Male Stress Urinary Incontinence

Definition & Causes

• Most common cause of male SUI = ISD, from:
  • Radical prostatectomy — most common single cause
  • BPH procedure (TURP)
  • Pelvic fracture (urethral injury)
• SUI develops only with concomitant internal AND external sphincter impairment — one alone does not cause SUI
  • Internal sphincter impairment (4):
    • Pelvic surgery
    • Bladder neck injury
    • Specific sympathetic neuropathic dysfunction
    • Embryologic disruption
  • External sphincter impairment (5):
    • RP (most common)
    • TURP
    • Pelvic fracture urethral injury
    • Myelopathy (traumatic/acquired)
    • Congenital (spinal dysraphism, sacral agenesis, exstrophy/epispadias)
• IPT = incontinence after prostate treatment — the AUA's preferred term over "post-prostatectomy incontinence", because it also covers RT and BPH surgery
• Mechanism: damage to the striated muscle and nerve fibers of the voluntary (striated) urethral sphincter

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Natural History & Pre-Treatment Counseling

• Continence = pad-free (no pad or protective device) — the accepted guideline definition
• Most men are NOT continent at catheter removal — counsel that continence is not immediate
• 90% continent at 6 months post-RALP; only a further 4% gain continence after that
• Maximum improvement by 12 months, minimal-to-no improvement afterwards
  • Exam answer: continence can keep improving for up to 2 years after RP → another reason to delay surgery
• Risk factors for IPT after RP (5):
  • older age
  • Larger prostate size
  • Shorter membranous urethral length
  • Lack of bilateral NVB preservation
    • Bilateral NVB preservation → 26% more likely continent at 6 months; no other surgical maneuver improves continence recovery
  • Prior pelvic radiation
• Open RP = robot-assisted RP for incontinence rates
• Prior radiation → counsel that they may require an AUS

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Evaluation of Incontinence After Prostate Treatment

• Hx + PE + QoL + Pad weight
• Categorize: SUI or UUI
  • UUI → manage as OAB

• History pointers:
  • Straining/walking/cough/exercise → SUI
  • Sudden compelling desire → UUI
  • Leakage while asleep + nocturia → UUI or severe SUI
• PVR — rules out overflow; elevated PVR may signal detrusor underactivity or obstruction
  • Exam answer: EAU makes PVR part of the basic assessment (strong) → elderly incontinent man with unremarkable exam + labs → next step = PVR
    • Mainly to detect chronic retention with overflow from outlet obstruction
  • PVR > 150 mL → EAU advises against antimuscarinics and combination therapy
  • High PVR → triggers invasive urodynamics or renal ultrasound
• Rule out a urethral stricture before attributing leakage to sphincteric incompetence

"Complicated" incontinence — refer for further assessment rather than treating empirically:

• Recurrent or total incontinence
• Incontinence associated with pain, hematuria, recurrent infection, prostate irradiation, or radical pelvic surgery
• Any other abnormality detected, e.g. a significant post-void residual

Severity by 24-h pad weight

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Conservative Management — always first

• Always start with pelvic floor muscle therapy
  • Should be offered to all patients
  • Improves time to continence (so QoL) but not overall continence at 12 months
  • offer PFMT ± biofeedback ± electrostimulation to men undergoing RP to speed recovery of UI
• PFME vs PFMT — PFME is self-guided, PFMT is practitioner-guided
  • Post-RP SUI persisting despite self-directed Kegels (PFME) → next step = PFMT led by a pelvic floor physical therapist — still helps after Kegels, usually tried before surgery

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Timing of Surgery

• If SUI → management should be offered 6–12 months after
  • Continence keeps improving for 6–12 months after RP → wait at least that long before a male sling or AUS; manage meanwhile with PFMT + containment

• Treat symptomatic vesicourethral anastomotic stenosis or bladder neck contracture before any incontinence surgery.
  • After radical prostatectomy, wait at least 6 months so a contracture can declare itself.

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Pre-Surgical Assessment

If no improvement & planning for surgical intervention, assess the following:

• Leakage still bothersome after the 6–12 month wait → exclude urethral / anastomotic stricture and bladder dysfunction before any anti-incontinence surgery

Pad weight — mild < 150 g · moderate 150–400 g · severe > 400 g

• → drives the choice of operation (see Management by Severity).

