postprostatectomy incontinence: all about diagnosis...

EURURO-2806; No of Pages 12

Review – Prostate Cancer

Postprostatectomy Incontinence: All About Diagnosis andManagement

Ricarda M. Bauer *, Patrick J. Bastian, Christian Gozzi, Christian G. Stief

Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universitat Munchen, Klinikum Großhadern, Munich, Germany

e u r o p e a n u r o l o g y x x x ( 2 0 0 8 ) x x x – x x x

avai lab le at www.sciencedi rect .com

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Article info

Article history:Accepted October 14, 2008Published online ahead ofprint on October 23, 2008

Keywords:Post prostatectomyincontinenceProstate cancerMale incontinenceDiagnosisMinimal invasive treatmentSlingArtificial urinary sphincterDuloxetinePelvic floor muscle trainingBiofeedbackElectrical stimulationInjection therapyStem cell therapy

Abstract

Context: The ever-increasing number of radical prostatectomies entailsan increasing number of patients suffering from postprostatectomystress incontinence despite improved surgical techniques. We providean overview of the current diagnosis and treatment of postprostatec-tomy stress incontinence.Objective: To review previous and recent literature on this subject and toassess the current standards of diagnosis and management of postpros-tatectomy incontinence.Evidence acquisition: The PubMed database was searched, and all articlespublished since 2000 were evaluated.Evidence synthesis: This review presents the current recommended diag-nostic tools and available noninvasive and invasive treatment options.Conclusions: The European Association of Urology (EAU) recommends atwo-stage assessment for diagnosis of postprostatectomy incontinence.Noninvasive therapy, pelvic floor-muscle training and biofeedback, isrecommended in early postoperative and mild incontinence. Pharma-cological treatment with duloxetine is especially effective in combina-tion with physiotherapy, where it synergistically improves thecontinence rate. For surgical treatment, the insertion of an artificialurinary sphincter, AS-800, is still the gold standard. In recent years,several minimal invasive treatment options have been introduced withdifferent rates of success, but they have not yet surpassed the results ofthe artificial sphincter.# 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author.E-mail address: [email protected] (R.M. Bauer).

1. Introduction

The increasing number of radical prostatectomiesentails an increasing number of patients sufferingfrom postoperative stress incontinence. Depending

Please cite this article in press as: Bauer RM, et al. Postprostatectom

(2008), doi:10.1016/j.eururo.2008.10.029

0302-2838/$ – see back matter # 2008 European Association of Urology. Publis

on the study, the incidence of early stress incon-tinence varies between 0.8% and 87.0% [1–4]. Thehuge range of reported incontinence rates is mostlikely determined to a large extent by the unknowninfluence of the operating physician [5] and the lack

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of a standardised definition of ‘‘incontinence.’’Thus, in high-volume centres with small numbersof surgeons, postprostatectomy continence rates arevery high, between 91% and 98% [6,7]. Incontinencethat persists for >1 yr postoperatively may decreasein these centres to<5% [8] and may even reach 1–2%.The incidence of de novo detrusor overactivityranges between 2% and 77%, and this may last upto 1 yr [6,9,10]. In addition, men aged <50 yr show asignificantly better rate of return to continence thanmen aged >70 yr [11].

Depending on the value put on urine leakage, thequality of life (QoL) of patients is strongly affected.Therefore, incontinence is one of the most fearedcomplications of radical prostatectomy.

2. Pathogenesis

The risk of incontinence following prostatectomyincludes preoperative factors (eg, age and preopera-tive continence status), intraoperative factors (eg,surgical technique and surgeon’s experience), andpostoperative factors [12,13]. A better understandingof the male pelvic anatomy has decreased thepostoperative incontinence rate [13,14]; the radicalprostatectomy as modified by Walsh revolutionisedthe surgical technique [15]. Due to the preservationof the neurovascular bundles, postoperative sexualfunction improved and, in addition, a significantimprovement in the postoperative continence rateoccurred [16,17].

