Post-operative incontinence and fistulae

The proximity of the urinary tract to the reproductive organs puts it at risk of injury and incontinence as a consequence of gynaecological surgery. Incontinence of urine after gynaecological surgery is not only distressing and disappointing to the patient but also causes considerable stress to the surgeon. In particular, formation of a urinary fistula after surgery is seen as a disaster both by the patient and the surgeon. It also has long-term medico-legal implications. Post-operative incontinence can be broadly divided into two groups. A. Patients who had incontinence before surgery These women have surgery to address this problem in the first place. If surgery fails, the reasons could be: (a) inadequate evaluation and counselling before surgery, (b) inappropriate operation or operative technique, (c) development of de-novo detrusor instability, (d) unrecognized injury to the lower urinary tract. B. Patients who did not have incontinence but developed this complaint after vaginal or abdominal surgery. Here, incontinence develops as an undesired outcome of surgery. This may be due to: (a) retention with over flow in the immediate post-operative period, (b) inadequate evaluation before vaginal surgery unmasking occult incontinence, (c) unrecognized injury to the lower urinary tract. In this article, the main emphasis will be on prevention, evaluation, diagnosis and management of urinary tract injury. Other causes of post-operative incontinence will be addressed briefly. A list of references has been provided for the interested reader.