Earlier in 2019, the AUA and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction 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.
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.
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.
Next: Are there any off-label pharmacologic treatments you would recommend?Are there any off-label pharmacologic treatments you would recommend?
The guideline does not address off-label treatment. There are off-label treatments in Europe and Japan. Duloxetine is available for stress urinary incontinence. Some people use treatments like imipramine for stress incontinence. Beyond that, there aren’t a whole lot of options. Most of these, as you know, are psychotropic medicines. For that reason, duloxetine has never been considered for FDA approval as treatment for urinary incontinence in the U.S., primarily due to litigation risk. But if you want to provide something off-label, that may be an option.
Do you ever use bulking agents while a patient is waiting for definitive therapy?
That’s a very good question. One of the bases for this guideline was the fact that bulking agent use is rampant. The problem with bulking agents is twofold. One, they’re not FDA approved for male incontinence. Two, their effect is generally fleeting; they’re not durable. They need to be repeated, and we’re not sure what the effect of bulking agents is on future therapy. We don’t think there is an effect, but that’s something that hasn’t been looked at thoroughly. The guideline counsels providers to explain to patients that bulking agents are not durable, will likely need to be repeated, and are not FDA approved.
It seems like every scientific meeting I attend, new artificial urinary sphincters and slings are presented. How does the guideline address these treatments?
This is an AUA-SUFU practice guideline. With that in mind, we looked only at FDA-approved treatments. The only FDA-approved artificial urinary sphincter in the U.S. when the literature review for this guideline was performed was the AMS 800 artificial urinary sphincter. Although multiple male slings are FDA approved, because their efficacy is similar, we did not evaluate individual sling types in this version of the guideline. There is a separate statement in the guideline about the newly FDA-approved adjustable balloons because these were thought to be different from slings and sphincters by the guideline committee.
Is there anything else you would like to add regarding male incontinence?
Male incontinence is now more recognized by the general public. Part of the reason is there are a lot more incontinence products available for men, which you and I have seen proliferate in big box stores, etc. Ten years ago, you couldn’t buy a pad for men. Now you can buy them in bulk. We know that the public is aware of this malady. We’re just trying to make sure people realize there are treatments available that can actually counter some of these problems.
The other thing to note is these problems are often created by us. Incontinence after prostate treatment is an iatrogenic problem. This isn’t like erectile dysfunction, where medical problems may cause it. This is related to prostate treatment.
The LURN (Symptoms of Lower Urinary Tract Dysfunction Research Network) showed us the prevalence of incontinence is very high in men-whether they have or haven’t undergone prostate treatment. Does the guideline address this?
Although this guideline is meant to deal with incontinence after prostate treatment, there are certainly statements that apply to patients who develop incontinence on their own. As you know, roughly 30% of men over the age of 70 will have some degree of urinary incontinence. If this is determined to be male stress urinary incontinence, then the evaluation and treatment is essentially the same as for those with incontinence after prostate treatment and the guideline statements related to evaluation, treatment, and surgical complication (of anti-incontinence surgery) apply to these patients as well.
Further, the fact that 30% of men develop incontinence without any prostate intervention provides a good baseline. I use this figure when counseling patients who are undergoing post-prostatectomy anti-incontinence surgery. It’s a good normalizing technique and a good way of telling people that, after artificial urinary sphincter placement, you will likely still leak a little bit.