Management of Iatrogenic Male Incontinence

Abstract

Iatrogenic incontinence is one of the most important and devastating complication for both the patient and the surgeon., several risk factors are common to all and they include preexisting detrusor and sphincteric dysfunction, increasing age, and surgical expertise. The diagnosis of iatrogenic incontinence according to the two-stage assessment recommended by the EAU guidelines has proven to be successful. Evaluation of iatrogenic incontinence patients needs a complete history taking, complete physical examination and Pad testing. Also a list of important investigations to reach the possible aetiology and it includes: Urinalysis,BUN, serum creatinine, Uroflowmetry, Urodynamic study, Cystourethro-graphy, and Endoscopy. However, the recommendations for treatment options are still only given generally without a clear association with stage and severity of incontinence. This limitation can only be overcome in the future if sufficient evidence is provided by future clinical studies. For early iatrogenic incontinence, noninvasive therapies like PFMT, biofeedback, and electrical stimulation are, in general, strongly recommended, although there is no strong data to support these recommendations. In addition, there is no conclusive data concerning the optimal timing to begin treatment—specifically for preoperative versus postoperative—noninvasive therapy. Regarding the pharmacological treatment as a part of non-invasive therapy: The efficacy of duloxetine in men has also been evaluated. Despite the efficacy shown, duloxetine has not yet received approval for treatment of male stress incontinence. Nevertheless, duloxetine is commonly used off-label to treat male stress incontinence. In early iatrogenic incontinence, de novo urgency with or without detrusor overactivity may play a certain role. For these patients, additional antimuscarinic treatment should be pursued. If noninvasive therapy fails, surgical therapy options are recommended, but the natural healing rate should be taken into account. Only in severe incontinence should surgical therapy be considered before 6 mo to 12 mo after surgery. For severe or persistent incontinence the artificial urinary sphincter is still the gold standard of treatment. The AMS-800 is associated with high continence and high patient satisfaction rates. It is currently the reference treatment for refractory sphincter incompetence in men. In recent years, numerous minimally invasive treatment options with different success rates have been investigated. But new surgical techniques must at least match the results of the artificial sphincter. Nevertheless, the patient demand for minimally invasive treatment options is high, and often, poorer results are accepted by the patients in order to avoid an artificial sphincter. Injection therapy has been used sucessfully using various types of injectable materials (eg, collagen, teflon, silicone, autologous fat, autologous chondrocytes, dextranomer/ hyaluronic acid copolymer). Recent studies concerning the use of stem cell therapy as a subtype of injection therapy. Slings can be recommended for patients with persistent mild or moderate incontinence. With various types of slings used as InVance system, REEMEX system, ProAct system and AdVanceretropubic system. For patients with severe incontinence the artificial sphincter is recommended, this technique is expensive and requires invasive surgery and experienced surgeons. It has a high rate of infection and a high rate of urethral