What are the treatment options for incontinence after prostatectomy?

Treatment Options for Incontinence After Prostatectomy

For men with persistent stress urinary incontinence after prostatectomy who fail conservative measures, an artificial urinary sphincter is the most effective surgical option, especially for moderate to severe incontinence, while male slings are appropriate for mild to moderate incontinence. 1, 2

Initial Conservative Management

• Pelvic floor muscle exercises (PFME) or pelvic floor muscle training (PFMT) should be offered in the immediate post-operative period to improve time-to-achieving continence 1
• Conservative management is the first-line approach for post-prostatectomy incontinence and should be tried for at least 6 months before considering surgical intervention 1
• For bothersome climacturia (orgasm-associated urinary incontinence), initial conservative measures include emptying the bladder prior to sexual activity, wearing condoms, using a penile variable tension loop, and implementing PFME/PFMT 1

Surgical Management Options

Patient Assessment Before Surgery

• Any symptomatic vesicourethral anastomotic stenosis (VUAS) or bladder neck contracture (BNC) must be treated before surgical correction of incontinence 1
• Surgery may be considered as early as 6 months if incontinence is not improving despite conservative therapy 1

Surgical Options Based on Severity

For Mild to Moderate Incontinence:

• Male slings (non-adjustable trans-obturator) are appropriate for patients with mild to moderate incontinence 2
• Patients should be counseled that failure rates for male slings exist, and if continence is not achieved, an artificial urinary sphincter may be subsequently needed 1

For Moderate to Severe Incontinence:

• Artificial urinary sphincter (AUS) is the preferred option for moderate to severe incontinence 2
• AUS is specifically recommended for patients who have undergone radiation therapy rather than male slings or adjustable balloons 1
• Patients should be counseled that the AUS will likely lose effectiveness over time, with failure rates of approximately 24% at 5 years and 50% at 10 years 1

Management of Failed Surgical Treatment

• For persistent or recurrent incontinence after AUS placement, evaluation should include history, physical examination, cystoscopy, and possibly cross-sectional imaging 1
• Options for AUS failure include proximal relocation or downsizing of the cuff, or tandem cuff placement 1
• For patients with persistent incontinence after male sling, an artificial urinary sphincter is recommended 1
• If an AUS device becomes infected, it should not be replaced for at least three months to allow infection clearance 1

Special Considerations

• For patients with both incontinence and erectile dysfunction, concomitant or staged procedures may be offered to address both conditions 1
• Urinary diversion with or without cystectomy may be considered in patients unable to obtain long-term quality of life with an AUS due to multiple device failures, intractable bladder neck contracture, or severe detrusor instability 1
• Only 3.6% of men who undergo radical prostatectomy subsequently receive surgical treatment for incontinence, suggesting potential underutilization of effective surgical options 3

Risk Factors for Post-Prostatectomy Incontinence

• Advanced patient age, larger prostate size, and shorter membranous urethral length are consistently associated with increased risk of incontinence after prostate treatment 1
• Patients undergoing TURP after radiation therapy or radical prostatectomy after radiation therapy should be informed of the high rate of urinary incontinence following these procedures 1