Jerry G. Blaivas, MD

Lower urinary tract symptoms are common in women who have pelvic organ prolapse (POP). For some, these symptoms resolve or improve after surgery for prolapse; for others, symptoms remain unchanged or become worse. These clinical pearls can help you decide how to counsel, evaluate, and treat patients who have POP and coexisting lower-tract symptoms.

How are POP and lower-tract symptoms related?

Lower-tract symptoms that result from, or coexist with, POP include urinary incontinence (stress, urge, mixed), irritative symptoms (frequency, urgency, nocturia), and difficulty voiding (hesitancy, weak or intermittent stream). Prolapse can produce lower-tract symptoms by:

• causing urethral obstruction
  
• dissipating the effects of abdominal pressure during Valsalva voiding, which makes voiding more difficult
  
• masking sphincteric incontinence.
  

Paradoxically, many women who have urethral obstruction caused by POP complain of symptoms of an overactive bladder (OAB). Ultimately, however, correlation between POP and lower-tract symptoms is unpredictable and poorly understood. Mild or moderate prolapse may be associated with significant lower-tract symptoms, whereas a very large prolapse may not be associated with any lower-tract symptoms at all.

Is prolapse causing symptoms or masking stress incontinence?

Some clues to answering this question can be obtained from the history:

• If the patient says that she voids better when the prolapse is reduced, prolapse is probably causing urethral obstruction
  
• If the patient says that she experienced stress incontinence previously but that it has subsided and she now only has difficulty voiding, she probably has occult stress incontinence and, possibly, urethral obstruction.
  

Occult stress incontinence can be diagnosed during the physical exam by examining the patient with a full bladder and manually reducing prolapse while she coughs or strains. The goal of any reduction maneuver is to simulate the effect of surgical correction of prolapse. You can gain more information by treating her with a well-fitting pessary and then documenting her symptoms (using a pad test and bladder diary). A more scientific means of assessment is to perform a urodynamic study while prolapse is reduced by a pessary or vaginal pack.

How is treatment established for lower-tract symptoms?

Prolapse is graded by any of several classifications that are based on the severity and extent of the condition.

Mild degrees of prolapse rarely, if ever, cause urethral obstruction or mask stress incontinence; you can manage lower-tract symptoms in these patients as if they did not have prolapse. Stress incontinence, which is common among these women, can be corrected either in isolation or in conjunction with repair of the prolapse, if such repair is indicated.

More advanced degrees of prolapse, defined as prolapse that extends to or beyond the hymen, are commonly associated with urethral obstruction or occult sphincteric incontinence, or both. This makes it important to diagnose these conditions (by means described earlier) before you intervene surgically to repair the prolapse.

Can surgery for POP affect lower-tract symptoms?

Paradoxically, surgical treatment of prolapse can treat lower-tract symptoms successfully in some patients but cause them in others. How can this be?

• Surgery works when prolapse has caused obstruction and the obstruction is relieved when you resupport the pelvic floor
  
• Surgery can cause symptoms when occult stress incontinence goes unrecognized and is unmasked after repair of prolapse without concomitant anti-incontinence surgery
  
• De novo irritative symptoms and OAB can arise secondary to placement of a sling.
  

Treat all prolapse surgery patients with prophylactic anti-incontinence surgery?

Some experts recommend that practice. But anti-incontinence surgery carries its own risk of complications, so we believe that the need for anti-incontinence surgery should be individualized—based on symptoms, anatomy, the results of diagnostic testing, and the patient’s quality-of-life priorities. Of course, when there is pre-existing or occult stress incontinence, you should routinely consider concomitant anti-incontinence surgery.

When is POP surgery effective for OAB symptoms?

The literature is scant on this question. We believe that, in patients who have an advanced degree of prolapse (especially when urethral obstruction has been documented), symptoms of OAB subside most of the time after effective prolapse surgery.

We do not recommend surgery for mild degrees of prolapse or when there is no pre-existing obstruction.

Lower urinary tract symptoms are common in women who have pelvic organ prolapse (POP). For some, these symptoms resolve or improve after surgery for prolapse; for others, symptoms remain unchanged or become worse. These clinical pearls can help you decide how to counsel, evaluate, and treat patients who have POP and coexisting lower-tract symptoms.

