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AUA: Incontinence after Prostate Therapy (2019): Difference between revisions

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* '''See [https://pubmed.ncbi.nlm.nih.gov/31059663/ Original Guidelines]'''
* '''See [https://pubmed.ncbi.nlm.nih.gov/31059663/ Original Guidelines]'''
* '''See Male SUI Surgery Chapter Notes'''
* '''See [[Functional: Surgery for Male SUI|Male SUI Surgery]] Chapter Notes'''


== Background ==
== Background ==
Line 39: Line 39:
== Diagnosis and Evaluation ==
== Diagnosis and Evaluation ==


* '''Recommended'''
=== UrologySchool.com Summary ===
** '''History and physical exam'''
*'''<span style="color:#ff0000">Recommended</span>'''
** '''Appropriate diagnostic modalities to categorize type and severity of incontinence and degree of bother'''
** '''<span style="color:#ff0000">History and Physical Exam</span>'''
* '''History and Physical Exam'''
** '''<span style="color:#ff0000">Labs</span>'''
** '''History'''
***'''<span style="color:#ff0000">Urinalysis +/- culture</span>'''
*** '''Characterize incontinence:''' important because treatments for SUI (caused by sphincteric insufficiency) and urgency incontinence (caused by bladder dysfunction) are different.
**'''<span style="color:#ff0000">Other</span>'''
**** '''In cases of mixed incontinence, determine which component is more prevalent and bothersome''' (stress or activity related versus urgency related)
***'''<span style="color:#ff0000">Appropriate diagnostic modalities to categorize type and severity of incontinence and degree of bother</span>'''
***** Increases in abdominal pressure such as that caused by straining, walking, cough, and exercise are suggestive of SUI
* '''<span style="color:#ff0000">Optional</span>'''
***** The sudden compelling desire to void that is difficult to defer and results in leakage indicates urgency incontinence.
**'''<span style="color:#ff0000">Post-void residual</span>'''
***** 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.
=== Recommended ===
***** 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.
*'''<span style="color:#ff0000">History and Physical Exam</span>'''
* '''Post-void residual (PVR)'''
** '''<span style="color:#ff0000">History</span>'''
** '''May be helpful to rule out significant retention of urine if overflow incontinence is suspected.'''
*** '''<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.
****'''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>'''
*'''<span style="color:#ff0000">Labs</span>'''
**'''<span style="color:#ff0000">Urinalysis +/- culture</span>'''
 
=== Optional ===
*'''<span style="color:#ff0000">Post-void residual (PVR)</span>'''
** '''<span style="color:#ff0000">May be helpful to rule out significant retention of urine if overflow incontinence is suspected.</span>'''
*** Elevated PVR may be an indication of detrusor underactivity or obstruction and thus may prompt further diagnostic evaluation
*** Elevated PVR may be an indication of detrusor underactivity or obstruction and thus may prompt further diagnostic evaluation


== Management ==
== Management ==


* '''Patients with urgency urinary incontinence or urgency predominant mixed urinary incontinence should be offered treatment options per the AUA OAB guidelines'''
* '''<span style="color:#ff0000">Patients with urgency urinary incontinence or urgency predominant mixed urinary incontinence should be offered treatment options per the [[AUA: Overactive Bladder (2019)|AUA Overactive Bladder Guidelines]]</span>'''
 
=== Non-surgical ===
 
==== Options (5) ====
# '''<span style="color:#ff0000">PFME/PFMT</span>'''
# '''<span style="color:#ff0000">Absorbent pads</span>'''
# '''<span style="color:#ff0000">Penile compression devices</span>'''
# '''<span style="color:#ff0000">Condom catheter</span>'''
# '''<span style="color:#ff0000">Urethral catheter</span>'''
*
* '''<span style="color:#ff0000">PFME/PFMT</span>'''
** '''<span style="color:#ff0000">Should be offered to all patients</span>'''
** 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
* '''<span style="color:#ff0000">Other options that can be used with or without PFME/PFMT:</span>'''
** '''<span style="color:#ff0000">Absorbent pads</span>'''
** '''<span style="color:#ff0000">Penile compression devices (clamps)</span>'''
*** Should not be left on the phallus overnight due to the risks of constant pressure
*** <span style="color:#ff0000">'''Not suitable for patients with (4):'''</span>
***# <span style="color:#ff0000">'''Memory deficits'''</span>
***# <span style="color:#ff0000">'''Poor manual dexterity'''</span>
***# <span style="color:#ff0000">'''Impaired sensation'''</span>
***# <span style="color:#ff0000">'''Significant component of OAB'''</span>
** '''<span style="color:#ff0000">Condom catheter</span>'''
** '''<span style="color:#ff0000">Urethral catheter</span>'''
*** '''<span style="color:#ff0000">Last resort</span>''' 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'''


