Reconstruction

Female SUI

Stress urinary incontinence (SUI) is leakage with increased abdominal pressure (coughing, sneezing, exercise, lifting). The workup distinguishes it from urgency and mixed incontinence, confirms it objectively, and — when surgery is planned — screens for the few situations needing urodynamics. Management climbs a ladder from pelvic-floor therapy through midurethral slings to autologous slings and colposuspension.

Definitions

• Stress urinary incontinence (SUI): leakage from increased abdominal pressure.
• Urgency urinary incontinence (UUI): leakage with a sudden, undeferrable desire to void. Mixed (MUI): both SUI and UUI.
• Intrinsic sphincter deficiency (ISD): often defined as ALPP <60 cm H₂O or MUCP <20 cm H₂O, frequently with minimal urethral mobility (the utility of urethral-function testing remains controversial).
• Mesh terms: perforation — mesh in the lower urinary tract; exposure — mesh extruded through skin or vagina.

Pathogenesis

Prevalence of female SUI is up to 49%. By the integral theory, three components support the proximal/mid-urethra: the pubourethral ligaments, the suburethral vaginal hammock, and the pubococcygeus muscle. Injury from surgery, childbirth, aging, or hormonal loss impairs mid-urethral function.

• ISD is the primary underlying cause of SUI; hypermobility is secondary. All women with SUI have some ISD; not all have hypermobility. Hypermobility is a sign of damaged support, not itself a cause.
• MUCP <20 or ALPP <60 cm H₂O indicates ISD; ALPP >90 cm H₂O signifies little or no ISD. In continent women, maximal urethral closure pressure occurs at the mid-urethra.

Differential Diagnosis (7)

Overflow incontinence, detrusor-overactivity incontinence, low bladder compliance, stress-induced detrusor overactivity, diverticulum, urinary fistula, and ectopic ureter.

Diagnosis and Evaluation

Mandatory work-up (4): history with bother assessment + physical exam; objective demonstration of SUI; urinalysis; and post-void residual (PVR).

• History — characterize the incontinence (stress/urgency/mixed/continuous), chronicity, frequency, severity and pad use, associated urinary/pelvic/GI symptoms, menopausal and obstetric history, prior pelvic surgery/treatments, and patient goals. Assessment of bother is paramount to the decision to operate; history alone does not definitively diagnose SUI.
• Physical exam (6): stress test (supine and/or standing) with a comfortably full bladder; focused abdominal exam; urethral mobility (Q-tip); pelvic prolapse; vaginal atrophy/estrogen status; focused neurologic exam.
• Objective demonstration — a positive stress test (involuntary leak coincident with raised abdominal pressure) is highly sensitive and specific; if not seen supine, repeat standing.
• Urinalysis screens for hematuria/pyuria; PVR screens for overflow.
• Adjuncts of limited value: questionnaires (low-quality evidence), the Q-tip test (shows mobility but doesn't diagnose SUI), and the pad test (confirms presence, not type).

Additional evaluation should be considered with (8): known/suspected neurogenic LUT dysfunction; inability to demonstrate SUI; inability to make a definitive diagnosis; elevated PVR; significant voiding dysfunction; urgency-predominant MUI; abnormal urinalysis; or high-grade POP (≥stage 3) where SUI is not shown on prolapse reduction.

• Cystoscopy should not be done in the index SUI patient; indications are suspected bladder pathology (e.g. microhematuria), structural LUT abnormality, or at the time of sling surgery (to confirm integrity/absence of foreign body). Suspect mesh/suture perforation with new LUTS, hematuria, or recurrent UTI.
• Urodynamics may be omitted when SUI is clearly demonstrated in an index patient. VALUE (NEJM 2012; n=630 uncomplicated SUI): preoperative office evaluation alone was non-inferior to evaluation plus UDS for 12-month success. UDS is reserved for non-index patients (neurogenic disease, unconfirmed SUI, subjective/objective mismatch, elevated PVR, significant voiding dysfunction, significant urgency/OAB, or prior POP/anti-incontinence surgery); with significant prolapse, do UDS with and without a pessary.

Management

Options: observation; non-surgical (urethral plugs, vaginal inserts, continence pessary, pelvic-floor muscle training ± biofeedback); and surgical (periurethral bulking, midurethral sling, autologous pubovaginal sling, Burch colposuspension). Stem-cell therapy should not be offered outside trials.

Bulking Agents

Polyacrylamide hydrogel (Bulkamid; FDA-approved 2020) has little long-term data. Indications: patients wishing to avoid more invasive surgery, or insufficient improvement after a prior anti-incontinence procedure; counsel on the expected need for repeat injections. Adverse events: implantation-site pain 13%, acute retention 6%, UTI 4%, hematuria 2%.

Midurethral Slings (MUS)

The most studied surgical treatment for female SUI and, after bulking agents, the least invasive.

