Male Stress Urinary Incontinence

Fig. 6.1

Patient 1: urodynamics tracing

Findings

Prior to commencing the procedure, the patient voided 461 mL, and on uroflowmetry, he achieved a Q _max of 44 mL/s and a Q _avg of 20 mL/s.

Filling Phase

First desire 148 mL.
No DO. There are several negative deflections in P _det tracing. These negative tracings are likely secondary to rectal contractions and are not considered an abnormal finding (a on Fig. 6.1).
Normal desire 352 mL.
Cystometric capacity was 651 mL.
The patient was asked to perform Valsalva maneuvers during this examination, which did not recreate his symptoms. The points at which he performed Valsalva are characterized by the sharp rise in intra-abdominal, intravesical pressure and flat P _det tracing (b on Fig. 6.1). The EMG tracing correlates with the Valsalva maneuvers suggesting the presence of sphincteric activity (c on Fig. 6.1). Bladder compliance was normal and P _det at capacity was 9 cm/H₂O. After catheter was removed, with Valsalva, the patient did have incontinence.

Voiding Phase

Q _max was 35 mL/s and average flow was 17 mL/s.
At p _Det, Q _max was 21 cm/H₂O.
Shape of the flow curve appears to be a normal bell curve.
Total voided volume was 720 mL and PVR was 0 mL.

In summary this patient’s UDS showed that he has normal bladder sensation, a normal bladder capacity, and normal compliance. Urodynamic stress incontinence was not demonstrated in the study; however, it had been demonstrated in physical exam. This can occur during UDS in postprostatectomy patients who may have decreased urethral compliance in addition to the urethral catheter used during the exam. This can be explained in this patient by the discrepancy in his preprocedure uroflowmetry (Q _max = 44 mL/s) and his voiding phase during UDS (Q _max = 35 mL/s). He does demonstrate a low detrusor pressure at Q _max; however, this does not reflect a poorly contractile bladder as the urethral resistance may be diminished in a patient with stress incontinence secondary to intrinsic sphincter deficiency.

6.4.1.5 Treatment Options

Penile clamping device
Periurethral bulking agents
Male sling
AUS

Being that he expressed a significant amount of distress over his symptoms, male sling and AUS were offered as the best option for success. In this patient with mild to moderate stress incontinence, no history of radiation, demonstrable stress incontinence on exam, and adequate bladder contractility, he was a good candidate for either procedure. When given the option, most patients with postprostatectomy incontinence choose to undergo placement of male sling to avoid a mechanical device [24]. He elected to undergo placement of an AdVance™ transobturator sling . Postoperatively, he passed his void trial and his PVR was 0 mL. He has remained continent 2 years postoperatively, does not use pads, and has not undergone secondary procedures.

6.4.2 Patient 2

6.4.2.1 History

This patient is a 65-year-old gentleman with a chief complaint of urinary incontinence following a radical prostatectomy 2 years prior to referral. His symptoms occurred exclusively when he coughed, sneezed, lifted heavy objects, or performed any moderate amount of activity. At night he used a safety napkin and he used three napkins on a daily basis (only used napkins rather than pads). He had no other lower urinary tract symptoms and past medical history was significant for a herniated lumbar disk. Prior to referral, he had tried Kegel exercises and utilized a penile clamp ; however, he had unsatisfactory results with both. On follow-up, he completed 1 day of a voiding diary notable for a morning void of 350 mL and did not find time to perform a 24-h pad test.

6.4.2.2 Physical Examination

General: no acute distress, appearing his stated age.
Psychologic: no signs of depression.
Neurologic: normal gait and sensory examination.
Cardiovascular: no labored breathing or extremity edema.
Abdomen: soft, nontender, nondistended, well-healed incision.
Genitourinary: napkin with urine spotting, a circumcised phallus without lesions or plaques. The testes were descended bilaterally, firm, nontender, and without masses, and there were no inguinal hernias bilaterally. Digital rectal exam revealed normal sphincter tone and an empty prostatic fossa. He was asked to perform a Valsalva maneuver and as a result he leaked several drops of urine.

6.4.2.3 Labwork/Other Studies

PSA was undetectable.
UA and urine culture negative.
PVR 0 mL.
Cystourethroscopy was performed, notable for the absence of urethral stricture, bladder neck contracture, and no abnormalities were noted along the bladder mucosa. Able to contract EUS.