=== Options ===
=== Surgical ===


==== Non-surgical (5): ====
==== Timing ====
# '''PFME/PFMT'''
* '''<span style="color:#ff0000">If there is no improvement at 6 months despite conservative therapy and the patient has bothersome IPT,</span>''' (i.e. patient does not want to wait until 12 month time point) '''<span style="color:#ff0000">surgery may be considered for early treatment'''
# '''Absorbent pads'''
** 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
# '''Penile compression devices'''
* '''<span style="color:#ff0000">Otherwise, treatment should be offered to patients with persistent bothersome SUI at 12 months.</span>'''
# '''Condom'''
** '''Conversely, treatment should be offered with caution in some patients who continue to display symptom improvement at 12 months'''
# '''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'''
==== Pre-surgical Evaluation ====
** '''Least invasive technique'''
# '''<span style="color:#ff0000">SUI should be confirmed</span>''' by history, physical exam, or ancillary testing
** '''Least effective surgical technique; cure is rare'''
#* 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
** '''Consider in patients who are unable to tolerate or refuse more invasive surgical therapy'''
# '''<span style="color:#ff0000">Cystourethroscopy should be performed to assess for urethral and bladder pathology that may affect outcomes of surgery</span>'''
* '''Adjustable balloon devices'''
#* '''Patients with symptomatic vesicourethral anastomotic stenosis or bladder neck contracture should be treated prior to surgery for IPT'''
** '''Consider for mild SUI'''
# '''<span style="color:#ff0000">Urodynamics (UDS) may be performed.</span>'''
** '''Disadvantages: increased incidence of intraoperative complications and need for explanation within the first 2 years compared to the male sling and AUS'''
#* '''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.'''
* '''Male slings'''
#** '''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'''
** '''Considered for mild to moderate stress urinary incontinence'''
#*** 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.
*** '''Poor efficacy in comparison to an AUS in patients with severe incontinence.'''
 
** '''Risks''' (generally low complication rate):
==== Contraindications ====
*** Urinary retention
* '''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.'''
**** Typically resolves within 1 week
 
*** Pelvic and perineal pain and paresthesia
==== Options (5): ====
**** Typically resolves within 12 weeks
# '''<span style="color:#ff0000">Urethral bulking agents</span>'''
*** '''Erosion or infection'''
# '''<span style="color:#ff0000">Adjustable balloon devices</span>'''
**** '''Both are exceedingly rare.'''
# '''<span style="color:#ff0000">Slings</span>'''
**** 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)'''
# '''<span style="color:#ff0000">AUS</span>'''
* '''AUS'''
# '''<span style="color:#ff0000">Urinary Diversion</span>'''
** '''Consider for mild to severe stress urinary incontinence'''
* Risks, benefits, and expectations of different treatments should be discussed using the shared decision-making model
** '''Preferred in patients with prior (3):'''
 
*** '''Radiation'''
===== Urethral bulking agents =====
**** Improved outcomes compared to male slings or adjustable balloons for treatment of patients with SUI after primary, adjuvant, or salvage radiotherapy
* '''Advantage'''
**** '''Complication rates are higher'''
**'''Least invasive technique'''
*** '''Urethral reconstruction'''
* '''Disadvantage'''
**** 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.
**'''Least effective surgical technique'''
**** '''Male slings will not be effective given post-surgical changes related to most types of urethral reconstruction in the posterior and anterior urethra'''
*** Cure is rare
**** '''Complications rates are higher'''
* '''<span style="color:#ff0000">Indication</span>'''
***** 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.
**'''<span style="color:#ff0000">Consider in patients who are unable to tolerate or refuse more invasive surgical therapy</span>'''
*** '''Vesicourethral anastomotic stenosis or bladder neck contracture'''
 
**** Decreased success rates when undergoing male slings
===== Adjustable balloon devices =====
** '''Contraindications:'''
* '''Disadvantages'''
*** '''Inadequate physical or cognitive abilities to operate the device'''
**'''Increased incidence of intraoperative complications and need for explanation within the first 2 years compared to the male sling and AUS'''
** '''Procedure'''
*'''<span style="color:#ff0000">Indication</span>'''
*** '''Single cuff perineal approach is preferred, superior outcomes compared to transverse scrotal incision'''
**'''<span style="color:#ff0000">Consider for mild SUI</span>'''
** '''Complications:'''
 
*** '''Intraoperative urethral injury'''
===== Male slings =====
**** '''If identified during implantation, procedure should be abandoned and subsequent implantation should be delayed'''
* <span style="color:#ff0000">'''Indication'''</span>
*** '''Persistent leakage'''
**'''<span style="color:#ff0000">Consider for mild to moderate SUI</span>'''
*** '''Mechanical failure'''
*** '''<span style="color:#ff0000">Poor efficacy in comparison to an AUS in patients with severe incontinence.</span>'''
*** '''Cuff erosion'''
* '''Risks''' (generally low complication rate):
**** 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.
** Urinary retention
**** '''Management:'''
*** Typically resolves within 1 week
***** '''AUS explant with the urethral catheter left in place for a few weeks to allow the urethral defect to heal'''
** Pelvic and perineal pain and paresthesia
***** '''AUS should not be re-implanted until at least 3 months'''
*** Typically resolves within 12 weeks
*** '''Infection'''
** '''Erosion or infection'''
**** '''Device infection occurs in <1-5% of cases'''
*** '''Both are exceedingly rare.'''
**** '''Presents with pain at the site of the AUS, fever, scrotal warmth or erythema, or skin changes'''
*** 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)'''
**** '''Management:'''
 
