Complex strictures - Incontinence

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Etiology:

  1. Bladder neck incompetence: In patients with pelvic fracture urethral injuries the bladder neck may also get involved due to direct bony fragment injury.  In some patients rail road technique is used to pass a urethral catheter into the bladder and if traction is given to bring the bladder down, it may lead to bladder neck incompetence.  Bladder neck injury is more common in children as the prostatic urethra is short in length.
    Under anesthesia Cystoscopy is performed through the supra pubic cycstostomy.  Normally closed circular bladder neck is evident.  In case of injury to the bladder neck, we may see a tear drop deformity due to injury to the circular bladder neck fibres.  As the injury is due to direct bony fragment, it is likely to be at 12 O’ Clock position.  Whenever we have a patient with wide open bladder neck, it may be due to retro pubic fibrosis keeping the bladder neck open or due to neurological  injury.
    If we suspect bladder neck incompetence in a patient of posterior urethral injury, we go ahead and perform anastomotic urethroplasty first and many patients may not need surgery for incompetence.  In case, the patient is incontinent after successful urethroplasty, we plan bladder neck repair at the end of one year.  Through a midline infra umbilical incision  the bladder is opened vertically.  This incision is carried through the bladder neck into the prostatic urethra.  The white firm scar at the bladder neck is excised.  The bladder neck is repaired in the anatomical fashion with absorbable sutures.  A Foley urethral catheter is kept for 3 weeks.  Results of this anatomical bladder neck repair are very encouraging.
    In those patients with wide open bladder neck, I have performed excision of the retro pubic fibrous scar and Omental wrap in few patients.  But in my hands the results have not been satisfactory.
    In those patients who have a false passage from the bladder into the prostatic urethra bypassing the functioning bladder neck excision of the false passage is performed through an abdominal approach. Posterior or total pubectomy may be required to excise this epithelised false passage.  Results of this procedure are rewarding.
    Artificial sphincter may be required to control /cure incontinence as a last resort.  In young men  insertion of artificial sphincter around the bladder neck will give them antigrade ejaculation but may lead to impotence due to dissection around the bladder neck. Usually the artificial sphincter is inserted around the proximal bulbar urethra.
  2. Overactive bladder (OAB): OAB is diagnosed with the symptoms of frequency, urgency and nocturia. The diagnosis is confirmed by urodynamics and the treatment is medical.
  3. False passage between the bladder and the urethra bypassing sphincter mechanism: This will lead to incontinence of urine. These false passages are a result of rail road technique, core through urethrotomy or anastomosis between the bulbar urethra and false passage or directly to the bladder.  Most of these patients need redo surgery with excision of the false passage and redo bulbo prostatic anastomosis. If the false passage is anterior to the prostate one may have to perform surgery through supra pubic incision and partial or total pubectomy may be necessary.