Can prostatectomy cause urinary incontinence?

Urinary Incontinence After Prostatectomy

Yes, prostatectomy commonly causes urinary incontinence, with long-term incontinence rates after surgery ranging from 12% to 16% of patients. 1

Types and Prevalence of Post-Prostatectomy Incontinence

Urinary incontinence following radical prostatectomy can manifest in several forms:

• Stress urinary incontinence (SUI): The most common type, occurring in 90% of men with post-prostatectomy incontinence 2
• Total urinary incontinence: Complete lack of urinary control with continuous passage of urine (uncommon)
• Sexual arousal incontinence and climacturia: Occurs in up to 30% of men following radical prostatectomy 1

According to the American Urological Association (AUA) guidelines, most men are not continent immediately after catheter removal, but continence generally improves over time 1. The cumulative rates of requiring surgical intervention for incontinence are 2.6% at 5 years, 3.8% at 10 years, and 4.8% at 15 years post-prostatectomy 3.

Risk Factors for Post-Prostatectomy Incontinence

Several factors increase the risk of developing urinary incontinence after prostatectomy:

• Advanced patient age: Particularly over 65 years 4
• Larger prostate size 1
• Shorter membranous urethral length (measured by MRI) 1
• Previous transurethral resection of prostate (TURP) 4
• Radiation therapy after surgery: Increases risk by 61% 3
• Low surgeon volume: Surgeons performing fewer than 49 prostatectomies per year have higher incontinence rates 3

Timeline of Continence Recovery

• Short-term incontinence: Expected immediately after surgery
• Recovery period: Most men achieve continence (not requiring protective pads) within 12 months of surgery 1
• Persistent incontinence: If no significant improvement after 6 months despite conservative therapy, surgical intervention may be considered 1

Management of Post-Prostatectomy Incontinence

Conservative Management

• Pelvic floor muscle exercises (PFME): Should be offered in the immediate post-operative period 1, 5
  • Improves time to achieving continence compared to no intervention
  • Most effective when started immediately after catheter removal

Medical Management

• Pharmacological options for mixed incontinence with overactive bladder symptoms:
  • Anticholinergics
  • Beta-3 agonists
  • Duloxetine (off-label) 6

Surgical Management

• Consider surgical intervention if incontinence persists beyond 6 months with no improvement despite conservative therapy 1
• Surgical options based on severity:
  • Mild-to-moderate incontinence: Non-adjustable trans-obturator slings 6
  • Moderate-to-severe incontinence: Artificial urinary sphincter 6
  • Approximately 8-9% of patients require subsequent procedures to resolve incontinence 1

Evaluation of Post-Prostatectomy Incontinence

Proper evaluation includes:

• Detailed history focusing on characterization and severity of incontinence
• Physical examination
• Urodynamic testing to determine if incontinence is due to:
  • Intrinsic sphincter deficiency (67% of cases alone, 23% combined with bladder dysfunction)
  • Bladder dysfunction (3% of cases alone) 2

Important Considerations

• Symptom of stress urinary incontinence accurately predicts intrinsic sphincter deficiency (95% positive predictive value) 2
• Urge incontinence symptoms are less reliable in predicting bladder dysfunction (44% positive predictive value) 2
• Patients should be informed that incontinence is expected short-term but generally improves to near baseline by 12 months after surgery 1