How are POP and lower-tract symptoms related?

Lower-tract symptoms that result from, or coexist with, POP include urinary incontinence (stress, urge, mixed), irritative symptoms (frequency, urgency, nocturia), and difficulty voiding (hesitancy, weak or intermittent stream). Prolapse can produce lower-tract symptoms by:

• causing urethral obstruction
  
• dissipating the effects of abdominal pressure during Valsalva voiding, which makes voiding more difficult
  
• masking sphincteric incontinence.
  

Paradoxically, many women who have urethral obstruction caused by POP complain of symptoms of an overactive bladder (OAB). Ultimately, however, correlation between POP and lower-tract symptoms is unpredictable and poorly understood. Mild or moderate prolapse may be associated with significant lower-tract symptoms, whereas a very large prolapse may not be associated with any lower-tract symptoms at all.

Is prolapse causing symptoms or masking stress incontinence?

Some clues to answering this question can be obtained from the history:

• If the patient says that she voids better when the prolapse is reduced, prolapse is probably causing urethral obstruction
  
• If the patient says that she experienced stress incontinence previously but that it has subsided and she now only has difficulty voiding, she probably has occult stress incontinence and, possibly, urethral obstruction.
  

Occult stress incontinence can be diagnosed during the physical exam by examining the patient with a full bladder and manually reducing prolapse while she coughs or strains. The goal of any reduction maneuver is to simulate the effect of surgical correction of prolapse. You can gain more information by treating her with a well-fitting pessary and then documenting her symptoms (using a pad test and bladder diary). A more scientific means of assessment is to perform a urodynamic study while prolapse is reduced by a pessary or vaginal pack.

How is treatment established for lower-tract symptoms?

Prolapse is graded by any of several classifications that are based on the severity and extent of the condition.

Mild degrees of prolapse rarely, if ever, cause urethral obstruction or mask stress incontinence; you can manage lower-tract symptoms in these patients as if they did not have prolapse. Stress incontinence, which is common among these women, can be corrected either in isolation or in conjunction with repair of the prolapse, if such repair is indicated.

More advanced degrees of prolapse, defined as prolapse that extends to or beyond the hymen, are commonly associated with urethral obstruction or occult sphincteric incontinence, or both. This makes it important to diagnose these conditions (by means described earlier) before you intervene surgically to repair the prolapse.

Can surgery for POP affect lower-tract symptoms?

Paradoxically, surgical treatment of prolapse can treat lower-tract symptoms successfully in some patients but cause them in others. How can this be?

• Surgery works when prolapse has caused obstruction and the obstruction is relieved when you resupport the pelvic floor
  
• Surgery can cause symptoms when occult stress incontinence goes unrecognized and is unmasked after repair of prolapse without concomitant anti-incontinence surgery
  
• De novo irritative symptoms and OAB can arise secondary to placement of a sling.
  

Treat all prolapse surgery patients with prophylactic anti-incontinence surgery?

Some experts recommend that practice. But anti-incontinence surgery carries its own risk of complications, so we believe that the need for anti-incontinence surgery should be individualized—based on symptoms, anatomy, the results of diagnostic testing, and the patient’s quality-of-life priorities. Of course, when there is pre-existing or occult stress incontinence, you should routinely consider concomitant anti-incontinence surgery.

When is POP surgery effective for OAB symptoms?

The literature is scant on this question. We believe that, in patients who have an advanced degree of prolapse (especially when urethral obstruction has been documented), symptoms of OAB subside most of the time after effective prolapse surgery.

We do not recommend surgery for mild degrees of prolapse or when there is no pre-existing obstruction.

Lower urinary tract symptoms are common in women who have pelvic organ prolapse (POP). For some, these symptoms resolve or improve after surgery for prolapse; for others, symptoms remain unchanged or become worse. These clinical pearls can help you decide how to counsel, evaluate, and treat patients who have POP and coexisting lower-tract symptoms.

How are POP and lower-tract symptoms related?