Hx of radiation — if yes, slings are contraindicated

UA + PVR + Ufm — UDS is optional if suspicion

• The catheter false-negative — high yield. Up to 35% of men with post-prostatectomy SUI will not demonstrate SUI with a catheter in place (scarring at the anastomosis; even a small catheter occludes the urethra). → Remove the catheter and repeat stress testing
• UDS findings that change the operation
  • Detrusor hypocontractility → AUS, not sling — inadequate detrusor function cannot overcome the fixed resistance of a compressive sling
  • Reduced compliance — prolonged high-pressure storage risks renal deterioration
• AUA 2012 UDS guideline: at minimum, assess PVR before invasive SUI therapy

Cystourethroscopy — if patient has bladder neck contracture, incise & delay AUS implant 3 months

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Management by Severity — the algorithm

Click the algorithm to open it full size.

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Male Sling (Perineal Male Sling, PMS)

Features supporting a sling:

• Mild-to-moderate incontinence — 24-h pad test < 150 g mild, < 400 g moderate
• Adequate detrusor contractility — a sling is a fixed resistance and needs a bladder that can overcome it
• Poor dexterity or limited cognitive capacity — no pump to operate
• No prior radiation
• Patient preference against AUS infection/erosion risk

After a failed sling:

• When placing an AUS after a failed sling, the sling may be left in place and the cuff sited 1.5–2 cm distal to it via a scrotal incision.
• Exam answer: after sling failure → AUS is preferred over:
  • Urethral bulking agents — approved only for women (the severity table still lists bulking as a mild–moderate option)
  • ProACT periurethral balloons — for mild–moderate SUI, but not used in sling failures
  • Repeat sling — harder with one already in place and often no improvement (the table keeps replacement as an option for trained providers)

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AUS — Components

• AMS 800 — three components: inflatable cuff, control pump, pressure-regulating balloon (PRB)
• Offer only in expert centers; warn of mechanical failure and explantation for infection or erosion in up to 24%

Composed of:

Cuff

• Location: bulbar urethra vs bladder neck
  • In salvage → change position, transcorporal
• (A) Size: 4–4.5 cm standard.
  • Available cuffs run 3.5 cm to 11 cm.
  • Choose a cuff smaller than the measured circumference — a snug fit without constriction.
  • In salvage, downsizing to 3.5 cm is an option, but the 3.5 cm cuff carries an increased erosion risk in previously irradiated patients.
    • Irradiated + severe urethral atrophy → transcorporal cuff preferred over the smallest 3.5 cm cuff
• (B) Single cuff.
  • In salvage, a second (tandem) cuff is described — but a single cuff placed more proximally is preferred:
    • The tandem's apparent benefit is the proximal position rather than the second cuff, and it carries a higher explant rate (17% vs 4%).

Pump

• In scrotum, deactivated 6 weeks post-op
  • Left deactivated with the cuff deflated for an average of 4–6 weeks — longer if irradiated → a pseudocapsule forms around the cuff and erosion risk falls

PRB (reservoir)

• Placed retropubic

PRB fill volume ~20 mL · Pressure 61–70 cm H₂O (51–60 after radiation)

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AUS — Indications, Contraindications, Technique

Indications

• Consider for mild to severe SUI · EAU: offer for moderate-to-severe — Strong
  • Standard treatment for moderate-to-severe post-prostatectomy SUI persisting at 1 year despite failed conservative and medical management
• Preferred after (3):
  • Radiation
  • Urethral reconstruction (slings won't work after posterior/anterior urethral reconstruction)
  • VUAS/bladder neck contracture (slings have decreased success)

Features supporting AUS:

• Moderate-to-severe incontinence (24-h pad test > 400 g = severe)
• Gravitational incontinence
• Failed sling or previous AUS
• Abnormal anatomy
• Prior radiation
• Adequate urethral tissue integrity · adequate bladder compliance · adequate cognition and dexterity

Beyond incontinence after prostate treatment, AUS is also used for:

• SUI after pelvic fracture urethral injury, spinal cord injury, or urethral reconstruction (the "stove-pipe" ISD urethra)
• Neurogenic bladder with sphincteric dysfunction
• Congenital disorders — myelomeningocele, sacral agenesis, the exstrophy/epispadias complex
• A last resort in women with ISD and a non-neurogenic bladder

Contraindications

Metastatic prostate cancer is not a contraindication to either AUS or a male sling.

