Male Stress Urinary Incontinence

Definition & Causes

• Most common cause of male SUI = ISD, from:
  1. Radical prostatectomy — most common single cause
  2. BPH procedure (TURP)
  3. 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 fibres of the voluntary (striated) urethral sphincter

Natural History & Pre-Treatment Counselling

• 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
• Risk factors for IPT after RP (5): older age · larger prostate size · shorter membranous urethral length · lack of bilateral NVB preservation · prior pelvic radiation
  • Bilateral NVB preservation → 26% more likely continent at 6 months; no other surgical manoeuvre improves continence recovery
  • Open RP = robot-assisted RP for incontinence rates
• Prior radiation → counsel that they may require an AUS

Evaluation of Incontinence After Prostate Treatment

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

Recommended	Optional
History + physical (incl. degree of bother)	PVR
Urinalysis ± culture
Modalities to categorize type + severity (voiding diary, pad weights)

• 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
• 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, haematuria, 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

Severity	24-h pad weight
Mild	< 150 g
Moderate	150–400 g
Severe	> 400 g

Conservative Management — always first

• Always start with pelvic floor muscle therapy
• PFME vs PFMT — PFME is self-guided, PFMT is practitioner-guided
  • 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

Timing of Surgery

• If SUI → management should be offered 6–12 months after

Timing	Condition
12 months	Default. Offer treatment for persistent bothersome SUI at 12 months
6 months	Early intervention — no improvement at 6 months despite conservative therapy + bothersome IPT + patient doesn't want to wait. Most severe SUI shows no significant improvement after 6 months
Delay/caution	Patient still showing improvement at 12 months → offer treatment with caution

• 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.

Pre-Surgical Assessment

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

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

Management by Severity — the algorithm

Click the algorithm to open it full size.

	(A) Mild & no Hx of RT	(B) Moderate & no Hx of RT	(C) Severe or Hx of RT
1	PFMT	Sling / Bulk	AUS
2	Sling / Bulking agent	AUS	—
3	AUS	—	—

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:

Mode of failure	Management
Infection or erosion	Explant as much as possible; consider AUS 3–6 months later
Inadequate continence	Place an AUS (with or without sling explant), or replace the sling — replacement only by providers trained in it

• 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.

AUS — Components

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.
• (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

PRB (reservoir)

• Placed retropubic

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

AUS — Indications, Contraindications, Technique

Indications

• Consider for mild to severe SUI · EAU: offer for moderate-to-severe — Strong
• 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

Absolute (6)	Relative (4)
Lack of physical/mental dexterity to work the pump	High-grade VUR
Repetitive UTIs	Recurrent bladder/urethral disease needing repeat transurethral instrumentation
Urethral diverticulum at implant site / poor urethral tissue integrity	Bladder neck contracture prior to treatment
Complex, unstable or recurrent urethral stricture	Detrusor overactivity
Small-capacity / non-compliant bladder before definitive treatment
Active infection at the surgical site
Detrusor–sphincter dyssynergia	Stones (require repeated urethral instrumentation)
High-pressure storage or contractions (> 40 cm H₂O)	Poor tissue quality — radiation contraindicates a sling; poor urethral integrity contraindicates AUS
Detrusor overactivity at low volumes	Immunosuppression
High-grade VUR at low intravesical pressure	Malignancy needing repeated urethral instrumentation

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
• 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
• 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

Post-AUS — Retention

• Early retention:
  • 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.
  • Retention persisting for several weeks suggests an undersized cuff — correlate with the pre-operative urodynamics and consider cuff replacement.
• Late-onset retention:
  • Cystoscopy and urodynamics to rule out obstruction, erosion and detrusor failure.

Post-AUS — Recurrent/Persistent SUI

If a patient presents later with SUI:

Click the algorithm to open it full size.

Step	Finding	Action
1	Cycle the device	Rules out inadvertent deactivation before anything else
2	R/o infection	If present → explant urgently
3	R/o erosion	If present → explant + Foley for 3 wks
4	Both absent → imaging to assess PRB volume	↓
4a	PRB < 20	Replace AUS (> 3 years) or replace the malfunctioning part (< 3 years)
4b	PRB > 20	Downsize the cuff · add cuff · move cuff location · increase pressure

AUS Complications

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

Complication	Numbers	Management
Infection	1–3%, up to 10% in high-risk/radiated (AUA gives < 1–5%). S. epidermidis (most common) + S. aureus	Urgent explantation — implant infections are not amenable to antibiotics. No reimplantation for ≥ 3 months. Late infections (> 4 months) suggest indolent organisms or haematogenous spread rather than implantation contamination
Cuff erosion	Up to 5% of implants	Explant (all components — assumed infected) + catheter a few weeks. No reimplantation < 3 months, and confirm urethral healing by urethrography. Pelvic radiation is the most important risk factor for cuff erosion. Approximate the perineal wound loosely, healing by secondary intention. Site the new cuff proximal or distal to the previous position, and consider nightly deactivation after re-implantation for a prior erosion. A transcorporal cuff is described here, though it is itself associated with higher erosion rates — largely because it is chosen for higher-risk urethras
Urethral atrophy	Due to chronic compression of the spongy tissue. Most common cause of gradual return of incontinence + AUS revision	Downsize cuff · move cuff proximal/distal to thicker urethra · tandem cuff
Mechanical failure	7–10-yr device life; failure ≈ 24% at 5 yrs, ≈ 50% at 10 yrs. Revision 16% at 2 yrs, 28% at 5 yrs — all	Micro-perforation of any of the 3 parts/tubing/connections → fluid loss. The cuff is the commonest site of leak. Within 3 years and with no infection or erosion, replacing only the malfunctioning component is reasonable; devices older than 3 years should be replaced in toto