Editing AUA: Incontinence after Prostate Therapy (2019)

'''See Male SUI Surgery Chapter Notes'''

===== Background =====

* '''Incontinence after prostate therapy (IPT) is caused by damage to the striated muscle and nerve fibers of the voluntary (striated) urethral sphincter'''
** The term “incontinence after prostate treatment” is used in this guideline over the familiar term “post-prostatectomy incontinence” because it is more inclusive and covers men who have incontinence after undergoing radical prostatectomy (RP), radiotherapy (RT) or BPH-surgery

===== Pre-treatment Counselling =====

* '''Commonly accepted definition of urinary continence: not requiring a pad or protective device to stay dry (pad-free)'''
* '''Factors associated with increased risk of incontinence after RP (5):'''
*# '''Older age'''
*# '''Larger prostate size'''
*# '''Shorter membranous urethral length'''
*# '''Lack of preservation of bilateral neurovascular bundle at time of RP'''
*#* No surgical maneuvers, other than preservation of bilateral neurovascular bundle, results in improved continence recovery. Men receiving bilateral neurovascular bundle preservation were 26% more likely to be continent at 6 months compared to men who did not
*# '''Prior pelvic radiation'''
*#* '''Radiation is a significant risk factor for IPT in patients undergoing RP or TURP.'''
*#** '''These patients should be informed that they may require an artificial urinary sphincter (AUS).'''
** '''Surgical approach: open RP has similar rates of urinary incontinence as robot-assisted RP'''
** '''BMI may impact IPT in the short-term; however, not considered to impact risk at 1-year after RP'''
* '''Natural history'''
** '''Continence after RP improves with time, and most men achieve continence within 12 months of surgery'''
*** '''Most men undergoing RP are not continent (pad-free) at the time of catheter removal and should be informed that continence is not immediate.'''
*** '''Majority of patients will reach their maximum improvement by 12 months with minimal to no improvement afterwards.'''
**** '''90% of patients will achieve continence at 6 months''' after robotic-assisted laparoscopic prostatectomy and only an additional 4% of patients will gain continence afterwards.
*** '''Conservative management with regular follow-up during the first year after surgery is recommended''' to assess patient progress
**** '''In addition to SUI, patients can also develop sexual arousal incontinence and climacturia following radical prostatectomy'''
* '''Pelvic floor muscle exercises (PFME)/Pelvic floor muscle training (PFMT)'''
** PFME is self-guided whereas PFMT is practitioner guided; both are training programs specific to the pelvic muscles
** '''Thought to support muscle strength and enhance blood flow to the sphincter to promote healing'''
** '''Prior to radical prostatectomy: may reduce the risk of IPT'''
*** '''The benefit of starting pre-operative PMFT is not consistent'''
*** Exercises are easier to learn in the pre-operative period due to post-operative muscle inhibition, sensory changes, urinary incontinence, and surgical pain
** '''Immediate post-operative period: should be offered'''
*** '''Improves time to continence (thus improving QoL) but not overall continence at 12 months'''

===== Diagnosis and evaluation of IPT =====

* '''Recommended:'''
** '''History + physical exam'''
** '''Appropriate diagnostic modalities to categorize type and severity of incontinence and degree of bother'''
* '''History and Physical Exam'''
** '''History'''
*** '''Characterize incontinence:''' important because treatments for SUI (caused by sphincteric insufficiency) and urgency incontinence (caused by bladder dysfunction) are different.
**** '''In cases of mixed incontinence, determine which component is more prevalent and bothersome''' (stress or activity related versus urgency related)
***** Increases in abdominal pressure such as that caused by straining, walking, cough, and exercise are suggestive of SUI
***** The sudden compelling desire to void that is difficult to defer and results in leakage indicates urgency incontinence.
***** Presence of incontinence while asleep as well as nocturia are also important to note, because this may indicate urgency urinary incontinence or severe SUI.
**** '''The severity of incontinence''' (can be determined by history, or more objectively, by pad testing), the progression or resolution of incontinence over time, exacerbating factors, and degree of bother.
***** The severity of incontinence (i.e. volume lost over time) is important to know, especially in the case of sphincteric insufficiency as some treatments (e.g., male slings), clearly have inferior results in severe incontinence.
** '''Post-void residual (PVR)'''
*** '''May be helpful to rule out significant retention of urine if overflow incontinence is suspected.'''
**** Elevated PVR may be an indication of detrusor underactivity or obstruction and thus may prompt further diagnostic evaluation

