Male Urinary Incontinence: Treatment Options
Male urinary incontinence requires type-specific treatment, with pelvic floor muscle training as first-line for stress incontinence and anticholinergics or β3-adrenergic agonists for urgency incontinence, while post-prostatectomy incontinence should receive immediate pelvic floor exercises with surgical options reserved for persistent cases after 6 months. 1, 2
Initial Assessment and Categorization
The evaluation must differentiate between stress urinary incontinence (leakage with increased abdominal pressure), urgency urinary incontinence (leakage with sudden urge), and mixed incontinence to guide treatment selection. 3, 2
Key diagnostic steps include:
- Focused history to characterize symptom type, severity, and impact on quality of life 3
- Physical examination including suprapubic assessment, external genitalia examination, and digital rectal examination 3
- Urinalysis to detect infections, hematuria, or glycosuria 3
- Post-void residual measurement to identify overflow incontinence from urinary retention 4, 3
- Bladder diary for at least 3 days to document urinary patterns 3
Treatment by Incontinence Type
Stress Urinary Incontinence
Conservative management:
- Pelvic floor muscle training (PFMT) is the primary first-line treatment 1, 2
- Conservative therapy should be attempted for at least 6 months before considering surgery 1
Surgical options (after failed conservative therapy):
- Artificial urinary sphincter (AUS) remains the gold standard, though patients must be counseled about failure rates of approximately 24% at 5 years and 50% at 10 years 1, 3
- Male slings may be considered for moderate incontinence 1
- Urethral bulking agents are an option for patients unable to tolerate invasive surgery, though efficacy is low and cure is rare 3
Urgency Urinary Incontinence
First-line pharmacological treatment:
- Anticholinergic medications 2
- β3-adrenergic agonists 2
- Posterior tibial nerve stimulation as an alternative first-line option 2
Behavioral interventions:
- Prompted voiding schedules, particularly for patients with cognitive impairment 5, 4
- Bladder training programs 5
Post-Prostatectomy Incontinence
Immediate post-operative management:
- Pelvic floor muscle exercises should be offered immediately post-operatively to improve time-to-achieving continence 1
- Conservative management for at least 6 months is mandatory before surgical intervention 1
Pre-surgical requirements:
- Any vesicourethral anastomotic stenosis or bladder neck contracture must be treated before incontinence surgery, as obstruction decreases surgical success rates 1, 3
- Cystourethroscopy is mandatory prior to any surgical intervention to assess for strictures or bladder pathology 3
Surgical timing and options:
- Surgery may be considered as early as 6 months if incontinence is not improving despite conservative therapy 1
- For patients with radiation history, AUS is specifically recommended over male slings or adjustable balloons 1
- For failed male sling, artificial urinary sphincter is the recommended next step 5, 1
Management of Lower Urinary Tract Symptoms Related to Benign Prostatic Obstruction
When incontinence occurs in the context of benign prostatic enlargement causing detrusor overactivity and urgency incontinence, treatment options include: 5, 6
Watchful waiting:
- Acceptable for patients with mild to severe symptoms who are not bothered by them, provided no imperative indications for surgery exist (upper tract dilatation or increased creatinine) 5
- Follow-up approximately yearly with repeated initial evaluation 5
Medical therapy:
- Alpha-blockers for symptom relief, with assessment of treatment success at 2-4 weeks 5
- 5α-reductase inhibitors (finasteride 5 mg daily) for patients with enlarged prostates, requiring at least 6 months to assess therapeutic benefit 7
- Finasteride reduces prostate volume by approximately 17.9% over 4 years and decreases risk of acute urinary retention by 57% and need for surgery by 55% 7
Special Considerations and Red Flags
Mandatory urology referral criteria: 3
- Hematuria
- Recurrent urinary tract infections
- Neurological disease
- Severe obstruction
- Abnormal PSA
- Persistent incontinence after 6 months post-prostate surgery despite conservative therapy
Management of surgical complications:
- Infected AUS devices should not be replaced for at least 3 months to allow infection clearance 5, 1
- For AUS failure, options include proximal relocation or downsizing of the cuff, or tandem cuff placement 5, 1
Palliative measures when definitive treatment fails or is not desired:
- Protective pads 2
- Penile sheaths 2
- Penile clamps 2
- Urinary diversion with or without cystectomy for patients unable to obtain long-term quality of life with AUS due to multiple device failures, intractable bladder neck contracture, or severe detrusor instability 5, 1
Common Pitfalls
Avoid proceeding with incontinence surgery without:
- Treating any bladder neck contracture or urethral stricture first 1, 3
- Performing cystourethroscopy to assess urethral and bladder anatomy 3
- Attempting conservative management for at least 6 months in post-prostatectomy patients 1
Recognize that up to 48% of men develop overactive bladder symptoms after prostate treatment, requiring urgency-specific management rather than stress incontinence treatments. 3