AUA: Incontinence after Prostate Therapy (2019): Difference between revisions
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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 | *'''<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''' | ||
***** | ****'''<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. | ***** 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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# '''<span style="color:#ff0000">Absorbent pads</span>''' | # '''<span style="color:#ff0000">Absorbent pads</span>''' | ||
# '''<span style="color:#ff0000">Penile compression devices</span>''' | # '''<span style="color:#ff0000">Penile compression devices</span>''' | ||
# '''<span style="color:#ff0000">Condom</span>''' | # '''<span style="color:#ff0000">Condom catheter</span>''' | ||
# '''<span style="color:#ff0000">Urethral catheter</span>''' | # '''<span style="color:#ff0000">Urethral catheter</span>''' | ||
* | * | ||
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***# <span style="color:#ff0000">'''Impaired sensation'''</span> | ***# <span style="color:#ff0000">'''Impaired sensation'''</span> | ||
***# <span style="color:#ff0000">'''Significant component of OAB'''</span> | ***# <span style="color:#ff0000">'''Significant component of OAB'''</span> | ||
** '''<span style="color:#ff0000">Condom | ** '''<span style="color:#ff0000">Condom catheter</span>''' | ||
** '''<span style="color:#ff0000">Urethral 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 | *** '''<span style="color:#ff0000">Last resort</span>''' in a patient who is unsuitable for alternative management | ||
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==== Timing ==== | ==== Timing ==== | ||
* '''<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) '''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 | ||
* '''<span style="color:#ff0000">Otherwise, treatment should be offered to patients with persistent bothersome SUI at 12 months.</span>''' | * '''<span style="color:#ff0000">Otherwise, treatment should be offered to patients with persistent bothersome SUI at 12 months.</span>''' | ||
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====== Contraindications ====== | ====== Contraindications ====== | ||
* '''<span style="color:#ff0000">Inadequate physical or cognitive abilities to operate the device</span>''' | *'''<span style="color:#ff0000">Inadequate physical or cognitive abilities to operate the device</span>''' | ||
====== Procedure ====== | ====== Procedure ====== | ||
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** '''<span style="color:#ff0000">If identified during implantation, procedure should be abandoned and subsequent implantation should be delayed</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">Persistent leakage</span>''' | ||
* '''<span style="color:#ff0000">Cuff erosion</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. | ** 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. | ||
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*** '''AUS should not be re-implanted until at least 3 months''' | *** '''AUS should not be re-implanted until at least 3 months''' | ||
* '''<span style="color:#ff0000">Infection</span>''' | * '''<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 | ** '''<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. | ||
* '''<span style="color:#ff0000">Decreased efficacy over time and reoperations are common</span>''' | * '''<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''' | ||
** ''' | ** '''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 | === 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 (4) ==== | |||
# '''<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">Elevated storage pressures or detrusor over-activity</span>''' | |||
#*'''Should be suspected in a patient with a normally functioning AUS''' | |||
* '''For persistent or recurrent SUI after''' | #'''<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''' | **'''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 | *** Failure of a male sling can be due to infection or erosion, or more likely, due to patient dissatisfaction with continence recovery | ||