Lower-tract symptoms that result from, or coexist with, POP include urinary incontinence (stress, urge, mixed), irritative symptoms (frequency, urgency, nocturia), and difficulty voiding (hesitancy, weak or intermittent stream). Prolapse can produce lower-tract symptoms by:

• causing urethral obstruction
  
• dissipating the effects of abdominal pressure during Valsalva voiding, which makes voiding more difficult
  
• masking sphincteric incontinence.
  

Paradoxically, many women who have urethral obstruction caused by POP complain of symptoms of an overactive bladder (OAB). Ultimately, however, correlation between POP and lower-tract symptoms is unpredictable and poorly understood. Mild or moderate prolapse may be associated with significant lower-tract symptoms, whereas a very large prolapse may not be associated with any lower-tract symptoms at all.

Is prolapse causing symptoms or masking stress incontinence?

Some clues to answering this question can be obtained from the history:

• If the patient says that she voids better when the prolapse is reduced, prolapse is probably causing urethral obstruction
  
• If the patient says that she experienced stress incontinence previously but that it has subsided and she now only has difficulty voiding, she probably has occult stress incontinence and, possibly, urethral obstruction.
  

Occult stress incontinence can be diagnosed during the physical exam by examining the patient with a full bladder and manually reducing prolapse while she coughs or strains. The goal of any reduction maneuver is to simulate the effect of surgical correction of prolapse. You can gain more information by treating her with a well-fitting pessary and then documenting her symptoms (using a pad test and bladder diary). A more scientific means of assessment is to perform a urodynamic study while prolapse is reduced by a pessary or vaginal pack.

How is treatment established for lower-tract symptoms?

Prolapse is graded by any of several classifications that are based on the severity and extent of the condition.

Mild degrees of prolapse rarely, if ever, cause urethral obstruction or mask stress incontinence; you can manage lower-tract symptoms in these patients as if they did not have prolapse. Stress incontinence, which is common among these women, can be corrected either in isolation or in conjunction with repair of the prolapse, if such repair is indicated.

More advanced degrees of prolapse, defined as prolapse that extends to or beyond the hymen, are commonly associated with urethral obstruction or occult sphincteric incontinence, or both. This makes it important to diagnose these conditions (by means described earlier) before you intervene surgically to repair the prolapse.

Can surgery for POP affect lower-tract symptoms?

Paradoxically, surgical treatment of prolapse can treat lower-tract symptoms successfully in some patients but cause them in others. How can this be?

• Surgery works when prolapse has caused obstruction and the obstruction is relieved when you resupport the pelvic floor
  
• Surgery can cause symptoms when occult stress incontinence goes unrecognized and is unmasked after repair of prolapse without concomitant anti-incontinence surgery
  
• De novo irritative symptoms and OAB can arise secondary to placement of a sling.
  

Treat all prolapse surgery patients with prophylactic anti-incontinence surgery?

Some experts recommend that practice. But anti-incontinence surgery carries its own risk of complications, so we believe that the need for anti-incontinence surgery should be individualized—based on symptoms, anatomy, the results of diagnostic testing, and the patient’s quality-of-life priorities. Of course, when there is pre-existing or occult stress incontinence, you should routinely consider concomitant anti-incontinence surgery.

When is POP surgery effective for OAB symptoms?

The literature is scant on this question. We believe that, in patients who have an advanced degree of prolapse (especially when urethral obstruction has been documented), symptoms of OAB subside most of the time after effective prolapse surgery.

We do not recommend surgery for mild degrees of prolapse or when there is no pre-existing obstruction.

Urethral diverticula are often overlooked as a source of recurrent urinary tract infection, voiding dysfunction, dyspareunia, and chronic pelvic pain. Here, in brief, is how to diagnose and manage this condition, including a look at surgical options.

What are the common complaints?

Urethral diverticula present in myriad ways—most often, as recurrent urinary tract infection, overactive bladder, stress urinary incontinence, and pelvic pain. Other common presenting symptoms include voiding dysfunction, a painful or palpable mass, and postvoid dribbling.

What can be done routinely during a pelvic exam to make the Dx?

