AUA, SUFU offer guidance on incontinence after prostate treatment

Earlier in 2019, the AUA and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) published a joint guideline on the subject of incontinence after prostate treatment. In this interview, Jaspreet S. Sandhu, MD, a member of this guideline’s panel, explains the rationale behind the guideline and summarizes its key points. (To read the guideline, see bit.ly/AUASUFUincontinenceguide.) Dr. Sandhu is a urologic surgeon at Memorial Sloan Kettering Cancer Center in New York. Dr. Sandhu was interviewed by Urology Times Editorial Consultant Gopal H. Badlani, MD, professor of urology at Wake Forest Baptist Medical Center, Winston-Salem, NC.

 

Please explain the rationale behind this guideline.

As you know, male incontinence is quite prevalent, particularly after prostate treatment. There are a lot of different ways of treating male incontinence. Unfortunately, these have never been evaluated thoroughly. We also have many studies that tell us what happens to continence recovery after prostate treatment, particularly after radical prostatectomy and radiation therapy. The AUA Practice Guidelines Committee decided, in partnership with SUFU, to come up with a guideline that codifies what happens to continence recovery after prostate treatment, and give current evidence as to the best way to treat this particular malady.

The variability is incredible when it comes to treating incontinence and, depending on where you go, there are different modes of treatment that are favored. There is a reasonable amount of evidence out there now that can help clinicians determine which modalities work better for which types of patients. That was the main rationale behind this guideline.

Another reason behind developing this guideline is the length of time many men wait to receive surgical treatment for incontinence. We say that if patients present with incontinence 12 months after surgery, they should be counseled that there are treatments available and should be evaluated for incontinence after prostate treatment. There is a caveat that if they have severe incontinence that is bothersome, surgical treatment can be offered at 6 months.

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The 12-month time frame is to capture patients from going further. The 6-month time frame is to make sure people realize there are things available even then, should they have severe incontinence. As you and I know, there’s a group of patients that are never told about possible treatments for incontinence. This is just a way of making sure everybody knows there are treatments available, and hopefully that knowledge will allow some of these patients to be offered or referred for treatment sooner.

 

How does the guideline address the period between prostatectomy and surgical treatment for incontinence?

The guideline has sections on pre-prostate treatment, post-prostate treatment, and evaluation of incontinence after prostate treatment. What you’re describing is the post-prostate treatment time frame. Generally, that applies to radical prostatectomy, but it can apply to patients who’ve had radiation therapy followed by a TURP or, in rare cases, after BPH surgery. Before treatment, the guideline says you should counsel patients about risk factors for incontinence. Following and sometimes even before treatment, pelvic floor muscle exercises and pelvic floor muscle therapy are definitely two options that can help hasten continence recovery. Beyond that, if patients continue to have incontinence after prostate treatment, then they can go on to evaluation and possibly surgical treatment.

 

Are there any pharmacologic aids that you recommend to patients while they’re waiting to see if they have established incontinence?

Before presentation for incontinence after prostate treatment, there are really no medicines available. Now, if it’s primarily urgency urinary incontinence, which can be determined based on history-generally leakage at night or leakage associated with urgency and not necessarily associated with activity-then you should follow the overactive bladder guideline, which has a very good algorithm as to how to treat these men primarily with pharmacologic therapy.

There is also a guideline statement that specifically says if urgency urinary incontinence or urgency predominant mixed urinary incontinence is suspected, those patients should be evaluated and treated, whenever they present, as overactive bladder patients. That particular group of patients can be treated with anticholinergics or beta-3 agonists as needed.

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