Conservative Treatment for Postprostatectomy Incontinence

Treatment Update

TreaTmenT UpdaTe Conservative Treatment for Postprostatectomy Incontinence Bilal Chughtai, MD,1 Richard Lee, MD,1 Jaspreet Sandhu, MD,2 Alexis Te, MD,1 Steven Kaplan, MD1 Buchanan Brady Foundation, Department of Urology, Weill Medical College of Cornell University, New York, NY; 2Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 1James Postprostatectomy incontinence (PPI) is a bothersome complication of radical prostatectomy. Although most men recover from PPI, some men continue to have persistent urinary incontinence. The initial management of persistent PPI usually consists of conservative measures such as pelvic floor muscle exercises. Surgical treatments are usually not entertained for men with urinary incontinence until conservative treatments have failed. This article discusses risk factors for PPI and various options for its treatment, including biofeedback and pharmacotherapy. [ Rev Urol. 2013;15(2):61-66 doi: 10.3909/riu0569] ® © 2013 MedReviews , LLC Key words Postprostatectomy incontinence • Radical prostatectomy • Pelvic floor muscle training • Pelvic floor stimulation P ostprostatectomy incontinence (PPI) is a bothersome complication of radical prostatectomy (RP). Although most men recover from PPI, some men continue to have persistent urinary incontinence and roughly half of these men seek treatment.1 It is important to understand the natural history of postprostatectomy urinary dysfunction prior to initiating treatment. Generally, the initial management of persistent PPI consists of conservative measures such as pelvic floor muscle exercises. Epidemiology and Natural History of Urinary Incontinence After RP RP, regardless of approach, leads to changes in urinary function, including urinary incontinence, that usually resolve by the end of the first postoperative year. The rate of urinary incontinence after RP depends on the definition of urinary incontinence and the methodology used to collect the data.2-4 Walsh and colleagues5 assessed the continence rate at 10 years in their first 593 patients undergoing the anatomic nerve-sparing Vol. 15 No. 2 • 2013 • Reviews in Urology • 61 4004170006_RIU0569.indd 61 30/07/13 6:22 PM Conservative Treatment for Postprostatectomy Incontinence continued RP. They reported that 6% wore 1 or fewer pads per day. No patient was reported as being totally incontinent. Catalona and Basler6 reviewed their series of 435 men undergoing nerve-sparing RP and found that, with a minimum of 18-month follow-up, 409 were continent. They defined continence as not needing pads and occasionally leaking 1 or 2 drops of urine with severe abdominal straining. Eastham and associates,2 in reviewing continence results after Etiology Proposed risk factors for urinary incontinence after RP are advancing age at the time of RP5,6 neurovascular bundle resection,2,5,6,11 the presence of an anastomotic stricture,4,12 increasing body mass index (BMI),13 increasing prostate volume,14 previous history of transurethral resection of the prostate,15 and decreased membranous urethral length.15 Increasing age leads to higher rates of male urinary incontinence in large-scale population studies,16 Multiple intraoperative maneuvers have been proposed to improve urinary continence, including bladder neck preservation, sparing of the seminal vesicles, suspension of the urethra, bladder neck intussusception, and mucosal eversion of bladder neck. RP, defined continence as those patients who did not use pads or who used a pad occasionally although they were consistently dry with moderate exercise; those who leaked urine onto 1 or more pads daily with moderate exercise were considered to have stress urinary incontinence (SUI), and those who were wet with normal activity were considered severely incontinent. The authors reported a continence rate of 91% at 2 years after RP. In cases in which PPI is prolonged, the most common type of incontinence is SUI. In fact, up to 95% of men presenting for consultation for post-RP incontinence have SUI as documented on urodynamic studies.7,8 Radiotherapy for prostate cancer can also lead to urinary incontinence; however, SUI after modern radiotherapy is rare, with a recent report claiming a rate of 0.7% in the absence of a transurethral resection of the prostate.9 Most men have incontinence immediately after RP. Recovery of urinary continence can take up to 1 year, with a small minority of patients