Podcast Transcript: Evaluation & Management of Post-Prostatectomy Incontinence

[Aditya Bagrodia]
All right. All right. So despite the fact that there's been tremendous progress, technological advances, and surgical management of prostate cancer, of course, stress incontinence is something that we see. And today, we're really hoping to dig in with Steve on some of the nuances, tips and tricks as we guide patients through the post-prostatectomy incontinence journey. So Steve, maybe I'll just start out with leading up to surgery, anything you recommend to surgeons performing prostatectomy in terms of prepping their patients for surgery?

[Steve Hudak]
Yeah, that's great. So I think expectation management is huge. It's not probably appropriate to overpromise outcomes from the beginning. I think it's important to prepare patients for, basically, the certainty of some degree of urinary leakage certainly immediately after catheter removal. And so that way their expectations are set, they're not surprised and disappointed if there is some leakage when the catheter comes out. And if they happen to be more continent than most, well, then they're going to be very pleased with that. So I think that trying to set the stage for quality of life expectations from the beginning are important.

But then I think it's very reasonable to not be doom and gloom about it. And let them know that over the course of the first six months to a year after the radical prostatectomy that the majority of men will regain continence to the degree of needing one pad per day or less. And it's probably only about 10 to 20% of men that will need further treatments for ongoing incontinence after radical prostatectomy.

So I think setting that stage early on, under-promise, over-deliver, but then not being too pessimistic with the long term and then probably concluding it with letting them know that if they are in that 10 to 20%, there are good, safe, well-tested and proven options both surgical and nonsurgical to improve that control, and secondarily, their quality of life.

[Aditya Bagrodia]
Perfect, perfect. Certainly in my end, I absolutely agree with that philosophy of trying to set realistic expectations, perhaps even under-promise and over-deliver, hopefully, and in addition I’ll have them start doing Kegel exercises. So I think here in our practice, typically patients are going to be doing Kegels, essentially, as soon as a catheter comes out and they're comfortable. You're going to see patients from the community, as well as internally, if they've been doing Kegels for 8 to 12 weeks without any meaningful improvement...what are your thresholds? What are your thoughts on pelvic floor physical therapy?

[Steve Hudak]
So I think that this is a resource that's very valuable. Unfortunately, it's not available in all communities. A good pelvic floor physical therapist that will work with an incontinent male can be difficult to find. And so certainly if there's one available at your practice or in your community, I think it is particularly important, especially if they seem to be struggling a little bit with the mechanics of pelvic floor physical therapy, obviously, it's hard without complex measuring devices to really know this...but you can try to assess if they really have captured the physical aspect of a Kegel. It's a foregone conclusion that guys will just know how to do it, but if they seem to be struggling with it, I think in this group it's particularly helpful. So if you have the combination of, like you said, a couple three months out and they don't seem to be making any progress, they feel like they're struggling with the mere act of a Kegel exercise, especially if that resource is available, I think there's a lot to gain and very little to lose by getting a physical therapist involved.

[Aditya Bagrodia]
Couldn't agree more. Yeah, and we really are, I think, blessed to have tremendous physical therapists that are really, really experts at what they do. And I think there's also a growing body of videos and so forth, even on YouTube that I'll often direct patients towards that can help make sure that they're being done properly. So let's say that they've gone through some lifestyle changes - decreasing caffeine, seeing a physical therapist - and they're still not quite where they want to be. And this is, I'm guessing, a lot of the patients that come into your door. Tell us a little bit about your intake and evaluation of these patients.

[Steve Hudak]
Yeah, that's great. So I think you bring up a good point in terms of different types of referrals and different types of practices that people have. I mean, certainly, I consider some of the incontinence surgeries well within the realm of a well-trained general urologist. So it's possible that there are still doctors in smaller practices that may care for the patient throughout the entire experience from pre-op evaluation, radical prostatectomy, post-op care and even surgical care for incontinence. So, I think that's a different setup for someone that's going to see them all the way along, compared to someone that may be in a bigger practice that focuses their surgical care on post-operative care of prostate cancer patient survivorship, prosthetics, et cetera. So sometimes, where you identify that patient matters. Many times those of us that do this work exclusively really won't see the patient until a year or sometimes longer out. So it's very, very different than seeing someone that's three or six months out.