Become accustomed to massaging the anterior vaginal wall underneath the urethra. Any discharge or excretion of fluid that you observe from the external urethral meatus as you massage is pathognomonic for urethral diverticulum. In addition, palpate the anterior vaginal wall for paraurethral masses. Sometimes, a diverticulum is ballotable but not palpable.

Which test is best?

Imaging has been used in different ways, with variable success.

• Most diverticula are well visualized by voiding cystourethrography or magnetic resonance imaging (MRI); we view these as complementary techniques, in fact, because some diverticula are visualized only by one modality or the other. MRI provides a superior examination for surgical planning because it defines urethral and diverticular anatomy most clearly
  
• Ultrasonography has been used with some success
  
• Positive-pressure urethrography, using a Tratner or double balloon catheter, is difficult to perform and uncomfortable for the patient.
  

What is the role of urethroscopy?

We find urethroscopy very helpful. One caveat: Inability to visualize a diverticulum or its opening does not, by any means, exclude a urethral diverticulum.

How should you manage a urethral diverticulum?

• Urinary tract infection should be treated with a culture-specific antibiotic; in some cases, the patient will become asymptomatic afterwards
  
• Overactive bladder symptoms can be treated with an anticholinergic
  
• In most cases, surgery proves necessary
  
• When you identify a urethral diverticulum during pregnancy, manage the patient conservatively during the antenatal period
  
• A patient who has an asymptomatic urethral diverticulum can be managed expectantly, but perform a pelvic exam periodically.
  

When is surgery appropriate? By what method?

Several observations are useful:

• Hardness or induration of the diverticular mass is extremely rare; such a finding should prompt surgical excision because it may signal cancer
  
• Marsupialization has been demonstrated to be successful for very distal and small urethral diverticula
  
• Most diverticula at the level of the midurethra and proximal urethra require some form of excision, broadly classified as partial ablation or complete excision
  
• Placement of a suburethral sling is controversial, but some experts believe that, to prevent stress incontinence, this intervention should be undertaken simultaneously with any other surgical treatment for diverticula of the proximal urethra
  
• Sometimes a Martius fat pad must be brought into the field to avoid devascularization and breakdown of the repair. When a suburethral sling is necessary, we routinely place a Martius flap between the urethra and the sling.
  

Urethral diverticula are often overlooked as a source of recurrent urinary tract infection, voiding dysfunction, dyspareunia, and chronic pelvic pain. Here, in brief, is how to diagnose and manage this condition, including a look at surgical options.

What are the common complaints?

Urethral diverticula present in myriad ways—most often, as recurrent urinary tract infection, overactive bladder, stress urinary incontinence, and pelvic pain. Other common presenting symptoms include voiding dysfunction, a painful or palpable mass, and postvoid dribbling.

What can be done routinely during a pelvic exam to make the Dx?

Become accustomed to massaging the anterior vaginal wall underneath the urethra. Any discharge or excretion of fluid that you observe from the external urethral meatus as you massage is pathognomonic for urethral diverticulum. In addition, palpate the anterior vaginal wall for paraurethral masses. Sometimes, a diverticulum is ballotable but not palpable.

Which test is best?

Imaging has been used in different ways, with variable success.

• Most diverticula are well visualized by voiding cystourethrography or magnetic resonance imaging (MRI); we view these as complementary techniques, in fact, because some diverticula are visualized only by one modality or the other. MRI provides a superior examination for surgical planning because it defines urethral and diverticular anatomy most clearly
  
• Ultrasonography has been used with some success
  
• Positive-pressure urethrography, using a Tratner or double balloon catheter, is difficult to perform and uncomfortable for the patient.
  

What is the role of urethroscopy?

We find urethroscopy very helpful. One caveat: Inability to visualize a diverticulum or its opening does not, by any means, exclude a urethral diverticulum.

How should you manage a urethral diverticulum?

• Urinary tract infection should be treated with a culture-specific antibiotic; in some cases, the patient will become asymptomatic afterwards
  
• Overactive bladder symptoms can be treated with an anticholinergic
  
• In most cases, surgery proves necessary
  
• When you identify a urethral diverticulum during pregnancy, manage the patient conservatively during the antenatal period
  
• A patient who has an asymptomatic urethral diverticulum can be managed expectantly, but perform a pelvic exam periodically.
  

