Jack Matthew Zuckerman, MD
Kurt A. McCammon, MD, FACS
BASICS
DESCRIPTION
• Stress urinary incontinence (SUI) is subjectively defined by the International Continence Society (ICS) as the “the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing” (1).
• SUI is also seen objectively on pressure flow urodynamics (UDS) as unintended leakage of urine during an increase in intra-abdominal pressure.
EPIDEMIOLOGY
Incidence
True SUI is rare in young men, but the incidence increases as men age. This predominance in the elderly mirrors the increased likelihood of having undergone prostate surgery as men age.
Prevalence
• The prevalence of UI in women is approximately twice that in men; however this gap narrows over time (2)
• Overall prevalence of moderate–severe urinary incontinence in men 20 yr of age and older is approximately 4.5% (3)
– 0.7% for men aged 20–34 yr
– 16% for men aged ≥75 yr
– SUI accounts for only 12.5% of moderate to severe UI, the remainder predominantly urge or mixed incontinence
RISK FACTORS
• Urologic procedures are the primary risk factor for male SUI
– Radical prostatectomy (RP)
Leading cause of male SUI, especially in older men
Postprostatectomy incontinence (PPI) has widely variable rates reported, from 3–89% depending on the timeframe and definition used for incontinence
Rates appear similar regardless of technique (retropubic, laparoscopic, or robotically assisted laparoscopic)
– Transurethral resection of the prostate:
Uncommonly results in sphincteric injury leading to SUI
• Urethral distraction injuries involving the membranous urethra
• Acquired or traumatic spinal cord pathology
• Congenital malformations
– Spinal dysraphism
– Exstrophy/epispadias complex
Genetics
N/A
PATHOPHYSIOLOGY
• Male continence relies on an intact internal and external urinary sphincter and a compliant bladder for storage of urine
– Internal sphincter
Bladder neck and prostate
Smooth muscle/involuntary
– External sphincter
Rhabdosphincter/voluntary
• Internal sphincter dysfunction can be caused by:
– Prior pelvic surgery, such as RP
– Traumatic or iatrogenic injury to the bladder neck or prostate
– Injury or dysfunction of the sympathetic innervation to the internal sphincter
– Congenital internal sphincter dysfunction
• Dysfunction or the external sphincter is termed intrinsic sphincter deficiency (ISD) and most frequently occurs following radical prostatectomy (RP) (5)
• A noncompliant bladder may exacerbate UI, however, by definition sphincteric dysfunction is required for SUI to be present
ASSOCIATED CONDITIONS
• Urinary incontinence negatively affects a man’s quality of life, even in those with minimal urine leakage (6)
• Depression is consistently associated with UI. It is unclear whether this incontinence is cause by depression and meds used to treat it or whether UI is actually causing the depression (3)
• Neurologic diseases
• Pelvic trauma
• Benign prostatic hypertrophy (BPH)
• Prostate cancer
– Prostate surgery, usually RP
• Pelvic radiation for urologic and nonurologic malignancy
GENERAL PREVENTION
• Careful surgical technique in avoiding damage to the external sphincter during RP.
• If postoperative radiation is used for adverse pathology following RP it is desirable to have the patient continent before radiation since this can adversely affect the return of continence postop.
• Patients with neurogenic bladder such as spina bifida, incontinence episodes can be limited through the use of intermittent catheterization and anticholinergics.
DIAGNOSIS
HISTORY
• Incontinence history
– Duration
– Severity (pads, diapers, tissues, etc.)
The nature of the absorptive device helps with the assessment of the degree of leakage
– Precipitating events (cough, sneeze, etc.)
• Presence/absence of urge symptoms
– Suggests pharmacologic therapy may benefit
• Frequency of urination
• Fluid intake, including use of caffeine, alcohol
• Use of medications such as diuretics or antihypertensive medications
• Neurologic or spinal cord disease or injury
• Voiding diary
• Prior pelvic surgery or other urologic surgery
• Prior pelvic radiation
• Prior anti-incontinence procedures
• AUA symptom score
• ICIQ (International Consultation on Incontinence Questionnaire), ICIQ-MLUTS
PHYSICAL EXAM
• Abdominal exam
– Surgical scars
– Palpable suprapubic mass suggests retention
• External genitalia and groin
– Skin breakdown or fungal/bacterial infection secondary to UI
– Scrotal exam to rule out hydrocele or testicular mass
– Digital rectal exam for assessment of the prostate as well as rectal tone
– Inguinal hernia
• Spine/back for deformity
• Cutaneous signs for spinal dysraphism
– Subcutaneous lipoma
– Vascular malformation
– Tuft of hair
– Skin dimple
• Reflexes
– Anal reflex (S2–S5)
Stroking circumanal skin leads to visible contraction; absence suggests peripheral or sacral nerve dysfunction
– Bulbocavernosus reflex (S2–S4)
Squeezing the glans leads to anal contraction
Absence suggests sacral nerve dysfunction
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis and urine culture
• PSA if known history of prostate cancer or has had a prostatectomy
Imaging
• Postvoid residual urine (PVR) measurement to rule out urinary retention
• Other routine imaging not indicated
Diagnostic Procedures/Surgery
• Pressure flow UDS are helpful to confirm stress incontinence and rule out other complicating factors such as urge incontinence/detrusor overactivity, detrusor underactivity, bladder outlet obstruction, and poor bladder compliance.
• Cystoscopy to rule out urethrovesical anastomotic stenosis (most often after radical prostatectomy) or urethral stricture is essential prior to any planned surgical intervention.
