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POST-PROSTATECTOMY INCONTINENCE
Category: Urology
Abstract : Post-prostatectomy incontinence Incidence Slightly <1% after TURP, and 0.5% after open prostatectomy (OP) performed for benign prostate disease.11 Results after radical prostatectomy (RP) for malignant disease are variable up to 40% suffer mild urinary leakage requiring pads, but this usually improves over 12 - 18 months post-surgery, severe UI persisting in 2 - 10%. Risk factors B
Post-prostatectomy incontinence
Incidence
Slightly <1% after TURP, and 0.5% after open prostatectomy (OP) performed for benign prostate disease.11 Results after radical prostatectomy (RP) for malignant disease are variable up to 40% suffer mild urinary leakage requiring pads, but this usually improves over 12 - 18 months post-surgery, severe UI persisting in 2 - 10%.
Risk factors
Increasing age; pre-existing bladder dysfunction; previous radiotherapy (TURP following brachytherapy has a 40% risk of severe UI); prior TURP; advanced stage of disease and surgical technique. Earlier recovery of continence after RP is achieved using a perineal approach, nerve-sparing techniques, and sphincter and bladder neck preserving procedures.
Pathophysiology
The proximal sphincter mechanism is removed at prostatectomy (TURP, OP, and RP). Post-prostatectomy continence therefore requires a functioning distal urethral sphincter mechanism and low bladder pressure during bladder filling. Direct damage to the external sphincter can occur during prostatectomy (at TURP it occurs particularly during resection between the 11 and 2 o'clock position, when the reference point for the position of the distal sphincter the verumontanum cannot be seen). Damage to the innervation of the sphincter can occur both during RP, OP, and TURP. Urodynamic studies before and after RP show that maximal urethral closure pressure (MUCP) and functional urethral length (the length of urethra over which the sphincter functions to maintain high pressures) fall. Nerve-sparing RP (where the neurovascular bundles are specifically identified and preserved) produces better continence rates and longer functional urethral lengths and MUCPs.
A substantial proportion of men also have overactive bladders (detrusor instability) before prostatectomy, and this may remain so after prostatectomy. The main cause of post-radical prostatectomy incontinence is sphincter dysfunction.
Evaluation
Wait for up to 12 months spontaneous improvement unless incontinence is severe.
- History: stress-induced leakage (cough, standing from a sitting position) suggests sphincter dysfunction.
- Examination: observe for leakage on coughing.
- Tests: post-void residual volume measurement on ultrasound (to exclude retention with overflow); urodynamic studies allow determination of bladder overactivity and sphincter function; cystoscopy allows identification of strictures (particularly important if artificial sphincter implantation is contemplated).
Treatment
Sphincter dysfunction: pelvic floor exercises; insertion of urethral bulking agents; bulbourethral sling (to compress the urethra). Artificial urinary sphincter insertion is usually deferred until 1 year post-prostatectomy, and is the most effective long-term treatment (80% success rate).
Bladder dysfunction: conservative treatment for bladder overactivity includes behavioural therapy, pelvic floor exercises, and anticholinergic medication. Surgery for intractable cases includes augmentation cystoplasty or urinary diversion. Catherization may be considered in the older patient.
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