• Types: retropubic (RMUS, e.g. TVT-R; top-down or bottom-up), transobturator (TMUS, e.g. TVT-O; inside-out or outside-in), and single-incision/adjustable slings.
• Mechanism: restricts posterior-urethral-wall movement and compresses the lumen during stress; patients without urethral mobility respond less well.
• Anatomy: retropubic — the dorsal nerves of the clitoris cross under the pubic bone ~1.4 cm from midline, and the obturator vessels are the closest major vessels; transobturator — avoids the true pelvis and levators, traversing obturator internus/membrane/externus and (laterally) the adductors, with the dorsal clitoral nerve ≥1–2 cm away.
• Material: soft, loosely woven, macroporous polypropylene monofilament mesh, pore size >75 μm (allows tissue ingrowth, reduces infection).
• Contraindicated with concomitant urethral diverticulectomy, urethrovaginal fistula repair, or urethral mesh excision (impaired healing → perforation). Avoid mesh with poor healing risk (radiation, scarring, poor tissue, chronic steroids, impaired collagen [Sjögren's, SLE], immunosuppression) — use a biologic (preferably autologous fascia) instead.
• Technique: placed loosely at the mid-urethra; single-incision slings need slightly tighter tension. Cystoscopy excludes trocar penetration; if the bladder is perforated, withdraw and re-pass the trocar.

Outcomes: retropubic and transobturator give similar results overall, but transobturator shows less durability with longer follow-up; single-incision slings lose efficacy over time. In ISD/fixed urethra, MUS success is lower and retropubic > transobturator (MUS still benefits ISD if some urethral mobility remains). Cure rates in the elderly with hypermobility match younger women (but more de novo urgency and slightly higher persistent SUI). For recurrent SUI, salvage MUS efficacy is similar to primary (higher bladder-perforation risk after prior retropubic suspensions).

Adverse events (overall low): bladder trocar injury 2.7–3.8% (higher with retropubic, 2.7–23.8% vs 0–1.3% transobturator; manage intraoperatively by repassing more laterally + Foley 3–7 days); voiding dysfunction 7.6%; vaginal mesh exposure 0.5–8.1%; urethral mesh perforation 0–0.6%; bladder mesh perforation 0.5–0.6%; groin pain (higher transobturator); bleeding/vascular injury (higher retropubic); and rarely infection, bowel perforation, death.

• Vaginal mesh exposure — usually within weeks–months; risk factors: diabetes, smoking, older age, >2 cm incision, prior vaginal surgery. Small (<1 cm) asymptomatic exposures may be managed conservatively (conjugated estrogen ± antibiotic cream); otherwise excise (continence maintained in most even with partial excision).
• Urethral or bladder mesh perforation — observation is never appropriate. Small areas: endoscopic management (excise/holmium laser); larger or failed: transvaginal/retropubic excision and reconstruction with non-overlapping suture lines ± labial fat-pad/omental interposition. An inverted-U incision is best for urethral perforation; an autologous fascial sling can augment the repair.
• Voiding dysfunction — de novo urgency in up to 12%, usually transient and much less than with pubovaginal slings; from a sling too tight or too proximal, or associated POP. A RCT showed higher voiding dysfunction needing surgery after retropubic vs transobturator (3% vs 0%). Manage with short-term intermittent catheterization; if persistent within the first 3 months, transvaginal sling release (midline incision through a single vertical vaginal incision) resolves symptoms while maintaining continence in most; incise within 4 weeks. After 3 months, formal sling excision/urethrolysis is needed.
• Sexual dysfunction — de novo dyspareunia 3–14%; sling removal can improve it.
• Regulatory note: the 2008 (updated 2011) FDA communications concerned transvaginal mesh for POP, not slings; an FDA panel deemed MUS products "safe and effective."

Pubovaginal Slings (PVS)

Positioned at the bladder neck (vs mid-urethra for MUS) under mild tension to compress the urethra during raised pressure. Indicated for ISD, hypermobility, MUI, concomitant cystocele/urethral diverticula, and neurologic conditions.

Feature	MUS	PVS
Position	Mid-urethra	Bladder neck
Material	Predominantly synthetic	Predominantly autologous
Donor morbidity	None	Yes
Corrects	Hypermobility	ISD + hypermobility
With urethral diverticulum repair	Cannot	Can
Postop voiding dysfunction	Lower	Higher

• Materials: autologous, allograft, xenograft, or synthetic. Autologous fascia is the gold standard for all forms of SUI (minimal inflammation, negligible erosion) — most commonly rectus abdominis fascia, or fascia lata (preferred after prior ventral hernia repair). Allograft (HIV risk ~1 in 1.67 million; CJD ~1 in 3.5 million) has questionable durability; xenograft (porcine dermis/SIS, bovine pericardium) has inferior long-term cure vs autologous in RCTs; synthetic PVS is no longer used (perforates the urethra 15× and is exposed in the vagina 14× more often than non-synthetic materials).
• Technique: drain the bladder before passing Stamey needles; cystoscopy after trocar passage and at tensioning; never tension the sling before the weighted speculum is removed and the vaginal incision closed.
• Outcomes: autologous PVS continence 61–97%; particularly helpful for ISD and recurrent SUI; effective for MUI (cure similar to pure SUI). The most common reason for dissatisfaction is urgency/urgency incontinence.
• Voiding dysfunction (obstruction) — higher than Burch. SISTEr (NEJM 2007; n=655): autologous rectus-fascia PVS vs Burch — PVS had higher success but more voiding dysfunction (63% vs 47%), UTI, and postop urgency incontinence. Permanent retention ≤5% (mostly preexisting neurogenic bladder). Transient retention usually resolves within ~10 days; if symptoms persist within 6 weeks, loosen the sling in the OR (not for synthetic); after 6 weeks or conservative failure, sling incision or formal urethrolysis (incision has comparable success with less morbidity; success 65–93%). Refractory storage symptoms after urethrolysis: consider anticholinergics and sacral neuromodulation.