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Stress urinary incontinence
• Urge urinary incontinence: Involuntary leakage accompanied by or immediately preceded by urgency
• Mixed urinary incontinence
• Overflow incontinence/urinary retention
• Postvoid dribbling (urine retained in the urethra)
• Situational incontinence: eg, the report of incontinence during sexual intercourse
• Urethrocutaneous fistula
• Urinary leakage may need to be distinguished from sweating
TREATMENT
GENERAL MEASURES
• Pelvic floor physical therapy (“Kegel” exercises)
– Efficacious following RP to allow quicker return of continence, though not found to improve overall continence (7)
– May also be used in men with SUI from other causes to strengthen the pelvic floor
• Lifestyle changes
– Limiting fluid intake
– Decreasing certain activities that cause SUI
• Penile clamps
• Condom catheter
MEDICATION
First Line
• Medication generally is not efficacious for male SUI. However, medical therapy is sometimes used in this population. None are officially FDA approved for this indication
– Tricyclic antidepressants
Imipramine 10–25 mg PO BID–TID
– Duloxetine 30–60 mg PO QD (8)
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Post prostatectomy incontinence (PPI)
– Artificial urinary sphincter (AUS)
Gold standard
Excellent long-term outcomes and high patient satisfaction (9)
– Urethral slings
Transobturator
Bone-anchored
Combined prepubic and transobturator
– Urethral bulking agents
Least effective and generally not used as a 1st-line surgical treatment
May be useful in the salvage setting after a failed sling
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Generally speaking SUI is stable or progressive in nature. It is not likely spontaneously resolved.
• PPI differs from other causes of SUI in that it has been shown to improve over time. However, a plateau is seen after approximately 2 yr and further improvements are not anticipated (4).
• With surgical treatment, and occasionally medical management, male SUI can be expected to improve dramatically in most cases.
COMPLICATIONS
• Urinary incontinence
– Social isolation/embarrassment
– Dermatitis
– Candidiasis
– Skin breakdown
– Foul odor
• Artificial urinary sphincter (AUS)
– Urinary retention
– Device infection or malfunction
– Urethral erosion
– Urethral atrophy
• Urethral slings
– Urinary retention
– Perineal pain
– Infection/sling erosion (rare)
– Osteitis pubis or chronic pain from bone-anchored slings
FOLLOW-UP
Patient Monitoring
• Following surgical or medical treatments patients should be followed with standardized questionnaires, such as the International Consultation on Incontinence Questionnaire Short Form.
• Patients may also be followed with 1-hr or 24-hr pad weight testing, but this can be burdensome to obtain regularly in the office.
• Self-reported pad counts are easier to obtain, but not as accurate as a pad weight test.
• No routine labs or imaging are required unless complicating factors in the initial history and physical were identified.
Patient Resources
National Kidney and Urologic Diseases Information Clearinghouse. http://kidney.niddk.nih.gov/kudiseases/pubs/uimen/
REFERENCES
1. Abrams P, Cardozo L, Fall M, et al. The standardization of terminology of lower urinary tract function: Report from the Standardization Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167–178.
2. Landefeld CS, Bowers BJ, Feld AD, et al. National Institutes of Health state-of-the-science conference statement: Prevention of fecal and urinary incontinence in adults. Ann Intern Med. 2008;148(6):449–458.
3. Markland AD, Goode PS, Redden DT, et al. Prevalence of urinary incontinence in men: Results from the national health and nutrition examination survey. J Urol. 2010;184(3):1022–1027.
4. Smither AR, Guralnick ML, Davis NB, et al. Quantifying the natural history of post-radical prostatectomy incontinence using objective pad test data. BMC Urol. 2007;7:2.
5. Chao R, Mayo ME. Incontinence after radical prostatectomy: Detrusor or sphincter causes. J Urol. 1995;154(1):16–18.
6. Liss MA, Osann K, Canvasser N, et al. Continence definition after radical prostatectomy using urinary quality of life: Evaluation of patient reported validated questionnaires. J Urol. 2010;183(4):1464–1468.
7. Hunter KF, Moore KN, Cody DJ, et al. Conservative management for postprostatectomy urinary incontinence. Cochrane Database Syst Rev. 2004;(2):CD001843.
8. Collado Serra A, Rubio-Briones J, Puyol Payás M, et al. Postprostatectomy established stress urinary incontinence treated with duloxetine. Urology. 2011;78(2):261–266.
9. Montague DK. Artificial urinary sphincter: Long-term results and patient satisfaction. Adv Urol. 2012;2012:835290.
ADDITIONAL READING
Burden H, Warren K, Abrams P. Diagnosis of male incontinence. Curr Opin Urol. 2013;23(6):509–514.
See Also (Topic, Algorithm, Media)
• Bulking Agents, Injectable
• Incontinence, Urinary, Adult Male
• Incontinence, Urinary, Following Radical Prostatectomy
• Intrinsic Sphincteric Deficiency
• ICIQ (International Consultation on Incontinence Questionnaire), ICIQ-MLUTS
• Overactive Bladder (OAB)
CODES
ICD9
788.32 Stress incontinence, male
ICD10
N39.3 Stress incontinence (female) (male)
CLINICAL/SURGICAL PEARLS
• SUI is uncommon in young men, but becomes more common with age as more patients are undergoing urologic procedures.
• Most effective treatments are surgical, though medical therapy may be helpful in men with very mild incontinence.
• The artificial urinary sphincter (AUS) remains the gold standard procedure for male SUI, however urethral slings are now commonly used with success approaching that of the AUS with proper patient selection.