I think regardless of your perspective, when you're seeing them within the first year, I think what's more important than a specific month cutoff is really their trajectory. So for example, if someone perhaps had a wide resection for aggressive prostate cancer, they're six months out and they've really seen no meaningful improvement over the last several months despite pelvic floor physical therapy, I don't think there's anything that's magical that's really going to happen in those next six months are any clear cutoff that has to happen. So I think it's the combination of timeframe, whatever disease parameters - certainly if it was a salvage procedure after radiation, then obviously, they're much more likely to fail conservative management - so pre-op and peri-op information is important. Time from surgery, trajectory of improvement are all important. And then digging deep into that history, I think, is necessary at the first visit.

I think, as a side note to that, I'd say that there are a couple of different ways to work through the evaluation. And the AUA guidelines leave a lot of latitude depending on a urologist's practice. Philosophically, I like to do the evaluation for interested patients in two steps, two separate visits. And it comes from the fact that when we think about the viewpoint of a patient that had a surgical treatment and then now has a problem, it's not necessarily a drastic complication like something that leaves them in the hospital for longer or a prolonged surgical leak or an infection. But in their mind, it's going to be I wasn't incontinent (or I was continent), and then I had this surgery and now I'm not continent.

So I personally don't like to go in there guns blazing and say, I'm "Dr. Hudak. I'm your surgeon. We're going to fix this with more surgery on the first day." I like to use that first visit, rather, to take a good history, use the 15 or 20 minutes in that appointment, really, to get to know their problem and to allow them to be comfortable with the plan of evaluating it, not jumping directly into surgery. So that first visit for me, again, is a history, a gaining of a two-way rapport, and then a little bit of education about the options that are available. If it appears to be pure or at least mixed stress incontinence, I'll give them some online and in-print materials about the options, and then leave it at that. I don't do an invasive physical exam, I don't do any invasive testing on that first visit. I do the history, I give them some information, and then if they're interested I'll set up a very short-term follow-up where we'll do a cystoscopy, some provocative maneuvers, a physical examination, and a residual check.

[Aditya Bagrodia]
Perfect. Any questionnaires that you use as a standard part when you're in taking these patients just to give some objective data to quantify symptom severity?

[Steve Hudak]
I don't find them to be clinically helpful. I certainly think they're relevant if we're doing well-designed research, but clinically helpful? Certainly I don't. The main things that I ask them are when do you leak, when do you not leak, what are your activity levels? And then basic flow dynamics stuff - do you have a good stream, blood in the urine, bladder infections? So I think the “when do you leak?” is important, obviously, because if it's an obvious classic stress case, they'll say, well, when I cough, when I lift. But sometimes they'll just say, "You know, Doc, when I'm up and walking around, I just will check my pad later and it'll be wet." And so that can be hard to characterize. In which case, the second question, when do you not leak, is important. So I think that patients that are dry all night is a pretty reliable indicator for this being a stress problem. I think patients that say “yeah, I'm wet but I can still feel that urge and walk to the bathroom, get to the toilet, and get a stream going.” I think that's a pretty reliable indicator of it not being a kind of an urge predominant problem.

And so, I think kind of a give and take of what causes it, what doesn't cause it, and then an overall assessment of their activity. I mean, there are younger men that will leak several pads a day but are still working full time, they still go to the gym, they still run. And that's very different than someone that may be homebound because of the degree of incontinence. And so, I think an assessment of that, and that's why I take that first visit to really have a conversation to get into those three things. And to me, that conversation is more helpful on a patient to patient basis than any printed questionnaires.

[Aditya Bagrodia]
Got it. Yeah. It sounds like it almost ultimately culminates in a bit of a bother impact on life and type of activities. Pad weights, bladder diaries - are those things that you prefer to get or is it kind of in the same camp of good for research, maybe not as clinically impactful?