Burch Colposuspension

Largely replaced by MUS (equivalent to TVT in RCTs; likely inferior to autologous fascial sling). Indications: patient preference to avoid mesh and fascial harvest, or a simultaneous abdominal procedure (e.g. hysterectomy).

Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is descent of the pelvic organs through weakened vaginal support. It is graded by compartment and quantified with POP-Q, and it interacts closely with urinary incontinence — including "occult" SUI unmasked by prolapse reduction.

Classification

• Anterior compartment: anterior vaginal-wall weakness, usually with bladder descent (cystocele).
• Posterior compartment: posterior weakness with rectal bulge (rectocele) ± small bowel (enterocele).
• Apical: descent of uterus/cervix (or vaginal cuff post-hysterectomy), vault, and/or bowel (enterocele).
• An enterocele is a true hernia of intestine into the vaginal wall. Prolapse is most frequent anterior > posterior > apex. Complete uterine prolapse (procidentia) can cause bilateral ureteral obstruction, relieved by correcting the prolapse.

Normal Pelvic Support (3 levels)

• Level I — suspends the uterus/upper vagina to the sacrum and lateral sidewall; loss → apical prolapse.
• Level II — paravaginal attachments of the mid-vagina to the levator fascia and arcus tendineus; loss → anterior wall prolapse/cystocele.
• Level III — lower-third attachments to the perineal membrane, levators, and perineal body; anterior loss → urethral mobility, posterior loss → distal rectocele/perineal descent.

Pathogenesis

• Well-established risk factors (3): age, obesity, and parity (risk rises with childbirths, slowing after the first two).
• Less established (7): smoking, chronic constipation, menopause/hormonal effects, hysterectomy/other pelvic surgery (a strong predictor of repeat pelvic-floor surgery), larger vaginally-delivered fetal weight, genetic predisposition, and race/ethnicity (more common in Caucasian and Hispanic than African-American women).

Incontinence and POP

POP can exacerbate storage LUTS, and >40% of women with SUI have a significant cystocele. UI procedures without POP correction can worsen certain prolapse; POP surgery improves storage symptoms in a significant proportion. Occult SUI is stress incontinence that appears only after prolapse reduction (previously masked) — failure to address it at POP surgery leads to more symptomatic postop SUI. Untreated POP is usually a quality-of-life condition but can rarely cause retention or renal failure from compression.

Diagnosis and Evaluation

• History — the only symptom strongly associated with prolapse at/below the hymen is a sensation of vaginal bulge; coexisting UI, fecal incontinence, and voiding/defecation/sexual symptoms correlate weakly. Evaluate defecatory disorders before POP surgery and discuss dyspareunia (some repairs cause it).
• Physical exam — external genitalia and estrogen status (signs of deficiency: urethral caruncle, urethral prolapse, labial adhesions); assess prolapse ideally in both lithotomy and standing; check anal sphincter tone (S2–4). Imaging plays a small role.

POP-Q System

Six points and three landmarks measured in cm relative to the hymen (negative = above, positive = below):

Point	Location
Aa	Anterior wall 3 cm proximal to the meatus (−3 to +3)
Ba	Most distal anterior-wall prolapse (−3 to +tvl)
Ap	Posterior wall 3 cm proximal to the meatus (−3 to +3)
Bp	Most distal posterior-wall prolapse (−3 to +tvl)
C	Cervix (or vaginal cuff)
D	Posterior fornix (distinguishes cervical elongation from uterine prolapse)

Landmarks: gh (genital hiatus), pb (perineal body), tvl (total vaginal length).

Staging (most severe point on straining): Stage 0 — no prolapse (Aa/Ba/Ap/Bp all −3); Stage 1 — >1 cm above the hymen; Stage 2 — within 1 cm of the hymen; Stage 3 — >1 cm below the hymen but not fully everted; Stage 4 — complete eversion (≥2 cm < tvl). Asymptomatic stage 1–2 is considered normal.

Management

• Anterior: pessary or prolapse repair.
• Apical: sacrocolpopexy (rare sacral pain/osteomyelitis). CARE trial — in women with prolapse but no preoperative SUI undergoing sacrocolpopexy, adding a Burch significantly reduced postoperative incontinence at every follow-up point.
• Posterior: rectocele repair (mesh-augmented repairs risk levator/gluteal pain and rectal penetration).
• The 2011 FDA safety communication concerned mesh placed transvaginally for POP and specifically excluded slings and transabdominal prolapse mesh.

Mesh Complications

Synthetic mesh (type I macroporous monofilament polypropylene) augments native-tissue prolapse repair — the current standard for POP is sacrocolpopexy with mesh suspension to the sacral promontory. Complications, though usually minor, can be difficult to reverse.

