Rigi10™ Malleable Penile Prosthesis
Also Known As
PPI, Incontinence after prostatectomy, Post-RP UI, Urinary leakage after prostate surgery, Stress urinary incontinence post-prostatectomy
Definition
Post-Prostatectomy Incontinence (PPI) refers to the involuntary leakage of urine that occurs as a complication following radical prostatectomy, the surgical removal of the prostate gland, typically performed for the treatment of prostate cancer. This condition can significantly impact a patient’s quality of life, creating both hygienic and social challenges.¹ The International Continence Society (ICS) defines urinary incontinence (UI) more broadly as any involuntary loss of urine that is demonstrable and problematic.¹ The mechanism behind PPI primarily involves damage to the urinary sphincter complex or its supporting structures during the surgical procedure. The prostate gland surrounds the initial part of the urethra, and its removal can affect the structures responsible for maintaining urinary control. Specifically, the internal urethral sphincter, located at the bladder neck, and the external rhabdosphincter, a voluntary muscle, play crucial roles in continence. Radical prostatectomy inherently involves the removal of the proximal urethral sphincter and can lead to injury or dysfunction of the remaining external rhabdosphincter or its nerve supply.¹ Consequently, the rhabdosphincter becomes the primary structure responsible for maintaining continence post-surgery.¹ Factors contributing to PPI include the extent of surgical dissection, potential injury to the neurovascular bundles that innervate the sphincter, and the development of post-operative fibrosis or scarring which can impair sphincter function.¹ Understanding PPI involves recognizing that it is an iatrogenic condition, meaning it results directly from medical treatment.²
Clinical Context
Post-Prostatectomy Incontinence is a condition encountered clinically after a patient undergoes radical prostatectomy, a common treatment for localized prostate cancer. The primary indication for addressing PPI arises when a patient experiences bothersome urinary leakage that negatively affects their daily activities, social interactions, and overall well-being.¹ The severity of PPI can range from occasional dribbling of urine with strenuous activity (stress urinary incontinence) to more continuous leakage. Patient selection for treatment depends on the severity and type of incontinence, the degree of bother to the patient, the time elapsed since surgery, and the patient’s overall health and preferences.¹˒²
Evaluation typically begins with a thorough medical history, physical examination, and urinalysis to rule out infection. Voiding diaries and standardized questionnaires are often used to quantify the leakage and its impact.¹˒² For instance, the American Urological Association (AUA) guidelines recommend that clinicians should evaluate patients with incontinence after prostate treatment with history, physical exam, and appropriate diagnostic modalities to categorize the type and severity of incontinence and degree of bother.² Prior to surgical intervention for stress urinary incontinence, stress urinary incontinence should be confirmed by history, physical exam, or ancillary testing, and cystourethroscopy should be performed to assess for urethral and bladder pathology.² Urodynamic testing may be performed in cases where it may facilitate diagnosis or counseling.²
Conservative management is typically the first line of approach, especially in the immediate post-operative period. This includes pelvic floor muscle exercises (PFME), also known as Kegel exercises, which aim to strengthen the external urethral sphincter and pelvic floor muscles.¹˒² Lifestyle modifications, such as managing fluid intake and avoiding bladder irritants, may also be advised. Pharmacotherapy, including antimuscarinic drugs for overactive bladder symptoms that might coexist with stress incontinence, or duloxetine (off-label in some regions) for stress incontinence, has limited and specific roles.¹
If conservative measures fail to provide adequate relief, surgical interventions are considered. The AUA guidelines suggest that surgery may be offered as early as six months post-prostatectomy if incontinence is not improving, and should be offered at one year if bothersome stress incontinence persists despite conservative therapy.² Surgical options include the implantation of an artificial urinary sphincter (AUS), which is considered the gold standard for moderate to severe PPI.¹˒² The AUS is a device with an inflatable cuff placed around the urethra, a pump implanted in the scrotum, and a pressure-regulating balloon. Male slings are another surgical option, generally indicated for mild to moderate stress incontinence.¹˒² Adjustable balloon devices may also be offered to non-radiated patients with mild to severe stress urinary incontinence.² Urethral bulking agents, which involve injecting material around the urethra to increase resistance, are also an option, though their efficacy is generally lower and often temporary, with cure being rare.¹˒²
Expected outcomes vary depending on the chosen treatment, patient factors, and surgeon experience. With PFME, many patients see improvement over several months; continence rates can be up to 70% (no pad use) at 12 months post-RP, and rise to 90% if one safety pad is considered acceptable.¹ Surgical treatments like AUS implantation can achieve high rates of social continence, though patients should be counseled about potential complications and the likelihood of needing revisions over time.² It is crucial for clinicians to inform patients undergoing localized prostate cancer treatment of all known factors that could affect continence and that incontinence is expected in the short-term, generally improving to near baseline by 12 months after surgery but may persist and require treatment.²