Every year, nearly 50 000 men in the UK are newly diagnosed with prostate cancer, and this is the most commonly diagnosed cancer in men (Cancer Research UK, 2018). Radical prostatectomy, which is the surgical removal of the prostate, is a popular treatment option for patients in whom the cancer has not spread beyond the prostate (i.e. the disease is localised). Although curing the cancer is paramount, the survivor's quality of life can be negatively affected by urinary incontinence or erectile dysfunction after a prostatectomy. In order to support men with post-prostatectomy incontinence (PPI), medical and nursing staff should understand the multimodal nature of treatment options, as well as which factors influence successful treatment outcomes and have a low side effect profile.
How common is PPI?
Most men will experience some urinary leakage immediately after their catheter is removed and in the first months after prostatectomy. Continence improves with time, but usually plateaus at 12 months after surgery (Parker et al, 2011). Long-term PPI rates vary in the literature from 11 to 69%, depending on patient and surgical factors as well as how the incontinence is defined and measured (Wei et al, 2000; Pompe et al, 2017).
Why does PPI occur?
After prostatectomy, stress urinary incontinence or urine leakage on coughing or exertion is often multifactorial. Men rely on the external urethral sphincter, the support of the pelvic floor and the length of the urethra to maintain bladder outlet resistance and continence. The functions of these components may be compromised by direct injury or via neuropraxia during prostatectomy. Importantly, some men have detrusor overactivity (and may therefore have symptoms of urinary frequency, urgency and nocturia), poor bladder capacity and reduced compliance, either as underlying conditions or as consequences of the surgery. Urodynamic testing is helpful in identifying the relative contribution of these factors, and it may direct a clinician to focus on treating the overactivity component of mixed PPI, which is defined as leak caused by a mixture of bladder overactivity and leak on exertion. Finally, risk factors such as older age (Kundu et al, 2004) and obesity (Ahlering et al, 2005) contribute to the development of PPI (Table 1).
| Risk Factor | Example |
|---|---|
| Preoperative continence status | Pre-existing detrusor overactivity, voiding dysfunction, small bladder capacity |
| Raised body mass index (BMI) | Especially body mass index >30 kg/m2 |
| Advancing age | Patient anatomy Large prostate volume, anatomic stricture, urethral length |
| Intraoperative considerations | Surgeon experience, surgical technique |
| Radiotherapy | Previous radiotherapy to the prostate or bladder |
Urine capture techniques
Various tools are available to capture leaked urine, for example, pads and various forms of catheters. Absorbent incontinence pads are typically available in the ‘liner’ and ‘diaper’ types (Figure 1). Alternatively, men may prefer to use absorbant pants, which may be single use or washable. Although all of these are popular options, there is some national variation regarding the availability of these products through the NHS, and some men choose to self-fund their preferred option (Fader et al, 2014).
Urethral catheters and urinary sheaths (external catheters) are another option, with leg bags available for discrete usage. However, indwelling urinary catheters have some disadvantages (Mitchell, 2008), and all catheters are prone to bacterial colonisation, infections, encrustation, blockages and stone formation. Penile clamps are devices that externally occlude the penile urethra to prevent leakage of urine (Figure 2). The main drawback of these devices is occlusion of arterial flow to the penis if left clamped for too long (more than 4 hours). Careful patient selection, that is, men with good cognitive ability, manual dexterity and intact genital skin and sensation, is important if this method is to be employed (Barnard and Westenberg, 2015). Men often benefit from advice on how to protect their bedding or furniture from accidental leaks. Some choose to carry a portable urinal bottle or may benefit from a toileting aid.
A number of charities, such as Bladder and Bowel UK, offer independent advice to patients on products available via their website and helpline (https://www.bbuk.org.uk/). The continence product advisor website (https://tinyurl.com/y56pxy4o) is an excellent impartial venture supported by the International Continence Society (ICS) and International Consultation on Incontinence (ICI) that gives evidence-based advice on the plethora of products available and how they may suit different patients.
Management methods
Conservative measures are important in the treatment of PPI, but care should be taken that their use does not delay treatment of men with moderate to severe leakage. The European Association of Urology (EAU) recommends lifestyle interventions including maintaining a healthy weight, reducing fluid intake, timed voiding and avoiding caffeinated drinks (Burkhard et al, 2018). The latter are known bladder irritants, and reducing their consumption may relieve some symptoms of overactivity contributing to mixed PPI (Bauer et al, 2011).
