Preexisting urinary incontinence or voiding dysfunction increases the likelihood of developing PPI. As most cases of SUI in males tend to arise following prostatectomy, presurgical SUI is relatively uncommon. In a recent study on 1000 adult men, urinary incontinence was prevalent in only 5.4%, of whom approximately one-fourth (26%) suffered from isolated SUI [17]. These men presumptively suffer from baseline intrinsic sphincter deficiency (ISD), which manifests as clinical SUI or low maximal urethral closure pressure on urodynamics [18, 19]. The intrinsic component of the urethral sphincter appears to be responsible for passive continence, while the extrinsic component plays a more substantial role in active continence [20]. Membranous urethral length, including both anatomic length based on magnetic resonance imaging (MRI) and functional length shown on urodynamic studies, has been shown to be directly associated with continence rates [19, 21–23]. Preserving the functional integrity of the distal urethral sphincter mechanism is thus necessary for maintaining postoperative continence.

Other functional or anatomic issues with either the bladder or the outlet can also predispose patients to developing PPI. Examples of such risk factors include neurogenic detrusor overactivity, as seen in Parkinson’s disease or other neurologic insult [24] larger prostate volume [25], and the presence of an anatomic stricture [26, 27] or post-prostatectomy anastomotic stricture [28, 29] causing outlet obstruction. ISD tends to be the most common underlying etiology in PPI, while isolated bladder dysfunction occurs in only less than 10% of cases [28, 29]; however, both sphincter and bladder dysfunction can coexist in at least one-third of incontinent patients [28, 29]. Bladder dysfunction can also occur de novo following prostatectomy [30, 31].

Advancing age has also been shown to be an independent risk factor for the development of PPI [14, 32–37]. Older men have a greater likelihood of requiring eventual artificial urinary sphincter (AUS) for severe PPI [38]. Strasser et al. hypothesize this age-related phenomenon to be related to a progressive reduction in striated muscle cells within the external urinary sphincter with increasing age [39]. Body mass index (BMI) is also associated with increased PPI rates, reportedly three times higher for patients with BMI >30 kg/m² compared to those with lower BMI [40]. Obesity may also present technical challenges, such as difficulty with performing the vesicourethral anastomosis, and often coexists with other comorbidities such as diabetes and vascular disease [41, 42]. Finally, patients who are undergoing salvage prostatectomy following prior radiotherapy or cryotherapy tend to experience higher rates of PPI [43] and greater likelihood of needing AUS implantation [44–47].

Postoperative continence outcomes may also be dictated in part by technical features intraoperatively. Most cases of PPI are likely a direct result of surgical injury to the native urinary sphincteric mechanisms [13], particularly the intrinsic component [28–30]. Bladder denervation during prostatectomy may also contribute to PPI due to the resultant impairment in detrusor contractility and poor bladder compliance.

Several studies have shown that bilateral nerve-sparing techniques may help preserve continence [19, 48–50], though this is debated [51, 52]. Bladder neck preservation may improve early return of continence at 3 months [53], though its effect on continence status at 6 and 12 months may not be significant [54, 55]. Other surgical maneuvers such as sparing of seminal vesicles, urethral suspension, and bladder neck mucosal eversion have also been suggested to reduce PPI rates [21, 36, 48]. Surgeon experience may play a role as well [56]. With respect to surgical approach, no significant differences in continence rates have been demonstrated between perineal and retropubic approaches [57, 58] or among open, laparoscopic, and robotic approaches [9, 11, 59–61].

The primary goal when approaching patients with PPI is to discern the degree of subjective bother and severity of incontinence in order to appropriately direct therapy. Evaluation of PPI patients should begin with a comprehensive history, including the onset, duration, type, and severity of incontinence, along with precipitating events. Subjective bother from incontinence can be discerned by assessing its impact on daily activities. A history of radiation increases the probability that detrusor overactivity or poor compliance may exist. A voiding diary can be helpful to quantify the fluid intake and functional bladder capacity [62]. Quantifying the severity of leakage based on the number of pads used per day [63, 64] or objectively using pad weights [65] or ultrasonic post-void residual volumes to assess bladder emptying [66] can be helpful to facilitate treatment decision-making.

Physical examination is an important component that should not be overlooked when evaluating PPI patients. In our clinical experience, we have found the standing cough test (SCT), introduced nearly 20 years ago by Kowalczyk et al. [67], to be a useful method to easily and reproducibly assess the severity of male SUI. From our experience in hundreds of PPI patients over more than a decade of focused clinical practice in prosthetic urology, we have recognized several distinct patterns of leakage commonly observed during routine implementation of the SCT. We recently attempted to standardize those leakage patterns and correlate them with other patient-reported indicators of condition severity and clinical outcomes [15]. In our pilot study, we reported a strong concordance (r = 0.74) between SCT patterns and patient-reported pad-per-day, which has been previously shown to correlate strongly with pad weights [68]. In addition to the SCT, neurological evaluation should be performed to assess the S2-S4 spinal segments, including anal sphincter tone, perineal sensation in the S2-S4 segments, and the bulbocavernosus reflex. Abdominal examination is performed to assess for prior scars and to detect a potentially distended bladder with overflow incontinence.

Office cystoscopy can be conducted to evaluate the integrity of the external urinary sphincter and bladder neck. Endoscopic evidence of urethral coaptation may suggest the degree of sphincter insufficiency. Patients with obstructive symptoms ideally should also be evaluated with cystoscopy before any surgical treatment to rule out anastomotic strictures [69]. Multichannel urodynamic testing may provide some information about bladder contractility [70] and Valsalva abdominal leak point pressure (ALPP) measurement to assess sphincter weakness [71]; however, its routine use in PPI appears to be of limited value, demonstrating poor correlation with anti-incontinence surgical outcomes [72, 73].

A range of options exists for managing PPI. A trial of conservative measures is certainly worth consideration prior to surgical treatment. Examples of effective nonsurgical methods include pelvic floor exercises (Kegel exercises) [74, 75] and behavioral modifications, such as limiting fluid intake or bladder irritants such as alcohol and caffeine [76]. Additional approaches such as biofeedback, pelvic floor stimulation, pharmacotherapy, and urethral bulking agents have also been studied, though with limited evidence to support their clinical utility in the PPI setting [69].

Surgical intervention for PPI is traditionally deferred for at least 1 year after prostatectomy [16], though in select cases it may be reasonable to consider surgical management even earlier. The AUS presently remains the gold standard for PPI treatment, though in more recent years, the male urethral sling has emerged as an attractive, less complex alternative. While slings can be effective for the management of mild-to-moderate PPI, more severe PPI is better managed with AUS [77, 78]. Kumar et al. recently demonstrated that patients usually prefer a sling if given the choice, since it takes effect immediately, has lower risk of severe complications, and avoids a mechanical device that may be subject to malfunction or the need for revision [79]. However, several factors must be taken into consideration when counseling patients on their surgical options for PPI [69, 80]. Our recently developed SCT-based grading scale to objectively assess PPI severity appears to help facilitate anti-incontinence surgical procedure selection with favorable patient-reported outcomes [15]. Nonetheless, we still unfortunately lack a standardized algorithm to stratify patients to the ideal treatment for PPI.