Urinary incontinence after prostate treatment

INTRODUCTION — Urinary incontinence is a known complication of prostate treatment that can significantly adversely impact quality of life [1]. Though it predominantly affects men after radical prostatectomy (RP) for prostate cancer, procedures for benign prostatic conditions can also result in urinary leakage.

Incontinence after prostate treatment (IPT) is a dynamic condition and can greatly improve in the first one to two years with conservative therapies. Ultimately, 5 percent of men choose to undergo an additional procedure for the treatment of their incontinence [2].

The classification, pathophysiology, risk factors, and management of IPT are discussed below. Incontinence in men not related to prostate surgery and specifics regarding the management of prostate cancer and benign prostatic hyperplasia are discussed elsewhere. (See "Urinary incontinence in men" and "Radical prostatectomy for localized prostate cancer" and "Surgical treatment of benign prostatic hyperplasia (BPH)".)

RATES OF INCONTINENCE — The incidence varies with the definition of incontinence and the method of evaluation. The literature generally uses "pad-free" as a strict definition of continence, but 0 to 1 pads per day has been accepted as a definition of "social continence" [3,4].

Immediately following catheter removal after radical prostatectomy (RP), a substantial proportion of men suffer from incontinence. Using 0 to 1 pads per day to define continence, 68.2 percent of men are continent by 3 months, 84 to 91 percent are continent by 12 months, and 93.2 percent are continent by 24 months postoperatively (figure 1) [3,5,6].

Similarly, transient incontinence is not uncommon immediately after surgery for benign prostatic hyperplasia (BPH). The highest rates occur following holmium laser enucleation, occurring in up to 16.2 percent at two weeks postoperatively and declining to 15.1, 11.2, 5.5, and 2.2 percent at 1, 3, 6, and 12 months, respectively [7,8]. Incontinence after simple open prostatectomy ranges from 1 to 8.4 percent [9,10]. Rates of incontinence are lowest following transurethral resection (TURP) or vaporization of the prostate, affecting only 1 to 2 percent of patients long term [11,12]. (See "Surgical treatment of benign prostatic hyperplasia (BPH)".)

RISK FACTORS FOR INCONTINENCE — Several authors have developed nomograms for predicting return of continence after radical prostatectomy (RP) [13,14]. Relevant risk factors are:

●Preoperative continence status – Preoperative incontinence is the most reliable predictor of incontinence after prostate treatment (IPT). In a survey of 482 men with prostate cancer, 11.9 percent had some degree of urinary leakage at baseline prior to RP [15].

●Nerve-sparing versus non-nerve-sparing surgery – A prospective study of 3707 patients found that patients who had non-nerve-sparing surgery had a 2.2-fold increased risk of incontinence compared with patients who had a bilateral nerve-sparing dissection at one year postoperatively. This benefit extended to older and impotent men. Thus, it is recommended that in those with favorable pathology on biopsy, nerve sparing should be considered to improve continence rates [16]. (See "Radical prostatectomy for localized prostate cancer", section on 'Nerve-sparing approach'.)

●Age – Older age is an independent predictor of worsened continence status after RP [4,17,18]. There is increased apoptosis of the striated muscle cells (and associated decreased function) of the external sphincter with age [19].

●Urethral length – Preoperative membranous urethral length is correlated with continence rates on meta-analysis, with a small but significant improvement with each additional millimeter of length (odds ratio 1.09, 95% CI 1.05-1.15) [20]. Similarly, longer postoperative functional urethral length is also associated with improved continence [5,21].

●Radiation – Radiation therapy to the prostate, following surgery for either benign or malignant prostate disease, is associated with substantially higher rates of IPT. Patients who have received brachytherapy with or without external beam radiation have incontinence rates of 18 to 70 percent after transurethral resection of the prostate (TURP) [22-24]. Similarly, men who undergo a salvage RP after radiation therapy have worse continence rates (30 to 45 percent) as well as increased risk of bladder neck contracture (30 to 42 percent) compared with men who were not treated with radiation therapy [25,26].

●Obesity – While patients with an elevated body mass index (BMI) are more likely to have incontinence in the short term, BMI does not predict incontinence at 12 months postoperatively [27,28].

PATHOPHYSIOLOGY — Incontinence after prostate treatment (IPT) can result from either bladder or sphincter dysfunction or a combination of the two.

