Mechanisms contributing to male continence:
- External (voluntary) sphincter (rhabdosphincter)
Striated muscle fibres under voluntary control. Innervated by somatic nerves originating from Onuf’s nucleus in S2 – S4, travelling via pudendal nerve.
Combination of slow and fast twitch fibres – fast twitch fibres more useful for rapid increases in abdominal pressure, slow twitch more tonic contraction during normal slow filling.
In men – circular fibres between membranous urethra and prostate apex
- Internal (involuntary) sphincter (bladder neck)
Concentric circular smooth muscle – remains closed during filling, not under voluntary control.
Supplied by alpha-adrenergic nerves from T11 – L2.
Essentially removed during prostatectomy.
- Viscoelastic properties of the bladder – a compliant structure without significant increase in pressure as the bladder fills.
- Conscious control and cerebral modulation
Causes of male SUI:
- Radical prostatectomy
- TURP
- Other prostate treatments – radiation, focal therapy
- Trauma – pelvic fracture urethral injury
- Surgery on bulbomembranous strictures
- Neuropathies – myelopathy, Parkinson’s
- Congenital conditions – exstrophy, myelomeningocele
Pathophysiology
Internal sphincter contribution to male continence is lost after radical prostatectomy
Both neural and muscular injury can occur to external sphincter during procedure – traction injury and thermal injury, thought to occur during apical dissection.
Isolated stress incontinence after RP is therefore essentially intrinsic sphincter deficiency.
Many men after RP or TURP may have detrusor overactivity and concomitant urge incontinence.
Scarring and fibrosis at the level of the anastomosis or bladder neck with post operative BNC or VUAS, or radiation treatment, may also contribute to reduced sphincteric and urethral coaptation.
Risk factors for post prostatectomy incontinence
| Patient factors | Surgical factors |
| · Age (> 70 worse, < 50 best)
· Pre-operative LUTS · Obesity · Functional urethral length (MUL > 12 mm good prognosis) · Previous treatment/salvage · ?Chronic cough ? Collagen disorders · Post op radiation |
· Nerve sparing – probably ?
· Retzius sparing – early continence · Rocco stitch – early continence · VUAS post op · Surgeon volume · Bladder neck sparing · Locally advanced tumour, wide apical dissection |
Incidence post radical prostatectomy:
- Expected initially following removal of catheter
- Total incidence rates vary with definition – no pads vs safety pad
- Continence improves following surgery and the vast majority of men do not need pads after 6 – 12 months
As a general rule:
- 50 % continent at 3 months
- 75 % continent at 6 months
- 90 % continent at 12 months
Post-EBRT or brachytherapy TURP reported to have incontinence rates 18 – 50 %.
Work-up
History:
- Characterise the incontinence – stress/mixed/urge
- Quantify – number of pads
- Pre-operative symptoms and overactivity
- Time since surgery, and change over time
- Level of bother
- Nocturnal continence
- Patient expectations
- Pharmacotherapy
- UTI symptoms
- Flow / obstructive symptoms (?VUAS)
- Prostate cancer history – likelihood of needing further treatment, planned/previous radiation
- Sexual symptoms – ED, climacturia
- Medical history / medications / immunosuppression
- Surgical history (inguinal, pelvic)
Examination:
- Performance status, level of function and frailty
- Co-ordination and dexterity
- Demonstrable stress leak
- Scars – abdominal, pelvic, inguinal surgery
- Inguinal herniae
- Skin integrity
- Scrotal exam – big hydrocele, small tight scrotum
Investigations:
- Bladder diary
- Pad weights
- ICIQ
- Urine culture and microscopy
- PSA
- Flow rate/PVR or ultrasound
- Cystoscopy – exclude urethral stricture or VUAS, assess coaptation if flexi
- Urodynamics
Indications for urodynamics:
- Suspicion of urgency and detrusor overactivity contributing to incontinence
- Suspicion of detrusor underactivity
- Up to 40 % may have bladder dysfunction on UDS – but this is usually not clinically significant
- Confirm the diagnosis
- AUA guideline – “may perform … where it may facilitate diagnosis and counselling” but not required prior to surgical therapy
The goal of assessment is to assess for and exclude urgency/overactivity, obstruction/VUAS, overflow incontinence, UTI, and assess suitability for further intervention.
The goals of treatment are to optimise the continence as much as possible, within the limits of the patient accepting the interventions.
Management options
General conservative measures
- Fluid restriction, weight loss, pre-emptive voiding, manage bowels
Pelvic floor physiotherapy
- Mainstay of conservative treatments
- No strong evidence for starting exercises pre-operatively but commonly done, and easier to learn pre-operatively
- Early PFEs after catheter removal recommended – hastens returns to continence, unclear whether long term benefit
- No harm from treatment and very likely to be beneficial
- Supervision by physiotherapist and biofeedback techniques (including imaging) commonly employed but no strong evidence for their benefit
Containment
- Pads
- Condom catheters
- Catheters – IDC/SPC
- Penile clamp – uncomfortable or painful but good for short vigorous activities. Small risk of ulceration and pressure necrosis if used for too long. May be useful to unmask DO/OAB.
Minimally invasive surgery
- Bulking agents – not recommended for use / little evidence to support efficacy for post prostatectomy incontinence – if used, likely to offer short term relief only
Medications
- Duloxetine – EAU offers weak recommendation, systematic review suggested 60 % improvement in short term pad weights and pad numbers, but high (38 %) rate of discontinuation
- Standard OAB therapies for urgency
Surgical management – slings and sphincter.