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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 ==
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== Diagnosis and Evaluation ==
== Diagnosis and Evaluation ==


* '''<span style="color:#ff0000">Recommended</span>'''
=== UrologySchool.com Summary ===
** '''<span style="color:#ff0000">History and physical exam</span>'''
*'''<span style="color:#ff0000">Recommended</span>'''
** '''<span style="color:#ff0000">Appropriate diagnostic modalities to categorize type and severity of incontinence and degree of bother</span>'''
** '''<span style="color:#ff0000">History and Physical Exam</span>'''
* '''<span style="color:#ff0000">History and Physical Exam</span>'''
** '''<span style="color:#ff0000">Labs</span>'''
***'''<span style="color:#ff0000">Urinalysis +/- culture</span>'''
**'''<span style="color:#ff0000">Other</span>'''
***'''<span style="color:#ff0000">Appropriate diagnostic modalities to categorize type and severity of incontinence and degree of bother</span>'''
* '''<span style="color:#ff0000">Optional</span>'''
**'''<span style="color:#ff0000">Post-void residual</span>'''
 
=== Recommended ===
*'''<span style="color:#ff0000">History and Physical Exam</span>'''
** '''<span style="color:#ff0000">History</span>'''
** '''<span style="color:#ff0000">History</span>'''
*** '''<span style="color:#ff0000">Characterize incontinence</span>'''
*** '''<span style="color:#ff0000">Characterize incontinence</span>'''
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******* The sudden compelling desire to void that is difficult to defer and results in leakage indicates urgency incontinence.
******* 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.
******* Presence of incontinence while asleep as well as nocturia are also important to note, because this may indicate urgency urinary incontinence or severe SUI.
**** '''<span style="color:#ff0000">Severity of incontinence</span>''' (i.e. volume lost over time)
****'''Progression or resolution of incontinence over time, exacerbating factors'''
*****Progression or resolution of incontinence over time, exacerbating factors, and degree of bother.
****'''<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
*****'''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.
***** In the case of sphincteric insufficiency, some treatments (e.g., male slings), clearly have inferior results in severe incontinence.
* '''<span style="color:#ff0000">Post-void residual (PVR)</span>'''
****'''<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>'''
** '''<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
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== 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 ===
=== Non-surgical ===


==== Options (5) ====
==== Options (5) ====
# '''PFME/PFMT'''
# '''<span style="color:#ff0000">PFME/PFMT</span>'''
# '''Absorbent pads'''
# '''<span style="color:#ff0000">Absorbent pads</span>'''
# '''Penile compression devices'''
# '''<span style="color:#ff0000">Penile compression devices</span>'''
# '''Condom'''
# '''<span style="color:#ff0000">Condom catheter</span>'''
# '''Urethral catheter'''
# '''<span style="color:#ff0000">Urethral catheter</span>'''
*
*
* '''PFME/PFMT'''
* '''<span style="color:#ff0000">PFME/PFMT</span>'''
** '''Should be offered to all patients'''
** '''<span style="color:#ff0000">Should be offered to all patients</span>'''
** Advantages:
** Advantages:
*** Safe treatment with minimal side-effects
*** Safe treatment with minimal side-effects
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*** Time and effort required
*** Time and effort required
*** Cost of repeated visits for PFMT
*** Cost of repeated visits for PFMT
* '''Other options that can be used with or without PFME/PFMT:'''
* '''<span style="color:#ff0000">Other options that can be used with or without PFME/PFMT:</span>'''
** '''Absorbent pads'''
** '''<span style="color:#ff0000">Absorbent pads</span>'''
** '''Penile compression devices (clamps)'''
** '''<span style="color:#ff0000">Penile compression devices (clamps)</span>'''
*** Should not be left on the phallus overnight due to the risks of constant pressure
*** Should not be left on the phallus overnight due to the risks of constant pressure
*** Not suitable for patients with (4):
*** <span style="color:#ff0000">'''Not suitable for patients with (4):'''</span>
***# Memory deficits
***# <span style="color:#ff0000">'''Memory deficits'''</span>
***# Poor manual dexterity
***# <span style="color:#ff0000">'''Poor manual dexterity'''</span>
***# Impaired sensation
***# <span style="color:#ff0000">'''Impaired sensation'''</span>
***# Significant component of OAB
***# <span style="color:#ff0000">'''Significant component of OAB'''</span>
** '''Condom catheters'''
** '''<span style="color:#ff0000">Condom catheter</span>'''
** '''Urethral catheter'''
** '''<span style="color:#ff0000">Urethral catheter</span>'''
*** '''Last resort''' in a patient who is unsuitable for alternative management
*** '''<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'''
*** '''Suprapubic catheter drainage is not a solution for the patient with severe intrinsic sphincter deficiency, as urethral leakage will persist'''


