What is the treatment for stress urinary incontinence in an 82-year-old man with prostate cancer, post-prostatectomy (prostate removal surgery) and radiation therapy?

From the Guidelines

For an 82-year-old man with stress incontinence following prostate cancer treatment with prostatectomy and radiation therapy, I strongly recommend discussing the option of artificial urinary sphincter (AUS) as a treatment option, as it has been shown to achieve complete continence in 20% of patients and high satisfaction rates, despite inherent risks such as persistent leakage, mechanical failure, erosion, and infection 1. When considering treatment options for this patient, it is essential to weigh the potential benefits and risks of each approach.

• Conservative measures such as pelvic floor muscle exercises (Kegel exercises) and behavioral modifications can be beneficial in managing symptoms, but may not be sufficient for severe cases.
• Pharmacologic options like alpha-adrenergic agonists may be limited due to potential side effects and comorbidities.
• Surgical interventions like male sling procedure may be considered, but AUS has been shown to be a viable option for patients with mild to severe stress urinary incontinence after prostate treatment, with 55% of patients experiencing leakage of only a few drops daily and 92% reporting they would undergo the surgery again 1. The patient's history of prostate cancer treatment with prostatectomy and radiation therapy increases the complexity of the condition, and a thorough discussion of the risks and benefits of AUS placement is necessary to determine the best course of treatment.
• The patient should be informed about the potential risks of AUS placement, including persistent leakage, mechanical failure, erosion, and infection, as well as the potential benefits of improved continence and quality of life.
• A comprehensive evaluation of the patient's overall health and suitability for surgery should be conducted before proceeding with AUS placement, considering factors such as life expectancy, comorbidities, and ability to manage potential complications.

From the Research

Treatment Options for Stress Urinary Incontinence

• The treatment of stress urinary incontinence in an 82-year-old man with prostate cancer after prostatectomy and radiation therapy can be complex and multifaceted 2, 3, 4, 5.
• Conservative measures such as pelvic floor muscle exercises (PFMT) are often considered the first line of treatment for stress urinary incontinence after prostatectomy 2, 3, 6.
• Studies have shown that early initiation of pelvic floor muscle exercises, such as Kegel's, can help hasten the return of continence and improve quality of life in patients after robotic prostatectomy 6.

Surgical Interventions

• If incontinence persists for more than 12 months postoperatively, surgical interventions such as male slings and artificial urinary sphincters (AUS) may be considered 3, 4, 5.
• The artificial urinary sphincter is considered the gold standard treatment for male stress urinary incontinence, providing the most efficacious and durable results 3, 4.
• However, the choice of surgical treatment depends on various factors, including patient history, severity of incontinence, and degree of bother 5.

Diagnostic Testing

• Diagnostic testing such as cystoscopy, urodynamics, and standing cough stress tests may be used to guide surgical treatment decisions and optimize patient continence goals 5.
• Patient history, including severity and degree of bother, is a critical component in guiding surgical decision making 5.

Considerations for Radiation Therapy

• A history of pelvic radiation can impact the overall duration and complication rate associated with artificial urinary sphincters (AUS) 5.
• This should be taken into consideration when making treatment decisions for patients with a history of radiation therapy.