Technique

• Single-cuff perineal approach preferred — superior to transverse scrotal incision
• Place the cuff as proximal on the bulbar urethra as possible, proximal to the convergence of the corporal bodies
• Incise skin → Colles fascia → bulbospongiosus muscle → Buck fascia where it reflects off the bulbar urethra onto the diverging corpora.
  • Sharp dissection dorsally (blunt risks the thinner dorsal urethra); minimal electrocautery
  • Commonest site of urethral perforation: the dorsal bulbar urethra, while mobilizing it off the corpora cavernosa (spongiosum thinnest here) → Metzenbaum scissors
• Create a 2-cm tunnel; the cuff gives a 2-cm zone of circumferential compression
• Remove any catheter >14 Fr before cuff sizing; cuff should fit snugly without constricting
• PRB approach: scrotal, perineal or abdominal.
  • Contraindications to scrotal/perineal → mesh hernia repair, radical cystectomy/extensive abdominal surgery — use the abdominal approach to avoid bladder/bowel injury
• Verify coaptation by urethroscopy — closed cuff should cause slight blanching
• Urethral injury intra-op → repair with 4-0 absorbable, ABORT the procedure, delay implantation; catheter 7 days. The risk of device infection outweighs any benefit
  • At reoperation after erosion or urethral injury → a transcorporal cuff lowers the risk of urethral injury (incisions go through the tunica albuginea, avoiding the spongiosum–cavernosum plane)
• Post-op: overnight stay, catheter out next morning, no drains; AUA says no antibiotics beyond 24 h peri-op (though many high-volume implanters give 1–2 weeks orally)

Bladder neck AUS

• For sphincteric UI where the prostate is undisrupted → myelomeningocele and other neuropathic disorders, children, exstrophy/epispadias. In these groups a bladder neck cuff should be considered before a bulbar cuff.
• Contraindicated after RP
• Advantages: lower likelihood of erosion and cuff atrophy
• Needs larger cuff (~8 cm), higher PRB (71–80), larger system volume. Robotic placement overcomes much of the technical difficulty

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Post-AUS — Retention

• Early retention:
  • Cause in the first days (catheter passes smoothly) → transient urethral edema from the periurethral dissection (the deactivated cuff exerts no coaptive pressure)
  • First, confirm the cuff is deactivated.
  • Insert a 10–12 Fr catheter for 24–48 h.
  • If the patient fails a trial of void at 48 h → place an SPC (image-guided) to reduce the risk of erosion.
    • Place under ultrasound or fluoroscopic guidance → avoids puncturing or contaminating the retropubic PRB
    • Not prolonged urethral catheterization or CIC → both risk cuff erosion, even with the cuff deactivated
  • Retention persisting for several weeks suggests an undersized cuff — correlate with the pre-operative urodynamics and consider cuff replacement.
    • → may need reoperation with cuff upsizing
• Late-onset retention:
  • Cystoscopy and urodynamics to rule out obstruction, erosion and detrusor failure.
  • Symptomatic VUAS with a bulbar AUS
    • → surgically uncouple the cuff, then treat endoscopically — balloon dilation or incision through a 21 Fr rigid cystoscope without uncoupling risks urethral erosion or cuff damage

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Post-AUS — Recurrent/Persistent SUI

If a patient presents later with SUI:

Click the algorithm to open it full size.

Onset points to the cause:

• Minor SUI of gradual onset, years after placement → urethral atrophy beneath the cuff
• Sudden loss of continence → device deactivation or mechanical failure

Erosion excluded — next test depends on cycling:

• Normal cycling (recurrent incontinence) → urodynamics next — exclude detrusor overactivity or ↓ bladder compliance before any surgical revision
  • Urgency incontinence from detrusor overactivity despite mirabegron, working AUS → onabotulinumtoxinA via a small flexible cystoscope through the deactivated AUS
    • Oxybutynin only with caution in older patients
• No urethral coaptation on cycling (SUI, no infection) → image the PRB by ultrasound or cross-sectional imaging (step 4)

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AUS Complications

Beyond the device-specific problems below, AUS surgery carries the general risks of bleeding/hematoma and injury to adjacent organs.