Types of incontinence — After prostate surgery, men can develop:

●Stress urinary incontinence (SUI) – Usually due to inadequate urethral sphincter function (see "Urinary incontinence in men", section on 'Stress urinary incontinence')

●Urge urinary incontinence (UUI) – Typically associated with either bladder outlet obstruction (BOO) or overactive bladder (OAB) syndrome (see "Urinary incontinence in men", section on 'Urge urinary incontinence')

●Overflow urinary incontinence – Can be due to BOO or detrusor underactivity (see "Urinary incontinence in men", section on 'Overflow incontinence')

●Mixed urinary incontinence – A combination of SUI and UUI (see "Urinary incontinence in men", section on 'Mixed incontinence')

Bladder dysfunction

Overactive — The development of de novo irritative symptoms after prostate treatment is common, with approximately one-third of incontinent patients [29-31] having at least some component of overactive bladder symptoms. However, the majority of men with UUI following prostate cancer surgery have concomitant SUI, with only 6 to 7 percent manifesting pure UUI [29,31].

Underactive — One study found a 33 percent rate of detrusor underactivity in patients who had undergone radical prostatectomy (RP), typically presenting as the complaint of requiring abdominal straining to urinate after the procedure, possibly due to denervation of the trigone [32]. Another study found detrusor underactivity affected 40 percent of men with IPT [33].

Outlet dysfunction

Obstruction — A bladder neck contracture (BNC; or vesicourethral anastomotic stricture) is a condition unique to men who have had prostate surgery or radiation that can lead to UUI or to overflow incontinence. The mean time to development of a postoperative stricture is four months, with most men presenting by one year [34]. Contemporary rates of BNC for open RP range from 2.6 to 9 percent, while rates following robotic surgery are lower (0 to 2.1 percent) [35-37]. Rates of BNC after endoscopic procedures for BPH vary but have been reported in as many as 12.3 percent of patients [38,39].

In addition to potentially causing overflow incontinence, BNCs are also relevant to the treatment of IPT, especially in the presence of intrinsic sphincter deficiency (ISD), in that the scar from the anastomosis itself may be partly responsible for a poorly coapting intrinsic sphincter. Consequently, BNCs are often seen in conjunction with SUI as well [29].

Intrinsic sphincter deficiency — ISD is the most common cause of IPT. Following RP, as an example, the vast majority of incontinent men (88 to 100 percent) have ISD as the main cause of their incontinence [29,32,40]. ISD is likely a direct result of the surgery, with injury to the external striated sphincter during ligation of the dorsal venous complex, damage to the smooth muscle of the urethra caused by the anastomotic sutures, and/or denervation due to dissection of the urethra and prostate [41].

PELVIC FLOOR MUSCLE TRAINING — Pelvic floor muscle training (PFMT; practitioner-guided training program) or exercise (PFME; self-guided home exercise program) are recommended prior to and immediately after prostate surgery to enhance continence recovery and may be reinstituted anytime postoperatively when incontinence after prostate treatment (IPT) is established.

Before prostate surgery — PFMT or PFME is recommended prior to prostate surgery. Exercises are more easily learned before surgery, as postoperative pain, sensory changes, and muscle inhibition can interfere with compliance [42]. Tactile [43-45], verbal [43,44,46], and visual cues [44] as well as pressure [47], surface electromyography biofeedback [45,46,48], and sonographic imaging [43] are efficacious in teaching men how to isolate and contract their pelvic floor muscles and should start at least three to four weeks preoperatively to allow for neuromuscular adaptation [43-46]. Preoperative PMFT hastens continence recovery after surgery [43,44,47,49].

Immediately following prostate surgery — PFME is hypothesized to support muscle strength and enhance blood flow to the sphincter to promote continence [50]. Following surgery, PFME should be recommended to all patients upon removal of the urethral catheter, as it has been demonstrated to speed continence recovery compared with control groups [51]. For those patients unable to properly perform pelvic contractions, practitioner-guided PFMT is indicated [52]. Patients can see significant improvements in continence recovery (and improvements in quality of life) in as few as three [48,49,53-55] to six months [50]. While time to continence is shortened, continence rates at one year remain similar between those who did and did not undertake a program of PFME/PFMT [56].

Beyond the perioperative period — PFME can be efficacious for the patient with established IPT at any point postoperatively. Numerous randomized controlled trials demonstrate the benefits of PFMT [48,49,53,57-60], and supervised PFMT is superior to PFME [61]. It is recommended that all patients with IPT should be encouraged to consider PFMT. Pelvic floor therapy provides patients with an opportunity to participate in and have some control over their health outcomes without risk [57,62].

EVALUATION OF INCONTINENCE

History and physical examination — Patient history is critical to identifying the types of incontinence, severity of incontinence, progression or improvement of leakage, and degree of bother, as all of these factors help determine what type of treatment is warranted.

Specifically, leakage occurring with cough, laugh, sneeze, walking, or other strenuous activity is suggestive of stress urinary incontinence (SUI). While a history of SUI has a 95 percent positive predictive value and 100 percent negative predictive value for the presence of SUI on urodynamic studies [63], the American Urological Association (AUA) guidelines recommend that "clinicians should take all reasonable measures to demonstrate SUI on physical exam [64]." This can be done by observation of leakage with coughing, straining, or positional changes (eg, bending or standing from sitting). (See 'Evaluation of sphincter function' below.)

