Urinary Incontinence Post Radical Prostatectomy

Male Urinary Incontinence

Urinary incontinence is the accidental leakage of urine. It can affect men of any age, although it becomes more common as men get older. It is not something men simply have to put up with - in most cases the cause can be identified and the leakage improved or resolved with the right treatment⁶.

The main types of incontinence seen in men are:

• Stress incontinence - leakage with coughing, sneezing, laughing, lifting or exercise. In men this is most often related to prostate surgery, particularly radical prostatectomy, and occasionally surgery for an enlarged prostate.
• Urgency incontinence - a sudden, strong need to pass urine with leakage before reaching the toilet. This is usually part of an overactive bladder.
• Mixed incontinence - a combination of stress and urgency leakage.
• Overflow incontinence - the bladder does not empty properly and constantly dribbles. In men this can be caused by obstruction from an enlarged prostate (BPH).
• Post-micturition dribble - a small leak of urine just after finishing passing urine, caused by urine pooling in the urethra.

Assessment of Male Incontinence

Because each type of incontinence is treated differently, an accurate diagnosis comes first. Assessment typically includes a detailed history (including how many pads are used per day), a bladder diary, a urine test, a flow rate test, and an ultrasound to check how well the bladder empties⁶.

Where the picture is mixed or unclear, or before considering surgery for incontinence, urodynamics - a pressure study of the bladder - helps confirm exactly what the bladder and sphincter are doing.

Treating Stress Incontinence in Men

Stress incontinence in men is usually caused by weakness of the urinary sphincter, most often after prostate surgery. Treatment depends on how much leakage there is (often measured in pads per day), how long it has been present, and how much it is affecting your life. Conservative measures come first; surgery is considered when leakage persists despite them.

Pelvic floor exercises

Pelvic floor muscle training is the first-line treatment for stress incontinence in men⁶. The pelvic floor muscles support the bladder and urethra, and strengthening them improves urinary control. The exercises only work if they are done regularly and correctly, so supervised teaching by a continence physiotherapist or continence advisor gives the best results. Before prostate surgery, patients are taught the exercises in advance so they are familiar with them during recovery. A printable exercise guide for men is in the brochures section below.

AdVance male sling

The AdVance sling^3,7 is a synthetic mesh sling placed under the urethra through a small incision in the perineum, usually as a day procedure. It repositions and supports the urethra so the sphincter can work more effectively. It is best suited to men with mild stress incontinence - typically one to two pads a day - and a sphincter that still has some function. Possible risks include temporary difficulty passing urine after the operation, perineal discomfort, infection, and the chance that leakage is not sufficiently improved, particularly in men who have had radiotherapy.

ATOMS adjustable device

The ATOMS device (Adjustable TransObturator Male System)⁸ is another option for mild to moderate stress incontinence. Like a sling, it is placed under the urethra through a perineal incision, but instead of a fixed strap it uses a small fluid-filled cushion connected to a port under the skin. The amount of support can be adjusted in the consulting rooms after surgery - by adding or removing fluid through the port - without a further operation. This adjustability is useful when the degree of leakage changes over time. A published systematic review reports that the majority of men are dry or significantly improved after ATOMS placement⁸. Possible risks include perineal discomfort (common in the early weeks), infection, erosion of the device, and the need for removal or revision in a minority of patients.

Artificial urinary sphincter

For moderate to severe stress incontinence, or where a sling is not suitable, the artificial urinary sphincter^4,5 remains the standard surgical option. A small fluid-filled cuff is placed around the urethra, with a pump in the scrotum and a reservoir in the abdomen, all hidden under the skin. The device and the operation are described in detail in the post-prostatectomy section below and on the dedicated artificial sphincter page, including results, risks and recovery.

Treating Urgency Incontinence and Overactive Bladder

Urgency incontinence is managed along a stepped pathway: simple measures first, then medication, then advanced therapies if needed⁹. The full pathway is described on the overactive bladder page; a summary of each step follows.