Complications

Mesh complications occur in ~10% of patients and may arise from the material, host response, surgical factors, or unknown processes — sometimes months to years later. The Committee on Gynecologic Practice advises counseling on: mesh exposure (1–19%), buttock/groin/pelvic pain (0–18%), de novo dyspareunia (2–28%), and reoperation (1–22%).

Diagnosis and Evaluation

• History/exam — review the prior operative record. Mesh penetration into urethra/bladder presents with hematuria, UTIs, and pain. Retropubic sling arms can injure the ilioinguinal (L1) and genital branch of the genitofemoral nerve (sharp localized pain); obturator arms can injure femorocutaneous, pudendal, perineal, inferior anal, or obturator nerves. Vaginal exposure presents with bleeding, infection, fistula, pain, dyspareunia, organ perforation, obstruction, or dysfunction.
• Imaging: VCUG (obstruction), CT (abscess), MRI (osteitis/osteomyelitis), translabial ultrasound (mesh location/size).

Management

• Expectant — mild voiding dysfunction/discomfort often resolves; asymptomatic exposure without pain or organ dysfunction can be observed. Persistent problems (prolonged voiding dysfunction, obstruction, pain/dyspareunia, erosion into an organ or vaginal exposure, defecatory dysfunction) warrant intervention.
• Medical — antibiotics if infection is suspected; vaginal estrogen for atrophy.
• Surgical — mesh removal improves symptoms in most with severe refractory pain. Counsel that removal carries a ~20% risk of anterior prolapse recurrence and a 30–50% risk of incontinence after sling removal; persistent retention may need urethrolysis.

Male SUI

Male SUI (most often incontinence after prostate therapy, IPT) results from damage to the striated urethral sphincter. After conservative management and time, surgery ranges from bulking and slings for milder leakage to the artificial urinary sphincter (AUS) — the gold standard across severities and the preferred device after radiation or urethral reconstruction.

Causes

SUI develops only with combined internal and external sphincter impairment.

• Internal sphincter impairment: pelvic surgery, bladder-neck injury, sympathetic neuropathy, embryologic disruption.
• External sphincter impairment: radical prostatectomy (most common); TURP (incontinence here usually reflects persistent overactivity, rarely sphincter damage — the Veterans Study found de novo UI no different from watchful waiting); pelvic fracture urethral injuries; myelopathy; congenital disorders (spinal dysraphism, sacral agenesis, exstrophy/epispadias).

Pre-treatment Counseling and Natural History

• Continence is defined as not requiring a pad/protective device (pad-free).
• Risk factors for IPT after RP (5): older age, larger prostate, shorter membranous urethral length, lack of bilateral neurovascular-bundle preservation (bilateral preservation → 26% more likely continent at 6 months), and prior pelvic radiation. Open and robotic RP have similar incontinence rates; radiation is a significant risk factor (warn of possible AUS need).
• Natural history: continence improves over time, with maximum by ~12 months; most men are not continent at catheter removal; ~90% are continent at 6 months after robotic RP (only +4% afterward). Manage conservatively with follow-up during the first year. Patients may also develop sexual-arousal incontinence and climacturia.
• Pelvic-floor muscle training should be offered immediately postoperatively — it improves time to continence (and QoL) but not overall continence at 12 months; preoperative PFMT benefit is inconsistent (though easier to learn before surgery).

Diagnosis and Evaluation

• Recommended: history/physical with bother; urinalysis ± culture; tools to categorize type/severity (voiding diary, pad weights). Optional: PVR (rule out retention/overflow).
• History — distinguish SUI from urgency/mixed; a voiding diary and pad test help. Severity by volume lost; with sphincteric insufficiency, male slings do worse in severe incontinence.
• Exam — abdomen, genitalia, perineum, rectum, neurologic; scrotal exam for pathology affecting pump placement; note prior incisions for AUS reservoir planning.
• Cystoscopy assesses for urethral/bladder pathology; treat symptomatic vesicourethral anastomotic stenosis or bladder-neck contracture before SUI surgery.
• Urodynamics is not required unless the diagnosis is in doubt; during UDS, remove the catheter and repeat stress testing — up to 35% of men with post-prostatectomy SUI will not leak with a catheter in place. Detrusor hypocontractility may favor AUS over a sling; reduced compliance is concerning (high-pressure storage threatens the upper tracts).

Management

Urgency-predominant disease is treated per OAB guidelines. Non-surgical (offered first): PFMT (offer to all; treat ≥3 months and wait 6–12 months after RP before surgery), absorbent pads, penile compression clamps (not overnight; unsuitable with memory deficit, poor dexterity, impaired sensation, or significant OAB), condom catheter, urethral catheter (last resort — note a suprapubic catheter does not solve severe ISD), and duloxetine.

Surgical timing: consider early surgery if no improvement at 6 months with bothersome (especially severe) SUI; otherwise offer at 12 months for persistent bothersome SUI (caution if still improving). Confirm SUI before surgery and perform cystoscopy. Relative contraindications: urinary-tract conditions needing future transurethral management (bladder cancer, refractory anastomotic strictures) and detrusor overactivity (counsel, not absolute).

