What are my treatment options for managing urinary incontinence due to an ongoing prostate issue, given that my current medication is ineffective?

Treatment Options for Urinary Incontinence from Prostate Issues

You should first clarify whether your incontinence is stress incontinence (leaking with activity/coughing) or urgency incontinence (leaking with sudden urge to urinate), as this fundamentally determines your treatment pathway. 1

Determining Your Type of Incontinence

Your physician needs to categorize your incontinence type through history and physical examination, asking specifically which activities cause leaking 1:

• Stress incontinence: Leaking occurs with physical activity, coughing, sneezing, or standing up
• Urgency incontinence: Leaking occurs with sudden, overwhelming urge to urinate (often with frequency and nocturia)
• Mixed incontinence: Both patterns present

If You Have Urgency or Mixed Incontinence

For urgency-predominant symptoms, you should be treated according to overactive bladder protocols, which means escalating through behavioral modifications and antimuscarinic medications. 1, 2

Treatment escalation for urgency incontinence:

• First-line: Timed voiding and bladder training 1
• Second-line pharmacotherapy if bladder training fails 1:
  • Alpha-blockers (tamsulosin, alfuzosin, silodosin) for slow urinary stream 1
  • Anticholinergic medications (oxybutynin) for frequency, urgency, or nocturia 1
  • Beta-3 agonist (mirabegron) as alternative to antimuscarinics 2

The choice of medication should be based on tolerability, adverse effect profile, ease of use, and cost 1. Oxybutynin has the highest discontinuation rate due to side effects (dry mouth, constipation, blurred vision), while other agents like solifenacin have lower discontinuation rates 1.

If You Have Stress Incontinence from BPH Treatment

For stress incontinence related to prostate surgery (TURP or other BPH procedures), you should first undergo pelvic floor muscle training, and if this fails after 6 months, surgical options including male slings or artificial urinary sphincter should be offered. 1, 3

Conservative management (try for at least 6 months):

• Pelvic floor muscle exercises (Kegel exercises) - should be started immediately 1, 3
• Referral to physical therapist for pelvic floor rehabilitation 1

Surgical options if conservative measures fail:

• Artificial urinary sphincter (AUS): Gold standard for moderate to severe incontinence 1, 3
• Male urethral sling: Option for moderate incontinence 1, 3

Important caveat: You should be counseled that AUS will likely lose effectiveness over time, with failure rates of approximately 24% at 5 years and 50% at 10 years 1, 3

Medication Adjustment for BPH-Related Symptoms

If your current BPH medication is inadequate, the specific adjustment depends on what you're currently taking 1:

If on alpha-blocker alone:

• Switch to different alpha-blocker (alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin) based on side effect profile 1
• Add 5-alpha reductase inhibitor (finasteride or dutasteride) if your prostate is enlarged (>30cc volume, PSA >1.5 ng/mL, or palpably enlarged) 1

If on 5-ARI alone:

• Add alpha-blocker for faster symptom relief (alpha-blockers work in 4 weeks vs 3-6 months for 5-ARIs) 1

Follow-up timing:

• For alpha-blockers, beta-3 agonists, or anticholinergics: reassess at 4 weeks 1
• For 5-ARIs: wait 3-6 months before assessing effectiveness 1

When to Refer to Urology

You should be referred to a urologist if medical management fails to address symptoms or if you experience intolerable side effects 1. Urologic referral allows for additional workup (urodynamics, cystoscopy, prostate volume assessment) and consideration of surgical interventions 1.

Common pitfall: Many men assume all post-prostate incontinence is the same type. Urgency incontinence (overactive bladder) affects up to 48% of men after prostate treatment and requires completely different medications than stress incontinence 1. Treating the wrong type will lead to continued failure.