Female voiding dysfunction following pelvic radiation or pelvic surgery can be related to a variety of issues including bladder dysfunction and bladder outlet disorders (Table 23.2). Bladder overactivity in this group can be related to neurologic injury, decreased compliance, bladder outlet obstruction, inflammation, irritation, or pain. During radical hysterectomy or abdominal perineal resection, posterior dissection along the bladder can lead to denervation of the bladder or urethra leading to urinary retention and/or intrinsic sphincter deficiency. Women that undergo abdominoperineal resection and/or radiation for rectal cancer have an increased incidence of urinary incontinence and detrusor overactivity [20]. Decreased outlet resistance in this group results from damage to the innervation of structural elements of the smooth and/or striated sphincter or damage that impairs the support of the bladder outlet in the female. A special consideration is outlet obstruction following neobladder creation which is reported to occur in 1.2–2.5 % of women undergoing neobladder creation [21, 22]. In patients with neobladder creation urinary leakage due to overflow incontinence and urethral stricture are common. A decrease in bladder compliance can also lead to lower urinary tract symptoms in women following pelvic surgery or radiation [23]. The decrease in compliance can either be related to neurologic injury at the time of surgery or delayed neurologic injury following pelvic radiation. Radiation can also cause remodeling of the detrusor muscle [24] and this damage long-term leads to a decrease in compliance and bladder function [25, 26].

A unique situation following radiation or surgery for pelvic malignancy in female patients is fistula formation. The most common cause of vesicovaginal fistula (VVF) formation is surgical injury during gynecologic, urologic, or other pelvic surgery [27, 28]. The incidence of fistula after hysterectomy is estimated to be 0.1–0.2 % [29]. Cervical, vaginal, and endometrial carcinoma are the most common causes of malignant VVF which account for 3–5 % of VVF [30]. Pelvic radiation is also a cause of urinary fistula and usually occurs several years after radiation treatment [31]. There have been numerous studies which have estimated the VVF rate after pelvic radiation to be between 0.6 and 2.0 % [32–34]. Another complication of pelvic surgery and radiation is ureterovaginal fistula formation. The most common cause for ureterovaginal fistulae is surgical injury to the distal ureter which includes ureteral laceration or transection, avulsion, crush injury, suture ligation, and/or ureteral ischemia due to compromise of the vascular supply or electrocautery injury. The incidence of ureteral injury during pelvic surgery has been estimated to be between 0.5 and 2.5 % [35].

A careful history is pertinent in diagnosing the likely physiologic mechanism for voiding dysfunction and devising a treatment plan. The physician should document predisposing factors for voiding dysfunction which may have been present prior to the pelvic surgery or pelvic radiation including: (1) Neurologic symptoms or spinal issues or surgeries, (2) Metabolic issues including diabetes mellitus control, (3) Benign prostatic hyperplasia, (4) Detrusor overactivity, and (5) Stress urinary incontinence. It has been documented that patients with prior BPH and detrusor overactivity will have their symptoms worsen with pelvic radiation. It is therefore, important to document these pre-existing conditions when evaluating a patient with new onset voiding complaints following pelvic radiation or surgery. The onset of symptoms can also shed light on the likely etiology. For example, immediate onset of urinary issues following discontinuation of the Foley catheter may be related detrusor overactivity versus urinary tract infection versus bladder neck or urethral irritation. Urinary fistula, however, presents days to months to years after the treatment whereas issues with compliance or strictures usually present several months to years after the initial surgery or pelvic radiation. Acute exacerbation of mild leaking usually point to urinary tract infection versus gradual onset of mild leaking which can represent overflow incontinence.

Further history should focus on the progression of symptoms over time. Issues with compliance and detrusor overactivity usually worsen over time while sphincteric incontinence usually gets better over time up until 18 months post procedure. The time of day that the urinary dysfunction occurs is also important in determining likely etiology. Urinary leakage that occurs during the day especially with change in position is more likely to be sphincteric incontinence due to gravity. Detrusor overactivity will often present as episodic urinary leakage or urge. Urinary leakage that occurs at night can also be related to detrusor overactivity, but overflow incontinence, storage issues such as compliance and issues with bladder augments capacity or neobladder capacity must also be considered. Patients with continuous daytime and nighttime leakage may be due to overflow incontinence versus urinary fistula. In all of these scenarios it is important to consider the associated voiding pattern. Are these patients having frequency with small volumes to suggest overflow or sphincteric incontinence or frequency with large volumes to suggest overactive bladder? Does the patient have associated urgency, a weak stream, hesitancy, straining or pushing to urinate? Is gross hematuria present and is it initial, continuous, or terminal hematuria to help delineate between stricture, radiation cystitis, or sloughing post radiation? All of these associated urinary complaints are key in steering any further workup and the treatment plan. It is also helpful to illicit any previous workup or treatments the patient underwent for their symptoms and the timing of assessments and treatments.