Leakage associated with sudden desire to void suggests urge urinary incontinence (UUI) [65]. Frequent nocturnal voids and enuresis are more often associated with overactive bladder than with intrinsic sphincter deficiency (ISD). A voiding diary documenting episodes of leakage, fluid intake, and associated urgency can be a useful adjunct to the history [66].

Assessment of the severity of leakage and degree of bother from incontinence may guide the shared decision-making process when discussing treatment options. The number of pads per day, size of pads, and wetness of pads have been shown to correlate well with 24 hour pad tests [67]. However, if there is any ambiguity about the severity of leakage, then a formal pad test (one-hour or 24 hour test) can be useful [68]. (See 'Pad test' below.)

Additionally, it is necessary to ascertain if further radiation therapy is likely as this, too, may affect surgical planning and decision making. (See 'Risk factors for incontinence' above.)

Urodynamics — Urodynamics permits better evaluation of sphincter and bladder function. These studies are not routinely recommended for the assessment of SUI, but they may be performed when there is an unclear history of the etiology of incontinence or if there is a discrepancy based on physical examination [64]. (See "Lower urinary tract symptoms in males", section on 'Diagnostic testing for persistent or complicated symptoms'.)

Evaluation of sphincter function — ISD contributes to incontinence after prostate treatment (IPT) in 88 to 100 percent of cases [5,29,40,63,69,70]. Leakage of urine during straining defines the finding of SUI. If the patient does not demonstrate SUI with the urethral catheter in place, the catheter should be removed and the provocative maneuver should be repeated as up to 35 percent of men may not demonstrate SUI while the catheter is in place [71].

Bladder storage and emptying — Detrusor overactivity is common in the general adult patient population, and testing in patients prior to prostate surgery has shown preoperative rates of detrusor overactivity between 32 and 55 percent [72,73]. Postoperatively, there is likely a strong association between ISD and detrusor overactivity as detrusor overactivity rarely is an isolated finding [32,73]. Additionally, there is an increase in detrusor underactivity (up to 40 percent) postoperatively [33].

Poor bladder compliance is rare in patients after prostate surgery but is a concerning finding given the potential for kidney damage in the setting of high bladder storage pressures. This is most common in patients with neurogenic bladders or severe radiation cystitis [64,74]. Bladder storage pressures should be addressed prior to treatment for the outlet, or patients can undergo periodic surveillance of their upper tracts [75].

Assess for obstruction — Bladder outlet obstruction after prostate surgery is most commonly due to a bladder neck contracture (BNC) in patients who have had a radical prostatectomy (RP), though it may also be due to urethral stricture disease due to prior instrumentation from any prostate surgery or catheterization (see 'Obstruction' above). If bladder outlet obstruction is documented on urodynamic study (with high detrusor pressure and low flow on voiding cystometrogram), the next step is a cystoscopy to determine the etiology of the obstruction.

Pad test — Pad testing is the gold standard for the quantification of degree of incontinence. The one-hour pad test has been described as a screening tool to determine the presence of incontinence, while the 24 hour pad test is more useful in quantifying the volume of leakage [76-78]. During the one-hour pad test, a patient drinks 500 cc of liquid and then completes various straining maneuvers (walking, standing from sitting, running in place, bending). A pad that weighs over 50 g is considered indicative of severe incontinence [68]. The 24 hour pad test more precisely quantifies the degree of incontinence and can affect surgical decision making, as the upper limit for a recommended sling placement is <200 g per day [79,80]. (See 'Volume of leakage determined by pad test' below.)

Cystoscopy with repositioning test — Preoperative cystoscopy is necessary to assess the condition of the urethra and the sphincter and to rule out any adverse pathology that may impact the procedure [64].

Two specific findings are useful to assess for sufficient residual sphincter function that would suggest the patient is a good candidate for the male sling. First, voluntary contraction of the sphincter can be visualized, and second, a "repositioning test" can be done by compressing and elevating the perineum posterior to the bulbar urethra, which should result in visual coaptation of the membranous urethra [81]. When the clinician gently elevates the perianal perineum, avoiding direct urethral compression [82], sphincteric closure is visible (radiographically or cystoscopically) only in those men with "sufficient residual sphincter function" [83].

In addition to the assessment of sphincter function, evaluation of the urethra and bladder neck is important, as stricture disease may complicate artificial urinary sphincter (AUS) placement. (See 'Anastomotic stricture/bladder neck contracture' below.)

Cognitive ability and manual dexterity — Prior to consideration of AUS implantation, it is necessary to assess if the patient has adequate cognitive and physical ability to operate the device. The patient must be able to cycle the scrotal pump by squeezing it between the index finger and thumb [64].