recovering continence up to 3 years after RP.10 and as surgeons operate on older patients and patients with increased BMI, urinary incontinence after RP will continue to remain a bothersome side effect. Multiple intraoperative maneuvers have been proposed to improve urinary continence, including bladder neck preservation, sparing of the seminal vesicles, suspension of the urethra, bladder neck intussusception, and mucosal eversion of bladder neck.5,11,15 Surgeon experience and technique are also related to urinary outcomes after RP.8 The consultation for post-RP incontinence have SUI.9,10 Radiotherapy for prostate cancer can also lead to urinary incontinence; however, SUI after modern radiotherapy is rare, with a recent report claiming a rate of 0.7% in the absence of a transurethral resection of the prostate (TURP).9 However, one must be cautious in the treatment of bladder outlet obstruction after radiotherapy (eg, TURP) or cryotherapy, as these patients have a higher rate of SUI. Patients undergoing RP after previous attempts at definitive therapy with primary radiotherapy or cryotherapy, also called salvage RP, have much higher rates of urinary incontinence.9 The rates of urinary incontinence after salvage RP have been reported to be roughly 50%. Conservative Measures Conservative management remains the mainstay of managing urinary incontinence after RP. In general, this includes limiting fluid intake, particularly at night; avoidance of known bladder irritants, such as caffeine and alcohol; and regular pelvic floor exercises. Bladder training and timed voiding have not been shown to be useful in men.17,18 Bladder training and timed voiding have not been shown to be useful in men. etiology of urinary incontinence is difficult to ascertain because of its multifactorial nature; however, treatment can generally be tailored based on straightforward evaluations. Generally, patients are not evaluated unless they seek treatment for urinary incontinence and usually not until at least 1 year after RP. In cases of prolonged incontinence, the most common type of incontinence is SUI. In fact, up to 95% of men presenting for Pelvic Floor Exercises and Behavior Modifications Pelvic floor exercises, also called Kegel exercises, consist of intermittent voluntary contractions of the urethral sphincter muscle. The duration of contractions and the number of contractions performed per day have not been standardized, but most experts believe that these exercises should be executed multiple times daily for several months to 62 • Vol. 15 No. 2 • 2013 • Reviews in Urology 4004170006_RIU0569.indd 62 30/07/13 6:22 PM Conservative Treatment for Postprostatectomy Incontinence see any effect. If patients are unable to generate a urethral sphincter muscle contraction, aids including biofeedback might be helpful. Pelvic floor exercises have been studied in the setting of PPI and appear to be beneficial at hastening return of continence. A randomized, controlled trial to evaluate the effect of pelvic floor exercise in men who had undergone RP used urinary continence at 3 months after surgery as the primary endpoint.19 In this study, 88% of the men in the treatment group achieved complete continence, measured by 24-hour pad weight, compared with 56% of the men in the placebo group. This difference was statistically significant. At 1 year, the difference between the two groups was only 14%. Subsequently Filocamo and colleagues20 randomized 300 consecutive patients who had undergone RP for clinically confined prostate cancer in two groups after catheter removal. One group of 150 patients took part in a structured pelvic floor muscle training (PFMT) program. This began before discharge and consisted of Kegel exercises. The remaining 150 patients constituted the control group; they were not formally instructed in PFMT. Incontinence was assessed objectively using the 1-hour and 24-hour pad test, as well as with the International Continence Society male questionnaire. This trial showed an earlier return to continence with 74% of the treated men being dry, measured by pad usage, compared with 30% in the untreated group at 3 months.20 Although this difference was statistically significant, the difference at 1 year (98.7% vs 88%) was not. Most recently, a multisite, randomized, controlled trial of 208 men with persistent incontinence greater than 1 year after RP was completed to evaluate the effectiveness of behavioral therapy for reducing persistent PPI.21 