===== Management of IPT =====

* '''Patients with urgency urinary incontinence or urgency predominant mixed urinary incontinence should be offered treatment options per the AUA OAB guidelines'''
* '''Options'''
** '''Non-surgical (5):'''
**# '''PFME/PFMT'''
**# '''Absorbent pads'''
**# '''Penile compression devices'''
**# '''Condom'''
**# '''Urethral catheter'''

** '''PFME/PFMT'''
*** '''Should be offered to all patients'''
*** Advantages:
**** Safe treatment with minimal side-effects
**** Provides patients with an opportunity to participate in their health outcomes.
*** Disadvantages:
**** Time and effort required
**** Cost of repeated visits for PFMT
** '''Other options that can be used with or without PFME/PFMT:'''
*** '''Absorbent pads'''
*** '''Penile compression devices (clamps)'''
**** Should not be left on the phallus overnight due to the risks of constant pressure
**** Not suitable for patients with (4):
****# Memory deficits
****# Poor manual dexterity
****# Impaired sensation
****# Significant component of OAB
*** '''Condom catheters'''
*** '''Urethral catheter'''
**** '''Last resort''' in a patient who is unsuitable for alternative management
**** '''Suprapubic catheter drainage is not a solution for the patient with severe intrinsic sphincter deficiency, as urethral leakage will persist'''
* '''Surgical'''
** '''Timing'''
*** '''If there is no improvement at 6 months despite conservative therapy and the patient has bothersome IPT,''' (i.e. patient does not want to wait until 12 month time point) '''surgery may be considered for early treatment'''
**** While almost all patients have reached their maximum improvement by 12 months, most patients with severe SUI will show no significant improvement after 6 months and may be candidates for early intervention
*** '''Otherwise, treatment should be offered to patients with persistent bothersome SUI at 12 months.'''
**** '''Conversely, treatment should be offered with caution in some patients who continue to display symptom improvement at 12 months'''
** '''Prior to surgical intervention for stress urinary incontinence'''
**# '''SUI should be confirmed''' by history, physical exam, or ancillary testing
**#* If there is any doubt as to whether the patient has SUI; all reasonable measures to '''demonstrate SUI on physical exam''', with or without provocative testing such as bending, shifting position, or rising from seated to standing position, should be taken
**# '''Cystourethroscopy should be performed to assess for urethral and bladder pathology that may affect outcomes of surgery'''
**** '''Patients with symptomatic vesicourethral anastomotic stenosis or bladder neck contracture should be treated prior to surgery for IPT'''
*** '''Urodynamics (UDS) may be performed.'''
**** '''UDS are not required before surgical intervention for IPT unless the clinician is in doubt of the diagnosis or it is felt that patient counseling will be affected.'''
***** '''During UDS, it is important that the catheter be removed and stress testing repeated in patients with suspected SUI who do not demonstrate stress incontinence with a catheter in place'''
****** Up to 35% of males with post-prostatectomy SUI will not demonstrate SUI with a catheter in place. This may be due to some scarring at the site of the anastomosis. In such cases, even a small catheter can occlude the urethra and prevent stress leakage.
** '''Contraindications'''
*** '''It is not known if poor bladder compliance and an uncorrected storage pressure are absolute contraindications to SUI surgery in IPT patients (***Campbell's lists this as contraindication***). However, these patients should be carefully followed to avoid upper tract decompensation.'''
** '''Options (5):'''
**# '''Urethral bulking agents'''
**# '''Adjustable balloon devices'''
**# '''Slings'''
**# '''AUS'''
**# '''Urinary Diversion'''
*** Risks, benefits, and expectations of different treatments should be discussed using the shared decision-making model

