Treatment Options for Incontinence After Prostatectomy
For patients experiencing incontinence after prostatectomy, pelvic floor muscle exercises should be offered as first-line treatment, with surgical options like artificial urinary sphincter considered after 6-12 months if conservative management fails. 1
Initial Assessment and Conservative Management
Assessment of Incontinence
- Evaluate patients with history, physical exam, and appropriate diagnostic modalities to categorize type (stress vs. urgency) and severity of incontinence 1
- Determine the progression or resolution of incontinence over time and degree of bother to guide treatment decisions 1
- Consider urodynamic testing or pad testing if the nature of incontinence cannot be definitively confirmed 1
First-Line Treatment: Pelvic Floor Muscle Exercises (PFME)
- PFME/PFMT should be offered immediately after catheter removal following prostatectomy 1
- Early implementation of PFME improves time-to-achieving continence compared to no treatment 1, 2
- PFME with biofeedback and electrotherapy (3 times weekly for 3 months) can significantly improve continence rates at 3 months (64% vs 9.1% in control group) 2
- While PFME hastens continence recovery, overall continence rates at one year may be similar between men who underwent PFME and those who did not 1
Pharmacological Options
- For patients with urgency urinary incontinence or mixed incontinence with urgency predominance, follow the AUA Overactive Bladder guideline for treatment options 1
- Duloxetine may hasten recovery but is often associated with gastrointestinal and central nervous system side effects 3
Surgical Management
Timing of Surgical Intervention
- Surgery may be considered as early as 6 months if incontinence is not improving despite conservative therapy 1
- Patients with severe incontinence at 6 months or who remain incontinent at one year post-procedure are appropriate candidates for surgical treatment 1
Surgical Options Based on Severity
For Moderate to Severe Incontinence:
- Artificial urinary sphincter (AUS) is the gold standard treatment, particularly recommended for patients who have undergone radiation therapy 4
- Patients should be counseled that AUS effectiveness decreases over time, with failure rates of approximately 24% at 5 years and 50% at 10 years 4
For Mild to Moderate Incontinence:
- Male sling techniques provide a more acceptable management option for less severe forms of urinary incontinence 3
- Transurethral bulking agents may be utilized in select patients 5
Management of Failed Surgical Treatment
- For persistent incontinence after male sling, an artificial urinary sphincter is recommended 4
- For AUS failure, options include proximal relocation, downsizing of the cuff, or tandem cuff placement 4
- If an AUS device becomes infected, it should not be replaced for at least three months 4
Special Considerations
Climacturia (Orgasm-Associated Incontinence)
- Occurs in up to 30% of men following radical prostatectomy 1
- Conservative measures include emptying the bladder prior to sexual activity, wearing condoms, using a penile variable tension loop, and implementing PFME 4
Concurrent Erectile Dysfunction
- For patients with both incontinence and erectile dysfunction, concomitant or staged procedures may be offered to address both conditions 4
High-Risk Patients
- Patients undergoing TURP after radiation therapy or radical prostatectomy after radiation therapy should be informed of the high risk of urinary incontinence 1
- Advanced age, larger prostate size, and shorter membranous urethral length are consistently associated with increased risk of post-prostatectomy incontinence 1
Long-term Outcomes
- Overall, 93.3% of men may achieve continence after one year with appropriate treatment 6
- For patients with multiple device failures, intractable bladder neck contracture, or severe detrusor instability who cannot obtain long-term quality of life with an AUS, urinary diversion with or without cystectomy may be considered 4