Urethral obstruction managed with urethrolysis: postsurgical intervention.(Gynecology)

FORT LAUDERDALE, FLA. -- Don't hesitate to intervene surgically if a patient is having significant voiding problems after anti-incontinence surgery, Dr. Victor Nitti said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Transient voiding dysfunction is not unusual after anti-incontinence surgery, but the diagnosis of urethral obstruction can be difficult to make, said Dr. Nitti, a urologist at New York University, New York.

The true incidence of obstruction after pelvic surgery remains unknown. The literature puts it anywhere from 2% to 24%, but in several large series reported by experienced surgeons approximately 1%-3% of anti-incontinence operations eventually required intervention to relieve obstruction.

Postsurgical obstruction stems from surgical alteration of the bladder outlet, either from tension or misplaced sutures. The most obvious presentation of the problem is urinary retention, followed by obstructive voiding symptoms, such as positional symptoms in which the patient needs to stand or bend a certain way to void.

Patients also may have irritative symptoms of frequency; urgency; or urge incontinence.

Most surgeons wait 3 months after surgery before intervention, Dr. Nitti said. Some patients' symptoms will resolve within 3 months, and further intervention is unnecessary All the literature on recurrent stress incontinence is based on waiting 3 months. However, Dr. Nitti said he has started to intervene earlier than 3 months at the request of frustrated patients. After 6 months, improvement without intervention is highly unlikely.

"The most important part of the evaluation is, without a doubt, the history, and the onset of their obstructive symptoms in relation to their surgery," Dr. Nitti said. "If you think your operation caused the problem, it probably did."