After a prostatectomy, how can one assess the risk of developing fecal incontinence, by checking the hypogastric nerve or the Pudendal (Perineal) nerve?

From the Guidelines

To assess the risk of developing fecal incontinence after a prostatectomy, checking the Pudendal (Perineal) nerve is the most appropriate option. The pudendal nerve provides motor innervation to the external anal sphincter, which is crucial for maintaining fecal continence. After prostatectomy, damage to this nerve can lead to weakening of the external anal sphincter, resulting in fecal incontinence. Assessment of pudendal nerve function through physical examination (testing anal tone and the anal wink reflex) or pudendal nerve terminal motor latency testing can help determine if there is nerve damage that might lead to fecal incontinence. The hypogastric nerve primarily controls ejaculation and bladder function but is not directly responsible for fecal continence. Pudendal nerve assessment is particularly important in patients who have undergone extensive pelvic surgery like radical prostatectomy, as the nerve can be damaged during dissection in the pelvic region, leading to postoperative complications including fecal incontinence, as discussed in the guidelines for incontinence after prostate treatment 1. Key factors to consider in the assessment and management of incontinence after prostate treatment include patient-reported outcome measures, standing cough test, and daily pad weights, as well as the severity grading of incontinence, which can be defined based on patient-reported pads per day usage 1. However, the most recent guideline updates emphasize the importance of understanding the nature of iatrogenic post-prostatectomy incontinence and assessing which patients will likely experience further symptom recovery versus those who will not, allowing clinicians to set clear expectations regarding short-, medium-, and long-term sequelae of incontinence after prostate treatment 1. In the context of real-life clinical medicine, prioritizing the assessment of the pudendal nerve is crucial for identifying patients at risk of fecal incontinence after prostatectomy, given the potential for nerve damage during surgery and the significant impact on quality of life. The guidelines for incontinence after prostate treatment provide a framework for clinicians to inform patients about the risks of incontinence, including the expected timeline for recovery and the potential need for treatment, as well as the importance of discussing risk factors and treatment options with patients prior to surgery 1. Ultimately, the assessment of the pudendal nerve is a critical component of post-prostatectomy care, as it enables clinicians to identify patients at risk of fecal incontinence and provide targeted interventions to mitigate this risk and improve patient outcomes.

From the Research

Assessing the Risk of Fecal Incontinence after Prostatectomy

To assess the risk of developing fecal incontinence after a prostatectomy, it is essential to consider the role of the hypogastric nerve and the Pudendal (Perineal) nerve.

• The hypogastric nerve is not directly mentioned in the provided studies as a factor in assessing the risk of fecal incontinence after prostatectomy 2, 3, 4, 5, 6.
• The Pudendal (Perineal) nerve, on the other hand, plays a significant role in controlling anal sphincter function. Studies have shown that unilateral pudendal neuropathy can impact the outcome of anal sphincter repair, with patients having a higher likelihood of poor postoperative function 3.
• Pudendal nerve latency has been suggested as a means of identifying prognostic factors for patients with fecal incontinence who undergo anal sphincter repair. However, the usefulness of electrophysiologic studies for prognostication of sphincteroplasty is still being evaluated 5.
• It is crucial to note that the provided studies primarily focus on urinary incontinence after prostatectomy, with limited direct discussion on fecal incontinence in relation to the hypogastric and Pudendal nerves 2, 4, 6.

Key Findings

• Fecal incontinence after radical prostatectomy occurs more frequently than previously recognized, with a higher incidence in radical perineal prostatectomy patients compared to retropubic prostatectomy patients 2.
• The severity of Lower Urinary Tract Symptoms (LUTS), higher age, extent of nerve-sparing surgery, and surgeon experience are significant independent predictors for post-prostatectomy incontinence (PPI) 4.
• Cognitive ability, as assessed by the Mini Mental State Examination (MMSE), has been identified as a non-modifiable risk factor for early PPI, with patients having an intermediate MMSE result having a higher risk of PPI 6.

Nerve-Sparing Surgery and Fecal Incontinence

• Nerve-sparing surgery is a crucial factor in reducing the risk of urinary incontinence after prostatectomy 4.
• However, the direct relationship between nerve-sparing surgery and fecal incontinence is not explicitly discussed in the provided studies.
• It is essential to consider the potential impact of nerve-sparing surgery on both urinary and fecal incontinence in patients undergoing prostatectomy.