4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 Clark ET AL. 40 Work up Work-up of IPT must include a thorough history and physical examination along with appropriate diagnostic tests to elucidate the type as well as degree of UI. 2 Validated questionnaires to determine the type of UI include The International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form(ICIQ-UI SF) and theMichigan Incontinence Symptom Index (M-ISI). 29,30 Asking a patient to keep a diary is useful to understand their daily habits (such as fluid and caffeine intake) and can provide real-time recording of their triggers and symptoms. Severity of symptoms is frequently assessed by asking patients how many pads per day they use, frequency of changing their pads, and how wet the pads are when they change them. Daily pad weight, however, provides the most objective measure of degree of incontinence. 31 The Male Stress Incontinence Grading Scale (MSGIS) as well ICIQ-UI SF have been shown to correlate with heavier pads in patients with SUI. 32 Physical exam should include maneuvers to confirm the presence of SUI such as having the patient cough or increase abdominal pressure via Valsalva maneuver. Urinalysis is a helpful adjunct to look for urinary tract infection, hematuria, or glucosuria which can cause similar symptoms to or exacerbate underlying IPT. Post void residual (PVR) can show if the patient is emptying well and rule out overflow incontinence. Cystourethroscopy should be performed prior to surgical intervention to assess the urethra and bladder for pathology such as urethral stricture or vesicourethral anastomotic stenosis as these can impact surgical intervention. 33 Ruling out bladder cancer is also important prior to surgical intervention. Bladder tumors, especially urothelial carcinoma in situ, can be associated with irritative voiding symptoms and the presence of cancer may influence the surgical options considered. For patients with a more complex presentation, invasive urodynamics is a useful tool. If patients fail conservative therapies, surgery is indicated for those who have bothersome SUI- predominant symptoms. Surgery is contraindicated for patients with risk of renal failure due to bladder dysfunction, anatomy that does not support implantable device, or pathology that requires chronic endoscopic management. Generally, patients with SUI may be offered surgical intervention at 1 year postoperatively for bothersome SUI if they have failed non-surgical therapy. The guidelines, however, allow intervention to be as early as 6 months if the patient shows no improvement of IPT while undergoing non-surgical therapy. 2 Surgical treatments for IPT Artificial urinary sphincter The artificial urinary sphincter (AUS) was first designed in 1976 and has seen several iterations over the years. 34 The AMS 800 (Boston Scientific, Marlborough, MA, USA) is a well-established and studied AUS. It is composed of a fluid-filled cuff that encircles the bulbar urethra, a pump, and a pressure regulating balloon (PRB). To be an appropriate surgical candidate, patients must have adequate cognitive function and manual dexterity to operate the device and stricture/stenotic disease must be ruled out. It is important to note that cognitive dysfunction and poor manual dexterity are predictors of AUS failure. 35 During the procedure, the patient is placed in the dorsal lithotomy position. The dissection should expose the bulbar urethra where it is circumferentially measured to select the appropriate cuff size. If a patient’s bulbar urethral circumference falls between cuff sizes, the larger cuff size should be selected to reduce risk of urethral compromise. The PRB is placed in the retropubic space and filled with enough fluid to achieve a pressure of 61-70 cmH 2 O. The pump should be placed in a subdartos pouch within the scrotum. Special consideration must be given to patients with risk factors for or history of urethral atrophy or erosion and previous RT. Cuff size, placement, and pressure can be modified to account for these risk factors. Patients should be counseled appropriately about AUS outcomes, durability, revision rates, and potential complications. In a study by Linder et al, 1,083 AUS placements were performed between 1983-2011 for men with SUI. With a median follow up of 4.1 years, 59% reported 0-1 pads per day and 94% reported high satisfaction. 36 Asystematic reviewof 12 studies showed a 0-1 pads per day rate of 61%-100% with “complete dryness” varying from 4%-86%. 37 Over time, revision of AUS may become necessary. Device failure rate at 10 years has been shown to be nearly 50%. 38 Bergeson et al evaluatedAUS revisions between 2007-2019 and showed PRB failure to account for one third of cases, mechanical cuff failure for 17%, and urethral atrophy for 8%. 39 In a study looking at bothprimary and revisionAUSpatients, three out of four patients were still satisfied 10 years following the procedure in both groups. 40 Urethral bulking agents Bulkingagents are cystoscopically injectedsubmucosally at the bladder neck to help coapt tissue and improve continence. While commonly used for female SUI due to ISD, they are rarely offered in male patients due to poor evidence and low efficacy/cure rates. 41