Surgical Options

• Transurethral bulking agents — least invasive, least effective (cure rare); for those unwilling/unable to undergo more invasive surgery; limited role after prostatectomy.
• Adjustable balloon devices (ProACT) — for mild SUI; more intraoperative complications and explantation within 2 years than slings/AUS.
• Bulbar urethral sling — for mild–moderate SUI (mild = 24-h pad weight <150 g, moderate <400 g); poor vs AUS in severe disease. Contraindicated with radiation, urethral erosion, or severe gravitational UI. Types: InVance (bone-anchored, compresses urethra; no longer available in the US), AdVance (transobturator; repositions/lengthens the membranous urethra without significant compression), Virtue (combined prepubic + transobturator, four-armed). Neither reliably works after pelvic-fracture urethral disruption. Low rates of retention (resolves ~1 week), pain/paresthesia (resolves ~12 weeks), and rare erosion/infection.
• Artificial urinary sphincter (AUS, AMS 800) — the gold standard for male SUI, effective across moderate–severe loss; revision ~16% at 2 years and ~28% at 5 years. Three components: control pump, pressure-regulating balloon (PRB), and a fluid-filled cuff giving a 2-cm zone of circumferential compression (standard bulbar PRB 61–70 cm H₂O; cuff most often 4 or 4.5 cm). Preferred after radiation, urethral reconstruction, or anastomotic stenosis/bladder-neck contracture (slings less effective; complication rates higher). Absolute contraindications (6): inability to operate the pump, repetitive UTIs, urethral diverticulum/poor tissue at the site, complex/recurrent stricture, small-capacity/non-compliant bladder, active infection. Relative: high-grade VUR, recurrent intravesical disease needing repeat instrumentation (a male sling allows a 24-Fr resectoscope), bladder-neck contracture, detrusor overactivity. Radiotherapy itself is not a contraindication.
  • Technique: single-cuff perineal approach (superior to transverse scrotal), cuff as proximal as possible on the bulbar urethra; size to urethral circumference; place the PRB (abdominal route if prior mesh hernia or extensive abdominal surgery) and pump in the anterior scrotum; verify coaptation by urethroscopy. A bladder-neck cuff is an option in neuropathic disorders (lower erosion/atrophy but higher PRB pressures, 4–6-week deactivation) and is contraindicated after radical prostatectomy.
• Bladder neck closure / urinary diversion — for motivated patients without adequate QoL or inadequate tissue for a sling/AUS: bladder-preserving options (Mitrofanoff, incontinent ileovesicostomy, suprapubic tube with bladder-neck closure) or, for a "hostile" bladder, cystectomy with ileal conduit or continent catheterizable pouch.

AUS Adverse Events

• Intraoperative urethral injury — repair, abandon, and delay implantation (infection risk).
• Infection (<1–5%) — skin flora (S. epidermidis most common, then S. aureus); presents with site/scrotal pain, fever, warmth/erythema; urgent explant — not reimplanted for ≥3 months.
• Cuff erosion (up to 5%) — from unrecognized injury or instrumentation; risk factors include radiation, prior erosion/infection, prior urethroplasty, repeat endoscopic treatments, prolonged catheterization, smaller/transcorporal cuffs (no increased risk with age, placement site, prior RP, or prior transobturator sling). Explant + urethral catheter for a few weeks; no reimplant for ≥3 months; confirm healing by urethrography.
• Urethral atrophy — chronic compression; the most common cause of gradual return of incontinence and AUS revision; manage by downsizing, relocating, or adding a tandem cuff.
• Mechanical failure — 7–10-year device life; ~24% at 5 years, ~50% at 10 years; replace an isolated component if revision is <3 years from implant (otherwise replace in entirety).

Special Situations

• Persistent incontinence after AUS/sling — causes: inadvertent deactivation, insufficient compression/oversized cuff, erosion, bladder storage failure, mechanical failure/fluid loss, plugged resistor, kinked tubing. Slow onset suggests atrophy; sudden recurrence suggests mechanical failure/erosion. Cycle the device to exclude deactivation; image the PRB (contrast X-ray/US) to distinguish fluid loss from atrophy; cystoscopy excludes erosion. UDS if storage failure suspected (best OAB predictors: capacity <200 mL, symptomatic OAB before surgery). Revision options: tandem cuff, 3.5-cm cuff, or transcorporeal placement (downsize rather than add a cuff in young patients). After sling failure → AUS recommended; after AUS failure → revision.
• Urethral stricture — safest initial approach is laser incision through a small endoscope (ureteroscope); open reconstruction for refractory cases.
• Climacturia — conservative first (empty bladder before sex, condoms, PFME); imipramine has been used but is generally avoided in men >65; AUS and transobturator slings (placed for SUI) improve climacturia.
• Concomitant IPT and ED — concomitant or staged procedures may be offered.
• Long-term results: ~76% of AUS patients are dry (0–1 pad/day); revision success is comparable to initial surgery (higher infection/erosion); prior adjuvant radiotherapy worsens prognosis.

Urinary Fistulae

A urinary fistula is an extra-anatomic communication between two or more epithelial- or mesothelial-lined cavities or the skin surface. Successful management follows shared principles and corrects reversible contributors before (and during) repair.

