What is the appropriate workup and treatment for a male patient presenting with incontinence, considering his past medical history, current medications, and potential underlying causes such as prostate or spinal cord issues?

Workup for Male Incontinence

Begin by determining whether the patient cannot void (retention/overflow) versus cannot hold urine (stress or urgency incontinence), as these require completely opposite management approaches. 1

Initial Clinical Assessment

History - Key Elements to Elicit

• Characterize the incontinence pattern: Ask specifically if leakage occurs with coughing/straining (stress), with sudden urge (urgency), continuous dribbling with bladder fullness (overflow), or mixed patterns 1
• Assess prostate treatment history: Document any prior radical prostatectomy, radiation therapy, TURP, or BPH procedures, as up to 48% of men develop overactive bladder symptoms after prostate treatment 1
• Review medications: Identify drugs that may contribute to incontinence, including diuretics, alpha-blockers, anticholinergics, and sedatives 1
• Quantify severity and bother: Use validated tools to assess impact on quality of life and determine urgency of intervention 1
• Screen for neurological disease: Ask about diabetes, spinal cord injury, multiple sclerosis, or Parkinson's disease, as up to 46% of men over 65 with presumed BPH have concurrent neurogenic detrusor dysfunction 2

Physical Examination - Specific Findings to Document

• Suprapubic palpation: Assess for bladder distention suggesting retention versus empty bladder with stress incontinence 1
• External genitalia: Examine for perineal wetness (incontinence) versus dry perineum with palpable bladder (retention) 3
• Digital rectal examination: Evaluate prostate size, nodules, and sphincter tone 1
• Neurological assessment: Test perineal sensation and bulbocavernosus reflex if neurogenic cause suspected 1

Essential Diagnostic Testing

Mandatory Initial Tests

• Urinalysis: Screen for urinary tract infection, hematuria, proteinuria, or glycosuria requiring further investigation 1
• Post-void residual (PVR) measurement: Perform via bladder scan or catheterization to identify overflow incontinence; elevated PVR indicates detrusor underactivity or outlet obstruction 3, 1
• 3-day bladder diary: Document voiding frequency, volume per void, incontinence episodes, and fluid intake patterns 1

Selective Advanced Testing

• Cystourethroscopy: Perform prior to any surgical intervention to assess for urethral stricture, bladder neck contracture, or bladder pathology that may affect surgical outcomes 4
• Urodynamic studies: Consider when the type of incontinence cannot be definitively determined from history/exam, when surgical intervention is planned, or for refractory retention after 2 failed voiding trials to differentiate detrusor underactivity from outlet obstruction 4, 3

Do not perform cystoscopy routinely in initial evaluation unless hematuria, history of bladder cancer, urethral stricture risk factors, or prior lower urinary tract surgery are present. 2

Type-Specific Management Pathways

For Stress Urinary Incontinence (Post-Prostatectomy)

• Conservative management first: Initiate pelvic floor muscle exercises/physical therapy for at least 6 months before considering surgery 5
• Surgical options if conservative measures fail:
  • Artificial urinary sphincter (AUS): Gold standard with broadest patient eligibility, though failure rates are approximately 24% at 5 years and 50% at 10 years 4
  • Male slings: Consider only in selected patients without radiation history 4
  • Urethral bulking agents: Efficacy is low and cure is rare; reserve for patients unable to tolerate more invasive surgery 4

For Urgency/Urge Incontinence

• First-line pharmacotherapy: Start anticholinergic agents (oxybutynin or tolterodine) for overactive bladder symptoms 6, 7
• Behavioral modifications: Implement bladder training, timed voiding, and fluid management 8

For Overflow Incontinence/Retention

• Immediate bladder decompression: Initiate clean intermittent catheterization (CIC) as preferred method; avoid indwelling catheters except as last resort due to high infection and erosion risk 2
• If BPH is the cause:
  • Start alpha-blocker (tamsulosin, alfuzosin) immediately at catheter insertion 3, 2
  • Add 5-alpha reductase inhibitor (finasteride 5mg or dutasteride) if prostate volume >30cc 2
  • Continue alpha-blocker for 2-3 days before attempting catheter removal 3
• If neurogenic dysfunction: Urodynamic testing is essential to differentiate detrusor underactivity from outlet obstruction; CIC is mainstay of treatment 2

Mandatory Referral Criteria

Refer immediately to urology if any of the following are present: 1

• Hematuria
• Recurrent urinary tract infections
• Neurological disease
• Severe obstruction
• Abnormal PSA
• Persistent incontinence >6 months post-prostate surgery despite conservative therapy
• Renal insufficiency due to retention
• Bladder stones or large diverticula with recurrent UTI

Critical Pitfalls to Avoid

• Do not assume all overflow incontinence in older men is purely BPH - nearly half have concurrent neurogenic dysfunction requiring different management 2
• Do not withhold alpha-blockers in appropriate candidates - they significantly improve voiding trial success rates after catheter placement 3
• Do not leave catheters in place beyond necessity - prolonged catheterization >3 days significantly increases infection risk 3
• Do not confuse overflow incontinence with stress incontinence - both may present with dribbling but require opposite treatments 3
• Do not proceed with incontinence surgery if bladder neck contracture or urethral stricture is present - treat obstruction first, as it decreases surgical success rates 4