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Post prostactetomy incontinence DIAGNOSIS ChristianCobreros ChristianCobreros 0 66 May 2, 2015 by ChristianCobreros ChristianCobreros
Post-prostatectomy Incontinence

Editor; Marcus Drake. Date of last amendment 26/12/11.

Current Definitions

The applicable terms for classification of post-prostatectomy incontinence (PPI) are those used in the standardisation of terminology in lower urinary tract function (Abrams et al. 2002). No specific distinction is made respecting gender or mechanism in this document.
The relevant terms thus comprise;
1. Stress urinary incontinence; the complaint of involuntary leakage on effort or exertion or on sneezing or coughing.
2. Urgency urinary incontinence; the complaint of involuntary leakage accompanied by or immediately preceded by urgency.
3. Mixed urinary incontinence; the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing.
4. Continuous urinary incontinence is the complaint of continuous leakage.

Previous definitions

The terms previously used for classification were the general terms in use in the contemporaneous standardisation documents, which were superceded by the publication of the current terminology of lower urinary tract function.

Perspectives

Men affected by PPI fall into two main subgroups;
  1. Following surgery for benign prostate obstruction (BPO) due to benign prostate enlargement (BPE).
  2. Following radical prostatectomy (RP) used for attempted cure of early prostate cancer. Radical prostatectomy is increasingly used in the modern era, and case-finding for PPI is becoming more widespread. Accordingly, there is a rising incidence of PPI associated with trends in prostate cancer management.
Measuring urinary leakage can be achieved by various approaches, but there is no one approach that is universally accepted as providing an objective evaluation on which to base appraisal of severity. Quantification can be achieved by the following methods;
  1. Number of pads used. A pad count over a defined period is the simplest quantitative evaluation. However, it suffers from the facts that; users vary in their reasons for changing a pad: pad use may reflect actual leakage, or fear of leakage: pad changes with leakage may be undertaken because of accumulating weight, perineal wetness or odour; and, pads differ in their absorbency.
  2. Pad weight over a defined time period. This is seemingly more objective, but leakage can vary with standardised provocations, even in the same individual. Standardising provocations across a population may fail to recapitulate the precipitating factors for an individual. Pad weighing may be perceived by some as unpleasant and embarrassing, which may hinder compliance.
  3. Questionnaires. Various tools have been developed to evaluate presence and bother associated with incontinence. They are appropriate for evaluation of the patient perspective of quantity, frequency and bother/ quality of life impact. The ICIQ-UI short form is recommended for routine use in PPI.
  4. Bladder diary. When designed appropriately, a diary will capture incontinence events and precipitating causes. They are strongly dependent on patient compliance and are potentially resource-intensive when analysing the data.
  5. Urodynamic tests. These are useful for full categorisation of the mechanism of incontinence. They are less reliable for assessing severity. Filling and voiding cystometry and videourodynamics are used routinely, and supplementary techniques include; a) assessment of maximum urethral closure pressure on urethral profilometry, b) abdominal leak point pressure and c) quantitative ambulatory urodynamics (leak sensing). These approaches are potentially confounded by the position of the patient during testing, the difficulty of standardising a provocation, the difficulty of reproducing precipitating provocations and the presence of a urethral catheter.

Grading of Incontinence

The terms “mild”, “moderate” and “severe” are not standardised in the context of PPI. The difficulties of assessing incontinence quantitatively mean that, where used, the precise contextual meaning should be stated. It is not possible to extrapolate these terms from one study to another, for comparative purposes or meta-analysis. “Mild” and “severe” may appear to convey an intuitive understanding recognised both by patients and clinicians. However, the perspective is hugely influential, which means that clinicians and patients will evaluate severity differently in many cases. Not uncommonly, surgeons differ in their perception of severity, particularly where urologists subspecialising in oncological urology are distinguished from those subspecialising in functional urology. The definer’s perspective therefore has to be stipulated in any definition, and both perspectives need to be addressed in an interventional context. In an epidemiological setting, it is legitimate to consider either perspective in isolation. It does not currently appear appropriate to use the term “moderate” incontinence, as there is insufficient evidence from which to derive a consensus to place the boundary between “mild” and “moderate”, or “moderate” and “severe”, from the perspective of either the clinician or the patient. The ICS Standardisation Steering Committee recognises the need for consensus and intends to make recommendations in due course.