The first step in the management of post-prostatectomy urinary incontinence (PPI) begins with a detailed history, including characteristics of the incontinence, patient expectations, as well as demographic variables such as the patient’s age [1]. This can help put the patient’s overall health status and long-term continence goals into context. The time since the radical prostatectomy should be ascertained as multiple studies have shown that it may take up to 1 year for most men to regain continence [2, 3]. As such, surgical therapy is typically deferred until after the first postoperative year for persistent urinary incontinence [4]. Recent evidence suggests that if patients have significant incontinence at 6 months, they are unlikely to recover, suggesting that surgical therapy may be considered as early as 6 months [5]. Preoperative factors such as obesity [6], preexisting incontinence, previous transurethral resection of the prostate (TURP), and prior radiation therapy [7] have been shown to be risk factors for post-prostatectomy incontinence. Furthermore, surgical factors such as the approach to the radical prostatectomy, whether open, laparoscopic, or robotic [8–11], and nerve-sparing status [12–14] are also important to clarify. Oncologic status, including PSA value, can help inform the urologist about the timing to potential anti-incontinence surgery in the event the patient should require further treatment for locally recurrent or metastatic disease [1]. Prior history of pelvic radiation and surgery, including prostate and bladder procedures, should be well documented. Finally, all medications that can affect the urinary tract should be reviewed, especially alpha-adrenergic blockers, anticholinergic agents, and beta-3 agonists.

It is useful to categorize the patient’s urinary incontinence as stress, urge, or a combination of both. Stress urinary incontinence as defined by the International Continence Society (ICS) is the complaint of involuntary leakage on effort or exertion or sneezing or cough. Urgency incontinence is the involuntary leakage accompanied by or immediately preceded by urgency [15]. In the event of mixed urinary incontinence, the urologist should elicit from the patient the most bothersome and significant component of the incontinence. In cases where the patient has difficulty characterizing their incontinence, it may be helpful to determine precipitating factors and also whether the leakage worsens with sexual activity or toward the end of the day, which may suggest underlying intrinsic sphincteric deficiency (ISD) [16]. It is also important to document whether the patient leaks urine at night as this is also a surrogate for primarily urgency incontinence.

The degree of incontinence should also be ascertained as this will guide the type of surgical management. Twenty-four-hour pad weights can be used to definitively document the amount of incontinence per day. A good surrogate marker to the severity of incontinence is patient self-reported pad usage. When asking a patient about “daily pad usage,” it is important to know the number of pads used in a typical day, the degree of saturation by urine, and the type of pads used, for instance, liners, pads, or undergarment.

Characterizing the patient’s lower urinary symptoms is also helpful, especially in terms of storage or voiding symptoms. The presence of voiding symptoms such as a weak urinary stream and intermittency can suggest a urethral stricture or bladder neck contracture. On the other hand, the absence of voiding symptoms can sometimes be elicited in a patient with severe to total incontinence due to the lack of significant bladder filling [16]. Ultimately, obtaining an accurate history and description of the incontinence is paramount to determining which further investigations may be required and setting reasonable expectations from proposed interventions.

Questionnaires and voiding diaries are valuable adjuncts in the assessment of post-prostatectomy incontinence. Questionnaires such as the American Urological Association Symptom Index [17] and the International Prostate Symptom Score [18] are instruments to aid in the classification of the patient’s voiding symptoms. The International Consultation on Incontinence Questionnaire (ICIQ) [19] is useful to assess the storage-type symptoms in these men. Overall, such questionnaires provide objective measures of a patient’s symptoms and the impact on their quality of life [20].

Voiding diaries, otherwise known as bladder diaries or frequency-volume charts, provide another objective instrument to record the frequency of voids, volume of voids, and fluid intake over a 3–7-day period [21]. This can be used to quantify the number of urinary incontinence episodes as well as the timing of incontinence. One of the main drawbacks is the difficulty in completing the voiding diary accurately. Studies have shown that a 4-day voiding diary is equivalent to a 7-day voiding diary; thus, in most circumstances, a 4-day voiding diary is used in the hopes of improving patient compliance [22].

The physical examination of a patient with post-prostatectomy incontinence should begin with a focused abdominal exam. The presence of surgical scars should be noted in addition to palpation for a distended bladder. A neurological exam including a digital rectal exam (DRE) assessing rectal tone and pelvic floor strength should be performed. A perineal and lower extremity exam with focus on the S2 to S4 spinal segments is important, including evaluation of perineal sensation and bulbocavernosal reflex [23]. Signs of skin irritation from incontinence can relate to severity of incontinence. Although rare causes of obstruction, the presence of meatal stenosis and phimosis should be documented [1]. Clinical demonstration of stress urinary incontinence is helpful and can usually be elicited by asking the patient to cough or bear down.