The precise aetiology of postprostatectomyincontinence has not been completely understooduntil now; however, dysfunction of the bladder neckas well as intraoperative damage of the nerves andsphincter may play a causative role [18,19]. In thisregard, damage of the urethral sphincter can result

Fig. 1 – Disturbance of the male integral system following radic

Sphincteric laxity is due to radical prostatectomy.


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not only from direct muscle damage but also fromdamage of the neuronal innervation [20]. Accordingto newly evolving understanding, the reason forincontinence despite good function of the sphincteris a sphincteric laxity due to postoperative intrinsicsphincter deficiency [21,22]. This is caused by adisturbance of the male integral system followingsurgery (Fig. 1).

Another important factor for sphincter functionseems to be the functional urethral length [23]. Theminimal length of the functional urethra should be>28 mm [4]. Other authors found no impact of thefunctional urethral length [9,24]. In addition, thepreservation of the bladder neck improves the earlycontinence rate; however, in the long term, theresults with and without bladder neck preservationare almost the same [25–28].

The preservation of the puboprostatic ligamentsseems to induce no better continence rate [9,29–31].Potentially, the ‘‘tip-sparing prostatectomy’’ withprotection of the seminal vesicles can decrease therates of incontinence and erectile dysfunction [32].But further studies are needed to confirm the firstresults. There are also indications that the restora-tion of the posterior part of the rhabdosphincter canenhance the results [33,34].

Nevertheless, all studies dealing with potentialissues influencing postpostatectomy incontinencehave only level III evidence, excluding a fewrandomised controlled trials. Thus it is not possibleto give evidence-based advice concerning the benefitof the different surgical techniques discussed [35].

3. Diagnosis

The diagnosis should be performed in a two-stepassessment which includes a urinary diary and a

al prostatectomy: (A) preoperative and (B) postoperative.



Fig. 2 – Initial and specialised assessment and management of urinary incontinence in men based on European Association

of Urology 2008 guidelines.

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questionnaire to assess the complaints (Fig. 2).There are several more or less complicated ques-tionnaires. With the International Consultation onIncontinence Questionnaire—Short Form (ICIQ-SF),recommended by the EAU, a very simple and shortquestionnaire is readily available [36]. Because of itsgreater feasibility, the ICIQ-SF is more favourable indaily practice than the well-known King’s HealthQuestionnaire. Nevertheless, QoL and desire fortreatment should be evaluated [37]. In addition, thestandardised 1-h pad test has been shown to beuseful [38,39].

After the initial diagnostic work-up a first-linetreatment can be started. If the first-line treatmentfails, a specialised clinical assessment is indicated(Fig. 2). In a urethrocystoscopy the sphincter andanastomosis region should be evaluated.

According to Stamey, the grade of stress incon-tinence can be determined to be mild (incontinenceonly with severe stress, such as coughing orsneezing), moderate (incontinence with minimalstress, including walking), or severe (incontinenceduring bed rest).


(2008), doi:10.1016/j.eururo.2008.10.029

4. Noninvasive therapies

Noninvasive therapy is the first-line treatment forearly incontinence that follows prostatectomywithin the first 6 mo to 12 mo. In particular, pelvicfloor muscle training (PFMT) is the most widelyrecommended noninvasive treatment.

With regard to the evaluation of conservativemanagement effectiveness for postprostatectomyincontinence, there are, however, some problems.Existing trials are mostly neither randomised norcontrolled; a standardisation of treatment is lacking;and the definitions for incontinence and continencevary from study to study. In addition, the normalrate of healing is often not taken into account, andthe studied patient groups are very heterogeneous.In numerous studies, PFMT is performed withoutbiofeedback, thus there is no control whether or notthe muscle training is performed in a correct way.Therefore, determining whether the training wasineffective due to the inherent ineffectiveness of thetreatment or whether it was simply performed in anincorrect way is often elusive. In addition, the



Table 1 – Results of Cochrane analyses concerning noninvasive therapy options

Cochrane analysis Surgery Intervention Results

Hunter et al [39] Radical prostatectomy TURP PFMT vs control No significant evidence

Biofeedback vs control

Electrical stimulation

Moore et al [41] Radical prostatectomy PFMT vs control No significant evidence

Biofeedback vs control

Electrical stimulation

Hay-Smith et al [40] Radical prostatectomy PFMT vs control No significant evidence

TURP

TURP = transurethral resection of the prostate; PFMT = pelvic floor muscle training.



effectiveness of physiotherapy strongly depends onintangible factors like patient motivation andcompliance [40,41].