The study consisted of three groups: a behavior therapy arm (pelvic floor muscle exercises and bladder control strategies), behavior therapy plus inoffice biofeedback and daily home pelvic floor muscle stimulation, and a control group. The primary outcome measure was percentage reduction in mean number of incontinence episodes at 8 weeks as documented by 7-day bladder diaries. Additional measures included multiple validated symptom scores, including the American Urological Association (AUA) Symptom Index and Expanded Prostate Cancer Index Composite, quality-of-life assessments, and pad counts. The authors reported that men in the behavioral therapy arm experienced a 55% (28 to 13) reduction in weekly incontinence episodes compared with a 24% reduction in the control group (P 5 .001). The arm with behavior therapy plus biofeedback and electrical stimulation (ES) had a 51% reduction, demonstrating no exercises, therefore, appears prudent for all men with PPI. Biofeedback Biofeedback has been used in addition to pelvic floor muscle therapy in some studies. Burgio and associates22 studied the use of preoperative biofeedback assisted behavioral training to decrease PPI. Participants were taught pelvic floor muscle control and received instructions in daily pelvic floor muscle exercise. Patients were taught to contract the sphincter muscles during 2- to 10-second periods separated by 2 to 10 seconds of relaxation, depending on initial ability. The main outcome measurements were duration of incontinence as derived from bladder diaries, severity of incontinence, impact of incontinence, and pad use. The Hopkins Symptom Checklist was used to measure psychological distress and the Medical Outcomes Study Short Form Health Survey was used to Most men regain continence after RP and it appears that pelvic floor exercises can reduce time to continence. additional benefits of biofeedback or pelvic floor muscle stimulation over behavior therapy alone (P 5 .69). In addition, the authors showed that the active treatment arms demonstrated improvements in total AUA Symptom Index (change of 22.5 and 22.1 vs a change of 20.9 in the control arm). Furthermore, 55% and 42% of participants in the active treatment arm reported wearing fewer pads as compared with 5% of those in the control group. The authors also demonstrated that the reduction in incontinence episodes was durable up to at least 12 months for patients in the active treatment group. Most men regain continence after RP and it appears that pelvic floor exercises can reduce time to continence. A trial of pelvic floor assess impact on health-related quality of life. They concluded that preoperative behavioral training could hasten the recovery of urine control and decrease the severity of incontinence following RP. A similar study done by Wille and colleagues23 questioned the benefit of early biofeedback after RP. The outcomes measured included a 20-minute pad test (an objective measure) and a urine symptom questionnaire. The study by Goode and colleagues21 showed no added benefit of biofeedback and ES versus pelvic floor exercises alone. Pelvic Floor Stimulation Pelvic floor stimulation (PFS) involves the ES of pelvic floor muscles using either a probe wired Vol. 15 No. 2 • 2013 • Reviews in Urology • 63 4004170006_RIU0569.indd 63 30/07/13 6:22 PM Conservative Treatment for Postprostatectomy Incontinence continued to a device for controlling the ES, or, more recently, extracorporeal pulsed magnetic innervation. It is thought that PFS of the pudendal nerve will improve urethral closure by activating the pelvic floor musculature. In addition, PFS is thought to improve partially denervated urethral and pelvic floor musculature by enhancing the process of reinnervation. The methods of PFS have varied in location, stimulus frequency, stimulus intensity or amplitude, pulse duration, pulse to rest ratio, treatments per day, number of treatment days per week, length of time for each treatment session, and overall time period for device use between clinical and home settings. Variation in the amplitude and frequency of the electrical pulse is used to mimic and stimulate the different physiologic mechanisms of the voiding response, depending on the type of etiology of incontinence (eg, detrusor instability, SUI, or a mixed pattern).24 Magnetic PFS does not require an internal electrode; patients may sit, fully clothed, on a specialized chair. There is one trial by Yokoyama and associates25 comparing