Management Principles

• Reversible factors — "Fistula TO MIIND" (8): Foreign body, Technical surgical problems, urinary Obstruction, Malignancy (biopsy if prior cancer), Ischemia/Infection, Nutrition, and Drainage (unobstructed drainage/stenting).
• Surgical repair principles (11): adequate exposure; debride devitalized tissue; remove foreign bodies; anatomically separate the cavities; watertight closure; well-vascularized healthy tissue flaps; multilayer closure; tension-free non-overlapping suture lines; adequate drainage/stenting; treat/prevent infection; maintain hemostasis.

Urogynecologic Fistulae

Vesicovaginal Fistula (VVF)

VVF accounts for 75% of acquired urinary-tract fistulae. Causes — "Radical, Obstetrical Colleagues' Trauma Causes Incontinence Fistula" (radiation, obstetric, cancer, trauma, postsurgical, external trauma, congenital/inflammatory/foreign body):

• Industrialized world — most common (>75%) is surgical bladder injury, usually at hysterectomy (iatrogenic cystotomy ~0.5–1.0%; fistula after hysterectomy ~0.1–0.2%), typically from an unrecognized cystotomy near the vaginal cuff → urinoma → drainage through the cuff.
• Developing world — most common is prolonged obstructed labor (pressure necrosis); obstetric fistulae tend to be larger, more distal, and involve the bladder neck/proximal urethra.
• Radiation fistulae can appear decades later — any fistula after radiation for malignancy may represent recurrence.
• Clear vaginal discharge after hysterectomy is not invariably a urinary fistula (also normal secretions, peritoneo-/lymphatic fistula, vaginitis, tubal fluid).

Diagnosis (4): history/physical (most common complaint is constant vaginal urinary drainage; pain is uncommon; post-hysterectomy VVFs lie along the anterior wall at the cuff); urinalysis ± culture; imaging — lower tract (cystogram/VCUG; non-diagnostic without voiding/postvoid images) and upper tract (CT urography — up to 12% of postsurgical VVFs have associated ureteral injury/ureterovaginal fistula); and cystoscopy.

• Dye test (optional): instill methylene blue/indigo carmine per urethra and watch a vaginal pack — proximal staining = VVF, distal = UI/urethrovaginal. If the pack is dye-free, give IV indigo carmine — proximal staining = ureterovaginal fistula. The double-dye (tampon) test (oral phenazopyridine + intravesical blue): yellow-orange at top = ureterovaginal, green in the middle = VVF, blue at the bottom = urethrovaginal.

Management:

• Conservative — a trial of indwelling catheter + anticholinergic for 2–3 weeks (spontaneous closure ~13%; favorable if <2–3 mm and non-devascularized). Tracts open ≥3 weeks despite drainage are unlikely to resolve.
• Fulguration — for small epithelialized fistulae <3–5 mm (± catheter); risks failure/enlargement with a thin septum, large/non-oblique tract, or inflammation. Fibrin sealant is adjunctive.
• Surgery — transvaginal or transabdominal (transvesical); success is similar and depends most on surgeon experience. Transvaginal: shorter operative time/stay, less blood loss (but limited cuff exposure, possible vaginal shortening with Latzko). Abdominal: for concurrent intra-abdominal pathology or complicated/large (>5 cm) fistulae. Tract excision isn't always necessary. Tissue interposition (recurrence, radiation, ischemic/obstetric, large, or tenuous repairs): transvaginal Martius flap or peritoneum; transabdominal omentum or peritoneum.
  • Martius flap (labial fat pad) — blood supply: external pudendal (superior), obturator (lateral), posterior labial/internal pudendal (inferior); preferred for low/distal fistulae (trigone, bladder neck, urethra).
  • Peritoneal flap — preferred for high post-hysterectomy VVF; omental flap (gastroepiploic supply) useful with infection/inflammation.
• Drainage — most use both urethral and suprapubic catheters; obtain a postoperative cystogram (with voiding/postvoid images) at 2–3 weeks. Simple-VVF repair success >90%; obstetric/large/radiation fistulae do worse; persistent severe sphincteric incontinence can remain despite successful closure. Non-candidates: urinary diversion or percutaneous ureteral occlusion with permanent nephrostomy.

Ureterovaginal Fistula

From surgical injury to the distal third of the ureter, most commonly at hysterectomy for benign disease (iatrogenic ureteral injury ~0.5–2.5%). Presents with constant incontinence 1–4 weeks postop while normal voiding is maintained (the other kidney still fills the bladder). Imaging: CT urography typically shows ureteral obstruction/dilation; retrograde pyelography may allow stenting; cystography excludes coexistent VVF. Management: prompt upper-tract drainage (stent or PCN); stenting may promote closure; if unsuccessful or with complete occlusion, surgical repair (usually ureteroneocystostomy, >90% success).

Vesicouterine Fistula

Among the least common; most commonly after Cesarean section. May or may not cause constant incontinence (cervical sphincter-like activity), except with an incompetent postpartum cervix. Management: prolonged catheterization/fulguration for small immature fistulae, hormonal induction of menopause (uterine involution), and surgery per fertility wishes (transabdominal hysterectomy + bladder closure, or uterine-sparing repair).