Pelvic floor muscle exercises
Pelvic floor muscle exercises (PFMEs) have been established as a routine intervention immediately before and after prostatectomy (NICE, 2014). Specialist physiotherapists teach men to find and activate the muscles around the external sphincter rather than simply clenching the buttocks or thighs. Filocamo et al (2005) suggested that PFMEs result in an earlier return to continence following prostatectomy, although at 12 months postsurgery, the continence outcomes in the exercise and non-excercise groups converged. A more recent Cochrane review has highlighted conflicting results from trials that test PFMEs (Anderson et al, 2015). Nonetheless, PFMEs have the advantage of being safe to use and continue to be an attractive treatment option in the short term.
Pharmacotherapy
At present, there are no licensed medications to treat stress urinary PPI in the UK. Duloxetine works by inhibiting the re-uptake of noradrenaline and seritonin and is occasionally used by patients off licence. EAU guidelines advise that duloxetine may hasten recovery but not improve PPI rates and may be associated with significant side effects (Burkhard et al, 2018). Anticholinergic medications or beta-3-agonists are effective in treating detrusor overativity in men with mixed PPI. Similarly, botoxulinum toxin A (Botox) injections into the bladder may be an option if overactivity is proven on urodynamic testing. However, the efficacy of Botox usually lasts 6–12 months, and it requires repeated administration. It may also lead to urinary retention, so men must be aware of and accept the possibility of needing self-catheterisation.
Bulking agents
Cystoscopic injection of endourethral synthetic or autologous bulking agents may be effective in the treatment of mild PPI. However, evidence of the efficacy of this treament in male incontinence is scarce compared to female incontinence (Kirchin et al, 2012), and many agents used historically are no longer commercially available. While studies have suggested that men with mild stress incontinence following prostatectomy or transurethral resection of the prostate may benefit from bulking with agents such as Macroplastique® (a water-soluble polyvinylpyrrolidone gel), the quality of this evidence is poor (Imamoglu et al, 2005). Further, cohort studies have shown that repeated injections are often required and that the long-term continence rates are poor (Attar et al, 2008).
Male slings
Male slings can be used for the management of PPI as they re-position the urethra to allow the sphincter muscle to appose and close. Further, a direct compressive effect may also prevent leakage. Several mesh types, positions and anchors have been described for male slings (Meisterhofer et al, 2019). The AdVance XP male sling is a polypropylene mesh passed beneath the bulbar urethra and through the obturator foramen (Figures 3 and 4). It may be suitable for men with mild to moderate PPI who are otherwise not able to use an artificial urinary sphincter (AUS) due to lack of manual dexterity. Pre- or post-surgical radiotherapy may fix the position of the urethra and cause urethral atrophy, making affected individuals less attractive candidates for slings. While some studies have shown that slings significantly improve urine leakage and quality of life (Bauer et al, 2017), NICE guidelines state that slings should only be used as part of a well-conducted randomised controlled trial (NICE, 2014). The only trial comparing the AUS and sling is MASTER (Male synthetic sling versus Artificial urinary Sphincter Trial: Evaluation by Randomised controlled trial), and the publication of its results in 2020 are eagerly anticipated.
Artificial urinary sphincter
The AUS is a three-piece device comprising an inflatable cuff positioned at the bulbar urethra, a pump in the scrotum which is activated by the patient and a reservoir of fluid in the pre-vesical space. The device is accepted as the ‘gold standard’ for PPI management (Burkhard et al, 2018) but requires the individual to have good cognition and manual dexterity to operate it safely. Successful continence has been reported in around 80%–90% of users (Kowalczyk et al, 1989; Imamoglu et al, 2005). Risks such as device infection, erosion and mechanical failure are often offset by the user's desire to be dry and the very high patient satisfaction rates. Men with previous radiotherapy or poor bladder compliance or capacity may have a higher risk of complications, but can still benefit from significant improvement in continence. Once the patient is no longer able to use the device (e.g. due to loss of cognition or manual dexterity), the AUS can remain in situ and be ‘deactivated’, at which point the incontinence will return and containment measures may be employed.
Urinary diversion
Urinary diversion involves surgical alteration of the route of urine flow away from the urethra. This is major surgery with all the inherent risks and is usually reserved for men with intractable leakage who have failed to benefit from or who are not suitable for an AUS. In an ileal conduit, a segment of bowel is used to make a stoma to collect urine in a bag outside the abdomen (Figure 5). Alternatively, a catheterisable ‘Mitrofanoff’ channel provides a continent diversion option for select men.
Conclusion
A wide range of management methods are available to men with PPI, ranging from conservative methods to invasive surgical options. Other than the patient's wishes, the severity of leakage, patient convenience, aetiological factors such as the presence of detrusor overativity or radiotherapy and patient factors such as hand function and cognition all affect the choice of management method. The rate at which prostate cancer is being diagnosed is on the rise, and thus the demand for treatment of PPI among survivors will increase. Community and continence teams should be supported in terms of access to conservative treatment options. They should also be able to consult and refer to specialist tertiary centres, which can offer all options for surgical treatment of PPI.