What is the initial workup and treatment approach for a male patient presenting with urinary incontinence?

Workup for Male Urinary Incontinence

Begin with a focused history, physical examination, urinalysis, and 3-day bladder diary to categorize incontinence type (stress, urgency, overflow, or mixed) and determine severity before proceeding with additional testing. 1

Initial History Components

The history must specifically address:

• Symptom characterization: Differentiate between stress incontinence (leakage with cough, sneeze, physical activity) versus urgency incontinence (sudden uncontrollable urge to void with leakage) versus continuous dribbling (suggests overflow) 1, 2
• Prostate treatment history: Document any prior prostate surgery (TURP, radical prostatectomy) or radiation therapy, as up to 48% of men develop overactive bladder symptoms after prostate treatment 1, 3
• Medication review: Identify drugs that may contribute to incontinence, including diuretics, alpha-blockers, anticholinergics, and sedatives 1, 2
• Degree of bother and quality of life impact: Assess how symptoms affect daily activities, social functioning, and patient motivation for treatment 1, 2
• Fluid intake patterns and dietary habits: Document timing and volume of fluid consumption, caffeine, alcohol, and bladder irritants 1, 4
• Associated symptoms: Assess for dysuria, hematuria, recurrent UTIs, obstructive voiding symptoms, and neurological symptoms 1, 2

Physical Examination

A systematic examination must include:

• Suprapubic palpation: Assess for bladder distention suggesting urinary retention 1, 4
• External genitalia examination: Evaluate for phimosis, meatal stenosis, or skin breakdown from chronic wetness 1
• Digital rectal examination: Assess prostate size, consistency, nodules, and tenderness to differentiate BPH from prostatitis or malignancy 1, 4
• Neurological assessment: Check lower extremity reflexes, perineal sensation, and anal sphincter tone to identify neurogenic causes 1, 2

Essential Diagnostic Testing

Mandatory Initial Tests

• Urinalysis with microscopy: Detect urinary tract infection, hematuria, proteinuria, or glycosuria that require further investigation 1, 2
• Urine culture if dipstick abnormal: Guide antibiotic therapy for documented infection 4
• 3-day frequency-volume chart (bladder diary): Document timing and volume of each void, fluid intake, and incontinence episodes to identify patterns such as nocturnal polyuria (>33% of 24-hour output at night) or reduced bladder capacity 1, 4
• Post-void residual (PVR) measurement: Essential to identify overflow incontinence; PVR >200-300 mL indicates significant retention requiring different management 1, 5

Selective Additional Testing

• Cystourethroscopy: Perform prior to any surgical intervention to assess for urethral stricture, bladder neck contracture, or bladder pathology 1
• Urodynamic studies: Consider when incontinence type cannot be definitively determined from history/examination, when surgical intervention is planned, or for refractory retention after 2 failed voiding trials to differentiate detrusor underactivity from outlet obstruction 1, 5
• Prostate-specific antigen (PSA): Consider in men with life expectancy >10 years to help predict prostate volume and screen for malignancy 4

Red Flags Requiring Immediate Urology Referral

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

• Hematuria (microscopic or gross) 1
• Recurrent urinary tract infections (≥2 in 6 months or ≥3 in 12 months) 1
• Neurological disease affecting bladder function 1, 4
• Severe obstruction (Qmax <10 mL/second on uroflowmetry) 1, 4
• Abnormal PSA or findings suspicious for prostate cancer 1, 4
• Bladder neck contracture or urethral stricture on examination or history 1
• Persistent incontinence >6 months post-prostate surgery despite conservative therapy 1

Special Considerations for Post-Prostatectomy Incontinence

For men with incontinence following prostate surgery or radiation:

• Timing assessment: Document when incontinence began relative to the procedure, as early incontinence (<3 months) often improves spontaneously 1, 3
• Differentiate stress versus urgency: Up to 48% develop urgency incontinence requiring anticholinergic/beta-3 agonist therapy rather than surgical intervention 1
• Radiation history: Document type and timing of radiation, as this affects surgical outcomes and complication rates 1
• Cystoscopy mandatory: Must be performed before any surgical intervention to rule out stricture or contracture that would decrease surgical success 1

Common Pitfalls to Avoid

• Do not assume all incontinence in older men is BPH-related: Up to 46% of men over 65 with presumed BPH have concurrent neurogenic detrusor dysfunction requiring different management 5
• Do not proceed with incontinence surgery if bladder neck contracture or urethral stricture present: Treat the obstruction first, as it significantly decreases surgical success rates 1
• Do not skip PVR measurement: Overflow incontinence requires bladder decompression and treatment of underlying cause, not anticholinergic therapy which would worsen retention 1, 5
• Do not treat empirically without categorizing incontinence type: Stress, urgency, and overflow incontinence require fundamentally different treatment approaches 1, 2