Strong pelvic support
Preoperative urinary incontinence
Prior radiation therapy
While preoperative risk factors may be important in counseling patients prior to radical prostatectomy, they actually play little role the evaluation and management of PPI, with the exception of prior radiation therapy. Radiation can influence the type of evaluation done and the type of treatment recommended.
Influence of Surgical Techniques
The surgical technique utilized to perform a prostatectomy has been evaluated with respect to effect on rates of incontinence. Factors such as perineal vs. retropubic surgical approach [34–36], robot-assisted laparoscopic prostatectomy (RALP) vs. open retropubic [37–41], bladder neck preservation [42, 43], and nerve sparing [44–50] have been reported by some to improve continence, while others have found no difference. Table 2.1 summarizes some of the risk factors for PPI.
As with preoperative risk factors, surgical technique of radical prostatectomy plays little role the evaluation and management of PPI once it is established that the patient has incontinence and is seeking intervention.
Evaluation of Post-prostatectomy Incontinence
The approach to the initial evaluation of a patient with PPI is similar to that of any patient with incontinence, in that a careful evaluation of the quality and quantity of the incontinence should be determined, along with the effect on quality of life for the individual patient.
General Medical History
Age, as mentioned previously, should frame the clinician’s understanding of the individual patient’s problems and likelihood of long-term continence . The time interval since RP should also be determined, given the time-dependent nature of return to continence (see Incidence).
Additional interventions for treatment of prostate cancer should also be determined. A history of radiation therapy, or current or future treatment of metastatic or locally recurrent disease may influence evaluation, timing, or type of treatment . Prior surgeries, especially involving the pelvis, and radiation therapy for purposes other than treatment of prostate cancer should be determined. The current stage and status of prostate cancer should be elicited.
Other medical conditions should be evaluated. For example, a neurogenic bladder can result from a history of trauma or surgery, and should be on the differential, if present .
Medications should be reviewed. Certain medications act directly on the GU tract and affect continence, for example alpha-adrenergic blockers can decrease urethral tone and can contribute to urinary incontinence, and anticholinergics may inhibit detrusor contractility. Other medications may indirectly contribute to UI, such as angiotensin-converting enzymes that can cause a chronic cough (exacerbation of SUI) and diuretics that increase voided volumes, which can exacerbate symptoms of urgency and frequency .
Finally, an evaluation of the patient’s overall health and performance status is important when considering therapy. Elderly patients are more likely to be on multiple medications, and so careful assessment of potential drug interactions is important when initiating new drug therapy aimed to treat UI. In addition, anticholinergic medications can have significant effects on cognition in the elderly patient, and decision to treat with this medication should be made based on a risk–benefit assessment. There are limited studies evaluating the success or complication rates following operative intervention, however it is generally recommended to ensure that the benefit outweighs any operative risk and to ensure patients have sufficient performance status to recover well from a surgical intervention . For an artificial urinary sphincter (AUS), for example, a patient must have sufficient hand dexterity and strength to use the device.
The evaluation of a patient with post-prostatectomy incontinence should begin with an assessment of the patient’s general medical history. This includes age, time interval since prostatectomy, additional prior interventions for treatment of prostate cancer, other medical problems, and medication history. Importantly, the patient’s performance status and overall health should frame clinician counseling on intervention options.
Characterization of Incontinence and Other Lower Urinary Tract Symptoms
Characterization of the quantity and type of the UI and the circumstances under which it occurs are important to help elucidate the cause and the severity of the symptoms.