Following an appropriate detailed history the clinician should focus on a detailed neurologic, abdominal, and genitourinary exam when evaluating patients with voiding complaints following pelvic radiation or surgery. Assess for abdominal fullness or discomfort related to a full bladder or the presence of a colostomy or non-healing wound. It is important to assess overall strength and sensation when trying to rule out systemic disease where voiding dysfunction is the initial complaint and the timing of pelvic surgery or radiation is a coincidence. The physician should also assess perigenital sensation, rectal tone, ability to contract the pelvic floor, and bulbarcavernosal reflex as part of the routine workup if the rectum is present. In women vaginal support should be assessed especially in patients who have had an anterior exenteration, hysterectomy, or a neobladder creation. Urethral obstruction due to anterior overcorrection is more likely in the neobladder population. Concomitant radiation therapy can also increase the risk of induration or irritation of the labia, urethra, or vagina in this population, and it has been shown to increase the risk or fistula formation. It is, therefore, important to document these findings during your initial evaluation.

During the initial evaluation the patients should have a UA to look for hematuria and to rule out UTI as the cause of the voiding complaints, and a post void residual (PVR) to rule out retention. If UTI is present treat accordingly and see the patient back to ensure the voiding symptoms have resolved. If retention is found the patient should be taught clean intermittent catheterization (CIC) if the patient is able to do so, and if not, a Foley catheter should be placed. If the catheter cannot be passed in a male and retention is present these patients should undergo flexible cystoscopy followed by wire passage, stricture dilation, and catheter placement. If UTI and urinary retention has been ruled out, the patient should be instructed to complete a voiding diary prior to their follow-up appointment to further assess the severity and chronology of their voiding dysfunction. The majority of patients with these complex presentations should undergo a pressure flow study or videourodynamics (VUDS) to further assess the etiology and severity of their voiding dysfunction. During VUDS it is important to document initial flow and PVR along with filling compliance, Valsalva leak point pressure (VLPP), and detrusor leak point pressure (DLPP). These parameters will assist in delineating stricture, detrusor overactivity, detrusor underactivity, denervation, and poor compliance as cause for the patients voiding dysfunction as well as assess the risk for upper tract deterioration. If sphincteric incontinence is suspected and cannot be demonstrated with catheter in place, the urethral catheter should be removed and leaking assessed using rectal pressure as VLPP.

After proper identification of the cause of the voiding complaint, it is important to counsel patients on the various treatment options. Detrusor overactivity in both male and female patients can be managed by first treating the underlying cause, i.e. obstruction, followed by anticholinergics in patients with refractory detrusor overactivity. Botox can also be offered in this population, but the patient must be counseled on the 5–10 % risk of retention and the need to do CIC following Botox administration. Patients who are unwilling to accept CIC should not be offered intravesical Botox as a treatment for their detrusor overactivity.

In patients with urinary retention following pelvic surgery or radiation, the etiology of their retention is important in determining the appropriate treatment. Patients with retention due to prostatic obstruction can be offered CIC versus TURP. Post radiation, however, sphincteric incontinence after TURP is more likely [36]. Individuals with urinary retention with normal bladder compliance can be managed with indwelling Foley catheter versus CIC versus suprapubic tube placement depending on patient preference and dexterity. In patient with poor bladder compliance, however, it is important to add anticholinergics or Botox to the treatment algorithm in order to promote dryness in between catheterization and decrease urinary leakage with the catheter in place. In patients with retention due to stricture the least aggressive treatment would be to dilate and leave an indwelling catheter for 3–5 days. Patients receiving this treatment must be warned that this is only a temporizing measure and that the stricture is very likely to recur without further treatment or daily catheterizations. Another treatment option for male patients with urethral stricture is direct vision internal urethrotomy (DVIU). This can be accomplished with either an endoscopic cold knife or laser and this treatment has good short and mid-term results. The best results are obtained by DVIU followed by daily catheterizations to maintain urethral patency. It is also important that patients undergoing this treatment be counseled that their incontinence may worsen due to damage to the sphincter, especially if the patient had prior radiation. In male patients with sphinteric incontinence following radical prostatectomy, the pad weight should determine the appropriate treatment, i.e. in patients with pad counts of less than two a male sling can be offered, whereas in patients with higher pad counts, an artificial urinary sphincter should be considered.