MANAGEMENT OF INCONTINENCE — For patients undergoing incontinence after prostate treatment (IPT) treatment, a shared decision-making process is recommended, whereby the urologist and the patient work together to decide the appropriateness of tests and interventions [84]. Decisions should be based on clinical evidence combined with patient preferences. Such a process yields better health outcomes by reducing anxiety and improving compliance [85-88].

Urge urinary incontinence — Management of urge urinary incontinence (UUI) after prostate treatment follows the same algorithm as in patients who have not had surgery or radiation. This is outlined in the American Urological Association and Society of Female Urology and Female Pelvic Medicine and Urogenital Reconstruction guidelines on the diagnosis and treatment of non-neurogenic overactive bladder in adults [89]. (See "Urinary incontinence in men".)

●The first-line therapy is behavioral. (See "Urinary incontinence in men", section on 'Nonpharmacologic therapy'.)

●The second-line treatment includes pharmacotherapy. (See "Lower urinary tract symptoms in males".)

●Third-line treatments include sacral neuromodulation, posterior tibial nerve stimulation, and botulinum toxin. (See "Lower urinary tract symptoms in males".)

Overflow incontinence — In the post-radical prostatectomy (RP) population, overflow incontinence is generally secondary to bladder neck contracture (BNC). BNCs can be managed with dilation, urethrotomy, and, rarely, open revision [90]. The relative timing of BNC and incontinence treatments is discussed below. (See 'Anastomotic stricture/bladder neck contracture' below.)

Mixed urinary incontinence — As noted above, detrusor overactivity postoperatively is usually found in association with intrinsic sphincter deficiency (ISD) and is rarely an isolated diagnosis [32,73] (see 'Bladder storage and emptying' above). Following artificial urinary sphincter (AUS) placement, up to 50 percent of patients with concomitant detrusor overactivity will experience improvement in their overactive bladder symptoms [91]. The presence of concomitant UUI should not prevent surgical treatment of bothersome stress urinary incontinence (SUI). Detrusor overactivity has not been shown to adversely affect outcomes of AUS or sling procedures [92-96].

Stress urinary incontinence — ISD is the most common cause of IPT, usually manifesting as stress incontinence. Treatment of SUI should begin with conservative measures and progress to surgery as needed.

Conservative treatments — In the first 6 to 12 months following prostate surgery, conservative treatments are recommended, including:

●Behavioral modification – Including fluid management, bladder retraining, and pelvic floor physiotherapy [60]. (See 'Pelvic floor muscle training' above.)

●Use of pads/incontinence briefs.

●Penile compressive devices – For patients who prefer to use penile compressive devices, the clamp should be released every two hours, the location on the shaft should be varied, and the clamp should not be worn while asleep (figure 2).

●Condom catheters – Condom catheters have a lower risk of urinary tract infection than urethral catheters [97] but must be fitted correctly and may not be able to accommodate all men [98]. (See "Placement and management of urinary bladder catheters in adults", section on 'External'.)

A randomized trial from the United Kingdom compared devices for male continence (pads, condom catheters, penile clamps, and body-worn urinals). While penile clamps were found to be the most secure and least likely to leak, they were also the most uncomfortable. The condom catheter was preferred for extended time periods and its convenience. Pads were preferred for overnight but noted to be uncomfortable when wet. Many patients opted for a combination of options depending on time of day and activity [99].

Unfortunately, there is no Food and Drug Administration (FDA)-approved pharmacotherapy for SUI. Alpha-adrenoceptor agonists, beta-2 adrenoceptor agonists, and serotonin-noradrenaline reuptake inhibitors (notably duloxetine) have been examined in small nonrandomized studies, but none of these medications are recommended [100].

Surgical options — Approximately 5 percent of patients will choose surgery for IPT, typically presenting at a median of 2.9 years after prostate therapy. Surgical options for IPT include AUS, male slings, and periurethral balloons. In a population-based study of RP patients, 2.8 percent of men underwent AUS placement and 1.1 percent underwent male sling placement [2].

Artificial urinary sphincter — The AUS is the most predictably reliable treatment for SUI for men with all degrees of incontinence [101-112].

The AUS is composed of a circumferential urethral cuff, a pressure-regulating balloon reservoir, and a scrotal pump (figure 3). It should be placed via a two-incision technique, using a perineal incision for cuff placement and an inguinal incision for balloon reservoir and scrotal pump placement [113,114]. The cuff opens after manual compression of the scrotal pump and automatically closes after a period of two to three minutes.

The literature is replete with studies demonstrating the efficacy of the AUS in both the short and long term [101-111]. In one large cohort, satisfaction at two years exceeded 90 percent [105]. Specifically, 20 percent of patients never leaked, 55 percent reported leakage of a few drops daily, and 22 percent had leaked less than a teaspoon daily [105]. In another large cohort with up to 11 year follow-up, mean pad use declined 85 percent (4.0 to 0.6 pads per day) following surgery [106].