When is surgery appropriate? By what method?

Several observations are useful:

• Hardness or induration of the diverticular mass is extremely rare; such a finding should prompt surgical excision because it may signal cancer
  
• Marsupialization has been demonstrated to be successful for very distal and small urethral diverticula
  
• Most diverticula at the level of the midurethra and proximal urethra require some form of excision, broadly classified as partial ablation or complete excision
  
• Placement of a suburethral sling is controversial, but some experts believe that, to prevent stress incontinence, this intervention should be undertaken simultaneously with any other surgical treatment for diverticula of the proximal urethra
  
• Sometimes a Martius fat pad must be brought into the field to avoid devascularization and breakdown of the repair. When a suburethral sling is necessary, we routinely place a Martius flap between the urethra and the sling.
  

Urethral diverticula are often overlooked as a source of recurrent urinary tract infection, voiding dysfunction, dyspareunia, and chronic pelvic pain. Here, in brief, is how to diagnose and manage this condition, including a look at surgical options.

What are the common complaints?

Urethral diverticula present in myriad ways—most often, as recurrent urinary tract infection, overactive bladder, stress urinary incontinence, and pelvic pain. Other common presenting symptoms include voiding dysfunction, a painful or palpable mass, and postvoid dribbling.

What can be done routinely during a pelvic exam to make the Dx?

Become accustomed to massaging the anterior vaginal wall underneath the urethra. Any discharge or excretion of fluid that you observe from the external urethral meatus as you massage is pathognomonic for urethral diverticulum. In addition, palpate the anterior vaginal wall for paraurethral masses. Sometimes, a diverticulum is ballotable but not palpable.

Which test is best?

Imaging has been used in different ways, with variable success.

• Most diverticula are well visualized by voiding cystourethrography or magnetic resonance imaging (MRI); we view these as complementary techniques, in fact, because some diverticula are visualized only by one modality or the other. MRI provides a superior examination for surgical planning because it defines urethral and diverticular anatomy most clearly
  
• Ultrasonography has been used with some success
  
• Positive-pressure urethrography, using a Tratner or double balloon catheter, is difficult to perform and uncomfortable for the patient.
  

What is the role of urethroscopy?

We find urethroscopy very helpful. One caveat: Inability to visualize a diverticulum or its opening does not, by any means, exclude a urethral diverticulum.

How should you manage a urethral diverticulum?

• Urinary tract infection should be treated with a culture-specific antibiotic; in some cases, the patient will become asymptomatic afterwards
  
• Overactive bladder symptoms can be treated with an anticholinergic
  
• In most cases, surgery proves necessary
  
• When you identify a urethral diverticulum during pregnancy, manage the patient conservatively during the antenatal period
  
• A patient who has an asymptomatic urethral diverticulum can be managed expectantly, but perform a pelvic exam periodically.
  

When is surgery appropriate? By what method?

Several observations are useful:

• Hardness or induration of the diverticular mass is extremely rare; such a finding should prompt surgical excision because it may signal cancer
  
• Marsupialization has been demonstrated to be successful for very distal and small urethral diverticula
  
• Most diverticula at the level of the midurethra and proximal urethra require some form of excision, broadly classified as partial ablation or complete excision
  
• Placement of a suburethral sling is controversial, but some experts believe that, to prevent stress incontinence, this intervention should be undertaken simultaneously with any other surgical treatment for diverticula of the proximal urethra
  
• Sometimes a Martius fat pad must be brought into the field to avoid devascularization and breakdown of the repair. When a suburethral sling is necessary, we routinely place a Martius flap between the urethra and the sling.
  

Voiding dysfunction—either difficulty voiding or urinary retention—after surgery for stress incontinence distresses the patient and challenges the surgeon. Here is our systematic approach to evaluating and managing such cases.

What does the operative note say?

Determine exactly what operation the patient underwent and whether appropriate steps were taken during surgery to evaluate the lower urinary tract. Remember: There are well over 30 different synthetic midurethral slings on the market; a variety of biologic materials are used for slings; and conventional suspension procedures are still being performed. Sling composition and surgical technique are the major determinants of subsequent treatment, so it is imperative to obtain the operative note.