magnetic PFS to ES with a control group. They found both therapies offered earlier continence compared with the control group after RP. This study was also not compared with Kegel exercises or behavioral therapies; as such, it is difficult to determine if this is better than Kegel exercises alone. A small, randomized trial analyzed the benefit of the early combined use of functional pelvic floor study reported a significant difference (P , .05) between active treatment (biofeedback and ES) and control (biofeedback only) groups in % of continent patients from 4 weeks (63.3% in group 1 and 30.0% in group 2) to 6 months (96.7% in group 1 and 66.7% in group 2). Biofeedback and PFS In a small study by Ribeiro and coworkers,26 36 patients were compared with control subjects. They found early biofeedback hastened the recovery of urinary incontinence and lessened the severity of incontinence. In the studies by Bales and associates27 and Burgio and associates,22 preoperative biofeedback with PFMT was compared with a no treatment arm. The control group in this trial did not undergo any training for Kegel exercises. These trials demonstrated a benefit to biofeedback and PFS. When biofeedback is compared with just being given instructions alone, there is no difference in recovery of incontinence.28 In a meta-analysis by MacDonald and colleagues29 a pooled analysis of biofeedback-enhanced PFMT was compared with some type of instructions alone. None of the studies showed an advantage over instructions alone. These results were confirmed in the multicenter randomized trial by Goode and colleagues.21 Pharmacotherapy There is no effective drug treatment for SUI in men. Duloxetine, a serotonin–noradrenalin reuptake There is no effective drug treatment for SUI in men. ES and biofeedback with regard to time to recovery and rate of continence after RP in 60 patients.19 The evaluation of continence was performed at time 0, at 2 and 4 weeks, and at 2, 3, 4, 5, and 6 months. The inhibitor, has shown efficacy for SUI management in women and there have been limited studies in men. The proposed mechanism of action is by blocking the reuptake of noradrenalin and serotonin in Onuf’s nucleus. This, in turn, would raise the activity of pudendal motor neurons, leading to an increase in striated urethral sphincter tone and detrusor relaxation. The data are limited in the use of these medications for post-RP SUI. There were two case series with no control group that evaluated the clinical efficacy of duloxetine, 40 mg/d, after RP in 15 and 18 patients, respectively, which showed some benefit.30 There has been one prospective, randomized study but this was a single-blind study in combination with PFS.31 At this time, duloxetine is not approved by the US Food and Drug Administration (FDA) for management of SUI after RP and is currently used off-label by some practitioners. There has also been interest in the use of α-adrenoceptor agonists for SUI. These agents are effective in increasing bladder outlet resistance during bladder filling in animal models.32 There have been few reports on the use of ephedrine, phenylpropanolamine, and midodrine in the treatment of SUI in men.33-35 These agents have potential for severe side effects, including disturbances in blood pressure, sleep, and cardiac arrythmias. The success of these agents is variable and they should be used with extreme caution. External Penile Compression Devices An external urethral compression device, or clamp, has existed in some form since the 18th century. One of the first descriptions was in a French medical journal in 1731. There are many variations to the design. These devices, in general, are relatively inexpensive, noninvasive, and reusable. The mechanisms of these devices are quite simple, in that they compress the urethra; this, in turn, also compresses the penile vasculature. Commercially 64 • Vol. 15 No. 2 • 2013 • Reviews in Urology 4004170006_RIU0569.indd 64 30/07/13 6:22 PM Conservative Treatment for Postprostatectomy Incontinence available devices are designed to minimize excess pressure and provide a reasonable amount of comfort. There is one randomized trial comparing the use of these devices; all clamps were effective in reducing the amount of urine lost.36 The device that was most effective in reducing incontinence episodes was also one that led to the most compromise of penile vasculature. Endoscopic Management and Urethral Bulking Agents Urethral bulking agents have