It is important to determine whether the patient considers the incontinence to be stress-related (involuntary loss of urine with activity, cough, or other event that increases intra-abdominal pressure) urgency-related (involuntary loss of associated with urgency), or a combination of both . If both are present it is important to try to determine which is more predominant and more bothersome. Sometimes patients are unable to express if urine loss is caused by activity or urgency. Incontinence can be insensible (occurring without stress or urgency) or may require more pointed questions as to when incontinence occurs (exactly what the patient is doing during incontinence episodes). In addition, a gravitational component to UI can increase suspicion for sphincteric incompetence as the underlying cause if UI worsens with sitting to standing or while standing, as compared to UI while lying down. Focusing on specific activities that cause or increase incontinence can be especially helpful for the patient with rare UI, where it is difficult to characterize the incontinence in great detail. A study by Mungovan et al. found that the activities that most commonly provoke urinary leakage in post-prostatectomy patients were walking at a comfortable speed and drinking fluids while seated . Identifying the precipitating factors in an individual patient can help the clinician determine the type of incontinence present, and ultimately the intervention that would be most beneficial. Also, some patients will complain that incontinence worsens towards the late afternoon or evening hours. When not associated with urgency, this is thought to occur as a result of “sphincter fatigue” in patients with underlying sphincteric dysfunction. Some patients will experience incontinence due to sexual arousal or orgasm. We believe this is mostly due to sphincteric insufficiency. It can be difficult to manage when it is the only time that a man experiences incontinence.
It is also very important to determine the severity of the incontinence. This is commonly done on an objective basis by assessing pad usage (see below). For patients with more severe incontinence, we find it useful to ask if they are able to voluntarily void at all when they are active. If the answer is no, it is usually a sign of severe sphincteric insufficiency.
With respect to other LUTS, we find it helpful to determine the presence of any overactive bladder symptoms (urinary frequency and urgency not related to incontinence) and nocturia. This knowledge can help to set reasonable expectations from treatment. Also the force of the urinary stream and subjective voiding pattern can be helpful to know. When decreased or abnormal, it may raise the suspicion of a stricture. However, some men who are totally incontinent will report very poor stream because they actually never void significant amounts. For these patients, it can be useful to ask about voiding when they get up from bed with a relatively “full” bladder.
Overall, the patient’s degree of bother related to urinary incontinence should be determined, as this will ultimately influence the patient’s decision on pursuing further treatment or continuing conservative management. Relevant questions pertaining to the patient’s history are summarized in Table 2.2.
Patient history questions
Mobility and activity?
Time since surgery
Type of surgery
Interventions following surgery (medical or surgical)
Prior abdominal or pelvic surgery
Other medical problems?
Constipation or fecal incontinence?
Characteristics of controlled voiding
Force of stream
Emptying bladder to completion
Characteristics of incontinence
Stress and/or urgency
Awareness of leakage (insensible)
Frequency of leakage
Degree or volume of leakage (number, size, wetness of pads)
Precipitating events or activities
Pattern of incontinence (day versus night)
Degree of bother
Characterization of the subjective type and degree of incontinence as well as any other LUTS is important as it may prompt further testing prior to intervention and can sometimes have a profound effect of the type of treatment offered .
The physical examination in the man with PPI should include several facets. The abdominal exam should include evaluation of the surgical scar. Palpation of the bladder in the lower abdomen should be performed to rule out a distended bladder to point towards an obstructive process. A digital rectal examination (DRE) will aid in assessment of rectal tone to help evaluate for neurologic factors, as well as a neurological examination of the perineum and lower extremities . The most important part of the exam is the evaluation of the perineum, genitalia and stress testing for incontinence. A full genital examination should be performed. The quality if the skin of the scrotum and perineum should be evaluated. The patient should be observed for gravitational incontinence and then asked to cough or bear down to evaluate for stress urinary incontinence . If the patient admits it incontinence with certain maneuvers (e.g., bending) he should be asked to perform such maneuvers especially if stress incontinence is not otherwise demonstrated. If the patient is wearing a protective pad, the wetness and size of the pad can be assessed during the physical exam. Though rare, meatal stenosis and phimosis can occur after prostatectomy, and should be ruled out as a cause of obstruction on examination .
The physical exam should include an abdominal exam and a full genital exam. In addition, assessment for stress urinary incontinence, including provocative maneuvers that cause incontinence elicited from the patient history, should be performed.
Voiding Diaries and Questionnaires
A voiding and intake diary (bladder diary) is an objective way for patients to describe both frequency and volume of voids, and is designed to include a description of episodes of urinary leakage, fluid intake, and the presence and degree of urgency associated with leakage over a 3–7 day period . The use of bladder diaries in the context of PPI is primarily of use when patients have significant urge UI, and are an inexpensive way to objectify the symptoms for the clinician to interpret . It provides information on the patient’s voiding patterns and can shed light on bladder capacity. It can also identify excessive fluid intake . Bladder diaries can be used to monitor changes in urge-related incontinence symptoms, whether over time or following an intervention, and for this reason are useful for measuring outcome .