Is intermittent self-catheterization an option?

If the patient has an indwelling catheter—of any type—remove it whenever possible and teach her intermittent self-catheterization.

Are symptoms consistent with expected outcome?

In the case of a patient who had a large cystocele repair in conjunction with an anti-incontinence procedure, for example, it is common for some form of retention or voiding dysfunction to be present for 2 weeks or longer. On the other hand, if a patient had a synthetic midurethral sling but no other procedure, it is highly unlikely, during a normal postoperative course, that she would be in retention 2 weeks after the procedure—unless the sling was placed too tightly.

Is there actual (or impending) lower-tract injury? Foreign body penetration?

Good endoscopic evaluation, with visualization of the urethra, of the vesical neck and anterolateral walls of the bladder, will answer these questions.

What is the condition of the pelvic floor?

Make certain that the patient has the ability to appropriately relax the pelvic floor when she attempts to void.

Is urethral dilatation or medication an option?

We believe that urethral dilatation is contraindicated because it might cause urethral erosion of the sling. It is also generally ineffective.

No pharmaceutical agent hastens the return of voiding. Cholinergic agents such as bethanechol are ineffective and cause considerable discomfort. Some experts recommend empiric diazepam (Valium) for patients who are unable to relax sufficiently.

Will intervention succeed?

Ultimately, you and the patient must agree on whether urethrolysis is to be performed or whether the suburethral sling or tape should be cut. Undertake a detailed discussion with her about the potential for, first, persistent voiding dysfunction and, second, recurrent stress incontinence. Cutting a synthetic, allograft, xenograft, or autologous sling will almost always result in resumption of normal voiding, provided the sling is appropriately detached from the urethra and there were no preoperative voiding symptoms. With synthetic, allograft, and xenograft slings, stress incontinence recurs in at least 50% of patients over time. With an autologous sling, the recurrence rate of stress incontinence is less than 10%.

Is it time to operate?

When urinary retention after a synthetic sling procedure is believed to be caused by obstruction, consider surgery within a few weeks. For a patient in retention who has an autologous, allograft, or xenograft sling, it is best to wait approximately 3 months before operating.

Be aware of the risk of failure!

Takedowns of Burch and Marshall-Marchetti operations are much more technically challenging, and yield a much lower success rate, than takedowns of sling procedures. No matter what the prior operation, there is a risk of recurrent sphincteric incontinence.

Voiding dysfunction—either difficulty voiding or urinary retention—after surgery for stress incontinence distresses the patient and challenges the surgeon. Here is our systematic approach to evaluating and managing such cases.

What does the operative note say?

Determine exactly what operation the patient underwent and whether appropriate steps were taken during surgery to evaluate the lower urinary tract. Remember: There are well over 30 different synthetic midurethral slings on the market; a variety of biologic materials are used for slings; and conventional suspension procedures are still being performed. Sling composition and surgical technique are the major determinants of subsequent treatment, so it is imperative to obtain the operative note.

Is intermittent self-catheterization an option?

If the patient has an indwelling catheter—of any type—remove it whenever possible and teach her intermittent self-catheterization.

Are symptoms consistent with expected outcome?

In the case of a patient who had a large cystocele repair in conjunction with an anti-incontinence procedure, for example, it is common for some form of retention or voiding dysfunction to be present for 2 weeks or longer. On the other hand, if a patient had a synthetic midurethral sling but no other procedure, it is highly unlikely, during a normal postoperative course, that she would be in retention 2 weeks after the procedure—unless the sling was placed too tightly.

Is there actual (or impending) lower-tract injury? Foreign body penetration?

Good endoscopic evaluation, with visualization of the urethra, of the vesical neck and anterolateral walls of the bladder, will answer these questions.

What is the condition of the pelvic floor?

Make certain that the patient has the ability to appropriately relax the pelvic floor when she attempts to void.

Is urethral dilatation or medication an option?

We believe that urethral dilatation is contraindicated because it might cause urethral erosion of the sling. It is also generally ineffective.

No pharmaceutical agent hastens the return of voiding. Cholinergic agents such as bethanechol are ineffective and cause considerable discomfort. Some experts recommend empiric diazepam (Valium) for patients who are unable to relax sufficiently.

