Evaluation and Management of Urinary Incontinence in Men

Initial Assessment and Diagnosis

The American Urological Association recommends beginning with a focused history and physical examination to categorize the type of incontinence and assess severity and bother, before proceeding with additional testing 1, 2
A thorough history should include symptom characterization to differentiate between stress and urgency incontinence, as well as assessing the degree of bother and impact on quality of life 1, 2, 3
The history should also address medical comorbidities, such as medications and lifestyle habits that may contribute to incontinence, and prostate treatment history 2, 4, 5
A systematic physical examination, including suprapubic area assessment, external genitalia examination, and digital rectal examination, is essential to evaluate for reversible causes and identify anatomical abnormalities 2, 4

Urinalysis is essential to detect urinary tract infections, proteinuria, hematuria, or glycosuria that require further investigation 2, 4
A frequency-volume chart or bladder diary should be obtained for at least 3 days to document urinary patterns and assess nocturia 2, 6
Post-void residual measurement is necessary to identify overflow incontinence and assess bladder emptying efficiency 2, 6
Urodynamic studies should be considered when the type of incontinence cannot be definitively determined, or when surgical intervention is being considered 1, 7

Men with incontinence following prostate surgery or radiation require specific evaluation, including assessing the timing of incontinence, differentiating between urgency and stress incontinence, and evaluating radiation history 1, 3, 5, 7
Up to 48% of men develop overactive bladder symptoms after prostate treatment, which requires different management 1, 3

The European Association of Urology recommends referring patients to urology if they present with hematuria, recurrent urinary tract infections, neurological disease, severe obstruction, abnormal PSA, or persistent incontinence after 6 months post-prostate surgery despite conservative therapy 4, 5, 6

Cystourethroscopy should be performed prior to any surgical intervention to assess for urethral stricture, bladder neck contracture, or bladder pathology that may affect surgical outcomes, as recommended by the American Urological Association 8
Urodynamic studies should be considered when the type of incontinence cannot be definitively determined from history/exam, when surgical intervention is planned, or for refractory retention after 2 failed voiding trials to differentiate detrusor underactivity from outlet obstruction, with a strength of evidence rated as moderate 9, 8

For stress urinary incontinence, surgical options such as artificial urinary sphincter (AUS) and male slings should be considered if conservative measures fail, with AUS being the gold standard but having failure rates of approximately 24% at 5 years and 50% at 10 years, as reported by the American Urological Association 10, 9
Urethral bulking agents may be considered for patients with stress urinary incontinence who are unable to tolerate more invasive surgery, although efficacy is low and cure is rare, with a strength of evidence rated as low 9, 8

Patients with recurrent urinary tract infections should be referred immediately to urology, as recommended by the American Urological Association 10
Patients with bladder neck contracture or urethral stricture should not proceed with incontinence surgery until the obstruction is treated, as it decreases surgical success rates, with a strength of evidence rated as high 11

Prompted voiding schedules and bladder training programs are recommended for patients with urgency urinary incontinence, particularly those with cognitive impairment, as per the American Heart Association, based on evidence from 2005 12
For patients with post-prostatectomy incontinence, artificial urinary sphincter is the recommended next step after failed male sling, according to the American Urological Association 13

Watchful waiting is an acceptable approach for patients with mild to severe symptoms of benign prostatic enlargement who are not bothered by them, provided no imperative indications for surgery exist, as recommended by the American Urological Association 14, 15
Alpha-blockers are recommended for symptom relief in patients with benign prostatic enlargement, with assessment of treatment success at 2-4 weeks, according to the American Urological Association 15

Recurrent urinary tract infections and severe obstruction are mandatory urology referral criteria, as per the American Urological Association 13, 14
Infected artificial urinary sphincter devices should not be replaced for at least 3 months to allow infection clearance, and options for AUS failure include proximal relocation or downsizing of the cuff, or tandem cuff placement, according to the American Urological Association 13
Urinary diversion with or without cystectomy may be considered for patients unable to obtain long-term quality of life with AUS due to multiple device failures, intractable bladder neck contracture, or severe detrusor instability, as recommended by the American Urological Association 13