been used to treat SUI in women and have also been applied to SUI in men, particularly in the setting of SUI due to RP. Glutaraldehyde cross-linked collagen has been approved by the FDA for the treatment of intrinsic sphincter deficiency since 1993. In men with postprostatectomy SUI, the technique consists of an endoscopic injection of collagen in the submucosa overlying or just distal to the urethral sphincter at four sites circumferentially until the urethra coapts. Collagen injection can be repeated after 4 weeks. Cummings and coworkers37 reviewed their initial series of glutaraldehyde cross-linked collagen used as an injectable bulking agent for the therapy of post-RP SUI. Preoperative severity of incontinence was measured as mild (1 to 2 pads/day), moderate (3 to 4 pads/ day), or severe (. 4 pads/day or total incontinence). Success was based on a scale that rated “good” as patient is dry or wearing only an occasional pad, “improved” as a decrease of leakage by 75% or more by patient estimate, or “failure” as no improvement. Men were also questioned at follow-up regarding the presence of voiding difficulties, retention, or irritative symptoms. The authors reported that 58% of patients had a “good” or “improved” result at a mean follow-up of 10.3 months. Smith and colleagues38 reviewed their series of men with PPI who underwent injection of glutaraldehyde cross-linked collagen and they stratified the patients as being “totally dry” or “socially continent” if they used no more than 1 pad daily. It should be noted that most authorities do not consider urethral bulking agents as a durable treatment for SUI in men, particularly after RP incontinence. In fact, the most recent International Consultation on Incontinence,41 a consensus meeting of incontinence experts, It should be noted that most authorities do not consider urethral bulking agents as a durable treatment for SUI in men, particularly after RP incontinence. Their analysis of men who underwent collagen injection revealed that 8.1% of the men were dry and 38.7% of the men achieved social continence, defined as the need for ≤ 1 urinary pad per day, after a median of four injections.38 In a more recent review, Westney and associates39 calculated pad usage before and after therapy. Treatment effect was stratified into quartiles of improvement of 0% to 25%, 26% to 50%, 51% to 75%, and 76% to 100%. Percent maximal response was calculated as % improvement 5 100 2 [(number of pads at maximum response/number of pads at presentation) 3 100]. The length of response was determined by patient questionnaire regarding the date at which leakage returned or increased. Patients classified as completely dry (using no pads and reporting absolutely no leakage) after collagen injection were placed in a separate 100% responder group; 17% of patients gained complete continence. Published success rate with urethral bulking agents is difficult to compare because of varying number of injections and multiple outcome measures used in studies, but ranges from 17% to 38%.37-39 In a study looking at both men and women with intrinsic sphincter deficiency, four men with PPI underwent injections of dextranomer/hyaluronic acid into proximal urethra for urethral incompetence.40 All four men had no improvements in symptoms. regarded urethral bulking agents as showing only modest success rates with low cure rates for SUI in men. Conclusions There are many interventions that fall under the category of conservative management. Most trials to date are small and have the potential for several forms of bias. Few trials used consistent forms of outcomes; some trials used patientreported symptoms and others used a pad test. The conservative interventions whether PFS, biofeedback, or variations of these require staff, equipment, and resources, and have shown no clear benefit over behavioral therapy or Kegel exercises. The management of PPI is complex. Attention should be paid to the natural history of recovery of continence after RP; if surgical correction is warranted, it should usually not be attempted until at least 1 year after RP. Surgical treatments, endoscopic or open, are usually not entertained for men with SUI until conservative treatments have failed. A trial of pelvic floor muscle exercises appears prudent in all men presenting for evaluation of PPI. References 1. 