Editing Incontinence after Prostate Therapy (2024) (section)

== Special Situations ==

=== 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 (5) ====
# '''<span style="color:#ff0000">Inadvertently deactivating the device</span>'''
#* Re-education must be performed
# '''<span style="color:#ff0000">Acute fluid loss</span>'''
#* '''The volume in the pressure regulating balloon can be assessed using computerized tomography or ultrasound.'''
# '''<span style="color:#ff0000">Poor cuff coaptation</span>'''
#* Cuff coaptation may be evaluated by cycling the device during cystoscopic visualization. 
#* Although rare, poor coaptation in the absence of fluid loss in the early post-operative phase is related to improper cuff sizing or incomplete engagement of the cuff tab. 
#* Either situation can only be addressed by operative revision.
# '''<span style="color:#ff0000">Wear or urethral atrophy</span>'''
#*'''Recurrent incontinence after years of normal function suggests either development of a new leak due to wear or urethral atrophy'''
#**Cystoscopy is the mainstay for evaluation of atrophy and erosion.
#**A leak can be confirmed by decreased volume in the pressure regulating balloon, which can be assessed by using ultrasound or computerized tomography.
# '''<span style="color:#ff0000">Elevated storage pressures or detrusor over-activity</span>'''
#*'''Should be suspected in a patient with a normally functioning AUS'''
#*UDS may be performed to evaluate filling pressures, capacity, presence of uninhibited detrusor contractions, and effective voiding. 
#**As a technical point, the cuff needs to be temporarily deflated and deactivated to allow for safe and atraumatic urodynamic sensor placement. If there are concerns regarding cuff damage, cystoscopy must be performed immediately to evaluate. 
#**In all cases of detrusor dysfunction, the underlying abnormalities must be addressed rather than performing any adjustments to the AUS with the exception of deflating and deactivating in the patient experiencing retention. 

==== Management ====

*'''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
** '''AUS, revision should be considered'''
*** Inadequate recovery of continence after AUS placement can be due to a host of factors, including suboptimal cuff sizing at the time of original operation or inadequate pressure regulating balloon gradient.
*** In patients with a possible distally located cuff, or those with a larger cuff, proximal relocation or downsizing of the cuff are both reasonable options and will likely lead to better continence. 
*** Tandem cuff placement is the addition of a cuff to the original cuff and has also been shown to be effective as a salvage procedure for patients with persistent incontinence. 
**** Specific additional risks of tandem cuff placement should be discussed with the patient prior to proceeding, including injury to the urethra during dissection, which would lead to aborting the case and the higher risk of subsequent erosion.

=== Patients presenting with infection or erosion of AUS or sling ===

*'''<span style="color:#ff0000">Erosion</span>'''
**'''A devastating complication that can lead to urine extravasation, infection, abscess formation and sepsis, and may result in long-term urethral fistula, urethral diverticula, or urethral stricture after AUS explant.'''
** Incidence
*** Occurs in 1-10% of cases on long-term follow-up
** Pathophysiology
*** 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.
** '''Diagnosis and Evaluation'''
*** '''Generally presents with with hematuria, dysuria, or difficulty emptying the bladder and is diagnosed with a cystoscopic demonstration of the AUS cuff within the urethra'''
** '''<span style="color:#ff0000">Management:'''
*** '''<span style="color:#ff0000">Explanting eroded device with urethral catheter alone, in situ urethroplasty, or anastomotic urethroplasty'''
**** During explant, the goal of erosion management is to maximize the chances of urethral healing without developing a fistula or stricture. 
**** The degree of urethral loss with erosion can be highly variable, ranging from a small <5mm hole in the urethra, to complete circumferential urethral loss under the 2cm cuff. 
***** '''<span style="color:#ff0000">The urethral defect will usually heal by leaving a urethral catheter in place for 3 weeks.''' 
***** Some authors, however, recommend a urethral repair in cases of larger urethral defects due to decreased rates of stricture. The decision on how to best manage the erosion takes into consideration the size of the urethral defect, quality of local tissues (there are heterogeneous degrees of inflammation, induration, and fibrosis), and surgeon preference/experience.
* '''<span style="color:#ff0000">Infection</span>'''
** Often times an infection is secondary to a pre-existing erosion. 
*** AUS isolated cuff infections are rare without an associated erosion. 
** '''<span style="color:#ff0000">Incidence'''
*** '''<span style="color:#ff0000">Device infection occurs in <1-5% of cases'''
** '''<span style="color:#ff0000">Diagnosis and Evaluation'''
***'''<span style="color:#ff0000">History and Physical Exam'''
****'''<span style="color:#ff0000">Presents with (4):'''
****#'''<span style="color:#ff0000">Pain at the site of the AUS'''
****#'''<span style="color:#ff0000">Fever'''
****#'''<span style="color:#ff0000">Scrotal warmth or erythema'''
****#'''<span style="color:#ff0000">Skin changes'''
** '''<span style="color:#ff0000">Management:'''
*** '''<span style="color:#ff0000">Explantation should be performed as soon as possible'''
**** '''Timing of removal is usually influenced by severity of the infection and acuity of the clinical situation as indicated by the associated signs and symptoms (e.g., purulent drainage, erythema, tenderness, fever, chills).'''
**** '''In the case of the AUS, the most conservative course of action is removal of all components, regardless of whether the infection and any associated reaction are limited to a single component.'''
**** '''An infected male sling should be removed as completely as feasible without damaging any adjacent structures.'''
* '''<span style="color:#ff0000">For patients seeking a replacement device (AUS or male sling) after infection and/or erosion, a waiting period of 3-6 months is recommended.''' 
** '''In the AUS patient, it may be necessary to proceed with transcorporal placement of the cuff to place the cuff at a different location along the urethra.'''

=== Sexual arousal incontinence or climacturia ===

* '''As with post-prostatectomy SUI, for those with sexual arousal incontinence or climacturia, conservative management (dehydration and emptying the bladder prior to sex, use of condoms to catch the urine, achieving orgasm while supine, 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.'''
* The use of a penile variable tension loop (a soft silicone tube placed around the penis and adjusted to provide pressure on the urethra to physically prevent leaking during sex) has been used with success
* '''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.'''
** Concomitant surgery is safe 
*** Rate of device infection, erosion or malfunction was not increased in combined compared to staged procedures. 
*** Similar continence, sexual function, and overall satisfaction in patients undergoing staged versus combined procedures