** '''Urethral bulking agents'''
*** '''Least invasive technique'''
*** '''Least effective surgical technique; cure is rare'''
*** '''Consider in patients who are unable to tolerate or refuse more invasive surgical therapy'''
** '''Adjustable balloon devices'''
*** '''Consider for mild SUI'''
*** '''Disadvantages: increased incidence of intraoperative complications and need for explanation within the first 2 years compared to the male sling and AUS'''
** '''Male slings'''
*** '''Considered for mild to moderate stress urinary incontinence'''
**** '''Poor efficacy in comparison to an AUS in patients with severe incontinence.'''
*** '''Risks''' (generally low complication rate):
**** Urinary retention
***** Typically resolves within 1 week
**** Pelvic and perineal pain and paresthesia
***** Typically resolves within 12 weeks
**** '''Erosion or infection'''
***** '''Both are exceedingly rare.'''
***** If a male sling is thought to be infected or documented to be eroded on cystoscopy, the '''management is similar to management of an infected or eroded AUS (see below)'''
** '''AUS'''
*** '''Consider for mild to severe stress urinary incontinence'''
*** '''Preferred in patients with prior (3):'''
**** '''Radiation'''
***** Improved outcomes compared to male slings or adjustable balloons for treatment of patients with SUI after primary, adjuvant, or salvage radiotherapy
***** '''Complication rates are higher'''
**** '''Urethral reconstruction'''
***** Urethral strictures of the anterior urethra and urethral stenosis of the posterior urethra can arise after RP, RT, or treatment for IPT. Urethral reconstructive surgery is often used to treat narrowing in the urethra.
***** '''Male slings will not be effective given post-surgical changes related to most types of urethral reconstruction in the posterior and anterior urethra'''
***** '''Complications rates are higher'''
****** Depending on the technique employed (urethra transecting or not) the blood supply to the urethra may be diminished and potentially decrease the life span of an AUS.
**** '''Vesicourethral anastomotic stenosis or bladder neck contracture'''
***** Decreased success rates when undergoing male slings
*** '''Contraindications:'''
**** '''Inadequate physical or cognitive abilities to operate the device'''
*** '''Procedure'''
**** '''Single cuff perineal approach is preferred, superior outcomes compared to transverse scrotal incision'''
*** '''Complications:'''
**** '''Intraoperative urethral injury'''
***** '''If identified during implantation, procedure should be abandoned and subsequent implantation should be delayed'''
**** '''Persistent leakage'''
**** '''Mechanical failure'''
**** '''Cuff erosion'''
***** Can be due to unrecognized urethral injury at the time of initial surgery or more likely due to subsequent instrumentation of the urethra including catheterization.
***** '''Management:'''
****** '''AUS explant with the urethral catheter left in place for a few weeks to allow the urethral defect to heal'''
****** '''AUS should not be re-implanted until at least 3 months'''
**** '''Infection'''
***** '''Device infection occurs in <1-5% of cases'''
***** '''Presents with pain at the site of the AUS, fever, scrotal warmth or erythema, or skin changes'''
***** '''Management:'''
****** '''Urgent AUS explantation'''
****** '''AUS should not be reimplanted until at least 3 months''' to allow the infection to clear and inflammation to subside.
**** '''Decreased efficacy over time and reoperations are common'''
***** '''The current version consists of''' a hydraulic system composed of '''3 separate parts:'''
*****# '''A urethral cuff''' of varying sizes
*****# '''A pressure regulating balloon reservoir''' with three available pressure profiles
*****# '''A control pump'''
****** The device will fail if any of the 3 parts, the tubing, or connections suffer a micro-perforation with loss of fluid
***** The rate of device failure increases with time, with '''failure rates of'''
****** '''≈24% at 5 years'''
****** '''≈ 50% at 10 years'''
***** '''An AUS might need to be replaced over time due to persistent or recurrent incontinence generally due to:'''
*****# '''Urethral atrophy'''
*****# '''Improper cuff sizing'''
*****# '''Partial fluid loss'''
* '''Urinary diversion'''
** '''Can be considered in appropriately motivated and counseled patients who are unable to obtain adequate long-term quality of life'''
*** '''If bladder preservation is feasible, conversion to a Mitrofanoff (e.g. Appendix, Monti), incontinent ileovesicostomy, or suprapubic tube with bladder neck closure may confer an improved QoL.'''
*** '''In the event of the “hostile” bladder, cystectomy in combination with either an ileal conduit or continent catheterizable pouch''' would best manage incontinence while protecting the upper tracts.
* Other potential treatments for IPT should be considered investigational