2. Penson DF, McLerran D, Feng Z, et al. 5-year urinary and sexual outcomes after radical prostatectomy: results from the Prostate Cancer Outcomes Study. J Urol. 2008;179(5 suppl):S40-S44. Eastham JA, Kattan MW, Rogers E, et al. Risk factors for urinary incontinence after radical prostatectomy. J Urol. 1996;156:1707-1713. Vol. 15 No. 2 • 2013 • Reviews in Urology • 65 4004170006_RIU0569.indd 65 30/07/13 6:22 PM Conservative Treatment for Postprostatectomy Incontinence continued 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Krupski TL, Saigal CS, Litwin MS. Variation in continence and potency by definition. J Urol. 2003;170 (4 Pt 1):1291-1294. Litwin MS, Lubeck DP, Henning JM, Carroll PR. Differences in urologist and patient assessments of health related quality of life in men with prostate cancer: results of the CaPSURE database. J Urol. 1998;159:1988-1992. Walsh PC, Partin AW, Epstein JI. Cancer control and quality of life following anatomical radical retropubic prostatectomy: results at 10 years. J Urol. 1994;152 (5 Pt 2):1831-1836. Catalona WJ, Basler JW. Return of erections and urinary continence following nerve sparing radical retropubic prostatectomy. J Urol. 1993;150:905-907. Groutz A, Blaivas JG, Chaikin DC, et al. The pathophysiology of post-radical prostatectomy incontinence: a clinical and video urodynamic study. J Urol. 2000;163:1767-1770. Kielb SJ, Clemens JQ. Comprehensive urodynamics evaluation of 146 men with incontinence after radical prostatectomy. Urology. 2005;66:392-396. Stone NN, Stock RG. Long-term urinary, sexual, and rectal morbidity in patients treated with iodine-125 prostate brachytherapy followed up for a minimum of 5 years. Urology. 2007;69:338-342. Saranchuk JW, Kattan MW, Elkin E, et al. Achieving optimal outcomes after radical prostatectomy. J Clin Oncol. 2005;23:4146-4151. Burkhard FC, Kessler TM, Fleischmann A, et al. Nerve sparing open radical retropubic prostatectomy--does it have an impact on urinary continence? J Urol. 2006;176:189-195. Elliott SP, Meng MV, Elkin EP, et al; CaPSURE Investigators. Incidence of urethral stricture after primary treatment for prostate cancer: data from CaPSURE. J Urol. 2007;178:529-534; discussion 534. Anast JW, Sadetsky N, Pasta DJ, et al. The impact of obesity on health related quality of life before and after radical prostatectomy (data from CaPSURE). J Urol. 2005;173:1132-1138. Konety BR, Sadetsky N, Carroll PR; CaPSURE Investigators. Recovery of urinary continence following radical prostatectomy: the impact of prostate volume— analysis of data from the CaPSURE Database. J Urol. 2007;177:1423-1425; discussion 1425-1426. Cambio AJ, Evans CP. Minimising postoperative incontinence following radical prostatectomy: considerations and evidence. Eur Urol. 2006;50:903-913; discussion 913. Nevéus T, von Gontard A, Hoebeke P, et al. The standardization of terminology of lower urinary tract 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. function in children and adolescents: report from the Standardisation Committee of the International Children’s Continence Society. J Urol. 2006;176:314-324. Eustice S, Roe B, Paterson J. Prompted voiding for the management of urinary incontinence in adults. Cochrane Database Syst Rev. 2000;(2):CD002113. Wallace SA, Roe B, Williams K, Palmer M. Bladder training for urinary incontinence in adults. Cochrane Database Syst Rev. 2004;(1):CD001308. Van Kampen M, De Weerdt W, Van Poppel H, et al. Effect of pelvic-floor re-education on duration and degree of incontinence after radical prostatectomy: a randomised controlled trial. Lancet. 2000;355:98-102. Filocamo MT, Li Marzi V, Del Popolo G, et al. Effectiveness of early pelvic floor rehabilitation treatment for post-prostatectomy incontinence. Eur Urol. 2005;48:734-738. Goode PS, Burgio KL, Johnson TM 2nd, et al. Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for persistent postprostatectomy incontinence: a randomized controlled trial. JAMA. 2011;305:151-159. Burgio KL, Goode PS, Urban DA, et al. Preoperative biofeedback assisted behavioral training to decrease post-prostatectomy incontinence: a randomized, controlled trial. J Urol. 2006;175:196-201; discussion 201. Wille S, Sobottka A, Heidenreich A, Hofmann R. Pelvic floor exercises, electrical stimulation and biofeedback after radical prostatectomy: results of a prospective randomized trial. J Urol. 2003;170(2 Pt 1):490-493. Mariotti G, Sciarra A, Gentilucci A, et al. Early recovery of urinary continence after radical prostatectomy using early pelvic floor electrical stimulation and biofeedback associated treatment. J Urol. 2009;181:1788-1793. Yokoyama T, Nishiguchi J, Watanabe T, et al. Comparative study of effects of extracorporeal magnetic innervation versus electrical stimulation for urinary incontinence after radical prostatectomy. Urology. 