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==== Timing ====
==== 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'''
* '''<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'''
** 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
** 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.'''
* '''<span style="color:#ff0000">Otherwise, treatment should be offered to patients with persistent bothersome SUI at 12 months.</span>'''
** '''Conversely, treatment should be offered with caution in some patients who continue to display symptom improvement at 12 months'''
** '''Conversely, treatment should be offered with caution in some patients who continue to display symptom improvement at 12 months'''


==== Pre-surgical Evaluation ====
==== Pre-surgical Evaluation ====
# '''SUI should be confirmed''' by history, physical exam, or ancillary testing
# '''<span style="color:#ff0000">SUI should be confirmed</span>''' 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
#* 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'''
# '''<span style="color:#ff0000">Cystourethroscopy should be performed to assess for urethral and bladder pathology that may affect outcomes of surgery</span>'''
#* '''Patients with symptomatic vesicourethral anastomotic stenosis or bladder neck contracture should be treated prior to surgery for IPT'''
#* '''Patients with symptomatic vesicourethral anastomotic stenosis or bladder neck contracture should be treated prior to surgery for IPT'''
# '''Urodynamics (UDS) may be performed.'''
# '''<span style="color:#ff0000">Urodynamics (UDS) may be performed.</span>'''
#* '''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.'''
#* '''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'''
#** '''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'''
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==== Options (5): ====
==== Options (5): ====
# '''Urethral bulking agents'''
# '''<span style="color:#ff0000">Urethral bulking agents</span>'''
# '''Adjustable balloon devices'''
# '''<span style="color:#ff0000">Adjustable balloon devices</span>'''
# '''Slings'''
# '''<span style="color:#ff0000">Slings</span>'''
# '''AUS'''
# '''<span style="color:#ff0000">AUS</span>'''
# '''Urinary Diversion'''
# '''<span style="color:#ff0000">Urinary Diversion</span>'''
* Risks, benefits, and expectations of different treatments should be discussed using the shared decision-making model
* Risks, benefits, and expectations of different treatments should be discussed using the shared decision-making model


===== Urethral bulking agents =====
===== Urethral bulking agents =====
* '''Least invasive technique'''
* '''Advantage'''
* '''Least effective surgical technique; cure is rare'''
**'''Least invasive technique'''
* '''Consider in patients who are unable to tolerate or refuse more invasive surgical therapy'''
* '''Disadvantage'''
**'''Least effective surgical technique'''
*** Cure is rare
* '''<span style="color:#ff0000">Indication</span>'''
**'''<span style="color:#ff0000">Consider in patients who are unable to tolerate or refuse more invasive surgical therapy</span>'''


===== Adjustable balloon devices =====
===== Adjustable balloon devices =====
* '''Consider for mild SUI'''
* '''Disadvantages'''
* '''Disadvantages: increased incidence of intraoperative complications and need for explanation within the first 2 years compared to the male sling and AUS'''
**'''Increased incidence of intraoperative complications and need for explanation within the first 2 years compared to the male sling and AUS'''
*'''<span style="color:#ff0000">Indication</span>'''
**'''<span style="color:#ff0000">Consider for mild SUI</span>'''


