Elsevier

European Urology

Volume 59, Issue 6, June 2011, Pages 985-996
European Urology

Review – Incontinence
Contemporary Management of Postprostatectomy Incontinence

https://doi.org/10.1016/j.eururo.2011.03.020Get rights and content

Abstract

Context

In recent years, despite improvement in the surgical technique, the prevalence of postprostatectomy incontinence has increased due to a rise in the number of radical prostatectomies performed annually.

Objective

The aim of this review is to evaluate contemporary noninvasive and invasive treatment options for postprostatectomy incontinence.

Evidence acquisition

In August 2010, a review of the literature was performed using the Medline database.

Evidence synthesis

All articles concerning noninvasive and invasive treatment for postprostatectomy incontinence were included.

Conclusions

No randomised controlled trials exist to compare currently used noninvasive and invasive treatments for postprostatectomy incontinence. Pelvic floor muscle training is recommended for the initial treatment of stress urinary incontinence (SUI). Additionally, antimuscarinic therapy should be applied for urgency or urge incontinence. For decades, the artificial urinary sphincter was the reference standard for persistent SUI. Nowadays, male slings are an alternative for men with mild to moderate postprostatectomy SUI.

Introduction

The reported prevalence of urinary incontinence in all men is as high as 39% and increases with age [1]. The most prevalent cause of stress urinary incontinence (SUI) in adult men is the radical prostatectomy (RP), a standard treatment for localised prostate cancer (PCa) [2]. Postoperative incontinence is one of the most feared complications of RP with a major impact on quality of life. Due to the increasing number of RPs performed for PCa, a substantial and increasing number of patients suffer from postoperative stress urinary incontinence (SUI). Despite improved surgical techniques, the reported SUI rates are between 5% and 48.0% [1]. In addition, especially during the first year after RP, overactive bladder (OAB) symptoms due to detrusor overactivity (up to 77% of patients) and de novo impaired bladder compliance (up to 50% of patients) may occur [3]. However, in most cases OAB symptoms are self-limiting after a year [3], [4], [5]. This large variation in the rates of reported incontinence after RP may be attributed, to a certain extent, on the influence of the interviewing physician as well as the lack of a standardised definition of both “postprostatectomy incontinence” and “postprostatectomy continence” [1], [6]. Postprostatectomy continence rates seem to depend on several factors including the methodology of definition (eg, definition of continence: no leakage at all, no pads but loss of a few drops of urine, one safety pad per day; use of questionnaires), patient factors (eg, age, body mass index, urethral length, possibly prostate volume, preoperative continence status, preoperative sphincter insufficiency, preoperative detrusor dysfunction), and surgical technique (eg, the experience of the surgeon, the surgical approach, and the technique of resection) [7]. In general, men <50 yr of age show a significantly better continence rate than men >70 yr after RP [8]. The treatment of postprostatectomy incontinence consists of three different approaches: conservative management, pharmacotherapy, and surgical treatment.

Overall, postprostatectomy incontinence has a major impact on quality of life affecting the patient's physical activity and social well-being and subsequently imposing a major burden for patients that needs to be addressed [9]. This paper reviews all of the currently available evidence in the field of management of postprostatectomy incontinence and makes recommendations for the evaluation, diagnosis, and treatment of this problem.

Section snippets

Evidence acquisition

In August 2010, we conducted a review of the literature using the Medline database. All articles concerning noninvasive and invasive treatment for postprostatectomy incontinence were included. Meeting reports were not included. In addition, other significant studies cited in the reference list of the selected articles and other significant studies published after the systematic review were evaluated. Multiple free-text searches were performed including the following terms: postprostatectomy

Diagnosis

Evidence for an appropriate, meaningful, and validated tool for the measurement of postprostatectomy incontinence is lacking. According to the European Association of Urology (EAU), the diagnosis of male urinary incontinence requires a two-step assessment (Fig. 1) [1]. The first step of the evaluation should include a medical history, an objective assessment of symptoms, and a physical examination including urine analysis and ultrasound for residual urine (postvoid residual). In addition, the

Conclusions

RP is the main causative factor for male SUI. However, there has been no standardised definition for postprostatectomy SUI incontinence. The evaluation and diagnosis of this problem should be performed according to the two-stage assessment recommended by the EAU guidelines. Validated questionnaires should be used to assess symptoms and impact of quality of life. Before surgical treatment, we recommend specialised clinical assessment including urethrocystoscopy and urodynamics.

Guideline

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