[Steve Hudak]
Yeah, same camp there, definitely those are very, very helpful if we're trying to do studies to evaluate this in large groups. Fortunately, there was a study that came out several years ago that really looked at pad weights and compared it to things that might be more easy to assess. And they found strong correlation, not just pad counts but pad weights compared to the combination of pad count, pad type, and assessment of how soaked it is when they change, and then the overall quality of life impact.

And this makes a lot of sense. So, a man may say, I leak two pads per day, and another man may say I leak four pads per day. And you would, obviously, think it might be hard to compare those. But if you dig into that and ask them what type of pad and how soaked are they and how much does it bother you, that man that leaks four pads per day might say, "I use a thin pad liner. It's barely damp when I change it. I'm very active, and it's very bothersome to me." And then compare that to the man that uses a full thickness depends type pull up undergarment twice a day that's fully soaked, it doesn't cause him bother and he barely leaves the house. And so you can see how just digging into it with some very simple questions will provide a lot more information than a simple pad count, and is a lot less cumbersome for you, for your patient, and for your office in terms of weighing the pads.

[Aditya Bagrodia]
Absolutely. And I think it's something we all come across clinically. What if they complain about climacturia specifically? Any thoughts on how that interfaces with general stress incontinence or even if it's a bit of an isolated symptom?

[Steve Hudak]
I like to dig into it a little bit. I think this term is becoming more mainstream, certainly, among urologists and secondarily, just to the available information that patients can get is becoming more of a thing that they know about. That being said, I rarely have a patient that comes in using that exact term. And so, I think it's important to be very, I guess, probing. And it can be difficult but obviously you'll generate a rapport with patient but be a bit probing as to whether it's incontinence during the physical act of sex, which is obviously an act that's can be straining and can cause a true stress environment, or is it simply isolated to leakage during the time of climax? And so, I think evaluating that and digging into that and then seeing is this just another other manifestation of the stress or is it isolated climacturia, and then combining that with any further information they gave you to really see, is it totally isolated climacturia or is this something that will just be treated in combination with other aspects of their overall picture of stress incontinence?

[Aditya Bagrodia]
Okay, super helpful. Quick comment on Cunningham clamps, condom caths....I feel like this is like, even over the course of my relatively finite career, something that's been coming across my desk less and less common, but a quick comment would be great.

[Steve Hudak]
We see very few men that are going to be successful with either of these in the long term. There are some anatomical considerations, obviously, you need a protuberant phallus to apply any of these, especially a condom catheter, given the fact that it's not just a single point fixation. And so, what I'll do for these miscellaneous devices is I'll refer the patients to a third party website where they know they can purchase them and try them on their own.

And I've actually learned a lot from my patients in these over the years, particularly for nonsurgical candidates or patients that are averse to surgery, sometimes they'll come in with handouts and pictures of, "Hey Doc, I saw this or that." And I've just been really surprised with what patients can find out on their own, those that are motivated.

But for those that are seeking these options, I give them a third party website that I trust where they don't have to... Obviously, if you Google “penis clamp” there can be some interesting things that come up onto their screen. So, I point them in the right direction if this is what they want. And there's different types of undergarments that are more discreet than just going to the grocery store. So there's really a wealth of information that's out there. As far as specific use of these, the one caveat that I would put in is that I think a Cunningham clamp is very, very helpful to serve as almost a test run, so to speak, compared to an artificial urinary sphincter. And when you think about it, that makes sense. It's a compressive device that the patient controls.

It's obviously different with regards to where it is anatomically, but I found it particularly helpful for the very severely incontinent male that perhaps doesn't even void because he's leaking so severely. And you'll see these patients particularly in the post-radiation, post-prostatectomy setting that they just basically are wet all the time. And so, for these patients it could be difficult, especially the radiated ones, to know do they have bladder dysfunction, or really bad sphincter dysfunction, or both?

And so, many clinics will have just the classic Cunningham clamp in their office. You can give them one and show him how to use it, tell him to not wear it 24 hours a day, and apply it. And if they can go two, three, four hours without severe urgency and discomfort, I found that this is a really good provocative maneuver that costs basically nothing and requires very little to no invasiveness to then see if it's a simulation to see if they have the appropriate bladder capacity to be successful with a sphincter.