===== Male slings =====
===== Male slings =====
* '''Considered for mild to moderate stress urinary incontinence'''
* <span style="color:#ff0000">'''Indication'''</span>
** '''Poor efficacy in comparison to an AUS in patients with severe incontinence.'''
**'''<span style="color:#ff0000">Consider for mild to moderate SUI</span>'''
*** '''<span style="color:#ff0000">Poor efficacy in comparison to an AUS in patients with severe incontinence.</span>'''
* '''Risks''' (generally low complication rate):
* '''Risks''' (generally low complication rate):
** Urinary retention
** Urinary retention
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====== Indications ======
====== Indications ======
*'''Consider for mild to severe stress urinary incontinence'''
*'''<span style="color:#ff0000">Consider for mild to severe SUI</span>'''
* '''Preferred in patients with prior (3):'''
* '''<span style="color:#ff0000">Preferred in patients with prior (3):</span>'''
** '''Radiation'''
** '''<span style="color:#ff0000">Radiation</span>'''
*** Improved outcomes compared to male slings or adjustable balloons for treatment of patients with SUI after primary, adjuvant, or salvage radiotherapy
*** 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'''
*** '''Complication rates are higher'''
** '''Urethral reconstruction'''
** '''<span style="color:#ff0000">Urethral reconstruction</span>'''
*** 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.
*** 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'''
*** '''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'''
*** '''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.
**** 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.
** '''Vesicourethral anastomotic stenosis or bladder neck contracture'''
** '''<span style="color:#ff0000">Vesicourethral anastomotic stenosis or bladder neck contracture</span>'''
*** Decreased success rates when undergoing male slings
*** Decreased success rates when undergoing male slings


====== Contraindications ======
====== Contraindications ======
* '''Inadequate physical or cognitive abilities to operate the device'''
*'''<span style="color:#ff0000">Inadequate physical or cognitive abilities to operate the device</span>'''


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


====== '''Complications''' ======
====== Complications ======
* '''Intraoperative urethral injury'''
* '''<span style="color:#ff0000">Intraoperative urethral injury</span>'''
** '''If identified during implantation, procedure should be abandoned and subsequent implantation should be delayed'''
** '''<span style="color:#ff0000">If identified during implantation, procedure should be abandoned and subsequent implantation should be delayed</span>'''
* '''Persistent leakage'''
* '''<span style="color:#ff0000">Persistent leakage</span>'''
* '''Mechanical failure'''
* '''<span style="color:#ff0000">Cuff erosion</span>'''
* '''Cuff erosion'''
** 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.
** 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:'''
** '''Management:'''
*** '''AUS explant with the urethral catheter left in place for a few weeks to allow the urethral defect to heal'''
*** '''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 re-implanted until at least 3 months'''
* '''Infection'''
* '''<span style="color:#ff0000">Infection</span>'''
** '''Device infection occurs in <1-5% of cases'''
** '''<span style="color:#ff0000">Device infection occurs in <1-5% of cases'''
** '''Presents with pain at the site of the AUS, fever, scrotal warmth or erythema, or skin changes'''
** '''<span style="color:#ff0000">Diagnosis and Evaluation'''
** '''Management:'''
***'''<span style="color:#ff0000">History and Physical Exam'''
*** '''Urgent AUS explantation'''
****'''<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.
*** '''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'''
* '''<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:'''
** '''The current version consists of''' a hydraulic system composed of '''3 separate parts:'''
**# '''A urethral cuff''' of varying sizes
**# '''A urethral cuff''' of varying sizes
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*** '''≈24% at 5 years'''
*** '''≈24% at 5 years'''
*** '''≈ 50% at 10 years'''
*** '''≈ 50% at 10 years'''
** '''An AUS might need to be replaced over time due to persistent or recurrent incontinence generally due to:'''
** '''AUS might need to be replaced over time due to persistent or recurrent incontinence generally due to (3):'''
**# '''Urethral atrophy'''
**# '''Urethral atrophy'''
**# '''Improper cuff sizing'''
**# '''Improper cuff sizing'''
**# '''Partial fluid loss'''
**# '''Partial fluid loss'''
===== Urinary diversion =====
===== 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'''
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== 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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