What are the treatment options for urinary incontinence post prostatectomy?

Treatment of Urinary Incontinence Post Prostatectomy

Start with pelvic floor muscle exercises immediately after catheter removal and continue conservative management for at least 6 months; if incontinence persists or is severe at 6 months, proceed to surgical intervention with artificial urinary sphincter as the gold standard, particularly for patients with prior radiation therapy. 1, 2

Initial Conservative Management (First 6-12 Months)

Immediate Post-Operative Period

• Begin pelvic floor muscle exercises (PFME) or pelvic floor muscle training (PFMT) immediately after catheter removal to accelerate time-to-continence, though overall continence rates at one year may be similar regardless of whether exercises were performed 1, 2
• Continue conservative therapy for at least 6 months before considering surgical options 1, 2

Assessment During Conservative Phase

• Evaluate incontinence severity through history, physical examination, and consider pad testing or urodynamic studies if the nature of incontinence cannot be definitively confirmed 2
• Monitor progression or resolution over time and assess degree of bother to guide treatment decisions 2

Evidence Limitations for Conservative Therapy

The evidence for one-to-one pelvic floor muscle training in men already incontinent at 6 weeks post-surgery is conflicting. A large multi-center trial showed no difference in urinary or quality-life outcomes at 12 months (76% vs 62% still incontinent, RR 0.85,95% CI 0.60-1.22), suggesting minimal benefit for formal therapy in men with established incontinence 3, 4. However, when PFMT is started immediately post-operatively as prevention, some evidence suggests benefit (10% vs 32% incontinent at one year, RR 0.32), though this finding has methodological limitations 3.

Surgical Management (After 6 Months)

Timing of Surgical Intervention

• Consider surgery as early as 6 months if incontinence is not improving despite conservative therapy 1, 2
• Patients with severe incontinence at 6 months or who remain incontinent at one year are appropriate surgical candidates 2

Pre-Surgical Requirements

• Treat any symptomatic vesicourethral anastomotic stenosis (VUAS) or bladder neck contracture (BNC) before proceeding with incontinence surgery, as these decrease success rates with male slings and worsen outcomes 5, 1

Primary Surgical Options by Severity

Moderate to Severe Incontinence or Post-Radiation Patients

• Artificial urinary sphincter (AUS) is the gold standard treatment, especially for patients who have undergone radiation therapy rather than male slings or adjustable balloons 1, 6
• Counsel patients that AUS effectiveness decreases over time: approximately 24% failure rate at 5 years and 50% at 10 years 1, 2
• AUS requires good manual dexterity for operation 6

Mild to Moderate Incontinence Without Prior Radiation

• Male slings or proACT devices are less invasive options for patients without prior radiation therapy 6
• Note that patients with VUAS or BNC have decreased success rates with male slings, making AUS the better option in this subgroup 5

Management of Surgical Failures

Failed AUS

• Evaluate with history, physical examination, cystoscopy, and possibly cross-sectional imaging 1
• Options include proximal relocation or downsizing of the cuff, or tandem cuff placement 1

Failed Male Sling

• Proceed to artificial urinary sphincter placement 1

Infected AUS

• Remove all components regardless of whether infection is limited to a single component 5
• Wait 3-6 months before replacing the device to allow infection clearance 5, 1

Special Clinical Scenarios

Concomitant Erectile Dysfunction

• Offer concomitant or staged procedures to address both incontinence and erectile dysfunction, though counsel patients about possible increased complication risk 5, 1

Climacturia (Orgasm-Associated Incontinence)

• Occurs in up to 30% of men following radical prostatectomy 2
• Conservative measures: empty bladder prior to sexual activity, wear condoms, use penile variable tension loop, implement PFME/PFMT 5, 1, 2

Refractory Cases

• For patients unable to obtain long-term quality of life after multiple AUS failures, intractable bladder neck contracture, or severe detrusor instability, consider urinary diversion with or without cystectomy 5, 1, 2
• In cases of "hostile" bladder, cystectomy combined with ileal conduit or continent catheterizable pouch protects upper tracts while managing incontinence 5

Risk Factors to Consider

• Advanced age, larger prostate size, and shorter membranous urethral length consistently increase risk of post-prostatectomy incontinence 1, 2
• Patients undergoing TURP or radical prostatectomy after radiation therapy have particularly high rates of urinary incontinence 1

Common Pitfalls

• Do not proceed with incontinence surgery without first treating bladder neck contracture or anastomotic stenosis, as this significantly worsens outcomes 5, 1
• Avoid premature surgical intervention before 6 months unless incontinence is severe and clearly not improving 1, 2
• Do not use bulking agents for male stress urinary incontinence, as they are not currently advised despite success in female SUI 6