Editing Incontinence after Prostate Therapy (2024) (section)

== Pre-treatment Counselling ==

==== Urinary Incontinence ====
* '''<span style="color:#ff0000">Inform patients undergoing RP that (2):</span>''' 
*# '''<span style="color:#ff0000">Incontinence is expected in the short-term and generally improves to near baseline by 12 months after surgery but may persist and require treatment</span>'''
*#* '''Most males undergoing RP are not continent (pad-free) at the time of catheter removal and should be informed that continence is not immediate.'''
*#* '''<span style="color:#ff0000">Majority of patients will reach their maximum improvement by 12 months with minimal to no improvement afterwards.</span>'''
*#** '''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.
*#** '''<span style="color:#ff0000">Conservative management with regular follow-up during the first year after surgery is recommended</span>''' to assess patient progress
*# '''<span style="color:#ff0000">All known factors that could affect continence (5):</span>'''
*## '''<span style="color:#ff0000">Older age</span>'''
*## '''<span style="color:#ff0000">Larger prostate size</span>'''
*## '''<span style="color:#ff0000">Shorter membranous urethral length (measured by MRI)</span>'''
*## '''<span style="color:#ff0000">Lack of preservation of bilateral neurovascular bundle at time of RP</span>'''
*##* No surgical maneuvers, other than preservation of bilateral neurovascular bundle, results in improved continence recovery at 12 months
*##** Patients receiving bilateral neurovascular bundle preservation were 26% more likely to be continent at 6 months compared to patients who did not
*##** Retzius sparing RP may be associated with early return to continence by continence rates at 12 months are similar to other techniques
*##* '''Patients with poor pre-operative potency still benefit from nerve sparing in terms of recovery of continence'''
*## '''<span style="color:#ff0000">Prior pelvic radiation</span>'''
*##* '''Radiation is a significant risk factor for IPT in patients undergoing RP or TURP.'''
*##** '''Radiation causes small vessel obliteration and endarteritis, resulting in ischemic tissue changes such as fibrosis and necrosis'''
*##**Urethral fibrosis decreases the functional capabilities of the external sphincter, ultimately affecting continence and outcomes following AUS or sling placement. 
*##***Even in the absence of direct damage to the sphincter, adjacent surgical cautery or laser energy further compromises sphincter function.
*##** TURP following brachytherapy or external beam radiation has been associated with incontinence rates of up to 70%. 
*##*** The need for subsequent resections, patient age, and pre-TURP urgency is correlated with higher rates of incontinence.
*##*** Little to no published evidence discussing post-TURP outcomes with patients who have undergone other forms of local therapy such as HIFU and cryotherapy. However, it is the opinion of this Panel that these patients have high risks of incontinence similar to post-TURP radiated patients.
*##** Salvage RP, regardless of the initial form of non-operative therapy or the operative approach (open or robotic), is associated with high rates of urinary incontinence rates (20%-70%)
*##* '''These patients should be informed that they may require an artificial urinary sphincter (AUS).'''
*#* '''<span style="color:#ff0000">Surgical approach: open RP has similar rates of urinary incontinence as robot-assisted RP</span>'''
*#* '''<span style="color:#ff0000">BMI may impact IPT in the short-term; however, not considered to impact risk at 1-year after RP</span>'''

=== Sexual Arousal Incontinence and Climacturia ===
* <span style="color:#ff0000">'''Inform patients undergoing localized prostate cancer treatment on the risks of sexual arousal incontinence and climacturia'''</span>
** '''Sexual arousal incontinence: inadvertent loss of urine during sexual arousal, foreplay, and/or masturbation.'''
** '''Climacturia (also known as orgasm associated urinary incontinence): involuntary loss of''' '''urine at the time of orgasm.''' 
***Pathophysiology of climacturia is not completely understood. 
****The mechanism is thought to relate to removal of the internal sphincter during RP, which is exacerbated by prior transurethral resection of the prostate (TURP). Bladder contraction at the time of orgasms with some degree of external sphincter insufficiency is thought to result in leakage during orgasm.
**Can occur following RP, with or without adjuvant RT, and can even occur following RT alone.
***Occurs in 30% of cases following prostate cancer surgery, 4% after RT
****Ejaculatory dysfunction, such as an anejaculation, is common after radiation
** Risk factors
**# Time since surgery (main risk factor; shorter time from surgery is associated with a higher rate of leakage)
**#Prior TURP
**#Shorter functional urethral and penile length following RP
**#*Not risk factors: age, pre-operative erectile function, or nerve sparing status
**Improvement can be expected throughout the postoperative period, but it can take several years to resolve, and typically persists in one-third of patients.

=== Pelvic floor muscle exercises (PFME) or pelvic floor muscle training (PFMT) ===
*'''Pelvic floor muscle exercise (PFME): an exercise program specific to the pelvic floor muscle group that is self-guided''' as a home exercise program only. 
**The patient may have learned the program through patient education literature or with a single basic instruction session from an appropriate practitioner.
*'''Pelvic floor muscle training (PFMT): a training program specific to the pelvic floor muscle group that is practitioner guided.'''
*'''<span style="color:#ff0000">May be offered prior to RP</span>'''
**Exercises for the pelvic floor muscle are easier to learn in the pre-operative period since mastery can be difficult postoperatively given muscle inhibition, sensory changes, urinary incontinence, and surgical pain.
**Typical preliminary goals of a preoperative program include proper patient education regarding pelvic floor muscle anatomy, physiology, awareness, and motor control, which maximize the effectiveness of exercises.  
**To allow for neuromuscular adaptation, preoperative PFMT should be started three to four weeks prior to surgery.
**The benefit of starting pre-operative PFMT in not consistent in the outcome data.
*'''<span style="color:#ff0000">Should be offered to all patients after RP upon removal of the urethral catheter</span>''' 
**'''<span style="color:#ff0000">Improves time to continence (thus improving QoL) but not overall continence at 12 months</span>'''
***PFME after catheter removal has been shown to improve time-to-achieving continence compared to control groups in RCTs