How should I evaluate stress urinary incontinence in a male patient, considering age, prior prostate surgery, radiation therapy, neurologic disease, chronic cough, constipation, and relevant medications?

Workup of Stress Urinary Incontinence in Men

Begin with a detailed history focusing on timing relative to prostate treatment, activities that provoke leakage, pad usage per day, and degree of bother, followed by physical examination including digital rectal exam and focused neurologic assessment, then urinalysis to exclude infection and hematuria. 1

Essential History Components

Characterize the incontinence pattern by asking specifically which activities cause leakage—this differentiates stress urinary incontinence (SUI) from sphincteric insufficiency versus urgency incontinence from bladder dysfunction. 1

Key historical elements to obtain:

• Timing and severity: Document when incontinence started, progression over time, and current pad usage per day (1-2 pads = mild, 2-4 pads = moderate, 5+ pads = severe). 1
• Prostate treatment history: Prior radical prostatectomy, radiation therapy (external beam or brachytherapy), transurethral resection of prostate (TURP), or combination treatments. 1
• Provocative activities: Leakage with coughing, sneezing, lifting, position changes (classic for SUI) versus leakage with urgency (suggests detrusor overactivity). 1, 2
• Sexual function symptoms: Ask about climacturia (orgasm-associated incontinence) and sexual arousal incontinence, which occur in up to 30% of men post-prostatectomy. 1
• Neurologic conditions: History of stroke, Parkinson's disease, diabetes with neuropathy, spinal cord injury, or multiple sclerosis. 1, 3
• Contributing factors: Chronic cough, constipation, heavy lifting, obesity. 1
• Medications: Alpha-blockers, diuretics, anticholinergics, sedatives that may affect continence. 1
• Degree of bother: Use validated instruments like the AUA Symptom Index or IPSS quality of life question to quantify impact. 4, 3

Physical Examination

Perform digital rectal examination to assess prostate size (if present), masses, or locally advanced cancer, and anal sphincter tone. 1, 4

Conduct focused neurologic examination assessing mental status, ambulatory status, lower extremity neuromuscular function, and perineal sensation. 1

Standing cough stress test: Have patient stand with full bladder and cough vigorously while observing for immediate urethral leakage (positive test confirms SUI). 1

Mandatory Initial Testing

• Urinalysis: Dipstick or microscopic examination to screen for hematuria, urinary tract infection, and glucosuria. 1, 4
• Post-void residual (PVR): Measure via bladder scan or catheterization; elevated PVR (>200-350 mL) suggests bladder dysfunction and predicts poorer outcomes. 4, 3

Optional Diagnostic Tests Based on Clinical Context

Uroflowmetry: Consider when planning invasive therapy or when initial evaluation suggests non-prostatic causes; maximum flow rate <10 mL/sec predicts urodynamic obstruction. 4, 3

Urine cytology: Obtain in men with predominantly irritative symptoms, especially with smoking history or risk factors for bladder cancer. 1, 4

Pad testing: 24-hour pad weight test quantifies severity objectively when patient-reported outcomes are unclear. 1

Pressure-flow urodynamic studies: Reserve for patients considering surgery with flow rates >10 mL/sec, or those with concomitant neurologic disease affecting bladder function. 1, 3

Cystoscopy: Indicated only for patients with history of hematuria, urethral stricture, bladder cancer, or prior lower urinary tract surgery—not routinely needed for SUI workup. 1, 4, 5

Special Considerations for Post-Prostate Treatment Incontinence

Timing matters: Most men are incontinent immediately after radical prostatectomy but achieve continence within 12 months; consider intervention at 6 months if no improvement despite conservative therapy. 1

Post-radiation TURP carries high incontinence risk: Patients undergoing TURP after radiation therapy have 27-43% risk of new-onset incontinence, with older age and pre-existing urgency as significant predictors. 1, 6

Adjuvant radiation increases risk: Men receiving radiation after prostatectomy experience higher rates of both stress and urgency incontinence compared to surgery alone. 1

Common Pitfalls to Avoid

• Don't assume all post-prostatectomy incontinence is pure SUI: Mixed incontinence with urgency component is common and requires different management. 1
• Don't rely solely on physician assessment: Physician estimates of continence are consistently more favorable than patient-reported outcomes. 7
• Don't order urodynamics routinely: Reserve for complex cases or when surgical intervention is planned and diagnosis remains unclear. 1, 3
• Don't miss reversible causes: Urinary tract infection, fecal impaction, and medications can worsen or mimic SUI. 1
• Don't forget to assess bother: Severity of incontinence doesn't always correlate with degree of bother; intervention decisions should incorporate patient preferences. 4, 3

Categorization for Treatment Planning

After workup, categorize as:

• Pure SUI (sphincteric insufficiency): Leakage only with physical stress, positive cough test, no urgency symptoms. 1, 2
• Mixed incontinence: Both stress and urgency components present. 2
• Complicated incontinence: Associated with high PVR, neurologic disease, prior pelvic radiation, or urethral stricture. 1, 6

This categorization guides whether to proceed with pelvic floor muscle training, pharmacotherapy, or surgical options like artificial urinary sphincter or male sling. 1