What is the approach to evaluating and managing urinary incontinence in men?

Workup of Urinary Incontinence in Men

Begin with a focused history and physical examination to categorize the type of incontinence (stress, urgency, overflow, or mixed), assess severity and bother, and identify reversible causes before proceeding with additional testing. 1

Initial Clinical Assessment

History Taking

The history should specifically address:

• Symptom characterization: Ask which activities provoke leakage to differentiate stress incontinence (sphincteric insufficiency) from urgency incontinence (bladder dysfunction) 1
• Severity and progression: Document whether symptoms are improving, stable, or worsening over time 1
• Degree of bother: Assess impact on quality of life and patient expectations 1
• Medical comorbidities: Review medications, lifestyle habits, and conditions that may contribute to incontinence 1, 2
• Prostate treatment history: Specifically inquire about prior radical prostatectomy, radiation therapy, or BPH procedures, as post-treatment incontinence requires different management 1

Physical Examination

Perform a systematic examination including: 1, 2

• Suprapubic area assessment: Evaluate for bladder distension 1
• External genitalia examination: Look for anatomical abnormalities 1
• Digital rectal examination: Assess prostate size and tenderness, though less accurate than ultrasound for volume estimation 1

Mandatory Initial Testing

All men with urinary incontinence require: 1, 2

• Urinalysis: Essential to detect urinary tract infections, proteinuria, hematuria, or glycosuria that require further investigation 1, 2
• Urine culture: Perform if infection is suspected to guide antibiotic therapy 2
• Frequency-volume chart/bladder diary: Obtain for at least 3 days to document urinary patterns, particularly useful for assessing nocturia and underlying mechanisms 1, 3

Ancillary Diagnostic Testing

Post-Void Residual (PVR) Measurement

Measure PVR to identify overflow incontinence and assess bladder emptying efficiency. 1, 3 This helps distinguish between obstruction-related incontinence and detrusor underactivity.

Cough Stress Test

If stress incontinence is suspected based on history, perform a cough stress test to objectively demonstrate leakage with increased abdominal pressure. 4 This confirms the diagnosis before considering surgical intervention.

Urodynamic Studies

Consider urodynamics when: 1

• The type of incontinence cannot be definitively determined from history and physical examination
• Surgical intervention is being considered (particularly for men with prior prostate treatment)
• Initial conservative treatment has failed

Cystourethroscopy

Perform cystoscopy before surgical intervention for stress incontinence to assess for urethral stricture, bladder neck contracture, or other pathology that may affect surgical outcomes. 1

Special Considerations for Post-Prostate Treatment Incontinence

Men with incontinence following prostate surgery or radiation require specific evaluation: 1

• Timing matters: Most men are not continent immediately after catheter removal following radical prostatectomy, with continence typically achieved within 12 months 1
• Differentiate urgency from stress: Up to 48% of men develop overactive bladder symptoms after prostate treatment 1
• Assess radiation history: Prior radiation significantly increases incontinence risk and affects treatment options 1

Red Flags Requiring Urologic Referral

Refer to urology before initiating treatment if any of the following are present: 2, 3

• Hematuria
• Recurrent urinary tract infections
• Neurological disease
• Severe obstruction (Qmax <10 mL/second)
• Abnormal PSA or findings suspicious for prostate cancer
• Persistent incontinence after 6 months post-prostate surgery despite conservative therapy 1

Common Pitfalls to Avoid

• Don't assume all incontinence in older men is due to BPH: Urgency incontinence from overactive bladder is extremely common and requires different treatment 1
• Don't skip the bladder diary: This simple tool provides objective data that often changes clinical management, particularly for nocturia 1
• Don't forget reversible causes: Review medications (diuretics, alpha-blockers, anticholinergics), assess for UTI, fecal impaction, and metabolic issues before labeling incontinence as chronic 4
• All UTIs in men are considered complicated: They require thorough evaluation, not just empiric treatment 2