovaginal sling has shown 90% resolution of SUI symptoms 4

3. Alternative surgical options:

   • Burch colposuspension (8% risk of de novo urge incontinence)
   • Urethral bulking agents (less invasive but lower success rates)

Evidence-Based Rationale

The American College of Physicians strongly recommends against pharmacologic therapy for stress urinary incontinence (Grade: strong recommendation, low-quality evidence) 3. Since this patient has already failed antimuscarinic therapy and has clear evidence of stress incontinence, surgical intervention is appropriate.

Studies specifically examining post-diverticulectomy SUI have shown excellent outcomes with surgical management. In one series, 90% of patients reported complete resolution of their SUI symptoms following autologous pubovaginal sling placement at the time of or after diverticulectomy 4.

Important Considerations

• The pooling of urine in the vaginal vault raises concern for possible recurrent diverticulum (3.4% recurrence rate) 5 or urethrovaginal fistula
• Preoperative imaging with MRI should be considered to rule out recurrent diverticulum before proceeding with anti-incontinence surgery
• Intraoperative cystoscopy should be performed during sling placement to confirm lower urinary tract integrity 1

Potential Complications and Management

• Post-sling urinary retention (3% with midurethral sling, 8% with autologous fascial sling) 1
• De novo urgency symptoms
• Mesh complications if synthetic material is used
• Sling failure (options include sling plication or placement of a second sling) 1

The evidence clearly supports surgical management for this patient with post-diverticulectomy stress urinary incontinence that has failed conservative measures. A midurethral sling or autologous pubovaginal sling would be the most appropriate next step to address her persistent symptoms and improve her quality of life.