URINARY INCONTINENCE AFTER

PROSTATECTOMY FOR BENIGN

DISEASE

DR. SWAPNIL TOPLE

DNB UROLOGY

INCIDENCE AND RISK FACTORS

Stress and total incontinence respectively

Open sx(retro-pubic or transvesical

prostatectomy)= 1.9% and 0.5%

TUIP= 1.8% and 0.1%

TURP= 2.2% AND 1.0%

EVALUATION OF PATIENT

HISTORY

PHYSICAL EXAM

URINALYSIS

URINE CULTURE

POST VOID RESIDUE (BY USG)

VOIDING DIARY (2-7 DAYS)

POLYURIA WITHOUT DIURETICS:BUN,

CREATININE, GLUCOSE

PAD TEST

CYSTO-URETHROGRAPHY

URODYNAMICS- TO CHARACTERISE THE

INCONTINENCE AND TO DETECT DETROSSOR

OVER ACTIVITY, DECREASED COMPLIENCE

AND/OR OUTFLOW OBSTRUCTION

HISTORY

KEEPING IN MIND URGE/STRESS/OVERFLOW/TOTAL

INCONTINENCE

When the problem began

Frequency of urination

Amount of daily fluid intake

Use of caffeine or alcohol

Frequency and description of leakage or urine loss,

including activity at the time, sensation of urge to urinate,

and approximate volume of urine lost

Frequency of urination during the night

Whether the bladder feels empty after urinating

Pain or burning during urination

Problems starting or stopping the flow of urine

Forcefulness of the urine stream

Presence of blood, unusual odor or color in the

urine

A list of major surgeries with their dates, and other

medical conditions

Any medications being taken

PHYSICAL EXAMINATION

General Physical examination

Neuro-urological examination

Perineal sensation

Anal tone

Voluntary contraction and relaxation of anal

sphincter

Bulbo-cavernosus reflex

VOIDING DIARY

The 7 days diary considered as gold standard

should be a detailed record of:

Daily eating and drinking habits

The times and amounts of normal urination

For each incident of incontinence, the log should also detail:

The amount of urine lost (may be asked to collect and

measure urine in a measuring cup during a 24-hour period)

Whether the urge to urinate was present

Whether you were involved in physical activity at the time

PAD TEST

Quantifies the severity of incontinence

The 24 hours home test is the most accurate pad

test because it’s the most reproducible

The 1 hour pad test is widely used, its more easily

done and standardized

A pad test may be helpful in quantifying in AUS

failures

BLOOD TESTING

BUN, creatinine, glucose are recommended only if

compromised renal function is suspected or if

polyuria(in the absence of diuretics)is documented

by the frequency volume chart

MANAGEMENT: GENERAL MEASURES

If UTI is the cause-its treated with antibiotics

Medicines those cause incontinence can be

discontinued or changed to halt the episode

GENERAL APPROACH FOR TREATING

SPECIFIC FORMS OF INCONTINENCE

Treating Stress Incontinence

The general goal for patients with stress incontinence is to strengthen the pelvic muscles

Behavioral techniques and noninvasive devices, including Kegel exercises and biofeedback

Devices and continent aids for blocking urine in the urethra (clamps, adhesive pads, and others)

Medications - (although not as often as for urge incontinence). Antidepressants (duloxetine, imipramine) are the main medications used for stress incontinence

Surgery is an option if symptoms do not improve with noninvasive methods

Treating Urge Incontinence

The goal of most treatments for urge incontinence is to reduce the hyperactivity of the bladder

Behavioral methods and lifestyle modification

Medications (anticholinergics are the main type of drugs used)

Procedures that stimulate the pelvic floor or nerves in the tailbone (the sacral nerves), which help retrain the bladder

Mirabegron (Myrbetriq)- A new, first-in-class drug that was approved in 2012 for treatment of overactive bladder. It works in a different way than anticholinergics and other drugs used for urinary incontinence

In people who have both (mixed incontinence), the

treatment usually is aimed at the predominant form

TOTAL INCONTINENCE

Medical treatment is not of much use

Surgical treatment options: timing of surgery is not

fixed

1. Artificial sphincter: it’s the treatment of choice for

total incontinence

2. Injectable agents(urethral bulking agents):

e.g. carbon coated zirconium oxide

beads(durasphere), hyluronic acid and

dextranomer (zuidex), dimithyl sulfoxide/ethylene

vinyl alcohol copolymer(vryx), hydroxyapatite

spheres in carboxy methyl cellulose

carrier(coapatite)

Bulking agents fail in upto 75% men. Of these who are improved

only minority actually become dry with short term follow up.

Therefore bulking agents have limited value in these men(LOE-

3, GOR-C)

3. Male sling procedures

Similar to all sling procedures, they cause passive

compression of urethra, which is dependant on the applied

sling tension

In countries where cost of AUS is a critical issue or for patients

demanding less invasive procedure or non mechanical device,

a sling procedure could be interesting alternative to artificial

sphincter for minor oe mild incontinence(LOE-3, GOR-C)

THANK YOU