Urethrovaginal Fistula

Mostly iatrogenic in industrialized countries (not associated with hysterectomy); from obstructed labor in the developing world. Proximal fistulae cause SUI or (at the bladder neck) continuous leakage; distal fistulae may be asymptomatic or splay the stream. Diagnose on exam, cystourethroscopy, and VCUG; associated VVF in up to 20%. Manage by excising foreign material and using soft-tissue flaps (most commonly Martius); SUI may persist.

Uroenteric Fistulae

Vesicoenteric Fistula

Diverticulitis is the most common cause of colovesical fistula (also colon cancer, Crohn's; less often radiation/infection/trauma). Pneumaturia is the most common presenting symptom; Gouverneur syndrome = suprapubic pain + frequency + dysuria + tenesmus; recurrent/refractory cystitis is suggestive. CT with contrast is the most sensitive/specific test — bladder-wall thickening adjacent to thickened colon, air in the bladder, and colonic diverticula; 80–100% have a cystoscopic abnormality (bullous edema is suggestive). Bourne test and oral activated charcoal are adjuncts. Management: non-operative (TPN, bowel rest, antibiotics) for selected non-toxic, minimally symptomatic, non-malignant cases (preferred initially in Crohn's); otherwise operative single-stage (resect, close, primary reanastomosis) or two-stage (with temporary diverting colostomy).

Ureteroenteric Fistula

Most common cause is IBD (Crohn's), usually right-sided involving the terminal ileum (rarely diverticulitis/UC; also trauma, urothelial carcinoma, radiation, urolithiasis, TB). Unlike vesicoenteric fistula, it presents more with bowel than urinary symptoms. CT/MRI are more useful than retrograde pyelography. Management: ureterolysis ± bowel resection.

Pyeloenteric Fistula

Historically from chronic inflammation (XGP); increasingly iatrogenic after percutaneous renal surgery/PCNL. Right-sided usually involves the duodenum; left-sided the descending colon. Non-specific symptoms. Manage with a large nephrostomy, bowel rest/suction, antibiotics, foreign-body (stone) removal, and stenting; a poorly functioning kidney → primary bowel closure + nephrectomy.

Rectourethral Fistula

In men, most commonly after radical prostatectomy (low incidence, but common given operative frequency; rectal injury at RP <1–2%; also cryotherapy, radiation, anorectal surgery). Presents with fecaluria, hematuria, UTI. VCUG/RUG is usually diagnostic; exclude ureteral injury; biopsy if prior pelvic malignancy. Given the location, persistent severe SUI risk after repair. Management: some close with catheter drainage/bowel rest/hyperalimentation (after open/lap prostatectomy); fecal diversion sometimes needed; staged repair for large/radiation-related/infected/immunocompromised cases or inadequate bowel prep. The York-Mason procedure (transrectal transsphincteric) is effective with low morbidity.

Urovascular Fistulae

• Renovascular/pyelovascular — most commonly after PCNL (or long-term nephrostomy). Presents with life-threatening hemorrhage/shock or intermittent gross hematuria; ~75% have an abdominal bruit. Manage by replacing/Foley-tamponading the tract, then transcatheter embolization; ~70% of biopsy-induced fistulae close spontaneously within 18 months (expectant management); RCC-related fistulae warrant nephrectomy.
• Ureterovascular — most are ureteroiliac artery fistulae; risk factors are prior vascular disease, radiation/pelvic surgery, and indwelling ureteral stents. May present with hematuria of any degree or life-threatening hemorrhage. Stable: radiographic evaluation then reconstruction/embolization; unstable: early surgery.
• Other — nephropleural/nephrobronchial and cutaneous fistulae (evaluate for distal obstruction in new urocutaneous fistulae).

Bladder Diverticula

A bladder diverticulum is a herniation of bladder urothelium through the muscularis propria. Because its wall lacks organized muscle, it empties poorly — predisposing to stasis, infection, stones, and (in acquired cases) malignancy.

Classification

Feature	Congenital	Acquired
Mechanism	Congenital detrusor weakness	Neurogenic dysfunction or outlet obstruction (almost always)
Location	~90% near the UVJ (lateral/posterior to the orifice)	Often near the UVJ; often multiple
Bladder wall	Smooth-walled, not trabeculated	Trabeculated, thick-walled
Obstruction	May occur without BOO (up to 60% have a syndrome/neuropathic cause)	In men usually >60 with BPH (~70%); in women suggests a BOO etiology
Malignancy risk	Virtually none	Increased (most commonly urothelial carcinoma)

Cellules and saccules are smaller outpouchings on the same continuum. A "Hutch" diverticulum lies superolateral to the ureteral orifice without trigone involvement, in neuropathic bladder with VUR. Diverticula may deviate the ipsilateral ureter (medial deviation most common). Congenital diverticula usually present in childhood with UTI from stasis (~13% have VUR).

