How to manage a fixed and immobile urethra due to scarring or other factors?

Management of a Fixed and Immobile Urethra

For patients with stress urinary incontinence (SUI) and a fixed, immobile urethra, physicians should offer pubovaginal sling (PVS), retropubic midurethral sling (RMUS), or urethral bulking agents as the preferred treatment options. 1

Treatment Options for Fixed/Immobile Urethra

First-line Surgical Options

• Pubovaginal sling (PVS) is the preferred option for completely non-mobile urethras due to its ability to provide appropriate support without excessive tension 1
• Retropubic midurethral sling (RMUS) may be considered for minimally mobile urethras, but should be used with caution 1
• Urethral bulking agents are effective alternatives, though patients should be counseled about the potential need for repeat injections due to higher recurrence rates 1

Contraindicated Options

• Transobturator midurethral slings (TMUS) should be avoided in patients with fixed urethras as they may require additional tension, which increases complication risks 1
• Synthetic mesh slings should be avoided in patients with poor tissue quality, significant scarring, or history of radiation therapy 1

Management of Traumatic Causes of Fixed Urethra

Initial Management

• Obtain urinary drainage as soon as possible via urethral or suprapubic catheter 1
• For traumatic injuries, perform urethrography every two weeks to monitor healing progress 1
• In blunt posterior urethral injuries, initial conservative treatment with planned delayed surgical management is recommended 1

Surgical Approaches

• For complex urethral strictures causing immobility:
  • Endoscopic treatment has low success rates for penile strictures; urethroplasty with oral mucosa is preferred 2
  • For short bulbar strictures, endoscopic treatment can be attempted initially 2
  • For long bulbar strictures, options include scar resection with end-to-end anastomosis, non-transecting end-to-end anastomosis, or augmentation urethroplasty 2
  • Perineal urethrostomy (boutonnière procedure) may be considered for complex strictures 2

Post-Traumatic Reconstruction

• When posterior urethral injury is associated with complex pelvic fracture, definitive surgical treatment with urethroplasty should be performed after healing of pelvic ring injury 1
• For blunt posterior urethral injuries, immediate endoscopic realignment is preferred over immediate urethroplasty in hemodynamically stable patients 1
• When endoscopic realignment fails, suprapubic catheter placement and delayed urethroplasty (preferably within 14 days) are indicated 1

Special Considerations

Diagnostic Approach

• Accurate diagnosis of the cause and extent of urethral immobility is essential:
  • Retrograde urethrogram is the standard initial imaging 3
  • Sonourethrography can define periurethral tissues and fibrosis, particularly useful for bulbar urethra 3
  • CT urethrography provides accurate measurement of stricture length 3
  • MRI is valuable for posterior urethral trauma evaluation and periurethral soft tissue assessment 3

Cautions and Contraindications

• Avoid placing synthetic mesh slings if:
  • The urethra was inadvertently injured during a procedure 1
  • The patient is undergoing concomitant urethral diverticulectomy, repair of urethrovaginal fistula, or urethral mesh excision 1
  • The patient has risk factors for poor wound healing (radiation therapy history, significant scarring, poor tissue quality) 1

Follow-up

• For urethral injuries, uretroscopy or uretrogram are the methods of choice for follow-up 1
• Return to sport activities should be allowed only after microscopic hematuria is resolved 1
• Long-term follow-up is essential as urethral strictures may recur, particularly after endoscopic management 4

Pitfalls to Avoid

• Attempting catheterization without proper evaluation in trauma patients can worsen urethral injuries 5
• Underestimating the high recurrence rate of urethral strictures after endoscopic treatment alone 4
• Placing excessive tension on synthetic slings in patients with fixed urethras, which increases risk of complications 1
• Failing to recognize that urethral strictures require proper treatment to prevent long-term complications including impaired renal function 4