What are the different types of incontinence in male patients and their respective treatments?

Types of Male Urinary Incontinence and Treatment

Male urinary incontinence is categorized into three primary types—stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed incontinence—each requiring distinct diagnostic approaches and treatment pathways based on the underlying mechanism. 1

Classification and Mechanisms

Stress Urinary Incontinence (SUI)

• SUI results from sphincteric insufficiency causing involuntary urine leakage during activities that increase intra-abdominal pressure (coughing, sneezing, lifting, exercise). 1
• Most commonly occurs after radical prostatectomy due to damage to the urethral sphincter mechanism. 2
• Patients report leakage specifically with physical exertion, not associated with urgency sensations. 1

Urgency Urinary Incontinence (UUI)

• UUI is caused by bladder dysfunction (detrusor overactivity) resulting in sudden, compelling urge to void with involuntary leakage. 1
• Occurs in up to 48% of men after prostate treatment and presents with frequency, urgency, and nocturia. 1
• Patients describe inability to reach the toilet in time after sensing the need to void. 1

Mixed Urinary Incontinence

• Combination of both SUI and UUI mechanisms occurring simultaneously. 1
• Treatment should target the predominant component first. 1

Overflow Incontinence

• Results from bladder outlet obstruction (benign prostatic hyperplasia, urethral stricture) or detrusor underactivity causing incomplete bladder emptying with continuous dribbling. 3
• Requires measurement of post-void residual volume for diagnosis. 4

Functional Incontinence

• Occurs when physical or cognitive impairments prevent timely toileting despite normal bladder function. 3

Diagnostic Differentiation

History must specifically identify which activities trigger leakage to differentiate SUI (physical exertion) from UUI (urgency sensation). 1

Key diagnostic questions include:

• Does leakage occur with coughing, sneezing, or lifting? (suggests SUI) 1
• Is leakage preceded by sudden, strong urge to void? (suggests UUI) 1
• Is there continuous dribbling or sensation of incomplete emptying? (suggests overflow) 4

Physical examination should include digital rectal examination to assess prostate size and pelvic floor muscle tone. 4

Post-void residual measurement is mandatory to identify overflow incontinence, with volumes >200 mL indicating retention. 4

A 3-day bladder diary documenting timing, volume, and circumstances of leakage episodes is essential for accurate classification. 4, 5

Treatment Algorithms by Type

For Stress Urinary Incontinence

First-line treatment: Pelvic floor muscle training (Kegel exercises) for minimum 3 months before considering surgery. 5

Specific technique requirements:

• Contract pelvic floor muscles for 6-8 seconds, followed by 6-second rest periods 5
• Perform 15 contractions per session, twice daily 5
• Isolate only pelvic floor muscles without contracting abdomen, glutes, or thighs 5
• Maintain normal breathing throughout (never hold breath to avoid Valsalva) 5
• Referral to physical therapist trained in pelvic floor rehabilitation is strongly recommended, as incorrect technique significantly reduces effectiveness. 5

Surgical intervention should be considered only after 6 months of failed conservative management. 5

Surgical options by severity:

• Moderate incontinence (1-2 pads/day): Male urethral slings are appropriate first-line surgical option for patients without radiation history. 1, 5
• Severe incontinence or radiation history: Artificial urinary sphincter (AUS) is the gold standard, though it has failure rates of 24% at 5 years and 50% at 10 years. 1, 5

Cystourethroscopy must be performed before any surgical intervention to assess for urethral stricture or bladder neck contracture, as these decrease surgical success rates. 4, 5

For Urgency Urinary Incontinence

Treatment follows the AUA Overactive Bladder guideline with behavioral modifications as first-line therapy. 1

Behavioral interventions:

• Timed voiding schedules 1
• Limiting caffeine and fluid intake 1
• Avoiding bladder irritants (citrus, tomatoes) 1

Pharmacologic therapy with anticholinergics (oxybutynin) or β3-adrenergic agonists should be offered when behavioral therapy fails. 1, 6

Anticholinergic options:

• Oxybutynin: Relaxes bladder smooth muscle by inhibiting muscarinic action of acetylcholine, increasing bladder capacity and diminishing uninhibited detrusor contractions 7
• Tolterodine 2 mg twice daily: Demonstrated statistically significant reduction in incontinence episodes and micturition frequency 8

β3-adrenergic agonists have fewer anticholinergic side effects compared to antimuscarinics and should be considered in patients intolerant to anticholinergics. 9

For Mixed Incontinence

Treat the predominant component first—if urgency predominates, follow UUI treatment pathway; if stress predominates, follow SUI pathway. 1

For Overflow Incontinence

α-1 blockers (tamsulosin 0.4 mg daily) are first-line pharmacologic treatment for overflow incontinence from benign prostatic hyperplasia. 10, 9

5-α reductase inhibitors can be added as adjunct therapy in patients with refractory symptoms and PSA ≥1.5 mg/dL. 9

Clean intermittent catheterization is first-line therapy for neurogenic bladder causing overflow incontinence. 9

Critical Red Flags Requiring Immediate Urology Referral

Immediate referral is mandatory for: 4

• Hematuria
• Recurrent urinary tract infections
• Severe obstruction
• Abnormal PSA
• Persistent incontinence beyond 6 months despite conservative therapy
• Neurological disease affecting bladder function

Common Pitfalls to Avoid

Do not proceed with incontinence surgery if bladder neck contracture or urethral stricture is present—treat the obstruction first, as it significantly decreases surgical success rates. 4

Do not assume all post-prostatectomy incontinence is stress incontinence—up to 48% have urgency components requiring different treatment. 1

Do not offer surgical intervention before 6 months post-prostatectomy, as continence continues to improve and generally stabilizes after one year. 5, 2

Measure post-void residual in all patients before initiating anticholinergic therapy, as these medications can precipitate urinary retention in patients with overflow incontinence. 4