Options for Managing Post-prostatectomy Urinary Incontinence

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Radical prostatectomy is the most common procedure for treating prostate cancer. Although minimizing risks of post-prostatectomy stress urinary incontinence (PPI) is a treatment priority to help patients stay dry and regain quality of life, as approximately 30% of patients develop PPI.

The range of options available to treat PPI continue to expand and improve. Massachusetts General Hospital's Department of Urology leads the refinement and follow-up studies of techniques, and serves as a major referral center for complex cases. Ajay Singla, MD, specialist in urinary incontinence and voiding dysfunction in both men and women, pioneered one of the largest databases on male sling outcomes more than a decade ago.

"Unfortunately, there is no medication that can be given to patients to treat stress urinary incontinence," he says. "Usually patients end up having some type of surgical management."

Dr. Singla continues to innovate in the field, including his work managing repeated cuff failures of artificial urinary sphincters (AUS) through revision surgeries.

Conservative Approach

To manage PPI, conservative measures such as pelvic floor conditioning and Kegel training to strengthen the external sphincter muscles remain a proven first step. After six to twelve months of conscientious Kegel training, if muscle rehabilitation is not adequate to prevent leaking, other options are available.

If at six months incontinence is severe, deeply troubling and disruptive to patients, Dr. Singla recommends ceasing to wait for Kegel results.

"Patients don't want to wait. It is devastating for men. They are embarrassed, depressed and they can't participate in social activities," he says.

Treatments for PPI

In cases that are refractory to Kegel sphincter rehabilitation or other conservative measures such as diet, fluid and bladder retraining approaches, two minimally-invasive options may be considered.

Injectable Bulking Agent

For carefully selected patients, injecting expansive materials can adequately fill the void created by removing the prostate. Administered in a 15-minute outpatient procedure, the material is injected in the lining where the prostate used to be. An injectable can improve—not cure—PPI by closing the urethral lumen. 

Advantage: Ease of treatment. It is performed with an endoscope without incision and can be readministered up to five times.

Disadvantage: High failure rate. Typically, it succeeds in only 20-30% of patients.

Upshot: In comorbid patients who are too frail to undergo other treatments or have a limited lifespan and want short-term relief from symptoms, injectables can be an excellent option for maintaining quality of life.

Male Sling

Modern male slings rely on new forms of synthetic mesh tape to reposition and compress the urethra. They have been redesigned in recent years, including replacing early-generation bone screws with anchors to improve performance and comfort and to reduce complications.

Advantage: Only a small groin incision is needed to insert the mesh sling tape. The sling provides a more natural physiological sensation of voiding. A patient can urinate in response to an urge cue, as opposed to AUS implant therapy, which requires the patient to depress the implant's button in the scrotum to urinate.

Disadvantage: It is contraindicated in patients with radiation damage. Slings are best suited for mild incontinence, requiring no more than two to three pads a day. "After five years, only about 52% of patients have a cure rate defined as consistent dryness," says Dr. Singla. "For slings, the long-term data is not available and the results are poor with high failure rate."

Upshot: "Slings can become a very attractive option for those who have dementia or tremors and can't operate the scrotum pump," says Dr. Singla. "But long-term, I tell patients the sling will likely fail."

AUS

For patients with severe incontinence, requiring three or more pads a day, the AUS remains the gold standard of care. The three-part device consists of a cuff placed around the urethra. A reservoir or pressure-regulating balloon and a pump placed in the scrotum. All are connected during surgery. If a patient's soaked pad at the end of a 24-hour period has 473 grams or more difference in weight from a dry pad, Dr. Singla says AUS should be considered to manage leakage of this magnitude.

Advantages: The steady evolution since the AUS debut in 1973 has improved outcomes and control of severe leakage, with over a 90% success rate. Patient age is not a factor. Dr. Singla has implanted patients as old as 92.

Disadvantages: As a mechanical device, it can malfunction and leak. As with any surgical procedure, there is a change of infection. Erosion or atrophy of lumen can occur over time if the device is too tight or too much pressure is applied. It requires manual dexterity to activate the pump button that initiates voiding, which may not be suited to patients with dementia.

Upshot: For carefully-selected patients with severe PPI, it provides optimal control.

Working Toward Quality of Life Improvements

The rapid evolution of materials and methods, in conjunction with advanced training at Mass General and other centers of excellence, keeps Dr. Singla optimistic that PPI patients will continue to enjoy improvements in quality of life.

"We continuously do training programs to increase awareness of options and improve outcomes," he says, "because patients are actively approaching and seeking help. And we are committed to providing that for them."

Learn about the Voiding Dysfunction and Incontinence Program at Mass General

Refer a patient to the Department of Urology