The pad test allows for the urologist to correlate the amount of actual leakage with the patient’s sensation of urine leakage. At times, a patient may report going through a large number of pads in a day of varying degrees of wetness which can make it difficult to characterize accurately. Moreover, differences in the type and size of pads add to this complexity. Studies have shown that the number of pads used is predictive of a patient’s response to therapy and may guide the type of surgical procedure to offer to the patient [21]. A study conducted by the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) suggested that patient perception of pad usage correlated well with the pad test [24]. However, others have proposed that weight of the pad correlates better with the degree of urinary leakage as compared to number of pads used, paving the way for the formal pad test [25]. A 24-hour pad test, considered by many to be the gold standard, is an objective measure of the degree of urinary incontinence. Due to the strict protocol to perform the test properly, some have advocated for the 1-hour pad test due to improved compliance [26]. As outlined by the ICS classification for stress urinary incontinence based on the 1-hour pad test, grade 1 is urine loss less than 10 g; grade 2, 11–50 g; grade 3, 51–100 g; and grade 4 is urine loss greater than 100 g [27]. Ultimately, an accurate assessment of the amount of incontinence is warranted, either by a detailed description of pad use from a reliable patient or from a prospective pad test.

Uroflowmetry combined with a post-void residual (PVR) is useful to assess bladder emptying and urinary obstruction especially in the presence of voiding symptoms. They are quick and easy tests to perform that may suggest urethral strictures or bladder neck contractures. Although no specific cutoff has been agreed on, both the American and Canadian Urological Associations recommend that PVR be included as part of initial assessment [28, 29]. Similarly, the European Urological Association guidelines and the International Consultation on Urological Diseases (ICUD) specify a PVR of greater than 200 ml to be concerning for obstruction [21, 30].

A urinalysis with a urine culture to rule out urinary tract infections is highly recommended [30]. Moreover, a urinalysis looking for microscopic hematuria can help rule out other bladder pathologies, such as bladder cancer and stones.

Cystourethroscopy should be performed prior to any surgical intervention for post-prostatectomy incontinence. It can aid in the identification of obstructive causes, such as urethral strictures or anastomotic strictures (i.e., bladder neck contractures). It may also identify the presence of bladder tumors, stones, or diverticula which should be addressed prior to surgical therapy for incontinence [1]. Urethral integrity and vascularity can also be assessed at that time [16]. The main role for cystoscopy prior to surgical therapy is to document the presence or absence of anastomotic strictures as these are prone to recurrence and may play a role in the type of surgical procedure offered [31]. This highlights the importance of performing cystourethroscopy to assess all anatomic components of the lower urinary tract [26].

The etiology of post-prostatectomy incontinence is multifactorial and can include bladder dysfunction, intrinsic sphincter dysfunction (ISD), or a combination of both. Urodynamics remains the gold standard test to help differentiate among these etiologies and to guide treatment.

The role of urodynamics to predict urinary outcomes following surgical intervention for incontinence remains debatable. The findings of decreased compliance in a chronically underfilled bladder or even detrusor overactivity have not been shown to impact on surgical outcomes [32–34]. Similarly, decreased detrusor contractility has not been shown to adversely affect artificial urinary sphincter (AUS) success significantly [35]. Moreover, in a study by Thiel et al., the authors failed to find a urodynamic parameter that would predict for failure after AUS placement, defined as leakage requiring one or more pads per day [36].

Cystometry at a medium fill rate, typically 50 mL/min, should be performed with a 7Fr urethral catheter and rectal catheter. The detrusor pressure should be recorded throughout the examination, calculated as the difference between the measured vesical pressure and rectal pressure. In patients with a known small-capacity bladder, the fill rate can be decreased. Filling sensation, bladder capacity, and compliance should be noted as per standard urodynamic protocol. The presence of detrusor overactivity and urinary leakage should also be documented. Bladder filling to at least 150 mL should be performed before the initiation of Valsalva and stress maneuvers such as coughing [16]. An abdominal leak point pressure (ALPP) should be recorded, which is the pressure necessary to overcome the sphincteric resistance [37]. Videofluoroscopy should also be performed as this can evaluate the bladder neck for the presence of contractures or strictures. In the presence of narrowing at the anastomosis, a 7Fr urethral catheter may occlude the urethra masking incontinence or falsely elevating the ALPP [38, 39]. In this situation, a second fill without a urethral catheter should be performed with the ALPP determined from the rectal catheter followed by a noninvasive uroflow [38, 40].