Urologists outline the best evidence-based management of post prostatectomy incontinence in a new review published in European Urology.

Despite improved surgical techniques, the prevalence of post prostatectomy incontinence continues to increase as more radical prostatectomy’s are being performed – approaching 100,000 a year in the U.S.

In men, radical prostatectomy is the most common cause of stress urinary incontinence, or SUI. Reported rates of SUI following radical prostatectomy range from 5 to 48%.

Yet the researchers report that there is a lack of evidence – especially from randomized controlled trials – comparing invasive and non-invasive management of the condition.

Using the best evidence that is available from past studies, the authors outline recommended management of SUI — which can start even before diagnosis, they note, with physiotherapy beginning immediately after catheter removal and also optional before surgery.

For diagnosis, Bauer and colleagues recommend a two-stage assessment of SUI, as per guidelines from the European Association of Urology, including validated questionnaires of patients’ symptoms and quality of life. The 24-hour pad test is the most accurate tool for diagnosis, they note, but for feasibility reasons the 1-hour test is much more common.

Once a diagnosis of SUI is made, treatment should proceed accordingly, beginning with conservative methods such as lifestyle interventions and muscle training.

The authors note that there are no approved medications for SUI in men, although duloxetine has been effective – with some risk of side effects – in off-label prescribing.

If conservative treatment fails after at least 6 months, doctors should consider surgery. For patients who wish for minimally invasive treatment, the authors say that male slings, including the InVance, AdVance, and Argus slings “seem to be a good alternative surgical treatment option,” at least in patients with mild or moderate SUI.

The artificial urinary sphincter, or AUS, has shown the highest success rates for treatment of SUI, and the patient’s age should not prevent doctors from using this method. However, AUS is expensive and complications include erosion, mechanical failure, and infection.

Bulking agents have not shown consistent success, and the authors say too many questions remain to make a recommendation for use of the adjustable balloon system.

Data is still lacking on these and other possible treatments for SUI. More research is also needed on the condition itself to better tailor treatment to patients’ needs, the authors note.

They conclude, “For the development of new, more successful, and potentially patient-specific surgical treatment options, it is necessary to improve and deepen the understanding of potentially different pathophysiologic mechanisms of post prostatectomy SUI.”

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