Bladder training and lifestyle measures

First-line treatment is non-surgical. Bladder training involves voiding to a clock at gradually lengthening intervals, with urge-suppression techniques (deep breathing, a pelvic floor squeeze, distraction) when an urge arrives early. Alongside this, fluid intake is reviewed, bladder irritants such as caffeine and alcohol are reduced, constipation is managed, and pelvic floor exercises are taught⁹. A printable bladder training leaflet is in the brochures section below.

Medication

If symptoms remain bothersome after a fair trial of bladder training, tablets that calm the bladder are added⁹. Two classes are used: anticholinergics (for example oxybutynin or solifenacin), which can cause dry mouth, constipation and, particularly in older patients, cognitive side effects; and the beta-3 agonist mirabegron, which avoids those side effects but can raise blood pressure. Medication is reviewed after about eight weeks, and the two classes can be combined if a single agent is not enough.

Botox injections into the bladder

Botulinum toxin-A (Botox) injected into the bladder wall reduces the involuntary bladder contractions that drive urgency¹⁰. It is given through a cystoscope as a day procedure. The effect typically lasts around six to nine months, after which treatment can be repeated. The main risks are urinary tract infection and incomplete bladder emptying, which can require temporary self-catheterisation - patients are counselled about this before the procedure. A patient brochure is in the resources below. Botox treats urgency incontinence; it does not help stress incontinence.

Nerve stimulation - peripheral and central

Two forms of nerve stimulation are recognised options when bladder training and medication have not controlled urgency incontinence⁹:

• Peripheral - percutaneous tibial nerve stimulation (PTNS). A fine needle electrode near the tibial nerve at the ankle delivers low-level stimulation that travels to the nerves controlling the bladder. A standard course is 12 weekly 30-minute sessions, followed by less frequent maintenance sessions in responders¹¹. It is well tolerated, with no implant and no systemic side effects; the main consideration is the time commitment of the weekly visits.
• Central - sacral neuromodulation (sacral nerve stimulation). A thin lead is placed next to a sacral nerve root in the lower back and connected to a small pacemaker-like device implanted under the skin of the upper buttock. It is done in two stages: a test phase with an external stimulator first, and a permanent implant only if the test produces a clear improvement¹². Risks include discomfort at the implant site, lead movement, infection, and the need for revision or battery replacement over the lifetime of the device.

Urinary Incontinence Post Radical Prostatectomy

Urinary incontinence post radical prostatectomy is a very important issue.

The important thing is to try to minimise the impact of your incontinence by doing a very accurate and precise operation.

A new innovation is to perform a pelvic floor reconstruction² at the time of surgery, which improves early continence.

Patients are taught pelvic floor exercises prior to surgery, so they are familiar with these exercises, and don't have to learn them after a surgery, so usually at a week after surgery I start patients on pelvic floor exercises.

They see a continence advisor to make sure that they're using these properly.

Patients can expect some degree of leakage which is quite variable.

It takes on average about 10 or 12 weeks for this to come good, but can take up to a year in some patients.

If they still have incontinence issues a year following surgery, we can look at additional treatments.

A new, relatively minimally invasive treatment is called an AdVance Sling³.

This is a synthetic sling, usually inserted as a day procedure.

It supports the urethra, and is very good for patients that have minimal incontinence of one to two pads a day.

If patients have more incontinence than this, and is a concern affecting their lifestyle, they can have an artificial sphincter inserted.

This is a synthetic cuff that's inserted around the urethra, and there's a pump in between the testes and the scrotum which is not visible.

The patients squeeze this pump, and the cuff that's around the urethra then deflates as fluid gets taken away from this cuff.

Patients then go and pass urine, and this remains deflated for approximately two minutes, and then auto-inflates and blocks off the urethra.

This procedure is a short, one hour procedure, done through a small two to three centimetre incision.

This device has an approximately 95% success rate⁴, so patients can be rest assured that even if they have an extreme outcome with surgery, that there is a good treatment that's available for them, in the form of an artificial sphincter which will give them a very high chance of a successful patient outcome⁵.