Many urologists already advocate PFMT pre-operatively. However, there is no evidence-baseddata for this recommendation. A recent randomisedand controlled study showed an improved post-operative continence rate in patients who hadpreoperative biofeedback [42]. Another study byBales et al showed no better outcome for patientsstarting PFMT with biofeedback preoperativelycompared with those who started after radicalprostatectomy [43].

Filocamo et al showed a significantly better earlycontinence rate in patients attending a rehabilita-tion programme with PFMT compared with patientswho did not [44]. After 1 yr there was no statisticaldifference between the incontinence rates of thetwo groups.

In three different Cochrane analyses, no signifi-cant evidence for the use of PFMT without biofeed-back or biofeedback alone could be shown (Table 1)[40,45,46]. In the meta-analysis of Hunter et al [40],no significant effectiveness of electrical stimulationcould be demonstrated, but this study showed somebenefit in patients treated with PFMT and biofeed-back. Floratos and van Kampen found some evi-dence for the use of biofeedback [44,47,48], but onlyvan Kampen took the normal healing rate intoaccount. Other groups found no significanceimprovement due to the use of biofeedback[43,49,50]. MacDonald et al reviewed eleven trialswith a total of 1028 men who performed PFMT fortreatment of postprostatectomy incontinence [42].All of these trials had a control group. The datashowed that patients who performed PFMT with orwithout biofeedback become continent faster thanpatients who did not perform PFMT.

The only study that showed evidence for theuse of electrical stimulation was published in 1976[51], but there was a number of issues with thestudy design and statistical analysis. In several


(2008), doi:10.1016/j.eururo.2008.10.029

subsequent studies no significant effectiveness ofelectrical stimulation could be shown [40,46].Transcutaneous electrical nerve stimulation hasbeen recommended by some studies, but againsignificant data-based evidence has not been pro-vided [20,52].

Behavioural therapies like bladder training, timedvoiding, reduction of fluid intake, and reduction ofbladder irritants (eg, coffee and hot spices) havebeen recommended by the EAU as well as by theInternational Continence Society for postprostatect-omy incontinence even though there is no clinicaldata-based evidence for this recommendation[37,38,53]. Moreover, there is no standardisation ofthese behavioural therapies.

5. Pharmacologic treatment

Currently, there is no approved pharmacologictherapy for male stress incontinence. However, forfemale stress incontinence the use of duloxetine, aserotonin-noradrenalin-reuptake-inhibitor (SNRI),is an established therapy [54]. Specifically, dulox-etine blocks the reuptake of noradrenalin andserotonin in the Onuf’s nucleus within the sacralspinal cord. Due to the increased concentration ofboth neurotransmitters, the activity of pudendalmotor neurons rises, which in turn increases thestriated urethral sphincter tonus and at the sametime relaxes the detrusor [55].

In recent years, the efficacy of duloxetine in menhas also been evaluated. Despite the efficacy shown,duloxetine has not yet received approval for treat-ment of male stress incontinence. Nevertheless,duloxetine is commonly used off-label to treat malestress incontinence.

Although the number of studies is rather low, theexisting two studies show a significant decrease inthenumber of incontinence episodes with duloxetine[56,57]. Unfortunately, there was no control group ineither study.





Filocamo et al evaluated 102 patients with post-prostatectomy stress incontinence randomised intotwo groups: PFMT + duloxetine versus PFMT alone.Incontinence QoL (I-QoL) significantly improved, andthe number of incontinence episodes was signifi-cantly reduced in group 1 after 16 wk. However, after20 wk (4 wk after discontinuation of duloxetinemedication), in group 2 the incontinence episodefrequency was significantly lower in comparisonwith group one [58]. The synergistic effect ofduloxetine in combination with PFMT can beexplained by the fact that PFMT and duloxetine treattwo independent therapeutic targets (sphincteractivity vs pelvic floor muscle support): the pelvicfloor muscle is itself not innervated by fibresoriginating from Onuf’s nucleus [59].

