What are the ways to improve urinary incontinence after prostatectomy?

Management of Urinary Incontinence After Prostatectomy

Pelvic floor muscle exercises (PFME) should be offered to all patients in the immediate post-operative period after radical prostatectomy as the first-line intervention to improve urinary continence recovery. 1

Initial Assessment and Classification

When evaluating post-prostatectomy incontinence, it's essential to:

• Determine the type of incontinence (stress, urgency, or mixed)
• Assess severity (number of pads used daily)
• Evaluate progression or resolution over time
• Measure degree of bother to the patient

This helps guide appropriate treatment selection and timing of interventions.

Non-Surgical Management Options

1. Pelvic Floor Muscle Exercises (PFME)

• Timing: Should be initiated immediately after catheter removal 1
• Benefits: Improves time-to-continence recovery in the short term (3-6 months) 1, 2
• Implementation methods:
  • Formal instruction by a physiotherapist 3
  • Structured programs like the 4-3-2 method (four sets daily, three contractions per set, each lasting two natural breaths) 4

Research shows that PFME with physiotherapist guidance leads to significantly better continence rates at 12 months (92% vs 72% for self-directed exercise) 3, though early continence rates at 3 months may be similar regardless of professional guidance.

2. Management of Urgency Incontinence

• For patients with urgency or urgency-predominant mixed incontinence (affects up to 48% of post-prostatectomy patients), follow the AUA Overactive Bladder guideline 1

Surgical Management Considerations

If incontinence persists despite conservative therapy:

• Surgery may be considered as early as 6 months if incontinence is not improving with conservative measures 1
• Prior to surgical intervention, stress urinary incontinence should be confirmed through history, physical exam, or ancillary testing 1

Surgical options based on severity:

• Severe incontinence: Artificial urinary sphincter (AUS) is first-line option 1
• Moderate incontinence: Discuss risks/benefits of AUS and male slings 1

Timeline for Recovery and Intervention

• Most men are not continent immediately after catheter removal 1
• Patients should be informed that continence generally improves to near baseline by 12 months 1
• Early intervention with PFME can hasten continence recovery 2
• If no significant improvement is seen by 6 months, or severe incontinence persists, consider surgical options 1

Important Caveats

1. Radiation history: Patients who undergo TURP after radiation therapy or radical prostatectomy after radiation therapy have higher rates of incontinence 1

2. Sexual function considerations: Counsel patients about the risk of climacturia (orgasm-associated incontinence), which affects up to 30% of men after prostatectomy 1

3. Long-term expectations: While PFME improves early continence recovery, overall continence rates at one year may be similar between those who did and did not receive formal PFME training 5, though more recent evidence suggests physiotherapist-guided training provides better long-term outcomes 3

4. Severe incontinence: PFME has limited benefit for patients with severe urinary incontinence (>3 pads daily) that persists beyond 16 weeks after surgery 5

The management approach should be guided by the type and severity of incontinence, with PFME as the foundation of early management, followed by surgical options for persistent cases.