Editing Functional: Surgery for Male SUI (section)

== Special Situations ==

=== Persistent Incontinence after Surgery (AUS or sling) ===
* '''Causes'''
*# '''Inadvertent deactivation'''
*# '''Insufficient urethral compression (oversizing of cuff)'''
*# '''Cuff erosion'''
*# '''Bladder storage failure'''
*# '''Mechanical failure with fluid loss'''
*# '''Plugged delay-fill resistor'''
*# '''Kinked tubing'''
* '''Timing'''
** '''After AUS insertion,'''
*** '''A slow onset of incontinence suggests atrophy'''
*** '''The sudden recurrence of incontinence indicates'''
**** '''Mechanical failure'''
**** '''Fluid leak'''
**** '''Erosion of the device'''
* '''Inadvertent deactivation'''
** '''Active cycling of the device excludes inadvertent deactivation'''.
*** '''If the pump is deactivated with inadequate fluid to cycle, passive filling can be achieved by squeezing the pump on its lateral edges or by pushing on the pump with a cotton-tipped applicator opposite the deactivation button'''.
* '''Mechanical failure with fluid loss'''
** '''Plain radiography (for contrast-filled systems) or ultrasonography (for saline-filled systems) of the pressure-reservoir balloon during cycling can help differentiate fluid loss from cuff atrophy.'''
*** '''If the pressure-reservoir balloon size changes with cycling and refills passively, mechanical failure is less likely and thus suggests cuff atrophy'''
* '''Cuff erosion'''
** '''Cystoscopy, in addition to excluding erosion, can be used to visualize the cuff during cycling and give insight into the likelihood of atrophy.'''
* '''Bladder storage failure'''
** '''Urodynamics should be performed when bladder storage failure is suspected'''
*** '''The best indicators for patients who may develop overactive bladder after treatment of their outlet for sphincteric incontinence include (2):'''
***# '''Bladder capacity < 200 mL on urodynamics or diary'''
***# '''Presence of symptomatic overactive bladder before surgical treatment for the incontinence'''
*** Patients with prior radiation therapy may develop urgency and frequency at a later time, but this is not a significant risk factor before proceeding with outlet procedures such as male slings or AUS.
*** Leak-point pressure and prior procedures do not indicate a risk for development of overactive bladder.
* '''Revision surgery for non-mechanical causes may require (3):'''
*# '''Tandem cuff'''
*# '''Modified cuff placement using 3.5-cm cuff'''
*# '''Transcorporeal placement'''
** '''When the cause of persistent UI is incomplete urethral occlusion, the addition of a second tandem cuff around the bulbar urethra can yield satisfactory continence.'''
*** Connection to the existing device requires division of the existing cuff tubing and use of a metal Y connector. An additional 3 mL of fluid must be added to the system.
** '''However, in a relatively young patient, the cuff should be downsized rather than placing a second cuff to avoid using additional locations on the bulbar urethra, which will be necessary for future device replacements over time.'''
=== Urethral stricture ===
* '''The safest approach for an initial stricture would be laser incision through a smaller caliber endoscope such as a ureteroscope.'''
** Although exploration of the AUS cuff with uncoupling of the cuff will allow safe endoscopic management of strictures and tumors with resectoscopes, this should be reserved for cases not amenable to simple laser incision with small caliber and scopes.
** Antegrade incision is feasible but offers less control than the retrograde approach.
** Open surgical reconstruction should be reserved for refractory cases.
===Climacturia===
*'''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'''
===Concomitant IPT and erectile dysfunction===
*'''In patients with concomitant IPT and erectile dysfunction, a concomitant or staged procedure may be offered.'''