The most common side-effect of duloxetine andthe most common reason for discontinuing therapyis nausea. Yet the risk for nausea can be reduced by atitration dosage which increases the dose over thefirst weeks up to the final doses of 40 mg twice perday [56].

In early postprostatectomy incontinence, de novourgency with or without detrusor overactivity mayplay a certain role [60]. For these patients, additionalanticholinergic treatment should be pursued. Cur-rently there are no evidence-based recommenda-tions in the existing guidelines for this treatment.

6. Surgical treatment

Some 2–5% of the patients with incontinence afterradical prostatectomy exhibit a persistent incon-tinence for >1 yr postoperatively despite conserva-tive therapy attempts. For these patients surgicaltreatment is recommended.

Table 2 – Results of recently used bulking agents

Bulking agent and study No. of patients Result

Macroplastique

Kylmala et al [65] 50 After first inj

56% improved

After repeate

Max. 4: 60% c

continence, 1

Imamoglu et al [64] 25 After 1–2 inje

incontinence

Deflux

Alloussi [66] 72 After 4–8 wk:

Durasphere

Secin et al [67] 8 No subjective


(2008), doi:10.1016/j.eururo.2008.10.029

6.1. Injection therapy

Various substances (eg, collagen, teflon, silicone,autologous fat, autologous chondrocytes, dextrano-mer/hyaluronic acid copolymer) have been used fordecades as bulking agents. Overall, the short-termeffects are good, but the long-term success rate ispoor because collagen, autologous fat, and auto-logous chondrocytes are subject to quick migration[61,62]. Additionally, with collagen there is a risk ofanaphylactic reaction. Westney et al showed a meanduration of response after collagen injection of6.3 � 8.14 mo. Complete continence was achieved in17% of the patients [62]. In several studies treatmentwith Teflon injection showed a continence ratebetween 17% and 76% [63,64]. After the detection ofTeflon in lymph nodes, spleen, lung, and brainfollowing Teflon injection in the external sphincterin research using animals, the use of Teflon formedical therapies was discontinued [65].

Agents currently used include dextranomer/hya-luronic acid copolymer (deflux), pyrolytic carbonmicrospheres (durasphere), and polydimethylsilox-ane (macroplastique). All of these new agents showa slower migration without compromising otherorgans [66,67]. Short-term data are good, but reach-ing satisfactory long-term results requires reinjec-tions (Table 2) [68–71]. Prior injection of bulkingagents does not appear to afflict the postoperativeresult of artificial urinary sphincter implantation[72]. Postinjection inflammations can cause a frozenurethra.

6.2. Stem-cell therapy

The first results for autologous myoblast andfibroblast injections in 63 patients with postprosta-

s after first injection Side-effects

ection: 12% continent,

continence

Dysuric complaints

d injections (max. 4):

ontinent, 24% improved

6% no change

ctions: 80% mild

, 23% severe incontinence

Two urinary tract infections

One urinary retention

58% continent, 39% improved Urinary tract infection

or objective cure –



Fig. 4 – REMEEX system.



tectomy incontinence were published by Strasseret al in 2008. They showed a continence rate of 65%and improvement for an additional 27% of patients[73]. Other groups were not able to confirm thesedata—most even stopped the treatment; however,none of these results are available in PubMed. Inaddition, the whole treatment involves a verycomplicated and time-consuming procedure.

6.3. Slings

6.3.1. Bone-anchored sling systems

The Invance sling uses a silicon-coated polyestersling positioned under the bulbar urethra via aperineal incision. It is attached to both ischiopubicrami by three titanium screws (Fig. 3).