2004;63:264-267. Ribeiro LH, Prota C, Gomes CM, et al. Long-term effect of early postoperative pelvic floor biofeedback on continence in men undergoing radical prostatectomy: a prospective, randomized, controlled trial. J Urol. 2010;184:1034-1039. Bales GT, Gerber GS, Minor TX, et al. Effect of preoperative biofeedback/pelvic floor training on continence in men undergoing radical prostatectomy. Urology. 2000;56:627-630. Dubbelman Y, Groen J, Wildhagen M, et al. The recovery of urinary continence after radical retropubic prostatectomy: a randomized trial comparing the 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. effect of physiotherapist-guided pelvic floor muscle exercises with guidance by an instruction folder only. BJU Int. 2010;106:515-522. MacDonald R, Fink HA, Huckabay C, et al. Pelvic floor muscle training to improve urinary incontinence after radical prostatectomy: a systematic review of effectiveness. BJU Int. 2007;100:76-81. Boy S, Reitz A, Wirth B, et al. Facilitatory neuromodulative effect of duloxetine on pudendal motor neurons controlling the urethral pressure: a functional urodynamic study in healthy women. Eur Urol. 2006;50: 119-125. Schlenker B, Gratzke C, Reich O, et al. Preliminary results on the off-label use of duloxetine for the treatment of stress incontinence after radical prostatectomy or cystectomy. Eur Urol. 2006;49:1075-1078. Brune ME, O’Neill AB, Gauvin DM, et al. Comparison of alpha 1-adrenoceptor agonists in canine urethral pressure profilometry and abdominal leak point pressure models. J Urol. 2001;166:1555-1559. Awad SA, Downie JW, Kiruluta HG. Alpha-adrenergic agents in urinary disorders of the proximal urethra. Part II. Urethral obstruction due to “sympathetic dyssynergia”. Br J Urol. 1978;50:336-339. Diokno AC, Taub M. Ephedrine in treatment of urinary incontinence. Urology. 1975;5:624-625. Nito H. Clinical effect of midodrine hydrochloride on the patients with urinary incontinence [article in Japanese]. Hinyokika Kiyo. 1994;40:91-94. Moore KN, Schieman S, Ackerman T, et al. Assessing comfort, safety, and patient satisfaction with three commonly used penile compression devices. Urology. 2004;63:150-154. Cummings JM, Boullier JA, Parra RO. Transurethral collagen injections in the therapy of post-radical prostatectomy stress incontinence. J Urol. 1996;155:1011-1013. Smith DN, Appell RA, Rackley RR, Winters JC. Collagen injection therapy for post-prostatectomy incontinence. J Urol. 1998;160:364-367. Westney OL, Bevan-Thomas R, Palmer JL, et al. Transurethral collagen injections for male intrinsic sphincter deficiency: the University of Texas-Houston experience. J Urol. 2005;174:994-997. Lightner DJ, Fox J, Klingele C. Cystoscopic injections of dextranomer hyaluronic acid into proximal urethra for urethral incompetence: efficacy and adverse outcomes. Urology. 2010;75:1310-1314. Herschorn S, Bruschini H, Comiter C, et al; Committee of the International Consultation on Incontinence. Surgical treatment of stress incontinence in men. Neurourol Urodyn. 2010;29:179-190. Main Points • Postprostatectomy incontinence (PPI) is a bothersome complication of radical prostatectomy (RP). Although most men recover from PPI, some men continue to have persistent urinary incontinence. • There are many interventions that fall under the category of conservative management. Most trials to date are small and have the potential for several forms of bias. If surgical correction is warranted it should usually not be attempted until at least 1 year after RP. • Conservative management remains the mainstay of managing urinary incontinence after RP. In general, this includes limiting fluid intake; avoidance of known bladder irritants, such as caffeine and alcohol; and regular pelvic floor (Kegel) exercises. • One study showed that preoperative behavioral training could hasten the recovery of urine control and decrease the severity of incontinence following RP. • There is no effective drug treatment for stress urinary incontinence (SUI) in men. There has also been interest in the use of a-adrenoceptor agonists for SUI; however, the success of these agents is variable and they should be used with extreme caution. 66 • Vol. 15 No. 2 • 2013 • Reviews in Urology 4004170006_RIU0569.indd 66 30/07/13 6:22 PM