Robert L. Segal, MD, FRCS(C)
Arthur L. Burnett, II, MD, MBA, FACS
BASICS
DESCRIPTION
• Post-prostatectomy incontinence (PPI) is a well-recognized complication of radical prostatectomy (RP) whether performed openly (perineal retropubic) or laparoscopically with or without robotic assistance.
• The definition of continence following RP in the literature varies widely, with the strictest definition of continence being no pads used.
EPIDEMIOLOGY
Incidence
• The incidence of PPI depends on the interval of time following surgery, the definition and methodology for assessing continence, and the experience of the surgeon.
• The overwhelming majority of men have some degree of PPI immediately after catheter removal.
• If PPI is defined as no pads/small protective pad or total control/occasional dribbling, experienced surgeons consistently report continence rates exceeding 95% at 1–2 yr after RP.
• Recent evidence suggests that PPI may improve after 2 yr.
Prevalence
Approximately 6% of men will undergo a procedure for the management of PPI at a median of 20 mo after RP (1)
RISK FACTORS (2)
• Body mass index (BMI) ≥25
• Compromised sexual potency (IIEF-EF <10)
• Enlarged prostate volume
• Increasing age (>65 yr)
• Nerve-sparing status (non vs. unilateral vs. bilateral)
• Presence of preoperative incontinence/lower urinary tract symptoms (LUTS)
• Previous TURP
• Surgeon inexperience
Genetics
N/A
PATHOPHYSIOLOGY
• PPI results primarily from injury to the rhabdosphincter resulting in SUI.
• Pre-existing detrusor instability (DI) is a less likely etiology of PPI.
• An anastomotic stricture may be the cause, or exacerbate PPI.
ASSOCIATED CONDITIONS
• Anastomotic stricture/bladder neck contracture
• Detrusor Instability (DI)/Overactive bladder (OAB)
• Sphincteric incompetence
GENERAL PREVENTION
• Achieving a bloodless surgical field following anatomic ligation of the dorsal venous complex is required to meticulously divide the prostatourethral junction.
• Maximal preservation of the rhabdosphincter is felt to minimize PPI.
• Encourage Kegel exercises—may accelerate continence recovery.
• Preoperative pelvic floor muscle training with biofeedback has not resulted in improved postoperative continence recovery (3)
DIAGNOSIS
HISTORY
• Assess the severity of LUTS and incontinence preoperatively.
– The International Prostate Symptom Score (IPSS).
• Inquire about the use of α-blockers because these agents may exacerbate PPI.
• Ascertain if the PPI is exacerbated by physical activity.
• Determine the severity of PPI by: Number of pads, degree of bother, and frequency of incontinence episodes.
• Assess the severity of LUTS.
• Inquire if PPI is improving, stable, or deteriorating:
– Deterioration of continence together with increasing voiding symptoms suggests an anastomotic stricture.
PHYSICAL EXAM
• Observe for skin excoriation secondary to PPI.
• Observe degree of pad saturation.
• Observe degree of incontinence when transferring from the sitting to standing position.
• Observe caliber of urinary stream.
DIAGNOSTIC TESTS INTERPRETATION (C)
Lab
Urinalysis to exclude urinary tract infection
Imaging
Sonographic post-void residual (PVR)
Diagnostic Procedures/Surgery
• Uroflowmetry
• 24-hr pad test to quantify PPI
• Urodynamics evaluation with or without fluoroscopy will help define the etiology for PPI
• Pressure flow study is useful for evaluating a possible obstructive anastomotic stricture
Pathologic Findings
None
DIFFERENTIAL DIAGNOSIS
• Anastomotic stricture
• Detrusor Instability (DI)/Overactive bladder (OAB)
• Stress urinary incontinence (SUI)
• Urge incontinence
• Overflow incontinence
• Mixed incontinence
TREATMENT
GENERAL MEASURES
• Kegel exercises should be encouraged as soon as urinary catheter removal
• Discontinue α-blockers
• Limitation of fluid intake
• Timed voiding
• Voiding before strenuous activity
• Counsel patient that incontinence following RP is the norm and that with time most patients will improve
MEDICATION
First Line
• α-Agonists generally not effective for SUI
• Imipramine (a tricyclic antidepressant) promotes external urethral sphincter muscle tone and may improve mild SUI (off-label use)
– Typical off-label starting dose is 25–50 mg PO QHS
• Anticholinergic agents may improve PPI secondary to DI
– Options include: Oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, trospium
Second Line
Periurethral bulking agents (bovine glutaraldehyde cross-linked collagen polydimethylsiloxane elastomer) are costly; they require multiple injections and have limited durable success in this setting.