* '''Persistent incontinence after surgery (AUS or sling)'''
** '''Diagnosis and Evaluation:'''
*** '''Same as prior: history + physical exam +/- other investigations to determine the cause of incontinence'''
*** '''Causes'''
**** '''Inadvertently deactivating the device'''
***** Re-education must be performed
**** '''Acute fluid loss'''
***** '''The volume in the pressure regulating balloon can be assessed using computerized tomography or ultrasound.'''
**** '''Recurrent incontinence after years of normal function suggests either development of a new leak due to wear or urethral atrophy'''
**** '''Elevated storage pressures or detrusor over-activity should be suspected in a patient with a normally functioning AUS'''
** '''For persistent or recurrent SUI after sling, an AUS is recommended'''
*** Failure of a male sling can be due to infection or erosion, or more likely, due to patient dissatisfaction with continence recovery
** '''For persistent or recurrent SUI after AUS, revision should be considered'''

===== Special Situations =====

* '''In a patient with bothersome climacturia, treatment may be offered.'''
** '''As with post-prostatectomy SUI, for those with sexual arousal incontinence or climacturia, conservative management (emptying the bladder prior to sex, use of condoms to catch the urine, and PFME) should be the initial treatment'''
** '''Imipramine, a tricyclic antidepressant, has been used, but this medication is generally contraindicated in men age > 65 due to the risk of somnolence, falling down, and changes in cognition.'''
** '''Both the AUS and the trans-obturator male sling, when implanted for SUI, are associated with high rates of improvement in climacturia'''
* '''In patients with concomitant IPT and erectile dysfunction, a concomitant or staged procedure may be offered.'''

===== Questions =====

# What is the guideline-based definition of urinary continence?
# What are risk factors for incontinence after RP?
# When are patients expected to achieve their maximum continence after RP?
# What is the workup for a patient presenting with incontinence after RP?
# What are non-surgical/surgical treatment options for IPT?
# When should surgical intervention be performed in a patient with bothersome incontinence after RP?
# Are any investigations needed prior to surgical intervention for incontinence after RP?
# What is the management of AUS cuff erosion?
# Which surgical treatment is preferred in patients with previous history of pelvic radiation?
# What are potential causes for persistent incontinence after surgical treatment?
# A patient previously treated with sling for incontinence after RP has persistent bothersome incontinence. What is the next treatment?

===== Answers =====

# What is the guideline-based definition of urinary continence?
#* Not requiring a pad or protective device to stay dry (pad-free)
# What are risk factors for incontinence after RP?
## Older age
## Larger prostate size
## Shorter membranous urethral length
## Preservation of NVB at time of RP
# When are patients expected to achieve their maximum continence after RP?
#* 12 months
# What is the workup for a patient presenting with incontinence after RP?
#* H+P +/- PVR [likely U/A, though not mentioned in guidelines]
# What are non-surgical/surgical treatment options for IPT?
## Non-surgical: PFMT/PFME +/- penile compression devices, pads, condom catheter, urethral catheter
## Surgical: bulking agents, inflatable-balloon devices, male sling, AUS
# When should surgical intervention be performed in a patient with bothersome incontinence after RP?
#* 12 months, unless patient prefers to be done at 6
# Are any investigations needed prior to surgical intervention for incontinence after RP?
## Objective confirmation of SUI
## Cystourethroscopy
# What is the management of AUS cuff erosion?
#* AUS explant with urethral catheter left in place for a few weeks; AUS should not be reimplanted for 3 months
# Which surgical treatment is preferred in patients with previous history of pelvic radiation?
#* AUS
# What are potential causes for persistent incontinence after surgical treatment?
## Patient self-deactivating device
## Fluid loss from system
## Urethral atrophy
## OAB
# A patient previously treated with sling for incontinence after RP has persistent bothersome incontinence. What is the next treatment?
#* AUS