Urinary Incontinence in Men

Background

• Urinary incontinence in men is usually due to bladder outlet obstruction, overactive bladder/urge incontinence, detrusor overactivity related to neurogenic bladder, or complications relating to prostate treatment.

Evaluation

• Assess the type, timing, and severity of incontinence, as well as associated voiding and other urinary symptoms.
• Ask about features associated with complicated incontinence that may require referral for specialty evaluation and management such as pain, hematuria, recurrent urinary tract infections, history of prostate irradiation, history of prostate or pelvic surgery, constant leakage, voiding difficulty, or suspected neurological disease.
• Initial testing should include urinalysis to look for causes of incontinence such as a urinary tract infection (Strong recommendation).
• For patients having voiding difficulty or other lower urinary tract symptoms, check post void residual and uroflowmetry (Strong recommendation).
• Consider other testing such as urodynamic testing, cystoscopy, and ultrasound imaging if there is no benefit with conservative or medical therapy (Weak recommendation).

Management

• Treat reversible causes, such as symptomatic urinary tract infection (UTI), and reduce use of medications that may be causing urinary incontinence (Strong recommendation).
• Offer conservative treatment to patients if there is no concern for complicated incontinence (such as symptoms of pain or hematuria).
  • Offer bladder training as first-line therapy for adults with urge or mixed urinary incontinence (Strong recommendation).
  • Offer pelvic floor muscle training to men undergoing prostatectomy (Strong recommendation).
  • Consider containment devices such as absorbent pads (Weak recommendation)
  • Encourage patients who are overweight and obese to lose weight and maintain weight loss (Strong recommendation).
  • Provide patient education such as advice about altering fluid intake pattern, avoiding or moderately consuming possible diuretics and irritants, such as caffeine and alcohol, and encourage urethral milking to prevent postmicturition dribble (Strong recommendation).
• For urge incontinence:
  • Consider offering anticholinergic medications in men with urge incontinence or mixed stress and urge incontinence if urge incontinence predominates (Weak recommendation).
    • Caution advised in patients with bladder outlet obstruction or postvoid residual urine > 250-300 mL.
    • Contraindicated in patients with narrow-angle glaucoma.
  • Other oral medication options include mirabegron, desmopressin (for short-term relief only), and duloxetine (for short-term relief).
  • Consider botulinum toxin A intravesical injection to patients with urge urinary incontinence if anticholinergic therapy ineffective, but advise regarding risk for urinary retention and urinary tract infection (Weak recommendation).
  • Consider electrical stimulation with surface electrodes as an adjunct to pelvic floor muscle training for benefit in the short term (Weak recommendation).
  • Consider sacral nerve modulation in patients who do not respond to conservative treatment (Weak recommendation).
  • Offer augmentation cystoplasty to patients who have failed all other treatment options (Weak recommendation).
• For incontinence due to neurogenic bladder, selection of treatment options should be guided by detrusor and sphincter activity based on urodynamics (Strong recommendation).
• For incontinence due to benign prostatic hypertrophy (BPH), consider conservative management, medications such as alpha-1 blockers or 5-alpha reductase inhibitors, and surgery as options (Weak recommendation).
• For incontinence following prostate cancer treatment:
  • Offer pelvic floor muscle training to men undergoing radical prostatectomy to speed recovery of urinary incontinence (Strong recommendation).
  • Offer bulking agents if mild postprostatectomy incontinence in patient who desires temporary relief of urinary incontinence symptoms (Strong recommendation).
  • Offer fixed slings to men if mild-to-moderate postprostatectomy incontinence (Strong recommendation).
  • Consider using an artificial urinary sphincter if moderate-to-severe postprostatectomy incontinence (Weak recommendation).