Prior to AUS placement, patients must be informed of the risks of mechanical failure, erosion, infection, and persistent incontinence [105,106,109]:

●Infection and erosion – Infection and erosion are the most common indications for early device explantation. Infection rates are generally less than 5 percent, and urethral cuff erosion occurs at rates between 1 and 10 percent [111,115]. While early erosions are likely related to unrecognized urethral injury during surgery, late erosions are most often related to subsequent urethral instrumentation or catheterization. The presentation of cuff erosion is variable but often includes dysuria and hematuria. The diagnosis is made cystoscopically [116,117]. While the urethral defect typically heals with urethral catheterization, repair of the eroded urethra diminishes subsequent urethral stricture rates [118]. Following AUS erosion/infection, the entire device should be removed, followed by a waiting period of three to six months prior to reimplantation, as washout combined with immediate device replacement has not been proven to be reliably effective [119].

●Device failure/persistent incontinence – In the setting of device failure in the absence of infection or erosion, the AUS can be explanted and a new one replaced immediately. The durability and efficacy of a reimplanted device in this setting is the same as that of a primary AUS [115,120,121].

With urethral atrophy, proximal relocation or downsizing of the cuff are both reasonable options that can restore continence. Tandem cuff placement is the addition of a cuff to the original cuff, which is also an effective salvage procedure for patients with persistent incontinence. However, initial tandem cuff placement is not recommended, as a review showed equivalent continence outcomes but a complication rate four times higher in the tandem cuff group [122,123]. Other options include replacing the pressure-regulating balloon with a higher-pressure system and using a transcorporal cuff placement to improve urethral coaptation, especially in the setting of prior radiation and/or erosion. With this technique, the urethral cuff is tunneled through the erectile bodies, whereby the tunica albuginea protects the dorsal aspect of the urethra.

In general, the efficacy and durability after secondary AUS placement for device failure appear to be similar to that after primary AUS placement, despite a slightly higher rate of cuff erosion [115,120,121]. Patient satisfaction relates more to continence status after AUS than to the number of reoperations [109,124].

Male sling — Male slings are recommended for nonradiated patients who have mild-to-moderate SUI after prostate surgery [64], and success rates are highest in men with pad weights <200 g per day [125,126]. (See 'Pad test' above and 'Volume of leakage determined by pad test' below.)

A male sling is a procedure where mesh is placed under the urethra to relocate the proximal urethra and/or compress the bulbous urethra [127]. This procedure is minimally invasive and can be an attractive option for men who would like to avoid a mechanical device (figure 4).

There are three type of male slings:

●Transobturator – The transobturator sling is a noncompressive sling that functions to relocate the proximal urethra closer to the sphincter complex and lengthen the membranous urethra [82]. The sling is placed perineally, via an outside-in transobturator approach. The sling is attached to the urethra, and, with proper tensioning, the bulbous urethra is repositioned approximately 2 to 2.5 cm proximally. Cystourethroscopy confirms coaptation of the membranous urethra [128].

Patients who undergo transobturator male sling placement have a 62 percent cure rate (range 34 to 91 percent) when defined as a negative one-hour pad test or 0 to 1 pads per day, and an additional 34 percent are improved [64]. In general, these patients had no prior radiation and <500 g (or < 5 pads) of daily leakage.

●Quadratic – The quadratic sling acts to both relocate the proximal urethra and compress the ventral urethra [129]. The sling is placed perineally via an inside-out transobturator approach, combined with a prepubic component that allows for compression of the distal bulbous urethra in addition to proximal relocation of the sphincter complex. The prepubic arms are then secured to the periosteum of the inferior pubic rami, and the transobturator arms are tunneled subcutaneously back to the perineal incision to facilitate adequate sling tensioning [130].

The quadratic sling with fixation is associated with similar success rates compared with transobturator slings, with a cure rate of 46 percent and cure/improvement rate of 79.2 percent at 12 months [131].

●Adjustable – Adjustable male slings are not currently approved for use in the United States (US). Adjustable slings have the ability to be altered to optimize continence or to prevent retention of urine at the expense of a higher explantation rate in some systems [132,133]. Risk factors associated with failure for the adjustable slings are similar to those for the fixed resistance slings [134], and overall success rates are also similar between fixed and adjustable devices [127,135].

Complication rates after male sling are low. Complications include urethral injury during trocar passage, transient urinary retention (0 to 30 percent) [80,136,137], and transient pelvic, perineal, or scrotal pain (0 to 20 percent) [79,137,138]. Pain and retention nearly always resolve (>98 percent resolution) with conservative management for both fixed and adjustable slings [133].

