Editing Functional: Surgery for Male SUI (section)

== Diagnosis and Evaluation ==
===UrologySchool.com Summary===
*'''<span style="color:#ff0000">Recommended</span>'''
**'''<span style="color:#ff0000">History and Physical Exam, including degree of bother</span>'''
**'''<span style="color:#ff0000">Labs</span>'''
***'''<span style="color:#ff0000">Urinalysis +/- culture</span>'''
**'''<span style="color:#ff0000">Other</span>'''
***'''<span style="color:#ff0000">Appropriate diagnostic modalities to categorize type and severity of incontinence (e.g. voiding diary, pad weights)</span>'''
*'''<span style="color:#ff0000">Optional</span>'''
**'''<span style="color:#ff0000">Post-void residual</span>'''
=== History and Physical Exam ===

* '''<span style="color:#ff0000">History</span>'''
**'''<span style="color:#ff0000">Characterize incontinence</span>'''
***'''<span style="color:#ff0000">Type of incontinence</span>'''
****Treatment for SUI (caused by sphincteric insufficiency) vs. 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.
****'''Differentiation between stress and urge UI can be aided by the voiding diary and pad test'''
***'''Progression or resolution of incontinence over time, exacerbating factors'''
*** '''<span style="color:#ff0000">Severity of incontinence</span>''' (i.e. volume lost over time)
****'''Can be determined by history, or more objectively, by pad testing'''
**** In the case of sphincteric insufficiency, some treatments (e.g., male slings), clearly have inferior results in severe incontinence.
***'''<span style="color:#ff0000">Degree of bother</span>'''
** Previous surgical procedures
** Symptoms of neurologic disease
* '''Physical exam'''
** '''Abdomen, back, genitalia, perineum, rectum, and neurologic system'''
** '''Scrotal exam''' 
***May detect pathologic processes that can influence pump placement such as hydrocele, hernias, and scrotal masses.
****If inguinal hernia identified and contralateral pressure-regulating balloon (PRB) placement is not possible, concomitant hernia repair is advisable.
** '''Previous surgical incisions should be noted when planning AUS pressure-reservoir balloon placement'''

=== Labs ===

* '''Urinalysis +/- culture are required before surgical correction of male UI'''

=== Other ===

* '''<span style="color:#ff0000">Cystoscopy</span>'''
** '''<span style="color:#ff0000">Should be performed to assess for urethral and bladder pathology that may affect outcomes of surgery[https://pubmed.ncbi.nlm.nih.gov/31059663/ ★]</span>'''
***'''Patients with symptomatic vesicourethral anastomotic stenosis or bladder neck contracture should be treated prior to surgery for incontinence after prostate therapy'''
****Unrecognized urethral pathologic processes can significantly complicate all surgical approaches
* '''<span style="color:#ff0000">Urodynamics (UDS) may be performed[https://pubmed.ncbi.nlm.nih.gov/31059663/ ★]</span>'''
**'''<span style="color:#ff0000">UDS are not required before surgical intervention for incontinence after prostate therapy unless the clinician is in doubt of the diagnosis or it is felt that patient counseling will be affected.</span>'''
***'''<span style="color:#ff0000">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</span>'''
****'''<span style="color:#ff0000">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.</span>'''
**'''Intrinsic sphincteric dysfunction will be identified in almost all cases.'''
** '''In 2012''', '''the American Urological Association (AUA) released guidelines on the use of urodynamics''' in the clinical evaluation of the patient with voiding dysfunction.
*** '''Specific recommendations for the patient with SUI include at minimum that: surgeons considering invasive therapy in patients with SUI should assess the PVR'''.
*** Furthermore, clinicians may perform multichannel urodynamics in patients with both symptoms and physical findings of stress incontinence who are considering invasive, potentially morbid or irreversible treatments, which include placement of the male sling or AUS.
** '''Detrusor hypocontractility may indicate the need for AUS instead of sling if adequate detrusor function does not exist to overcome the fixed resistance of a compressive sling'''
** '''Reduced bladder compliance is concerning because prolonged storage at high pressures may lead to deteriorating renal function.'''