3rd Annual Jefferson Urology Symposium: Men’s Health Forum

© The Canadian Journal of Urology TM : International Supplement, August 2020 37 Male urinary incontinence after prostate disease treatment Etiology of IPT Radical prostatectomy UI after RP is largely SUI however UUI may develop as well. SUI following RP is thought to result from several possible anatomic and nerve-related changes that occur from surgery. Rhabdosphincter incompetence alone has been found to be the sole cause of SUI after RP in 40%-92% of cases. 7 Given, however, that a large fraction of men recover continence by 6-12º months postop, it is thought that the insult is likely to the nerves and supporting tissue of the sphincter rather than direct sphincter damage per se. Studies have shown that preservation of membranous urethral length (MUL) > 12 mm is associated with increased continence following RP as well. 8 UUI related to detrusor overactivity (DO) has been found to develop after RP as well. In a study by Groutz et al, post-RP DO was found in up to 34% of men. However for only about 7%of menwas it the sole cause of UI. 9 A review by Thirucheivam et al of men with UI after RP who underwent urodynamic assessment found a more variable rate of overactivity between 2%-63%. 10 Overall, men with UI after RP should be evaluated for both SUI and UUI and treatment decisions based upon the relative components of each. Radiation therapy RT to the prostate has long been known to have deleterious effects on the bladder and rectum, potentially leading to long term tissue damage and dysfunction. Pathologically, DNA-damage induced by RT can lead to long term inflammation, endarteritis, urothelial proliferation, collagen deposition, and fibroblast infiltration. 11 In the bladder, these inflammatory changes can lead to a nociceptive response that may manifest as DO. 12 Hoffman et al found that men who received pelvic RT for prostate cancer (with or without prior RP) had a higher rate of DO that those who did not get radiation (70%versus 38%, respectively) and had lower maximum cystometric capacity (253mLversus 307mL, respectively). 13 UI after prostate RT in the absence of surgical prostate therapy should raise the suspicion for DO which should be the initial focus of investigation. Surgery for BPH Surgical removal of the obstructive prostatic adenoma in BPHcan be associatedwith the development of other lowerurinary tract symptoms includingUI. Rassweiler et al found that after transurethral resection of the prostate, between 30%-40% of men can experience transient SUI, which drops down to < 0.5%over long term followup. 14 Studies of the holmium laser enucleation of the prostate (HoLEP) have also shown postoperative UI; Cho et al reported a de novo SUI and UUI rate of ~10% each after HoLEPwhich fell to about 1%each at 12months. 15 These men need careful evaluation to assess all the possible types of UI that may be present. Prevention of IPT Preventativemeasures for IPThave principally involved increased knowledge of PFMT and refinement of RP techniques. The 2019 AUA/SUFU guidelines recommend that PFMT may be offered in the pre-RP setting and should be offered after surgery. Recent data suggest apossible increasedvalue for pre-surgical PMFT. In a randomized trial by Milios et al, men planning RP randomized to intensive PMFT (120 contractions per day) versus conventional PMFT (30 contractions per day) starting 5-weeks preop experienced a faster return to continence and less severe leakage on 24-hour pad weight test. 16 Thismore intensive regimen is promising and deserves future study. Techniques in RP have advanced significantly and have led to increased continence rates postoperatively. Sridhar et al reviewed surgical factors associated with increased postoperative continence which included bladder neck preservation, neurovascular bundle preservation, athermal division of the dorsal venous complex, preservation of ancillary anatomic support to the rhabdosphincter, preservation of MUL, and anatomic anterior/posterior reconstruction. 17 A recent review by Phuken et al of the Retzius-sparing technique in RALP showed that it was associated with improved continence rates and short time to continence recovery compared to standard RALP. 18 Patient evaluation Office evaluation of men with IPT should begin with the relevant history and physical examination. Multiple questionnaire tools exist to help distinguish the types of UI menmay experience. The International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI SF) and the Michigan Incontinence Symptom Index (M-ISI), Tables 1 and 2, respectively, are brief tools designed to assess precipitating leakage events and symptoms. 19,20 An additional quasi-objective evaluation tool is the bladder diary for tracking fluid intake and leakage/ symptom timing. Pad use including type, frequency, and level of dampness should also be assessed to better roughly define the quantity of leakage experienced.