- Urinary incontinence is a common complication after prostatectomy for benign disease, with stress incontinence occurring in around 2% of patients and total incontinence in around 1% depending on the surgical method. - Evaluation of patients involves taking a detailed history, physical examination, urinalysis, pad tests to quantify incontinence severity, and urodynamics to characterize the type of incontinence and detect other issues. - Treatment depends on the type of incontinence, with behavioral techniques and pelvic floor exercises used for stress incontinence initially, medications for urge incontinence, and surgical options like artificial urinary sphincters for more severe cases of total incontinence.

1. URINARY INCONTINENCE AFTER
PROSTATECTOMY FOR BENIGN
DISEASE
DR. SWAPNIL TOPLE
DNB UROLOGY

2. 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%

3. 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

4.  URODYNAMICS- TO CHARACTERISE THE
INCONTINENCE AND TO DETECT DETROSSOR
OVER ACTIVITY, DECREASED COMPLIENCE
AND/OR OUTFLOW OBSTRUCTION

5. 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

6.  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

7. PHYSICAL EXAMINATION
 General Physical examination
 Neuro-urological examination
 Perineal sensation
 Anal tone
 Voluntary contraction and relaxation of anal
sphincter
 Bulbo-cavernosus reflex

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14.  In people who have both (mixed incontinence), the
treatment usually is aimed at the predominant form

15. 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)

16.  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)

17. THANK YOU