Periurethral balloons — While periurethral balloons are most appropriate in patients with mild SUI [64], there are two reports demonstrating efficacy of the ProACT device in patients with moderate-to-severe SUI [139,140]. Radiation is a contraindication to placement due to an increased risk of balloon migration and fibrosis [141].

Periurethral adjustable balloon placement is a minimally invasive placement of two silicone balloons near the bladder neck for external compression of the prostate. The bladder is filled with contrast to opacify the bladder and bladder neck. The balloons are placed just distal to the bladder neck and passed percutaneously via the perineum under fluoroscopic guidance [142] or under transrectal ultrasound guidance [121]. Ports connected to the balloons are buried superficially to allow for adjustment in balloon volume as needed percutaneously.

A systematic review and meta-analysis of the ProACT device reported a dry rate of 60.2 percent and a dry or improvement rate of 81.2 percent. Patients required on average 3.2 adjustments [143]. In a comparative trial, the adjustable sling had higher cure rates (68 versus 55 percent, p = 0.01) and lower explantation rates than the ProACT device (5 versus 24 percent, p <0.001) [144].

Complication and revision rates for the ProACT device are higher than those for slings. Immediate complications include bladder and urethral perforation (5.3 percent), infection (2.2 percent), and urinary retention (1.5 percent). The overall revision rate was 22.2 percent over a mean of 3.6 years of follow-up for erosions, device leakage, and device migration in the meta-analysis [143].

Initial surgical treatment — The decision to have surgery for IPT, and which procedure to choose, is based on a shared decision-making model, whereby the clinician informs the patient of the risks, benefits, expectations, and alternatives for the recommended surgical choices, taking into considerations the patient's understanding, beliefs, and preferences. The initial surgical treatment is selected based on the following considerations:

Sling versus AUS — The transobturator male sling and the AUS were compared in a prospective randomized trial (MASTER) of 380 men with urodynamically demonstrated stress incontinence after prostate surgery [145]. Using a strict definition of success as lack of "any leakage of urine," male sling had a 13 percent dry rate versus 16 percent for the AUS. Using a slightly less strict definition, "leakage less than once per week," 34 percent of male sling versus 35 percent of AUS recipients achieved continence at 12 months after surgery. Nevertheless, the subjective degree of urinary incontinence was greatly reduced after both procedures. Preoperative pad weight was measured in all patients but was not evaluated in most patients postoperatively, which limited objective outcome assessment. While subgroup analyses of greater urinary incontinence at baseline (>250 g pad weight) favored AUS, the study was insufficiently powered to show a difference in outcomes based on preoperative pad weight. Patient satisfaction was greater in the AUS group compared with the sling group (90.6 versus 72.2 percent, p <0.001). Based on a multitude of nonrandomized studies demonstrating a higher likelihood of objective sling success in men with <200 g on 24 hour pad weight, we still favor AUS for men with baseline incontinence >200 g on 24 hour pad weight but agree with the authors of the MASTER trial that surgical selection should be based on a discussion regarding the risks and benefits of the AUS and various sling options.

Tissue compliance determined by the repositioning test — When deciding if a male sling is likely to succeed, it is important to understand that adequate tissue compliance is necessary for successful urethral compression and/or proximal repositioning with a sling. (See 'Cystoscopy with repositioning test' above.)

By reflecting the degree of residual sphincter function, a positive repositioning test is associated with a surgical success rate >80 percent, while only 25 percent of patients with a negative test were cured [146-148]. Following a negative repositioning test, the patient should be offered AUS implantation.

Volume of leakage determined by pad test — Another risk factor for sling failure is high-volume leakage. One study showed for each 1 g increase in preoperative 24 hour pad weight, cure rate decreased by 0.4 percent [149].

Two large cohort studies demonstrated that the transobturator sling performs best in patients with a leaked volume of <200 g/day [125,126]. The multinational trial of the quadratic sling with fixation did not show a difference in success rates based on pad weight, likely due to the additive efficacy provided by the prepubic component in addition to the transobturator repositioning. In that study, objective success (79 percent) and subjective success (71 percent) were achieved even in men with >400 g/day of leakage [131]. Another study corroborated the efficacy of the quadratic sling up to three years out, with 25/29 patients rating their outcome as "very much improved" by Patient Global Impression of Improvement (PGI-I) questionnaire [150]. However, that study excluded patients with severe incontinence. (See 'Male sling' above.)

Based on the preponderance of evidence, it is generally recommended that the male sling be reserved for patients with mild-to-moderate SUI, with pad use <3 pads per day or <200 g per day, while those with more significant leakage are more appropriately treated by implantation of a circumferential AUS.