SURGERY/OTHER PROCEDURES
• Surgical intervention should not be pursued until at least 1 yr post-prostatectomy because of the temporal improvements in the condition
• Surgical intervention should not be contemplated at 1–2 yr if there is evidence of progressive improvement
• Imperative to exclude anastomotic stricture and DI before embarking on surgical correction of SUI
• Surgical options:
– The specific surgical procedure is dictated by severity of PPI.
– More severe cases best managed with an artificial urinary sphincter (AUS)
– In many cases, surgery achieves marked improvement in PPI but some degree of SUI may persist
Male slings
Artificial urinary sphincter (AUS)
ADDITIONAL TREATMENT
Radiation Therapy
Although there is no role in the treatment of PPI, data suggest that radiation administered in the adjuvant setting following RP may not worsen incontinence but may limit resolution of continence particularly if the radiation is administered before continence returns.
Additional Therapies
• Urethral dilation should be performed if evidence of bladder outlet obstruction and anastomotic stricture.
• Transurethral incision of the stricture may be required if stricture reoccurs despite multiple dilation(s).
• In Europe duloxetine, a serotonin-norepinephrine reuptake inhibitor is approved for stress incontinence (US approval is only for neuropathic pain and depression).
Complementary & Alternative Therapies
Biofeedback may have a role in selected patients in strengthening pelvic musculature.
ONGOING CARE
PROGNOSIS
• The overwhelming majority of men will spontaneously regain urinary continence following RP.
• The small subset of men with persistent SUI will improve, providing the appropriate surgical procedure is performed.
• The worst prognosis exists for cases with severe refractory anatomic strictures (bladder neck contractures) who must 1st be made totally incontinent with subsequent placement of an AUS.
• PPI secondary to DI likely to improve with anticholinergic agents.
COMPLICATIONS
• Dermatitis
• Diminished self-esteem:
– Limitation of physical activity
– Withdrawal from sexual activity
– Complications of treatment for PPI
FOLLOW-UP
Patient Monitoring
• Pad use
• Impact of PPI on quality of life
Patient Resources
http://www.webmd.com/urinary-incontinence-oab/mens-guide/urinary-incontinence
REFERENCES
1. Kim PH Pinheiro LC, Atoria CL, et al. Trends in the use of incontinence procedures after radical prostatectomy: a population based analysis. J Urol. 2013;189(2):602–608.
2. Abdollah F, Sun M, Suardi N, et al. A novel tool to assess the risk of urinary incontinence after nerve-sparing radical prostatectomy. BJU Int. 2013;111(6):905–913.
3. Geraerts I, Van Poppel H, Devoogdt N, et al. Influence of Preoperative and Postoperative pelvic floor muscle training (PFMT) compared with postoperative PFMT on urinary incontinence after radical prostatectomy: A randomized controlled trial. Eur Urol. 2013;64(5):766–772.
ADDITIONAL READING
• Ficarra V, Novara G, Rosen RC, et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted \radical prostatectomy. Eur Urol. 2012;62:405–417.
• Gacci M, Ierardi A, Rose AD, et al. Vardenafil can improve continence recovery after bilateral nerve sparing prostatectomy: Results of a randomized, double blind, placebo-controlled pilot study. J Sex Med. 2010;7:234–243.
• Healy KA, Gomella LG. Retropubic, laparoscopic, or robotic radical prostatectomy: is there any real difference? Semin Oncol. 2013;40(3):286–296.
See Also (Topic, Algorithm, Media)
• Bulking Agents, Injectable
• Incontinence, Urinary, Adult Male
• Stress Urinary Incontinence, Male
CODES
ICD9
• 788.39 Other urinary incontinence
• 997.5 Urinary complications, not elsewhere classified
ICD10
• N39.498 Other specified urinary incontinence
• N99.89 Oth postprocedural complications and disorders of GU sys
CLINICAL/SURGICAL PEARLS
• Post prostatectomy incontinence (PPI) is very common, with the vast majority (95%) resolving 6–12 mo postoperatively.
• Kegel exercises should be instituted immediately after catheter removal postoperatively.
• It is crucial to determine the exact pattern of urinary leakage.
• If conservative measures fail, treatment for bothersome SUI requires surgery.
• Type of surgery is dictated by severity of SUI.