Practical evaluation of post-prostatectomy incontinence

Abstract

For patients undergoing radical prostatectomy, urinary incontinence is not an uncommon postoperative complication. For some, it can resolve over time, while in others the condition persists and requires medical and/or surgical intervention. This summary provides a review of the recommended evaluations to perform in this setting. I ncontinence is one of the most significant complications of a radical prostatectomy (RP). Rates reported after RP range from 2% to 57% depending on the definition used.1-5 This summary will provide an overview of the evidence-based evaluation of incontinence in RP patients. Causes of post-RP incontinenceAlthough incontinence may be present before RP (reported rates up to 21%), 6-9 preoperative incontinence is likely due to urge incontinence rather than stress incontinence.The most common causes of incontinence post RP are damage to the distal urethral sphincter through direct injury, or injury to the nerve supply or supporting structures.10 While bladder dysfunction can also be present in 26% to 46% of patients postoperatively, it is rarely the sole cause of incontinence in this setting. 11-16Radiation can also be a contributing factor with respect to postoperative incontinence. Among patients who undergo RP after failed radiation therapy, the incidence of urinary incontinence has been reported to be as high as 44%. 17 Reported rates of incontinReported rates of incontinence after radiation and high-intensity focused ultrasound alone are 6.6% to 23% and 0.5% to 15.4%, respectively. [18][19][20] Unpublished data from the Toronto University Health Network demonstrate that, among patients who underwent radiation therapy after RP, the incidence of urinary incontinence was not dependent on the timing of the radiation. Furthermore, those who underwent early radiation (up to six months after surgery: mean 3.6 months) and those who underwent late radiation (after six months: mean 30.1 months) had similar rates of incontinence after the radiation therapy (early: 24.5%; late: 23.3%). Evidence-based evaluationAll of the recommended evaluations listed below are based on a review of the literature conducted by Herschorn and colleagues as part of the Fourth International Consultation on Incontinence Committee on Surgical Treatment of Urinary Incontinence in Men.21 Table 1 provides a summary of the recommendations, with the levels of evidence and grade of recommendation shown for each.History can provide a great deal of important information in the work-up of the post-RP patient with urinary incontinence. The critical factors to include are age, radiation history, date of surgery, type of surgery (nerve sparing vs. non-nerve sparing) and type of leakage (urge vs. stress; enuresis suggests urge). Other critical factors include time of day and degree of leakage (number of pads), fluid, caffeine and alcohol intake, medications, and other medical conditions.The physical examination typically does not provide a great deal of information, although meatal stenosis, phimosis and retention can be iden...

A pragmatic approach to the characterization and effective treatment of male patients with postprostatectomy incontinence

“…If urethrocystoscopy and assessment of bladder emptying are recommended before surgical treatment and rather consensual [1,13,17], some additional evaluations such as urodynamics are more and more debated [17]. Urodynamic studies have been recommended until recently to assess the cause of incontinence [17,18].…”

“…Urodynamic studies have been recommended until recently to assess the cause of incontinence [17,18]. However, there are several reports that do not show reliable predictive value of urodynamics regarding PPI surgical treatment outcomes [13,19,20].…”

“…These recent contributions support, if needed, the crucial role of clinical evaluation of PPI, which must integrate physical examination, symptom evaluation, and quality of life measures. Overall, patient history, physical examination, urinalysis, postvoid residual noninvasive measure, voiding diary, and pad test are the tools requested for primary evaluation [17].…”

Severe postprostatectomy incontinence: Is there an association between preoperative urodynamic findings and outcome of incontinence surgery?

“…Recommended preoperative evaluation of PPI includes the patient's medical history, a bladder scan for postvoid residual volume, voiding diaries and pad tests, all with evidence levels 1-2 and grades of recommendation A-B [2]. There is little evidence for or against cystoscopy (level 2-3, grade B) and urodynamics (level 3, grade C), but these invasive investigations are nevertheless also recommended before surgical treatment of PPI [1,3].…”

The potential role of stem cells in the treatment of urinary incontinence

“…Post-prostatectomy incontinence results from a failure to store urine secondary to inadequate resistance of the outlet sphincter [Potosky et al 2004;Bauer et al 2009]. Surgical damage to the urethral sphincter occurs due to direct injury to the sphincter itself, as well as to surrounding nerves and supportive tissue [Radomski, 2013]. As in females, surgical therapies are the mainstay of therapy and include transurethral bulking agents, bulbar urethral slings, and artificial urinary sphincters (AUS).…”