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

* '''See [https://pubmed.ncbi.nlm.nih.gov/31059663/ Original Guidelines]'''

== Background ==

== Diagnosis and Evaluation ==

** '''<span style="color:#ff0000">History</span>'''

*** '''<span style="color:#ff0000">Characterize incontinence</span>'''

******* 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.

***** In the case of sphincteric insufficiency, some treatments (e.g., male slings), clearly have inferior results in severe incontinence.

** '''<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

== Management ==

=== Non-surgical ===

==== Options (5) ====

*

** Advantages:

*** Safe treatment with minimal side-effects

*** Time and effort required

*** Cost of repeated visits for PFMT

*** Should not be left on the phallus overnight due to the risks of constant pressure

*** '''Suprapubic catheter drainage is not a solution for the patient with severe intrinsic sphincter deficiency, as urethral leakage will persist'''

==== Timing ====

** 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

** '''Conversely, treatment should be offered with caution in some patients who continue to display symptom improvement at 12 months'''

==== Pre-surgical Evaluation ====

#* 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

#* '''Patients with symptomatic vesicourethral anastomotic stenosis or bladder neck contracture should be treated prior to surgery for IPT'''

#* '''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'''

==== Options (5): ====

* Risks, benefits, and expectations of different treatments should be discussed using the shared decision-making model

===== Urethral bulking agents =====

===== Adjustable balloon devices =====

===== Male slings =====

* '''Risks''' (generally low complication rate):

** Urinary retention

====== Indications ======

*** Improved outcomes compared to male slings or adjustable balloons for treatment of patients with SUI after primary, adjuvant, or salvage radiotherapy

*** '''Complication rates are higher'''

*** 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.

*** '''Male slings will not be effective given post-surgical changes related to most types of urethral reconstruction in the posterior and anterior urethra'''

*** '''Complications rates are higher'''

**** 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.

*** Decreased success rates when undergoing male slings

====== Contraindications ======

====== Procedure ======

* '''Single cuff perineal approach is preferred, superior outcomes compared to transverse scrotal incision'''

** 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'''

*** '''AUS should not be reimplanted until at least 3 months''' to allow the infection to clear and inflammation to subside.

** '''The current version consists of''' a hydraulic system composed of '''3 separate parts:'''

**# '''A urethral cuff''' of varying sizes

*** '''≈24% at 5 years'''

*** '''≈ 50% at 10 years'''

**# '''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'''

== Special Situations ==

=== Climacturia ===