The first data about a bone-anchored sling werereported in 2001, when, in a cohort of 16 patients, acontinence rate of 88% with no complications wasreported [74]. Onur et al showed a better success ratein a cohort of 46 patients using silicon-coated bone-anchored slings (97% success rate) rather than slingswith composite grafts (75%). They recommended theuse of bone-anchored slings only for low andintermediate levels of incontinence [75]. Rajpurkaret al reported only a cure rate of 37% in a cohort of 46patients [76].

In a study with 50 patients, Fassi-Fehri et alreported a 50% cure rate [77]; 26% patients showedan improvement; and 24% patients showed atreatment failure. After radiation, patients had asignificantly lower cure rate of 25%. They foundsignificantly more complications, with six cases ofacute urinary retention and six cases of persistentperineal pain. Explantation was necessary in fourpatients.

In a study with 42 patients, Gilberti et al reporteda cure rate of 62%; 8% of patients were improved;

Fig. 3 – Invance sling.


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and 30% of patients had a failed treatment [78].In 26 patients synthetic material was used; in4 patients biological material was used; and in12 patients mixed materials were used. Betterresults were seen with synthetic slings.

The implantation of an artificial sphincter is stillpossible after failed bone-anchored sling therapy,with equally results comparing to patients with nosurgical pretreatment [79].

6.3.2. Readjustable sling systems

The REMEEX system is a readjustable suburethralsling; it is composed of a monofilament slingconnected via two monofilament traction threadsto a suprapubic mechanical regulator. The regulatoris a permanent subcutaneous implant over theabdominal rectum fascia 2 cm above the pubis.Additionally, implant adjustment is possible via aneternal manipulator (Fig. 4).

The first results for this system were published in2004 by Sousa-Escando et al [80]. In this study sixpatients were treated, and five of them were cured.In a multicentre European study with 51 patientswith a mean follow-up period of 32 mo, 33 patients(64.7%) were cured [81]. Twenty-five of these curedpatients needed no pads; the other eight patientsneeded only small pads or sanitary napkins. Almostall patients needed at least one readjustment of thesling under local anaesthesia. The sling had to beremoved in three cases: In one case urethral erosionoccurred, and in two cases the regulator wasinfected. In five patients an intraoperative bladderperforation occurred, and three mild perinealhaematomas were seen. Perineal discomfort or painwas very common and was treated with oral painmedication. Another group showed similar resultsin 18 patients [82].

The Argus system was first described by MorenoSierra et al in 2006 [83]. The system is composed of aradiopaque cushioned system with silicone foam



Fig. 5 – AdVance sling.

Fig. 6 – ProACT system.



42 mm � 26 mm � 9 mm thick for soft bulbar ure-thral compression, two silicone columns formed bymultiple conical elements, which are attached to thepad and allow system readjustment, and tworadiopaque silicone washers which allow regulationof the desired tension. In a cohort of 48 patients witha mean follow-up of 7.5 mo, Romano et al showed acure rate of 73%. Three urethral perforations duringsurgery were reported, and the sling had to beremoved in five patients. Seven patients had acuteurinary retention, and, except for one patient inwhich the sling needed to be loosened, it resolvedspontaneously. No severe complications were seen[84].

6.3.3. Functional retrourethral sling

The functional retrourethral sling (AdVance sling) isa new and innovative sling suspension which offers,for the first time, a nonobstructive, functionaltherapeutic approach (Fig. 5). Other slings, includingthe Pro-ACT system and the artificial urinarysphincter, achieve continence mainly by compres-sion of the urethra [85,86]. In urodynamic studies noobstruction of the urethra due to the retrourethralsling was seen [87]. The sling adjusts the changedanatomy after radical prostatectomy by reposition-ing the lax and descended supporting structures ofthe sphincter to the former preoperative position.Thus continence can again be achieved.

This sling was first described by Rheder andGozzi. In the first report, 20 patients and 4 cadaverswere treated. The cure rate, defined as no pad use,was 40%, and the improvement rate, defined as 1–2pads per day, was 30% [87]. In a recent study with67 patients these data were confirmed: The cure ratewas 52%, and the improvement rate 38% [88].

