Bradley C. Gill, MD, MS
Sandip P. Vasavada, MD, FACS
BASICS
DESCRIPTION
• Inability to void spontaneously following surgery for stress urinary incontinence
• Voiding with Valsalva or straining following surgery for stress urinary incontinence
• Procedure performed may be either midurethral sling or retropubic urethropexy
EPIDEMIOLOGY
Incidence
• Estimated 3–11% for midurethral sling
• Estimated 3–7% for retropubic urethropexy
Prevalence
• More common with retropubic or transvaginal slings than transobturator slings
• Likely more common with synthetic than biologic sling materials
• Episodes are generally transient and last days to weeks but resolution up to 3 mo can occur
RISK FACTORS (1)
• Weak detrusor contraction or incomplete voiding preoperatively
• Procedure done with “tension” rather than “tension free” placement
• Inability to urinate or elevated post-void residual postoperatively
PATHOPHYSIOLOGY
• Iatrogenic urethral obstruction by extrinsic compression
• Retropubic suspension can cause urethral “kinking”
• Tension-free vaginal tape has lowest rate of retention
• Retention is frequently self-limited and will resolve within 6–12 wk following anti-incontinence surgery
ASSOCIATED CONDITIONS
• Bladder diverticulum
• Cystocele
• Cystolithiasis
• Detrusor hypocontractility
• Recurrent urinary tract infections
• Urethral stricture
DIAGNOSIS
HISTORY
• Details of retention
– Timing of symptom onset with regard to surgery
– Duration of symptoms and consistency with voiding
– Associated with discomfort, distention, or incontinence
• Urologic conditions
– Detrusor hypocontractility on urodynamic studies
– Episodes of cystolithiasis
– Recurrent urinary tract infections
– Cystocele
• Urologic interventions
– Intra-detrusor botulinum toxin injections
– Previous midurethral sling or urethropexy
• Other interventions
– Abdominopelvic surgery, radiation, or injury
– Spine surgery or injury
• Current medications
– Antimuscarinics or anticholinergics
– Alpha adrenergic agonists
• Diabetes mellitus
PHYSICAL EXAM
• Visual inspection of the abdomen and suprapubic area
• Abdominal palpation with attention to the suprapubic area
• Visual inspection of external genitalia for discharge or bleeding
• Speculum examination
– Swelling or bulging anterior vaginal wall
– Incisional discharge or bleeding
– Cystocele
• Palpation of external genitalia, vaginal sidewalls, and pelvic floor muscles
– Urethral or anterior vaginal wall bulging or tension
– Tension and mobility of surgically placed sling or sutures
– Pelvic floor muscle tension, spasm, or tenderness
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Renal function panel
• Serum electrolytes
• Blood counts
Imaging
• Bladder volume ultrasound
• Residual bladder volume after decompression
Diagnostic Procedures/Surgery
• Catheterization only if easily passable with indwelling left temporarily
• Cystoscopy if catheterization not possible with guide wire placement
DIFFERENTIAL DIAGNOSIS
• Bladder diverticulum
• Detrusor hypocontractility
• Occult urinary retention or incomplete emptying
• Sling placed under too much tension
• Neurogenic bladder
• Diabetic cystopathy
• Cystocele
• Medication
TREATMENT
GENERAL MEASURES (2,3)
• Catheterization and observation of iatrogenic obstruction
– Trial of intermittent self-catheterization to observe for resolution
– Temporary indwelling catheter with office visits for trails of voiding
– Cystoscopy and guidewire placement if catheterization not possible
– Consider operative intervention if no resolution within 3 mo
• Emergent bladder drainage for an impassable urethra
– Operative sling incision pending anticipated delay for arranging surgery
– Suprapubic aspiration and drainage at bedside
– Percutaneous nephrostomy tubes if no other options are possible
• Careful urethral dilation may be considered soon after surgery
• Evacuation of hematoma if suspected as etiology of urethral compression
MEDICATION
First Line
N/A
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Elective bladder diverticulectomy as indicated
• Transvaginal retropubic urethrolysis if more conservative measures fail
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Excellent considering multiple options
• Major risk is incontinence recurrence
– 15–20% recurrence of stress urinary incontinence symptoms
COMPLICATIONS
• Infection
• Urethral/bladder injury
• Recurrent incontinence
FOLLOW-UP
Patient Monitoring
• Office follow-up every 7–14 days for trials of voiding if an indwelling catheter placed
• Standard postoperative follow-up if a surgical intervention is pursued
Patient Resources
N/A
REFERENCES
1. Tse V, Chan L. Outlet obstruction after sling surgery. Br J Urol Int. 2011;108(S2):24–28.
2. Ingber MS, Vasavada SP, Moore CK, et al. Force of stream after sling therapy: Safety and efficacy of rapid discharge care pathway based on subjective patient report. J Urol. 2011;185(3):993–997.
3. Song PH, Yoo ES. Five-year outcomes of the transection of synthetic suburethral sling tape for treating obstructive voiding symptoms after transobturator sling surgery. Urology. 2012;80(3):551–555.
ADDITIONAL READING
• Chapple CR. Retropubic suspension surgery for incontinence in women. In: Campbell-Walsh Urology. 2012; Edition 10, Chapter 71:2047–2068.
• Dmochowski RR, et al. Slings: Autologus, biologic, synthetic, and midurethral. In: Campbell-Walsh Urology. 10th ed. 2012; Chapter 73:2115–2167.
See Also (Topic, Algorithm, Media)
• Urethral Sling, Indications, and Anatomic Positions
• Urethral Sling, Materials
• Urethra, Obstruction
• Urinary Retention, Adult Female
CODES
ICD9
• 599.60 Urinary obstruction, unspecified
• 788.29 Other specified retention of urine
• 997.5 Urinary complications, not elsewhere classified
ICD10
• N36.8 Other specified disorders of urethra
• N99.89 Oth postprocedural complications and disorders of GU sys
• R33.8 Other retention of urine
CLINICAL/SURGICAL PEARLS
• Think about how sling vectors impact function.
• Many cases will resolve themselves with time.
• If consistently occurring change the technique.