What is the management approach for urinary incontinence after radical prostatectomy?

Management of Post-Radical Prostatectomy Urinary Incontinence

Start with pelvic floor muscle exercises immediately after catheter removal, and if incontinence persists beyond 6-12 months despite conservative therapy, proceed to surgical management with artificial urinary sphincter as the gold standard. 1, 2

Initial Assessment

Perform a focused evaluation to categorize the type and severity of incontinence: 2

• Document progression or resolution over time and quantify the degree of bother to the patient 2
• Measure incontinence severity using pad testing if the nature cannot be definitively confirmed 2
• Consider urodynamic testing to differentiate stress incontinence from detrusor overactivity, particularly if the clinical picture is unclear 2
• Identify risk factors including advanced age, larger prostate size, and shorter membranous urethral length, which predict worse outcomes 2

Conservative Management (First-Line)

Initiate pelvic floor muscle exercises immediately after catheter removal as the primary treatment: 1, 2

• These exercises hasten continence recovery in the early postoperative period 2
• Continue for at least 6-12 months before considering surgical options 2
• Note that while exercises accelerate recovery, overall continence rates at one year may be similar between treated and untreated patients 2

For overactive bladder symptoms (urgency, frequency, urge incontinence), add anticholinergic medications, which show 50% improvement and 43% complete recovery rates 3

Pharmacotherapy with duloxetine may hasten recovery when combined with pelvic floor exercises, but is limited by significant gastrointestinal and central nervous side effects 4

Timing for 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 are appropriate surgical candidates 2
• Those who remain incontinent at one year post-procedure should definitely be offered surgery 2

Surgical Management Options

Artificial Urinary Sphincter (AUS)

The artificial urinary sphincter is the gold standard surgical treatment for post-prostatectomy stress incontinence: 1, 2

• Particularly recommended for patients who have undergone radiation therapy, where it is preferred over male slings or adjustable balloons 1
• Counsel patients about device longevity: failure rates are approximately 24% at 5 years and 50% at 10 years 1, 2
• Reoperations are common and expected over time 1

Device complications management: 1

• If malfunctioning but not infected, the AUS can be explanted and replaced in the same operative setting
• If infected, wait at least 3 months before replacement, preferably at a different urethral location
• For cuff erosion, explant with urethral catheter left in place for several weeks to allow healing

Male Slings

Male slings are appropriate for less severe forms of stress incontinence in patients who have not undergone radiation: 1, 4

• Infection and erosion rates are very low 1
• If sling fails due to inadequate continence recovery, proceed to artificial urinary sphincter 1

Management After Benign Prostatic Hyperplasia Surgery

Surgical management of stress incontinence after BPH treatment is identical to post-radical prostatectomy management: 1

• Persistent stress incontinence occurs in 0-8.4% of patients after open, laparoscopic, or endoscopic BPH surgery 1
• Offer sling or AUS after conservative measures fail, though outcomes data in this population is limited 1

Management of Persistent or Recurrent Incontinence After Surgery

For persistent incontinence after AUS placement, perform systematic evaluation: 1

• Verify the patient has properly activated and cycled the device
• Use cystoscopy to evaluate cuff coaptation
• Obtain cross-sectional imaging to rule out fluid leak or measure reservoir volume
• Review the original operative report for cuff size, location, and balloon pressure
• Consider proximal relocation or downsizing of distally located or oversized cuffs 1
• Tandem cuff placement is effective as a salvage procedure 1

For persistent incontinence after sling failure, implant an artificial urinary sphincter 1

Special Considerations

Climacturia (orgasm-associated incontinence) occurs in up to 30% of men: 2

• Empty bladder prior to sexual activity
• Use condoms during intercourse
• Consider penile variable tension loop
• Implement pelvic floor muscle exercises 2

Salvage Options for Multiple Failures

For patients with multiple device failures, intractable bladder neck contracture, or severe detrusor instability who cannot achieve acceptable quality of life with AUS, consider urinary diversion with or without cystectomy 2