6.3.4. Pro-ACT system

The ProACT system is an adjustable therapy option;it uses the principle of augmenting titration for


(2008), doi:10.1016/j.eururo.2008.10.029

optimal urethral coaptation. Two balloons areplaced bilaterally at the bladder neck. Titaniumports are placed in the scrotum for volume adjust-ment (Fig. 6). Postoperative readjustment is verysimple, and only local anaesthesia is necessary. Thissystem was first introduced in 2000.

A study of the ProACT system was first publishedby Huebner and Schlarp in 2005. In 117 patients witha mean follow-up period of 13 mo, an improvementin 92% of the patients could be shown. Sixty-sevenpercent of the patients were dry, and in 8% there wasno improvement. After 2 yr, QoL improved from 34.7to 66.3. The balloons were readjusted a mean ofthree times. Pad use decreased from a mean of sixpads per day to a mean of one pad per day. In32 patients reimplantation was necessary, with asuccess rate of 75% [89]. In 2007 Huebner and Schlarppublished another study comparing their first50 patients with their last 50 patients. In groupone 52% of patients were dry; in group two 60% ofpatients were dry. In group two a better overallresponse was seen as well as better improvement ofQoL and shorter operative time. The pad reductionwas significant and similar in both groups [90].

Trigo-Rocha et al reported comparable data [91].Gregori et al reported on the use of ultrasound-

guided placement of the balloons to reduce com-plications and to advance the perfect placement ofthe balloons [92].The data show that the complica-tion rate declines and the success rate improveswith the surgeon’s experience.

The ProACT system is not recommended afterradiation therapy due to a higher complication rateand an unsatisfactory success rate.

6.3.5. Artificial urinary sphincter

The artificial urinary sphincter (AUS) is, despite thenew surgical treatment options, still the gold



Fig. 7 – Artificial urinary sphincter, AS-800.



standard for the surgical treatment of male incon-tinence. The technique is well-engineered. Since thefirst introduction of the AS-721 in 1972 the artificialsphincter has been modified several times to thecurrent AS-800 (Fig. 7). Nevertheless, the interven-tion is expensive and requires invasive surgery andexperienced surgeons. It has a high rate of infectionand a high rate of urethral atrophy due to thesustained high occlusion pressures on the urethra.In addition, the patient must have the mental andphysiologic ability to handle the sphincter.

The success rate of the AUS is still the bestcompared with all the other available surgical treat-ment options for postprotstatectomy incontinence.Even the long-term results are very good [93,94].

Age should not be considered as an exclusionfactor for AUS implantation. The procedure has ahigh rate of success even in men aged >75 yr [95].

In 2003 Wilson et al published a new implantationtechnique with only a single scrotal incision. Theregulation balloon was placed in the cavum retzii. Ina cohort of 37 patients, a cure rate of 66% wasachieved. Operative time can be reduced with thisnew technique. Follow-up after 1 yr showed nodifference in complication rate between the single-incision technique and the traditional method [96].Sotelo et al also showed no increased risk for thesingle-incision technique compared with the dou-ble-incision technique in high-risk patients with ahistory of radiation therapy and cryotherapy [97].Nevertheless most urologists still use the two-incision technique.

Double-cuff systems are used to reduce urethralatrophy and increase continent rates. A recentlypublished study of 56 patients showed no differencebetween single- and double-cuff systems except for


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a higher risk of complications and additionalsurgeries for the single-cuff patients [98].

Another approach to problems associated with theAS-800 was the development of a new artificialurinary sphincter with a conditional occlusion thatreduces the pressure on the urethra and allowsthe possibility of a self-adjustment of the pressurewhile increasing abdominal pressure. The firstresults are promising. In this small group of ninepatients, the continence rate was similar to thecontinence rate after the placement of the AS-800. Noserious adverse events occurred [99], but furtherstudies are needed to evaluate the long-term benefitfor the urethra.

