From the Guidelines
For a patient presenting with urinary incontinence and a scarred, open proximal urethra, the next best step is to perform a definitive evaluation using urethro-cystoscopy, retrograde urethrography (RUG), voiding cystourethrography (VCUG), or ultrasound urethrography to confirm the diagnosis and assess the severity of the urethral stricture 1.
Key Considerations
- The patient's symptoms and signs, such as decreased urinary stream, incomplete emptying, and dysuria, suggest the presence of a urethral stricture, which requires further evaluation 1.
- Urethro-cystoscopy and RUG are essential for confirmation of the diagnosis, assessment of stricture severity, and procedure selection 1.
- Determination of urethral stricture length and location allows the patient and urologist to engage in an informed discussion about treatment options, perioperative expectations, and expected outcomes following urethral stricture therapy 1.
Potential Next Steps
- If the patient has symptomatic urinary retention or needs catheterization prior to another surgical procedure, urethral endoscopic management (e.g., urethral dilation or direct visual internal urethrotomy [DVIU]) or immediate suprapubic (SP) cystostomy may be considered for urgent management 1.
- Further evaluation with urodynamic studies and consideration of surgical intervention, such as urethral reconstruction or artificial urinary sphincter placement, may be necessary if symptoms persist 1.
From the Research
Treatment Options for Urinary Incontinence
The patient's condition of urinary incontinence with a scarred, open proximal urethra requires careful consideration of treatment options.
- Open retropubic colposuspension is a surgical treatment that involves lifting the tissues near the bladder neck and proximal urethra to correct deficient urethral closure 2, 3.
- This procedure has been shown to be effective in treating stress urinary incontinence, with overall cure rates ranging from 68.9% to 88.0% 2, 3.
- Comparison with other surgical techniques, such as suburethral slings and needle suspension, has found no significant difference in incontinence rates in all time periods evaluated 2, 3.
Considerations for High-Risk Patients
For patients with complex conditions, such as a scarred, open proximal urethra, careful consideration of risk factors is necessary.
- Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are essential for high-risk patients 4.
- Surgical strategies, such as optimization of testosterone, avoidance of 3.5 cm AUS cuff, transcorporal AUS cuff placement, relocation of AUS cuff site, use of lower pressure-regulating balloon, penile revascularization, and intermittent nocturnal deactivation, can be considered to decrease device complications 4.
Non-Surgical Treatment Options
Non-surgical treatment options, such as pelvic floor muscle training and physiotherapy, can also be considered.
- These techniques can be effective in treating mild to moderate urinary incontinence, but may not be sufficient for more severe cases 5, 6.
- Physiotherapeutic techniques, such as magnetostimulation, vibration training, and biofeedback, can be used to activate the pelvic floor muscles and improve continence 6.