Incontinence as a Consequence of Surgical Procedure on the Prostate
Despite the advent of new surgical methods, urinary incontinence after prostate procedures remains a clinically significant iatrogenic complication. For patients, it represents a significant stress factor that carries physical and psychosocial consequences.
The Rate of Incontinence Decreases Over Time Post-Procedure
Statistics tracking the occurrence of incontinence after prostate surgery often vary. The differences in numbers can be influenced by the use of different criteria for defining incontinence, as well as evaluating urinary leaks at various time intervals post-surgery. Generally, significant improvement occurs within 12 months post-procedure. While about 1% of men suffer from persistent incontinence after transurethral resection of the prostate, the incidence of incontinence immediately following radical prostatectomy is high, ranging from 20%–40%. A year after the procedure, 5%–10% of men still report sufficiently troublesome urinary leaks that they need to seek medical assistance.
Pathophysiology and Risk Factors Influencing Incontinence Development
Multiple factors likely contribute to the development of incontinence post-surgery, although the exact cause is not entirely clear. For radical prostatectomy, potential causes include inadequate function of the external sphincter due to its injury or disruption of nerve supply during the procedure. Other reasons may include the shortening of the functional length of the urethra, interruption of the continuity of the smooth muscle of the vesicourethral junction, or disruption of the nerve supply to the urethra or bladder neck. Detrusor instability with reduced bladder capacity, often cited as a culprit, exacerbates incontinence, especially in the first few months post-operation. Additional risk factors include vesicourethral anastomosis stricture, older patient age, prostate size, and higher body weight.
Treatment Options
Early treatment of incontinence primarily involves a conservative approach using rehabilitation, possibly along with anticholinergic medications. The foundation is strengthening the sphincter mechanism, ideally starting alongside biofeedback prior to the procedure itself, which undoubtedly accelerates the return to full continence.
When conservative therapy fails and incontinence persists, other treatment modalities come into play.
- Injection Procedures: A simple procedure that increases urethral resistance. Teflon, collagen, or silicone may be used for periurethral application. Studies suggest that this method has less favorable outcomes compared to artificial sphincter implantation, with effects lasting only a short time. On the plus side, it is a safe, well-tolerated, and easily repeatable treatment for persistent incontinence.
- Sling Procedures: This method involves implanting a tape that compresses the ventral side of the urethra, thus increasing its resistance. In the Czech Republic, the Argus sling technique is most commonly used. Sling procedures are not suitable for patients with severe incontinence or those who have undergone radiotherapy. Complications include sling erosion into the urethra, urinary retention, infection, or perineal pain.
- Artificial Sphincter: This method is used for patients with stress incontinence, particularly after radical prostatectomy. It is highly effective but associated with several risks. Complications include infection, urethral erosion, or mechanical failure of the sphincter. It is noted that up to half of the cases may experience failure within ten years. This method is also suitable for patients post-radiotherapy.
Conclusion
If incontinence persists even after exhausting the "common" treatment options, specialized solutions like bladder augmentation or permanent urinary diversion come into play. If these procedures are not feasible or the patient declines them, high-quality incontinence aids become essential. Today’s market offers a wide range of suitable products that respect male anatomy. In addition to traditional pads or diaper pants, men can also use a penile sheath. A clear advantage now is the ability to combine various aids according to the patient’s individual needs.
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Sources:
1. Ženíšek J. Urinary Incontinence after Radical Prostatectomy. Urology for Practice 2010; 11 (1): 26–28.
2. Sandhu J. S., Breyer B., Comiter C. et al. Incontinence after Prostate Treatment: AUA/SUFU Guideline. J Urol 2019; 202: 369–78.
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