What are the next steps for a 48-year-old female with incontinence 3 months after urethral diverticulectomy?

Management of Incontinence After Urethral Diverticulectomy

For a 48-year-old female with incontinence 3 months after urethral diverticulectomy, the next steps should include urodynamic testing to determine the type and cause of incontinence, followed by appropriate targeted therapy based on those findings.

Initial Assessment

• Perform urodynamic testing to determine the specific type of incontinence (stress, urge, mixed) and underlying mechanisms, as UDS findings change management in 42.5% of cases 1
• Conduct cystourethroscopy to assess for urethral and bladder pathology that may affect treatment outcomes, including checking for residual diverticulum or urethral stricture 1
• Consider pelvic floor imaging with MRI to evaluate for recurrent diverticulum, as this is the gold standard imaging test for urethral diverticula 2, 3

Common Causes of Post-Diverticulectomy Incontinence

• De novo stress urinary incontinence (SUI) is a common complication after urethral diverticulectomy, occurring in approximately 13-15% of patients 4, 3
• Incontinence may result from weakening of anatomical support of the urethra and bladder neck or damage to the urethral sphincter mechanism during diverticulectomy 3
• Recurrent diverticulum may present as persistent or recurrent incontinence, with recurrence rates around 3.4% 4

Management Algorithm

Step 1: Conservative Management (First 6 Months)

• Initiate pelvic floor muscle exercises as first-line therapy 5
• Consider medical therapy with anticholinergics like tolterodine if urodynamics show detrusor overactivity 6
• Use absorbent products as a temporary measure while pursuing definitive treatment 1

Step 2: Surgical Management (If Conservative Measures Fail)

• For confirmed stress urinary incontinence:

  • Autologous fascial pubovaginal sling is preferred over synthetic materials due to prior urethral surgery 1, 7
  • Synthetic sling surgery is contraindicated in patients with history of urethral diverticulum 1

• For recurrent diverticulum:

  • Redo diverticulectomy via a dorsal approach may be necessary 4
  • Consider placing a rectus fascia pubovaginal sling during repair to improve surgical outcome 3

Special Considerations

• Patients should be monitored for at least one year following urethral surgery for complications including stricture formation, which typically develops within a year of injury 1
• Urodynamic assessment is crucial for achieving successful outcomes in patients with preexisting incontinence 7
• Simultaneous placement of a fascial sling during diverticulectomy has been shown to be effective without increased risk of infection or erosion in patients with confirmed SUI 7, 8
• Be aware that urethrovaginal fistula is a rare but serious complication that may present as persistent incontinence after diverticulectomy 3

Prognosis

• With appropriate surgical management, approximately 72% of patients achieve complete continence after treatment for post-diverticulectomy incontinence 4
• Patients with de novo SUI who undergo autologous sling placement have excellent outcomes, with nearly all achieving continence, though approximately 23% may require clean intermittent self-catheterization 4