Evaluation & Management of Post-Prostatectomy Incontinence

In this episode of BackTable Urology, Dr. Aditya Bagrodia discusses post-prostatectomy incontinence with UT Southwestern urologist Dr. Steve Hudak. Urinary leakage is very common after the post-prostatectomy catheter is removed. Although the majority of men will regain continence in the long-term, 10-20% will need further treatment for their incontinence.

First, Dr. Hudak emphasizes the importance of comprehensive incontinence evaluation in the clinic. He prefers to schedule two different appointments to make incontinent patients feel more comfortable; he will only take a good medical history in the first appointment and save the cystoscopy and more provocative maneuvers for the second appointment. Dr. Hudak's clinical evaluation consists of a variety of quality of life questions as well as specific questions about pad weight, pad quantity, and pad size.

Further incontinence treatment can be non-surgical or surgical. Among the non-surgical therapies, Dr. Hudak suggests Kegel exercises and pelvic floor physical therapy. Dr. Hudak encourages urologists to explore these non-surgical options with their patients first. When deciding to move onto surgical intervention, Dr. Hudak explains that the trajectory of improvement is more important than a generalized timeframe because surgery is most effective in the time period in which a patient’s progress plateaus.

Pelvic slings and the artificial urethral sphincter (AUS) are the two most common surgical techniques for resolving urinary incontinence. Urologists must take into account their incontinence patients’ medical status, progress, goals, severity of leakage, and age before deciding whether to place a pelvic sling or an AUS. Dr. Hudak notes that the AUS is preferable in patients with severe arthritis, patients who have received radiation therapy, and patients with gravity incontinence. Two possible complications with the AUS are infection and erosion, as the AUS is a mechanical device with a half-life of seven to ten years. The sling is preferable in patients with mild incontinence, as it is a less invasive surgical technique and has a minimal risk of infection.

In some cases, it is possible that post-prostatectomy patients will also need post-operative radiation, so it is crucial to time the incontinence surgery correctly. Dr. Hudak recommends performing sling surgery before radiation, but concedes that radiation treatment should not be delayed solely due to incontinence surgery. His rule of thumb is: perform surgery if radiation is presumed, but not planned. If he has to perform surgery after radiation therapy, he waits at least 3-6 months after radiation to do so, allowing his patients to restore to their baseline levels of health.