Drawbacks to the use of diaries include patient difficulty in completing them accurately and in a timely manner, which increases as the number of days recorded increase. Also, urinary leakage that occurs less than once daily will have a limited ability to be represented. The Fifth International Consultation on Incontinence (ICUD) provided recommendations in their Incontinence text in 2013 in which they give a grade C recommendation (based on expert opinion) for the use of bladder diaries in the initial evaluation of patients with PPI to help communicate voiding patterns .
Questionnaires are another useful tool to objectively measure symptoms and their influence on quality of life, and are a more commonly utilized tool in patients with PPI. There are many available questionnaires that can be focused on symptoms, measures of patient-reported outcomes, or influence on quality of life. Patients with obstructive symptoms can have their symptoms characterized by questionnaires such as the American Urological Association score for BPH (AUA-7) , and the International Prostate Symptom Score (IPSS) . Patients with urgency symptoms can be better assessed with the International Consultation on Incontinence Modular Questionnaire (ICIQ) . The European Association of Urology published guidelines on management of urinary incontinence in 2014 where they provided a grade B recommendation (based on well-conducted clinical nonrandomized trials) on the use of questionnaires as a way to provide a standardized assessment of voiding symptoms .
For the patient with PPI, voiding and intake diaries and questionnaires are not an essential part of the evaluation in routine clinical practice for all patients. Diaries are most useful when there are complaints of overactive bladder symptoms, nocturia or nocturnal enuresis as a predominant complaint (especially if daytime incontinence is minimal). Diaries may also be useful in cases where excessive fluid intake is suspected. Questionnaires are most beneficial in the research setting, but can be useful when trying to differentiate stress for urgency incontinence in cases where direct questioning is less conclusive ( e.g., the MESA questionnaire) .
Pad Usage and Pad Tests
Determining the number of pads a patient with PPI requires has been shown to affect patient’s perception of degree of severity of incontinence. Fowlers et al. found that patients who wore pads were more likely to report urinary leakage as a medium or big problem than those who did not require pads but still reported urinary leakage . The number of pads required also influences patient perception of continence. Sacco et al. showed that patients requiring one pad daily consider themselves continent and have good perception of health-related QoL (HRQoL) , while requirement of two or pads daily had worse HRQoL outcomes, and patients were less likely to consider themselves continent .
Pad tests are often used to help evaluate the relationship between the patient’s sensation of urinary leakage and the actual volume of urine leaked. Several studies have shown that quantifying incontinence by pad weights or pad number can predict outcomes of certain interventions . We believe that a 24-h pad test is the gold standard objective measurement of PPI. The number of pads is not a perfect measure of leakage, as some patients will tolerate a saturated pad prior to changing, while others may change pads frequently with even mild leakage. In addition, there is variability in the size and type of pad . Tsui et al. showed that the severity of incontinence was not related to the number of pads used, but better correlated to the pad weight, and recommends that pad weight be used rather than pad count alone . However, there is evidence that a pad test may not be absolutely necessary to quantify the degree incontinence, provided that patients can accurately express the size, number and wetness of the pads that they use. In a prospective study conducted by the SUFU foundation, patient perception of number of pads required on a daily basis correlated well with actual number of pads collected during pad testing over a 24-h period. When patients were asked, “to what extent does urine loss affect your quality of life?” with options not at all, small amount, moderate amount and significant amount, they were stratified into four groups which were shown to be different in the number of pads required . The study concluded that a pad test might not necessary to accurately determine the severity of PPI, if carefully collected prospective information about incontinence is obtained.
We believe that an accurate assessment of the degree of incontinence is important before recommending certain interventions. The literature would support the premise that sling procedures are less effective in cases of severe incontinence. How one assesses the degree of incontinence will vary depending on the clinical scenario. If a patient wears multiple extra large pads/day ( i.e., diapers) and admits that they are always wet to soaked, that may enough to conclude that incontinence is severe. Conversely if the patient is wearing one extra small or small pad per day incontinence is likely mild (or moderate at the worst). However the majority of patient fall between these two extremes. In such cases formal pad testing, or a least an accurate assessment of pad number, size and wetness is recommended.
