Figure 2.

Evaluation and treatment algorithm for women with postoperative U/UUI. U, urgency; UUI, urgency urinary incontinence; H, history; P, physical examination; U/A, urinalysis; PVR, postvoid residual; UTI, urinary tract infection; Abx, antibiotics, UT, upper tract; POP, pelvic organ prolapse; BOO, BOO, ISC, intermittent self-catheterization; UDS, urodynamics; N/A, none; OAB, overactive bladder. Notes: (1) Cystoscopy may be considered at any point in the workup, regardless of temporal relationship to original surgery or type of symptoms. (2) May be performed through a transvaginal or transabdominal approach (with laparoscopic or robotic assistance). (3) If symptoms improve or resolve, no additional treatment may be necessary. If bothersome symptoms persist, workup with history, physical, urinalysis, and PVR should be repeated. In the setting of LUTS and anterior compartment POP, a brief pessary trial can be attempted. If the symptoms improve with pessary in place, either a long-term pessary or POP repair may be considered. 5. While either option may still be performed for bothersome and symptomatic POP, the patient should be counseled that their U/UUI may persist and additional treatment via the OAB pathway may be beneficial. (6) A high suspicion for BOO should be maintained through the clinical presentation, even in the absence of elevated PVR or frank urinary retention. (7) While ISC is the preferred method of managing LUTS in the setting of elevated PVR, an indwelling urethral or suprapubic catheter may also be considered. (8) A high-pressure, low flow pattern on UDS makes the diagnosis of BOO definitive. As women do not require a sustained bladder contraction to void efficiently under normal circumstances, the absence of a high-pressure, low-flow pattern does not rule out BOO. Fluoroscopy (video-UDS) may be helpful to delineate the location of obstruction during the pressure-flow study. (9) A midline sling incision through a transvaginal approach is accepted as the initial procedure of choice in a woman with a previous MUS. Some surgeons will remove several mm of sling on either side of midline at the time of surgery to maximize voiding afterward. As there is no definitive method of determining how much sling to remove, this step must be balanced with the increased possibility of redeveloping SUI afterward. Those women who underwent an autologous BNS may require a more extensive sling excision or urethrolysis. All women should be counseled regarding the potential for additional surgical procedures in the future for SUI, BOO, or both. (10) If there is a strong temporal relationship between worsened or de novo bothersome UUI and MUS, consideration may be given for MUS incision in the early postoperative period (>4 weeks). Typically, a period of conservative management (with or without OAB pharmacotherapy) is reasonable before proceeding with another surgical procedure. (11) References[2,3,4,5]