Will intervention succeed?

Ultimately, you and the patient must agree on whether urethrolysis is to be performed or whether the suburethral sling or tape should be cut. Undertake a detailed discussion with her about the potential for, first, persistent voiding dysfunction and, second, recurrent stress incontinence. Cutting a synthetic, allograft, xenograft, or autologous sling will almost always result in resumption of normal voiding, provided the sling is appropriately detached from the urethra and there were no preoperative voiding symptoms. With synthetic, allograft, and xenograft slings, stress incontinence recurs in at least 50% of patients over time. With an autologous sling, the recurrence rate of stress incontinence is less than 10%.

Is it time to operate?

When urinary retention after a synthetic sling procedure is believed to be caused by obstruction, consider surgery within a few weeks. For a patient in retention who has an autologous, allograft, or xenograft sling, it is best to wait approximately 3 months before operating.

Be aware of the risk of failure!

Takedowns of Burch and Marshall-Marchetti operations are much more technically challenging, and yield a much lower success rate, than takedowns of sling procedures. No matter what the prior operation, there is a risk of recurrent sphincteric incontinence.

Voiding dysfunction—either difficulty voiding or urinary retention—after surgery for stress incontinence distresses the patient and challenges the surgeon. Here is our systematic approach to evaluating and managing such cases.

What does the operative note say?

Determine exactly what operation the patient underwent and whether appropriate steps were taken during surgery to evaluate the lower urinary tract. Remember: There are well over 30 different synthetic midurethral slings on the market; a variety of biologic materials are used for slings; and conventional suspension procedures are still being performed. Sling composition and surgical technique are the major determinants of subsequent treatment, so it is imperative to obtain the operative note.

Is intermittent self-catheterization an option?

If the patient has an indwelling catheter—of any type—remove it whenever possible and teach her intermittent self-catheterization.

Are symptoms consistent with expected outcome?

In the case of a patient who had a large cystocele repair in conjunction with an anti-incontinence procedure, for example, it is common for some form of retention or voiding dysfunction to be present for 2 weeks or longer. On the other hand, if a patient had a synthetic midurethral sling but no other procedure, it is highly unlikely, during a normal postoperative course, that she would be in retention 2 weeks after the procedure—unless the sling was placed too tightly.

Is there actual (or impending) lower-tract injury? Foreign body penetration?

Good endoscopic evaluation, with visualization of the urethra, of the vesical neck and anterolateral walls of the bladder, will answer these questions.

What is the condition of the pelvic floor?

Make certain that the patient has the ability to appropriately relax the pelvic floor when she attempts to void.

Is urethral dilatation or medication an option?

We believe that urethral dilatation is contraindicated because it might cause urethral erosion of the sling. It is also generally ineffective.

No pharmaceutical agent hastens the return of voiding. Cholinergic agents such as bethanechol are ineffective and cause considerable discomfort. Some experts recommend empiric diazepam (Valium) for patients who are unable to relax sufficiently.

Will intervention succeed?

Ultimately, you and the patient must agree on whether urethrolysis is to be performed or whether the suburethral sling or tape should be cut. Undertake a detailed discussion with her about the potential for, first, persistent voiding dysfunction and, second, recurrent stress incontinence. Cutting a synthetic, allograft, xenograft, or autologous sling will almost always result in resumption of normal voiding, provided the sling is appropriately detached from the urethra and there were no preoperative voiding symptoms. With synthetic, allograft, and xenograft slings, stress incontinence recurs in at least 50% of patients over time. With an autologous sling, the recurrence rate of stress incontinence is less than 10%.

Is it time to operate?

When urinary retention after a synthetic sling procedure is believed to be caused by obstruction, consider surgery within a few weeks. For a patient in retention who has an autologous, allograft, or xenograft sling, it is best to wait approximately 3 months before operating.

Be aware of the risk of failure!

Takedowns of Burch and Marshall-Marchetti operations are much more technically challenging, and yield a much lower success rate, than takedowns of sling procedures. No matter what the prior operation, there is a risk of recurrent sphincteric incontinence.