A healthy 59-year-old woman with no history of urinary incontinence undergoes vaginal hysterectomy with anterior and posterior (A&P) repair for uterine prolapse, a large cystocele, and a rectocele. Two weeks postoperatively, she presents to your office with a new complaint of intermittent leakage of urine.
What is the most likely cause of this complaint following her surgery?a. Urethral diverticulum
Many patients who have uterine prolapse or a large protuberant cystocele will be continent because of urethral obstruction caused by the cystocele or prolapse. In fact, at times these patients may need to reduce the prolapse in order to void. Following surgical repair, if the urethrovesical junction is not properly elevated, SUI may result. This incontinence may present within the first few days to weeks following surgery. Typically, patients undergoing hysterectomy for prolapse will be evaluated with urodynamic or other studies to help determine if they are likely to leak once normal anatomy is restored following surgery. If they are shown to leak when the cystocele is reduced, the physician may recommend a concomitant procedure to support the mid urethra, such as a mid-urethral sling, to avoid the development of SUI postoperatively. Rectovaginal fistula would present with passage of stool from vagina. Vesicovaginal fistula would present with continuous leakage of urine from the vagina. Detrusor instability would have been present prior to her surgery.