1. 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

2. 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

3. 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, rd International Consultation on Incontinence

6. URODYNAMIC TESTS

7. 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

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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 %

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

17. 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

20. 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

21. URODYNAMIC TESTS

22. 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

23. 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

24. 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

25. 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

27. URODYNAMIC TESTS

28. URODYNAMIC TESTS
BTX A

29. URODYNAMIC TESTS

30. 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

31. 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.

32. Thank you.

33. 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.

34. 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