6.4.2.4 UDS

See Fig. 6.2.

Fig. 6.2

Patient 2: urodynamics tracing prior to transobturator sling

Findings

The patient underwent urodynamics to continue his evaluation; however, throughout the exam he was quite uncomfortable and did not tolerate bladder filling.

Filling Phase

First sensation 100 mL.
First desire to void was noted at 207 mL.
Normal desire to void occurred a t 224 mL.
DO noted.
SUI (SUI noted without catheter on initial exam). No UUI noted.
Cystometric capacity was 247 mL.

Voiding Phase

During the voiding phase, a Q _max of 17 mL/s was obtained with a P _det of 18 cm/H₂O at Q _max. There was a normal bell curve during the voiding phase, and the patient’s PVR was 14 mL. It is also important to note the absence of high abdominal pressures during the voiding phase, suggesting the patient does not normally perform a Valsalva maneuver to void.

In summary this patient’s UDS demonstrated normal compliance, detrusor overactivity , and reduced bladder capacity. The utility of a voiding diary becomes evident in this patient’s case. His first morning void was approximately 375 mL, suggesting that functional capacity was not represented in the examination (likely from discomfort). Additionally, detrusor overactivity was noted during the examination although he did not complain of urinary urgency and frequency. The presence of detrusor overactivity is not unusual in postprostatectomy patients and is reported to be as high as 40 % of postprostatectomy patients during UDS [13, 15].

6.4.2.5 Treatment Options

Penile clamping device
Periurethral bulking agents
Male sling
AUS

This patient elected to undergo placement of an AdVance™ male sling. Postoperatively he had complete resolution of his stress incontinence and did not require the use of pads. He was able to void without difficulty and his PVR was 0 mm. Unfortunately, the patient presented after 2 years with recurrent stress incontinence for which he resumed using sanitary pads. He also complained of increased urinary frequency (voiding up to 15 times daily), urinary urgency, and nocturia. On his voiding diary, it was noted he was drinking approximately 1 L of herbal tea and coffee in addition to water and 3–4 glasses of wine after dinner. After behavioral modification including fluid restriction, caffeine restriction, and decreasing alcohol consumption, his OAB symptoms improved. He did continue to experience stress incontinence and he underwent videourodynamics as part of his new evaluation.

6.4.2.6 UDS

See Fig. 6.3.

Fig. 6.3

Patient 2: urodynamics tracing after treatment failure with transobturator sling

Filling Phase

First sensation was noted at 92 mL.
First desire at 147 mL.
Normal desire at 207 mL.
Cystom etric capacity at 313 mL.
No DO noted.
Bladder compliance was normal.
VLPP was measured at 90 cm/H₂O (volume 255 mL), as this was the lowest intravesical pressure where he leaked.

Voiding Phase

Q _max was 17 mL/s.
P _det at Q _max = 39 cm/H₂O.
Total voided volume was 246 mL and PVR was 66 mL. On fluoroscopy his bladder had a normal contour and leakage was noted as contrast passed alongside the catheter. As he voided there was funneling of the bladder neck and kinking at the location of the sling.

In summary, the second UDS showed resolution of his detrusor overactivity seen on his prior study, stress incontinence with an abdominal leak point pressure of 90 cm/H₂O, and a nonobstructed bladder outlet (bladder outlet index = 5).

6.4.2.7 Treatment Options

Periurethral bulking agent
Repeat male sling
AUS

For patients who have failed surgical management with a male sling and continue to have continued stress incontinence, a repeat urodynamics is warranted. One needs to reassess bladder compliance, detrusor function, and rule out obstruction. Prior to subjecting the patient to a second procedure, further investigation is warranted to treat any underlying etiology to mixed urinary incontinence. Furthermore, videourodynamics (Fig. 6.4a,b) can be utilized to visualize the degree of mobility in the proximal urethra, sling placement, and examine the contour of the bladder. After the appropriate workup is obtained, patients who fail therapy with a male sling can be considered for placement of an AUS. Several studies have reported promising outcomes and patient satisfaction after a failed male sling [29, 30].

Fig. 6.4

(a, b) Fluoroscopic images for patient 2 captured during videourodynamics prior to undergoing implantation of artificial urinary sphincter. Both images capture funneling of the bladder neck and urethral kinking likely caused by the transobturator sling

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