Prior radiation therapy or explanted AUS — Not surprisingly, prior AUS explantation and external beam or interstitial radiation [127,132,134] are predictive of diminished efficacy for most male slings, as radiation and fibrosis create a poorly compliant and relatively noncompressible urethra. Specifically, the success rate in men with radiation has been reported to be as low as 0 to 25 percent cure, with 29 to 50 percent improvement versus >80 percent cure in a nonradiated comparable cohort [126,151]. Therefore, AUS is the treatment of choice in this population with IPT.  

Comorbidities — Two cohort studies found that a poor Charleston Comorbidity Index [152] and higher American Society of Anesthesiologists (ASA) class [153] predicted adverse outcomes for the male sling and AUS, respectively. There is not sufficient information regarding the effect of comorbidities on the outcome of periurethral balloon surgery.

SUI following BPH surgery — The rate of bothersome SUI following surgical management for benign prostatic hyperplasia (BPH) typically ranges from 0 to 8.4 percent [10,154]. Transurethral resection of the prostate (TURP) following external beam or interstitial radiation has a substantially higher risk of SUI compared with TURP in the nonradiated patient, with incontinence rates up to 70 percent [22,24], and the risk increases with the number of surgeries [155].

The evaluation of such patients should be similar to that for post-RP SUI, including consideration of bladder dysfunction as a contributing factor. If conservative management is unsuccessful, then surgery is indicated. Male sling and AUS surgery are safe and efficacious in men with SUI after BPH treatment, with results similar to those published for post-RP SUI surgery [10,156,157]. For those men with post-TURP SUI who have a history of radiation therapy, AUS is the treatment of choice.

Sexual arousal incontinence and climacturia — Leakage during sexual activity affects an average of 30 percent of patients following prostate cancer surgery, with reported ranges of 20 to 93 percent [158]. One-third of men with this disorder report avoiding sexual situations secondary to fear of leakage [159]. Leakage during sexual arousal relates to ISD, while incontinence during orgasms likely involves an uninhibited bladder contraction at the time of orgasm in conjunction with external sphincter weakness [160].

Conservative treatment is recommended initially, with behavioral management (voiding prior to sex, condom use). Pelvic floor muscle exercises have also shown efficacy [45]. A variable-tension soft silicone loop placed around the penis during sex has demonstrated efficacy, decreasing the reported bother in patients and partners, from 14 and 61 percent to 2 and 11 percent, respectively [161]. Surgical success with male sling or AUS mirrors that for SUI surgery in general [162,163].

Concomitant refractory erectile dysfunction — For men who have SUI and erectile dysfunction (ED) refractory to medical management, concomitant penile prosthesis and AUS can be offered. There are conflicting data on the infection risk and complication rate of staged versus combined procedures. In a Surveillance, Epidemiology, and End Results Medicare database study, there was no difference between the 90 day complication rate of a combined AUS/penile prosthesis implant and that of an AUS or a penile prosthesis alone [164]. Similarly, in another study, a combined implantation was not associated with an increased rate of device infection, erosion, or malfunction with over 1.5 years of follow-up [165].

Anastomotic stricture/bladder neck contracture — The relative timing of BNC and incontinence treatments can be challenging, but a staged approach is generally recommended, with initial treatment of the symptomatic BNC and delay of incontinence treatment surgery for four to six weeks after assuring that the BNC has not recurred [166,167]. However, in a study of a heterogeneous population of patients with incontinence and BNC after RP, for the patients with an asymptomatic BNC diagnosed on preoperative cystoscopy, a simultaneous incision of the BNC and AUS placement was performed. None of these patients required a re-incision of the BNC with an average follow-up of 26.6 months [168].

Salvage surgical treatment — When a patient develops recurrent SUI after previously having a good result of an AUS or sling, reevaluation with history, physical examination, and urodynamics is indicated to determine the specific pathophysiology surrounding the incontinence (eg, detrusor overactivity, persistent ISD, decreased bladder compliance). Additionally, strong consideration should be made to perform a cystoscopy to evaluate for device erosion. (See 'Evaluation of incontinence' above.)

Following AUS — With recurrent incontinence after AUS, the device should be cycled by the urologist to assess functionality. An imaging study can be used to verify the presence of fluid in the reservoir to rule out a leak. During exploration, if a leak is confined to one part of the device, the remaining components may be left in situ if they were placed within the prior two years [111,115,169,170]. In the case of urethral atrophy causing recurrent SUI, a tandem cuff can be placed, the cuff can be downsized or repositioned proximally, or, alternatively, a higher-pressure balloon reservoir can be inserted [171]. Efficacy after secondary AUS placement is similar to that for primary AUS [115,120,121]. (See 'Artificial urinary sphincter' above.)

Following sling — With persistent or recurrent incontinence following male sling surgery, the surgical choices are repeat sling versus AUS implantation.

