From the Guidelines
Lower urinary tract symptoms (LUTS) after prostatectomy should be managed with a multimodal approach, including pelvic floor muscle exercises, conservative measures, and medical or surgical interventions as needed, with the goal of improving symptoms and quality of life. According to the most recent guidelines, patients undergoing radical prostatectomy should be informed of the risk of incontinence and its potential impact on quality of life 1. The initial management of LUTS after prostatectomy should focus on:
- Pelvic floor muscle exercises (Kegel exercises), which should be started before surgery if possible and continued afterward, performing 3 sets of 10 contractions daily
- Conservative measures, such as bladder training, timed voiding, and fluid management, for stress incontinence
- Medical options, including anticholinergics like oxybutynin (5mg 2-3 times daily) or solifenacin (5-10mg daily) for urgency and frequency, or mirabegron (25-50mg daily) for patients with persistent symptoms Some key points to consider in the management of LUTS after prostatectomy include:
- Incontinence is expected in the short-term after surgery, but generally improves to near baseline by 12 months after surgery 1
- Patients should be informed of the risk of sexual arousal incontinence and climacturia following radical prostatectomy 1
- Surgery may be considered as early as six months if incontinence is not improving despite conservative therapy 1
- The primary care clinician should ask about urinary continence, the frequency of urination, amount of leakage, and whether pads are being used, and ideally, the primary treating specialist would discuss urinary side effect management goals with the patient, and would provide the primary care clinician with a baseline patient-reported measure of urinary symptom burden and management options as well as indications for referral 1. Surgical interventions, such as male sling procedures or artificial urinary sphincter placement, may be considered for patients with persistent stress incontinence. Overall, the management of LUTS after prostatectomy requires a comprehensive approach that takes into account the patient's individual needs and symptoms, with the goal of improving quality of life and reducing the burden of urinary symptoms 1.
From the Research
Post-Prostatectomy Lower Urinary Tract Symptoms
- Lower urinary tract symptoms (LUTS) can improve after robotic-assisted laparoscopic prostatectomy, mitigating concerns about urinary incontinence 2
- Studies have shown that LUTS can improve in a majority of patients after radical prostatectomy, with associated improvements in quality of life 2, 3
Risk Factors for Post-Prostatectomy LUTS
- Increased patient age is significantly associated with increased postoperative pad use 2
- Being in the D'Amico low-risk group can reduce the average number of pads used per day 2
- Body mass index (BMI) is an independent risk factor for post-prostatectomy LUTS 3
Management of Post-Prostatectomy Urinary Incontinence
- Pelvic floor muscle training is an effective first-line intervention for post-prostatectomy urinary incontinence 4, 5
- Protocols for pelvic floor muscle training vary, but common recommendations include three sessions per day with six to 15 contractions per session 4
- Pelvic floor muscle exercise is a protective factor against post-prostatectomy LUTS 3
Predictors of Postoperative LUTS Improvement
- Preoperative international prostate symptom score (IPSS), prostate volume, and post-void residual (PVR) are significant predictors of postoperative IPSS improvement 6
- Transurethral plasmakinetic enucleation of the prostate (PKEP) may improve early postoperative storage symptoms of LUTS in patients with a small-volume prostate and bladder outlet obstruction 6