Prostate cancer and prostatic hyperplasia - a benign enlargement of the prostate common in men aged 50 and over - are two conditions widely associated with the occurrence of male incontinence. These two conditions can be treated with surgery, but the risk of stress urinary incontinence remains high after radical prostatectomy and the risk of urgency also after transurethral resection. The experts of the Cochrane Incontinence Group offer an update on the epidemiology of this incontinence and on the evidence of the effectiveness of the conservative treatments available.
- It is not uncommon for men to experience urinary incontinence after prostatectomy: the prevalence of urinary incontinence after radical prostatectomy is widely reported, ranging from 2% to 60%, depending on the post-procedure period. Studies report a prevalence of 36 to 50% of incontinence in the 3 months following radical prostatectomy. At 12 months, this rate drops to 16 to 20%.
- Urinary incontinence is less common after transurethral resection of the prostate (TURP) for benign prostate disease. Most cases are actually related due to persistent incontinence prior to surgery. "Early" urge urinary incontinence, just after the procedure, affects up to 30% to 40% of men, but stress incontinence or late "stress urinary incontinence" is rare and affects less than 0.5% of patients.
What Mechanisms?
- There is a debate in the literature on the question of the causes of incontinence after prostatectomy: is this incontinence due to an effect on the detrusor muscle (bladder) or on the sphincter, because these two abnormalities generally coexist. The development of detrusor overactivity and/or sphincter insufficiency are the main causes of persistent incontinence after radical prostatectomy. But we do not know precisely which is the primary factor and/or the secondary factor. Added to these two side effects is the age factor often synonymous with sphincter atrophy and neural degeneration as well as certain antecedents of interventions, the pre-existence of neurological diseases, including Parkinson's and dementia or the taking of certain medications.
- After transurethral resection of the prostate (TURP), incontinence is thought to be mostly related to pre-existing abnormalities of bladder function, including detrusor overactivity, rather than direct sphincter injury.
What conservative treatments?
Post-prostatectomy treatments are rather “conservative”, that is to say they do not involve drugs or surgery, biofeedback type therapies with intra-anal probe being considered here as non-invasive. These treatments include pelvic floor muscle exercises, transcutaneous (non-invasive) electrical stimulation delivered by surface electrodes, anal electrical stimulation, lifestyle interventions, extracorporeal magnetic stimulation and penile clamps…
This meta-analysis concludes,
- moderate evidence of the benefits provided by pelvic floor strengthening exercises, in terms of reduction of urinary incontinence: i.e. 10% at 1 year in the intervention groups vs 32% in the control groups. However, further research is still needed.
- Some studies show a certain rate of patient satisfaction with external compression devices (forceps), which reduce the loss of urine at best.
- Finally, there are few data on the effectiveness of lifestyle interventions, including better management of fluid intake, healthy eating, caffeine avoidance, physical exercise, loss of weight and smoking cessation.
The effectiveness of different conservative approaches to post-prostatectomy incontinence is therefore uncertain , conclude the experts who call for rigorously designed trials to better identify the needs of incontinent patients post-prostatectomy or post-transurethral resection of the prostate. Finally, on the use of protections, also considered as a measure of the severity of incontinence (pad test), the experts did not identify any statistically significant difference, at 12 months, between the patients in the intervention groups (40% ) vs control groups (42%).
This suggests that, regardless of the effectiveness of the various conservative treatments, male pads provide patients with a good level of comfort and safety during the years following surgery.
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