Diagnosis and Evaluation

• Most are found while investigating LUTS, hematuria, or infection. Finding a diverticulum in an adult should prompt evaluation for BOO plus endoscopy and lower/upper-tract imaging.
• Labs: urinalysis, culture, cytology, PSA if appropriate.
• Imaging: lower tract — CT and/or VCUG (VCUG with AP/oblique/lateral views shows anatomy, size, VUR, and emptying); upper tract — CT or renal US (up to 7% of adults have silent hydroureteronephrosis; up to 30% of children have upper-tract abnormalities). DDx of a fluid-filled peri-vesical structure (5): Müllerian cysts, gynecologic abnormalities, urachal cysts, ectopic ureter/ureterocele, postsurgical changes (lymphocele).
• Cystoscopy — inspect the entire interior for stones or abnormal epithelium; biopsy carefully (thin wall, perforation risk).
• Urodynamics — videourodynamics helps identify neurogenic dysfunction (treat before/with surgery to avoid recurrence). Contractility may appear falsely diminished from a "pressure sink" (detrusor decompresses into the diverticulum) but is actually similar to BPH without diverticula; PVR may be elevated from retained diverticular urine.

Management

Options: surveillance, surgery (endoscopic/open/laparoscopic/robotic), or catheterization.

• Surveillance — for adults with minimal symptoms and no complicating factors; counsel on the increased malignancy risk (from stasis/chronic inflammation) and the need for periodic reassessment (symptoms, cytology, endoscopy). Diverticulum size does not correlate with symptoms or complications.
• Surgery — indications (5): stones in the diverticulum, upper-tract deterioration (obstruction/reflux), persistent symptoms refractory to medical therapy, recurrent UTI, and carcinoma/premalignant change. Tumors within a diverticulum have a poor prognosis (the wall lacks muscularis propria → early transmural/extravesical spread and inaccurate staging at TUR) — an aggressive approach is advised, and invasive diverticular tumors are an indication for timely cystectomy (2015 CUA NMIBC). Manage coexisting BOO before or with the diverticulum.
  • Endoscopic — TUR of the diverticular neck + fulguration of the lining, for elderly/comorbid patients or those undergoing TURP.
  • Open/lap/robotic — usually a transvesical extraperitoneal approach; place ureteral stents to avoid ureteral injury (diverticula often adhere to the ureter). Complications: ureteral injury/bleeding/adjacent-organ injury, UTI, prolonged extravasation, and late urinary fistula.
• Catheterization (CIC or indwelling) — for poor emptying with persistent symptoms after relieving obstruction, or in patients unfit/unwilling for surgery.

Female Urethral Diverticula

A female urethral diverticulum (UD) is a urine-filled periurethral cystic structure connected to the urethra by an ostium. Most are acquired from infected periurethral (Skene) glands and present with the classic triad of storage LUTS, pain, and infection — though size does not correlate with symptoms.

Background and Anatomy

• Prevalence up to 1–6% of adult women; most present in the 3rd–7th decade; the vast majority are acquired.
• Most acquired UD arise from infection of the periurethral (Skene) glands.
• The ostium lies postero/ventrolaterally at the 4 and 8 o'clock positions in the mid- or distal urethra in >90%. Two-thirds show inflammatory changes; most are benign, but premalignant/malignant change occurs — the most common malignancy in a urethral diverticulum is adenocarcinoma (recall: most common female urethral cancer is squamous; male is urothelial).

Differential Diagnosis — Periurethral Masses (7)

Periurethral bulking agents, vaginal leiomyoma, Skene gland abnormalities, Gartner duct abnormalities, vaginal-wall cysts, urethral mucosal prolapse, and urethral caruncle.

• Urethral caruncle — an inflammatory lesion of the distal urethra, most common in postmenopausal women; focal (vs circumferential urethral prolapse). Treat conservatively first (topical estrogen/anti-inflammatory creams, sitz baths); excise large/refractory/atypical lesions.

Diagnosis and Evaluation

• Symptoms span asymptomatic (up to 20%) to debilitating masses; the most common (3) are storage LUTS, pain, and infection — recurrent cystitis should raise suspicion. Other symptoms: dysuria, hematuria, post-void dribbling, retention, stress/urge incontinence, dyspareunia, a vaginal mass (compression may express urine/pus), and discharge (vaginal pruritus is not a symptom). Size does not correlate with symptoms.
• Exam — the urethra can be "stripped" to express pus/urine.
• Imaging (no gold standard; 5 options): double-balloon positive-pressure urethrography, VCUG, IV urography, ultrasound, MRI — none reliably diagnoses malignancy.
• Cystourethroscopy — the ostium can be hard to find; stones are found in 4–10%.

Management

Options: observation, or surgical excision and reconstruction (most common), marsupialization, endoscopic unroofing, fulguration, or incision/obliteration.

• Observation — natural history is poorly known; counsel on malignancy risk; non-operative care uses low-dose antibacterial suppression and post-void digital stripping.
• Diverticulectomy — principles (8): mobilize a well-vascularized anterior vaginal-wall flap; preserve the periurethral fascia; identify and excise the neck/ostium; remove the entire sac; watertight urethral closure; multilayer non-overlapping absorbable closure; close dead space; preserve/create continence. Successful excision removes the ostium (often with the urethral catheter seen in the lumen); additional procedures (buccal graft, Martius/vaginal flaps) are not needed to close the urethra. Do not place synthetic mid-urethral mesh synchronously (erosion/infection risk). Adverse events: recurrent UTI, incontinence, recurrent diverticulum, and (uncommon) urethrovaginal fistula — diverticulum size does correlate with recurrence risk.