7. Conclusions

Incontinence following radical prostatectomy is stillthe most feared complication for men. Due tomodified surgical techniques, incontinence rateshave been decreasing in recent years. However, evenin high-volume departments the incontinence rateremained around 1% after 1 yr postoperatively. Thediagnosis of postprostatectomy incontinence accord-ing to the two-stage assessment recommended bythe EAU guidelines has proven to be successful.

However, the recommendations for treatmentoptions are still only given generally without a clearassociation with stage and severity of incontinence.This limitation can only be overcome in the future ifsufficient evidence is provided by future clinicalstudies. Moreover, there exists no single precisedefinition for incontinence, therefore a fair compar-ison of study results is often not possible.

For early postprostatectomy incontinence, non-invasive therapies like PFMT, biofeedback, andelectrical stimulation are, in general, strongly recom-mended, although there is no strong data to supportthese recommendations. In addition, there is noconclusive data concerning the optimal timing tobegin treatment—specifically for preoperative versuspostoperative—noninvasive therapy. Further pro-spective placebo-controlled studies with sufficientpower are required to provide stronger evidence forthese recommendations. The combination of phy-siotherapy and medical treatment with duloxetineshows better results in theshort-term compared witheither of the two therapies alone (Table 3).

Based on the evidence gathered for all patientsshortly after removal of the catheter, supervisedPFMT with biofeedback can be recommended.Additional treatment with duloxetine is useful tosupport the early success. But due to the lack ofapproval of duloxetine for male incontinence,



Table 3 – Quality of evidence for male incontinencetreatment options

Treatment Level ofevidence

Grade ofrecommendation

PFMT 2 B

Duloxetine 3–4 C

PFMT + Duloxetine 1 A

Bulking agents 3 B

Slings 3 B

ProAct 3 B

AUS 1 A

PFMT = pelvice floor muscle training; AUS = artificial urinary

sphincter.



patients might have a reimbursement problem withtheir health insurance.

If noninvasive therapy fails, surgical therapyoptions are recommended, but the natural healingrate should be taken into account. Only in severeincontinence should surgical therapy be consideredbefore 6 mo to 12 mo after radical prostatectomy.

For severe or persistent incontinence the artificialurinary sphincter is still the gold standard oftreatment. The AS-800 is associated with highcontinence and high patient satisfaction rates. Itis currently the reference treatment for refractorysphincter incompetence in men (Table 3).

In recent years, numerous minimally invasivetreatment options with different success rates havebeen investigated. But new surgical techniquesmust at least match the results of the artificialsphincter. Nevertheless, the patient demand forminimally invasive treatment options is high, andoften, poorer results are accepted by the patients inorder to avoid an artificial sphincter. Slings can berecommended for patients with persistent mild ormoderate incontinence. For patients with severeincontinence the artificial sphincter is recom-mended, but slings can also be used for patientswho prefer a less invasive treatment.

Stem-cell therapy should not be recommendedcurrently.

For the development of new, more successful,and potentially patient-specific treatment options,it is necessary to improve and deepen our under-standing of the different pathophysiologic mechan-isms of male postprostatectomy incontinence.

Author contributions: Ricarda M. Bauer had full access to all the

data in the study and takes responsibility for the integrity of

the data and the accuracy of the data analysis.

Study concept and design: Bauer, Stief.

Acquisition of data: Bauer.

Analysis and interpretation of data: Bauer, Gozzi, Bastian.


(2008), doi:10.1016/j.eururo.2008.10.029

Drafting of the manuscript: Bauer.

Critical revision of the manuscript for important intellectual content:

Gozzi, Bastian, Stief.

Statistical analysis: None.

Obtaining funding: None.

Administrative, technical, or material support: Gozzi, Bastian.

Supervision: Stief.

Other (specify): None.

Financial disclosures: I certify that all conflicts of interest,

including specific financial interests and relationships and

affiliations relevant to the subject matter or materials

discussed in the manuscript (eg, employment/affiliation,

grants or funding, consultancies, honoraria, stock ownership

or options, expert testimony, royalties, or patents filed,

received, or pending), are the following: Christian Gozzi does

consultancy work, lectures, and participates in clinical trials

for American Medical Systems.

Funding/Support and role of the sponsor: None.

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