Male SUI

Male Stress Urinary Incontinence

Predicting continence recovery after prostatectomy, from Matsushita 2015

Prevalence: ~30% (range 20-93%), 50% report as bothersome, 33% avoid sexual situations
SUI: 70% SUI also report climacturia...and 70% climacturia report SUI
Robotic surgery decreases time to no climacturia
Risk factors: prior TURP, shorter urethral length
Management: pre-sex urination, condoms, PFPT

Symptoms: duration, frequency, severity (PPD, pad type), precipitating factors
Self-reported hx SUI: 95% PPV, 100% NPV
Prior prostatectomy: 5% will have persistent SUI 2yrs after surgery
Prior TURP: SUI 0-8%, up to 70% have reported some urge incontinence
Medications: a-blockers, diuretics, anticholinergics
Associated symptoms: assess sexual, erectile, and bowel function
UUI: 29-48% with SUI also report OAB symptoms

Exam: assess cognitive function and manual dexterity, inguinal hernias, prior surgical scars, neuro exam
DRE: check prostate (if present), rectal tone, and pelvic floor dysfunction
Post-void residual: check to ensure patient does not have overflow incontinence
Bladder diary: 3-days is adequate, can use for UUI or unclear symptoms
Pad weight: assess severity, < 200g mild, 200-400g moderate, > 400g severe
UA/UCx: treat UTI prior to surgery
Cystoscopy: required preop or intraop, assess for stricture, bladder neck contracture
Urodynamics: use only if it would affect treatment options, 35% patients will not demonstrate SUI while UDS catheter is in place (bladder neck contracture may be present)

Consider anti-incontinence surgery at 12mo, but can offer as early as 6mo
Assess: BMI, prior surgery/XRT, SUI severity
poor manual dexterity or cognitive function, high surgical risk, bladder neck contracture, poor compliance, VUR at low pressures, bladder cancer (relative)
Bladder neck contracture: repair prior to any incontinence treatment, and confirm success with cystoscopy

PPD: median 4 PPD preop, down to median 0.6 PPD postop
Success: full continence (20%), few drops of leakage (55%), less than a teaspoon leakage (22%)
Satisfaction: 92% would undergo again, 96% would recommend to a friend
Prior XRT: AUS has better results than sling (continence 56% vs 89%) but increased revision rate overall (HR=1.56)

Device failure: normal life expectancy 7-10yrs, 24% at 5yrs, 50% at 10yrs
Retention: rare, often due to stricture or bladder neck contracture
Infection: 1-5%, explant immediately, can perform immediate or delayed (3-6mo) reimplant
Erosion: 1-10%, risks include prior XRT (use lower pressure reservoir), DM, CAD, and prior revisions, presents with hematuria, dysuria, or retention, explant and place catheter with possible intraop urethral repair, delay reimplant by 3-6mo
Urethral atrophy: slowly worsening incontinence, manage with downsizing, repositioning, transcorporal placement or tandem placement, do not increase reservoir pressure
Persistence incontinence: accidental deactivation, fluid loss, or improper cuff sizing
Recurrent incontinence: fluid loss, urethral atrophy, or cuff erosion
Fluid loss: assess for balloon leak with CT or US imaging
Cystoscopy: consider to assess erosion or atrophy, cycle cuff
Revision: 25%, consider cuff resizing, adjusting position, tandem cuff, or transcorporal approach
Urinary diversion: multiple AUS failures, intractable BNC, detrusor instability

Kegels: can start before prostatectomy, decrease time to regaining continence but do not improve overall chances of regaining continence
Pelvic Floor PT: consider as adjunct if mild SUI
Catheters: useful for high volume leakage and skin breakdown but should be last resort, SPT will not work if patient has sphincteric incompetence
Condom catheter: may provide improved quality of life but require proper sizing
Clamps: release every 2 hours to prevent erosion and do not wear overnight (urethral erosion), do not use if patient has memory deficits, poor manual dexterity, impaired sensation, or OAB symptoms
Pads: variety of options for patient preferences, but even 1 PPD may be bothersome

Indications: mild/moderate incontinence (24hr pad weight < 150-400g), not recommended for prior XRT or urethral erosion
Patient preference: all else being equal, most men (2%) prefer sling placement due to AUS complication risk
Success: 50-60% dry, 25% improved but not dry, lower rates if prior XRT or severe SUI
Failure: if sling fails, AUS has lower failure rate than repeat sling (6% vs 55%)
Complications: urinary retention (0-44%, resolves within 1 week), pelvic/perineal pain (12-17%, most resolve within 12 weeks), erosion/infection (1-2%)

Agents: bovine collagen, macroplastique
May require repeat injections
Efficacy: full continence (17%), improvement (50%), increased leakage (1.5%)
Complications: retention, frequency, dysuria, UTI

AUA Core Curriculum
Al-Mousa, R. and H. Hashim. "Evaluation and Management of Men with Urinary Incontinence." Campbell-Walsh Urology 12 (2020).
Boone, T., J. Stewart, and L. Martinez. "Additional Therapies for Storage and Emptying Failure." Campbell-Walsh Urology 12 (2020).
Cameron, A. "Complications Related to the Use of Mesh and Their Repair." Campbell-Walsh Urology 12 (2020).
Matsushita, Kazuhito, et al. "Preoperative predictive model of recovery of urinary continence after radical prostatectomy." BJU international 116.4 (2015): 577-583.
Sandhu, Jaspreet S., et al. "Incontinence after prostate treatment: AUA/SUFU Guideline." The Journal of urology 202.2 (2019): 369-378.
Wessells, H. and A. Vanni. "Surgical Procedures for Sphincteric Incontinence in the Male." Campbell-Walsh Urology 12 (2020).
Wieder JA: Pocket Guide to Urology. Sixth Edition. J.Wieder Medical: Oakland, CA, 2021.