Simple Diagnostic Studies
A urinalysis is generally recommended as an initial diagnostic study for patients with urinary incontinence to rule out an infectious cause, along with a urine culture . In addition, older men are at risk of diseases of the bladder such as bladder cancer, carcinoma in situ, bladder stones, and urethral strictures, often presenting with overactive bladder symptoms, which can be reflected in hematuria or pyuria. Performing a urinalysis can help rule out some of these causes of UI . The EAU provides a grade A recommendation (based on clinical studies of good quality) for routinely performing a urinalysis .
A post-void residual (PVR) helps assess for incomplete emptying and obstruction as a cause of voiding symptoms. The Canadian Urological Association (CUA) published guidelines on adult UI in 2012 and provides a grade A recommendation (based on clinical studies of good quality) to include a PVR as part of the routine assessment . The American Urological Association also recommend in their guidelines on the surgical management of SUI, updated in 2009, to perform a PVR as an essential part of the patient evaluation . There are not specific values associated with abnormal PVRs , however it provides the clinician an understanding of the patient’s ability to empty their bladder, which can be related to symptoms. The ICUD recommends that a PVR of greater than 200 mL should be considered a sign of an obstructive urinary problem . Uroflowmetry, similar to assessment of PVR, is useful in assessing for obstructive urinary patterns .
Routine assessment of bladder emptying is important in the evaluation of PPI. This is most easily accomplished by determination of a post void residual (or random check of bladder volume in a patient with severe incontinence who does not void). This is most commonly done by a bladder scan ultrasound. Uroflow is generally reserved for patients who complain of some emptying symptoms (incomplete emptying or slow stream ).
Imaging for PPI
Differences on imaging have been shown to exist between patients with and without incontinence following a prostatectomy. These studies have been performed to help elucidate causes of PPI, rather than helping evaluate degree or outcomes of urinary incontinence. Tuygun et al. performed pelvic magnetic resonance imaging (MRI) on patients following prostatectomy and found that patients with PPI had a higher incidence of fibrosis, thereby concluding that fibrosis plays a key factor in the pathogenesis of PPI .
Paparel et al. studied the change in urethral length on preoperative and postoperative pelvic MRIs in patients undergoing radical prostatectomy and found that membranous urethral length loss was associated with incontinence, and recommend preservation of this length intraoperatively to help improve continence .
In clinical practice, imaging does not have a significant role in evaluating PPI and predicting treatment outcomes unless other pathologies are being excluded, for example fistulae or underlying cancerous processes . The most common form of imaging is the voiding cystourethrogram done as part of videourodynamics. While this can provide a very accurate anatomic assessment of the lower urinary tract, it has not been found to be superior to standard urodynamics in a head to head trial.
Urodynamic studies (UDS) remain the gold standard for diagnosing the type of incontinence in patients post-prostatectomy. However, it is not always a requirement to perform in the setting of PPI. Urodynamics can be used to diagnose bladder dysfunction such as detrusor overactivity or decreased compliance and the capacity of the bladder. It can also be used to determine the abdominal leak point pressure (ALPP) , which, in men following a prostatectomy, is primarily related to sphincteric incompetence .
It is important to note that urodynamics may not serve to predict outcome following intervention, but serve to diagnose the type of incontinence present. Thiel et al. failed to find a urodynamic parameter that would identify those patients who failed artificial urinary sphincter (AUS) placement, with failure defined as requiring one pad or more following placement . Similarly, ALPP may provide an “objective measure” of urethral resistance to an increase in abdominal pressure but fails to predict surgical outcomes . Twiss et al. evaluated 29 patients with SUI following prostatectomy and found that ALPP on UDS failed to correlate with their degree of urinary incontinence, as determined by the 24-h pad test. They concluded that ALPP has limited clinical value in the setting of PPI management, and recommend focusing on the presence or absence of SUI and bladder dysfunction during urodynamics to guide management and diagnosis .