***** '''Urgent AUS explantation'''
===== AUS =====
***** '''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'''
====== Indications ======
**** '''The current version consists of''' a hydraulic system composed of '''3 separate parts:'''
*'''<span style="color:#ff0000">Consider for mild to severe SUI</span>'''
****# '''A urethral cuff''' of varying sizes
* '''<span style="color:#ff0000">Preferred in patients with prior (3):</span>'''
****# '''A pressure regulating balloon reservoir''' with three available pressure profiles
** '''<span style="color:#ff0000">Radiation</span>'''
****# '''A control pump'''
*** Improved outcomes compared to male slings or adjustable balloons for treatment of patients with SUI after primary, adjuvant, or salvage radiotherapy
***** The device will fail if any of the 3 parts, the tubing, or connections suffer a micro-perforation with loss of fluid
*** '''Complication rates are higher'''
**** The rate of device failure increases with time, with '''failure rates of'''
** '''<span style="color:#ff0000">Urethral reconstruction</span>'''
***** '''≈24% at 5 years'''
*** 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.
***** '''≈ 50% at 10 years'''
*** '''Male slings will not be effective given post-surgical changes related to most types of urethral reconstruction in the posterior and anterior urethra'''
**** '''An AUS might need to be replaced over time due to persistent or recurrent incontinence generally due to:'''
*** '''Complications rates are higher'''
****# '''Urethral atrophy'''
**** 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.
****# '''Improper cuff sizing'''
** '''<span style="color:#ff0000">Vesicourethral anastomotic stenosis or bladder neck contracture</span>'''
****# '''Partial fluid loss'''
*** Decreased success rates when undergoing male slings
'''Urinary diversion'''
 
====== Contraindications ======
*'''<span style="color:#ff0000">Inadequate physical or cognitive abilities to operate the device</span>'''
 
====== Procedure ======
* '''Single cuff perineal approach is preferred, superior outcomes compared to transverse scrotal incision'''
 
====== Complications ======
* '''<span style="color:#ff0000">Intraoperative urethral injury</span>'''
** '''<span style="color:#ff0000">If identified during implantation, procedure should be abandoned and subsequent implantation should be delayed</span>'''
* '''<span style="color:#ff0000">Persistent leakage</span>'''
* '''<span style="color:#ff0000">Cuff erosion</span>'''
** 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'''
* '''<span style="color:#ff0000">Infection</span>'''
** '''<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">Urgent AUS explantation'''
*** '''AUS should not be reimplanted until at least 3 months''' to allow the infection to clear and inflammation to subside.
* '''<span style="color:#ff0000">Mechanical failure</span>'''
*'''<span style="color:#ff0000">Decreased efficacy over time and reoperations are common</span>'''
** '''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'''
** '''AUS might need to be replaced over time due to persistent or recurrent incontinence generally due to (3):'''
**# '''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'''
* '''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.'''
** '''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.
** '''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
 
===== Other =====
 
* Other potential treatments for IPT should be considered investigational


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


=== Persistent incontinence after surgery (AUS or sling) ===
=== Persistent Incontinence after Surgery (AUS or sling) ===
* '''Diagnosis and Evaluation:'''
 
** '''Same as prior: history + physical exam +/- other investigations to determine the cause of incontinence'''
==== Diagnosis and Evaluation ====
** '''Causes'''
* '''Same as prior: history + physical exam +/- other investigations to determine the cause of incontinence'''
*** '''Inadvertently deactivating the device'''
 
**** Re-education must be performed
==== Causes (4) ====
*** '''Acute fluid loss'''
# '''<span style="color:#ff0000">Inadvertently deactivating the device</span>'''
**** '''The volume in the pressure regulating balloon can be assessed using computerized tomography or ultrasound.'''
#* Re-education must be performed
*** '''Recurrent incontinence after years of normal function suggests either development of a new leak due to wear or urethral atrophy'''
# '''<span style="color:#ff0000">Acute fluid loss</span>'''
*** '''Elevated storage pressures or detrusor over-activity should be suspected in a patient with a normally functioning AUS'''
#* '''The volume in the pressure regulating balloon can be assessed using computerized tomography or ultrasound.'''
* '''For persistent or recurrent SUI after sling, an AUS is recommended'''
# '''<span style="color:#ff0000">Elevated storage pressures or detrusor over-activity</span>'''
** Failure of a male sling can be due to infection or erosion, or more likely, due to patient dissatisfaction with continence recovery
#*'''Should be suspected in a patient with a normally functioning AUS'''
* '''For persistent or recurrent SUI after AUS, revision should be considered'''
#'''<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'''
 
==== 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'''


=== Climacturia ===
=== Climacturia ===
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