Repeat sling — Only in carefully selected patients should a repeat sling be offered. In a report of 33 patients who received repeat transobturator sling following failed prior sling, the cure/1 pad per day rate was 79 percent at 6 months and 72 percent at 17 months, but it must be noted that these patients were carefully selected and only offered repeat sling if they demonstrated a positive repositioning test, while those with fixed or scarred external urethral sphincter were excluded [172]. Another study demonstrated a 72 percent success rate at 6 months versus 56 percent success rate at 17 months with repeat sling and noted that patients with early sling failure (<6 months) were less likely to achieve continence upon repeat surgery [173].

In a cohort of 30 patients who failed prior incontinence surgery, implantation of an adjustable male sling was associated with a satisfaction rate of 83 percent at 24 months [174].

Implanting AUS in patient with in situ sling — While a secondary sling can be performed with success in highly selected patients at experienced centers [147,172], it is generally agreed that the most efficacious treatment option is AUS implantation. In a cohort of 61 men who failed transobturator sling, 29 underwent repeat sling and 32 underwent AUS implantation. In the group that had AUS placed, only 6 percent failed, compared with 55 percent who failed repeat sling [175].

AUS after sling has a similarly excellent success rate compared with primary AUS [176,177]. In men treated with a male sling, 13 percent will ultimately undergo secondary AUS implantation [178]. With prior transobturator sling, the AUS cuff can be placed distal to the previous sling, which neither renders the operation more difficult nor decreases AUS efficacy [127,179]. With prior quadratic sling, the polypropylene sling is readily identified and dissected off the underlying muscle or urethra, and the AUS may be placed in routine fashion [180].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Urinary incontinence in adults" and "Society guideline links: Diagnosis and management of prostate cancer" and "Society guideline links: Benign prostatic hyperplasia".)

SUMMARY AND RECOMMENDATIONS

●Incidence – Incontinence after prostate treatment (IPT) has an incidence of <2 percent after endoscopic management of benign prostatic hyperplasia (BPH) and 9 to 16 percent at one year after radical prostatectomy (RP). The rates of incontinence generally decrease over the first year. (See 'Introduction' above and 'Rates of incontinence' above.)

●Pathophysiology and risk factors – Men can develop both stress urinary incontinence and urge urinary incontinence after RP. Risk factors for IPT include preoperative incontinence, older age, non-nerve-sparing surgery, radiation, and shorter urethral length. (See 'Pathophysiology' above and 'Risk factors for incontinence' above.)

●Pelvic floor muscle training – For patients undergoing prostate treatment, we suggest pelvic floor muscle training/exercise rather than observation (Grade 2C). It should be started at least three to four weeks prior to prostate surgery and can be continued immediately after surgery or whenever IPT is diagnosed. (See 'Pelvic floor muscle training' above.)

●Evaluation of incontinence – History with an emphasis on the type of leakage and activity associated with leakage and a physical examination demonstrating stress urinary incontinence are key to the preoperative workup. A cystoscopy is also recommended to rule out bladder/urethral pathology and facilitate the repositioning test. A pad test can quantify the degree of incontinence. Urodynamic studies are only needed when there is an unclear history, when the physical examination is not consistent with the given history, or when obstruction is suspected. (See 'Evaluation of incontinence' above.)

●Management of incontinence – (See 'Management of incontinence' above.)

•Urge incontinence – Urge urinary incontinence should be treated with behavioral modification, pelvic floor muscle exercises, and anticholinergics/beta-3 agonists, followed by chemodenervation or neuromodulation as necessary. This treatment regimen is the same for IPT as for urinary incontinence due to other etiologies. (See "Urinary incontinence in men", section on 'Urge urinary incontinence'.)

•Stress incontinence – Stress urinary incontinence in IPT patients should be initially managed with behavioral modification, pelvic floor muscle training/exercises, and pads/incontinence briefs/penile clamps/condom catheters until 6 to 12 months postoperatively. (See 'Conservative treatments' above.)

Surgical options for stress urinary incontinence in IPT patients include the following (see 'Surgical options' above):

-The artificial urinary sphincter is the most predictably reliable surgery for all types of incontinence. (See 'Artificial urinary sphincter' above.)

-Male slings are more effective with mild-to-moderate stress urinary incontinence (with pad use <3 pads per day or <200 g per day) and no history of radiation. (See 'Male sling' above.)

-Periurethral balloons are an effective minimally invasive option for men with mild-to-moderate stress urinary incontinence but who have a high revision and complication rate. (See 'Periurethral balloons' above.)

There are a number of special considerations for patients when deciding to use a sling versus an artificial urinary sphincter device, including history of radiation, severity of leakage, detrusor contractility, prior treatment, and the presence of a vesicourethral anastomotic stricture. (See 'Initial surgical treatment' above and 'Salvage surgical treatment' above.)