Treatment Options for Incontinence After Prostatectomy

Initial Conservative Management

Pelvic floor muscle exercises (PFME) or pelvic floor muscle training (PFMT) should be offered in the immediate post-operative period to improve time-to-achieving continence 2
Conservative management is the first-line approach for post-prostatectomy incontinence and should be tried for at least 6 months before considering surgical intervention 2
For bothersome climacturia (orgasm-associated urinary incontinence), initial conservative measures include emptying the bladder prior to sexual activity, wearing condoms, using a penile variable tension loop, and implementing PFME/PFMT 3

Any symptomatic vesicourethral anastomotic stenosis (VUAS) or bladder neck contracture (BNC) must be treated before surgical correction of incontinence 4
Surgery may be considered as early as 6 months if incontinence is not improving despite conservative therapy 2

Artificial urinary sphincter (AUS) is specifically recommended for patients who have undergone radiation therapy rather than male slings or adjustable balloons 1
Patients should be counseled that the AUS will likely lose effectiveness over time, with failure rates of approximately 24% at 5 years and 50% at 10 years 5

For persistent or recurrent incontinence after AUS placement, evaluation should include history, physical examination, cystoscopy, and possibly cross-sectional imaging 5
Options for AUS failure include proximal relocation or downsizing of the cuff, or tandem cuff placement 6
For patients with persistent incontinence after male sling, an artificial urinary sphincter is recommended 3
If an AUS device becomes infected, it should not be replaced for at least three months to allow infection clearance 1

For patients with both incontinence and erectile dysfunction, concomitant or staged procedures may be offered to address both conditions 3
Urinary diversion with or without cystectomy may be considered in patients unable to obtain long-term quality of life with an AUS due to multiple device failures, intractable bladder neck contracture, or severe detrusor instability 7

Advanced patient age, larger prostate size, and shorter membranous urethral length are consistently associated with increased risk of incontinence after prostate treatment 2
Patients undergoing TURP after radiation therapy or radical prostatectomy after radiation therapy should be informed of the high rate of urinary incontinence following these procedures 2