Algorithms of Incontinence Management Men Educational Course of the ICS VUNA Annual Meeting 2011 Hue, June 21-23 Algorithms of Incontinence Management Men Helmut Madersbacher Innsbruck/Austria

The problem investigation and management of urinary incontinence in men suffers a gender bias in favour of women. Research and publications are based predominantly on female samples most articles in men focus on post-prostatectomy incontinence, implying indirectly the unlikelihood of other causes incontinence rate in men over 60 ranging from 8 % (Seoul) to 23 % (Birmingham) Boyle P., et al., BJU Int, 92: 943, 2003

Who are the men who leak? Elderly men Men with functional or cognitive impairment Men with neurological disorders After prostate surgery TURP, radical prostatectomy and other therapy for prostate cancer Hunskaar et al, 2005 3rd International Consultation on Incontinence

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Initial management History- /Symptom Assessment Clinical Assessment General medical history History of neurological disease, relevant surgery and radiation therapy Medications with potential effects on the lower urinary tract

Initial management History- /Symptom Assessment Clinical Assessment Time of onset and duration of incontinenc Presence of concomitant LUTS Precipitating or aggravating factors of urinary loss Grade of bother and impact on quality of life Questionnaires may facilitate the disclosure of symptoms

Initial management QUESTIONNAIRES Highly recommended questionnaires to assess symptoms and quality of life impact of urinary incontinence ICI-Q ICS male SF Highly recommended questionnaires to assess quality of life impact of urinary incontinence I-QOL SEAPI-QMM

ICI-Q Avery KN et al., J. Urol, 2007

Initial management History- /Symptom Assessment Clinical Assessment Weight Abdominal examination kidney and bladder palpation Perineal / genital inspection erythema due to incontinence Stress test Neurological examination sacral neuronal pathways Rectal examination to assess prostate, the resting tone of the sphincter and the ability to contract it

Initial management Clinical Assessment Urinalysis & Urine Cytology OAB-like symptoms can be caused by Urinary Tract Infection Bladder cancer (specially CIS) Bladder stones Urethral strictures

Initial management Charts and Diaries Micturition time chart times of micturition, day and night for 48 hours Frequency volume chart volume voided, as well as of time of each micturition day and night for 48 hours Bladder diary times of micturitions, voided volumes, incontinence episodes, fluid intake for 48 hours. Charts and diaries are the most effective additional test in the basic evaluation of incontinent patients

Initial management Short-term test (1-hour) positive of > 1g Pad Tests Aim at quantifying the volume of urine loss by weighting a perineal pad before and after some type of leakage provocation Short-term test (1-hour) positive of > 1g Long-term test (24-hour) positive of > 4g High test-retest correlation, higher with long-term test

Initial management Postvoid residual urine Recommended in men with symptoms suggestive of bladder outlet obstruction Ultrasound, Palpation, Catheterisation Large intra-individual and inter-individual variability need for multiple measurements PVR in % of bladder capacity: balanced bladder emptying < 20 %

Initial management Urodynamic tests and imaging of the lower urinary tract are not indicated in the initial assessment

Algorithms of Incontinence Management in Men Patients with post-micturition dribbling, post- prostatectomy incontinence, and OAB are suitable for initial non-specialized management Men with complicated incontinence (haematuria, pain, UTIs, LUTS, incontinence after radiation therapy or radical pelvic surgery, recurrent incontinence) are suitable for specialized management Men with treatment failure after non-specialized treatment are suitable for specialized management

Algorithms of Incontinence Management in Men Patients with post-micturition dribbling, post- prostatectomy incontinence, and OAB are suitable for initial non-specialized management Men with complicated incontinence (haematuria, pain, UTIs, LUTS, incontinence after radiation therapy or radical pelvic surgery, recurrent incontinence) require specialized management Men with treatment failure after non-specialized treatment need specialized management

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Specialized management Urodynamic Tests To understand the reasons for failure of previous treatments for incontinence To identify or rule out factors contributing to incontinence To obtain information on lower urinary tract dysfunction To predict the outcome of a treatment To predict the consequences of lower urinary tract dysfunction on the upper urinary tract

Specialized management Urodynamic Tests Fundamental to distinguish the main factors contributing to post-prostatectomy or post-RT urinary incontinence sphincter weakness, detrusor overactivity, mixed incontinence, bladder outlet obstruction Need for urodynamics before invasive therapy Cioè solo il 56% delle pazienti con SUI hanno incontinenza da sforzo urodinamica

Specialized management Imaging of the Lower Urinary Tract Retrograde urethrogram and cystourethrography can have a role in the identification of anastomotic strictures Videourodynamics is the gold standard to evaluate post-prostatectomy incontinence, combining functional and imaging data

Algorithms of Incontinence Management in Men Patients with post-micturition dribbling, post- prostatectomy incontinence, and OAB are suitable for initial non-specialized management Men with treatment failure after non-specialized treatment need specialized management Men with complicated incontinence require specialized management

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Urinary incontinence in men Summary (I) Initial management Aims to identify 3 groups for initial management post-micturition dribble alone urgency with or without incontinence post-prostatectomy incontinence Treatment Post-mictuition dribble: PFM training, manual compression of the bulbous urethra Urgency/OAB: non-invasive therapy with lifestyle interventions, bladder training, antimuscarinics, α-blocker Post-prostatectomy stress incontinence PFM training, lifestyle interventions, bladder training

Urinary incontinence in men Summary (II) Specialized management If initial management fails, or „complicated“ incontinence is present: further assessment by additional testing with symptoms suggestive of DO or persisting sphincter incontinence urodynamic studies recommended Treatment When basic management has failed, for sphincter incompetence: male slings, artificial sphincter for IDO: Botulinum Toxin A, neuro-modulation, bladder augmentation for post-prostatectomy incontinence: male slings, artificial sphincter When associated with poor bladder emptying urodynamics (detrusor weakness, bladder outlet obstruction, restore balanced voiding.

Thank you.

AdVanceTM male sling TO sling relocates the sphincter into the intrapelvic pressure zone Supports dorsal support structures of sphincter Rehder P, Gozzi C Eur. Urol. 2007, E-pub.

Thank you Helmut Madersbacher Innsbruck/Austria Educational Course of the ICS VUNA Annual Meeting 2011 Hue, June 21-23 Thank you Helmut Madersbacher Innsbruck/Austria