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Urinary incontinence in men

Urinary incontinence in men
Literature review current through: Jan 2024.
This topic last updated: Jan 03, 2022.

INTRODUCTION — Urinary incontinence is defined as involuntary leakage of urine. Men are sometimes reluctant to bring incontinence to the attention of their clinician. Only one in five men with symptoms is likely to seek care, and men are only half as likely as women to seek care (22 versus 45 percent, respectively), despite the availability of many types of treatments [1,2].

Urinary incontinence can limit participation in activities and lower quality of life. Men with urinary incontinence have a higher rate of depression and are more likely to decrease participation in activities (eg, decrease work hours, change employment, or take voluntary early retirement) [3]. Some evidence suggests that urinary incontinence may have a greater emotional and social impact on quality of life for men than for women [1,2,4].

Men are more likely to experience urinary incontinence as they get older [5,6]. In a study among community-dwelling men, the prevalence of at least one urinary incontinence episode in the preceding 12 months increased from almost 5 percent at ages 19 to 44 years, to 11.2 percent at ages 45 to 64 years, to 21 percent in men older than 65 years [7]. In other studies, the prevalence of urinary incontinence in men older than 65 years ranged from 11 to 34 percent, with a prevalence of daily incontinence of 2 to 11 percent [5,8-10]. The prevalence in men living in nursing homes is higher compared with those in community settings and men with urinary incontinence have a higher risk of institutionalization [1,2,11,12].

This topic will discuss the epidemiology, causes, classification, evaluation, diagnosis, and management of urinary incontinence in men [13].

Urinary incontinence in women is discussed separately. (See "Female urinary incontinence: Evaluation" and "Female urinary incontinence: Treatment".)

CAUSES/CLASSIFICATIONS OF INCONTINENCE — Types of male urinary incontinence differ in their etiologies, clinical manifestations, and treatments.

A patient may have more than one type of urinary incontinence. The etiology of each type of incontinence may be multifactorial with a variety of contributing pathophysiologic mechanisms.

Urge urinary incontinence — Urge urinary incontinence (UUI), the most common type of incontinence among men, manifests as a sudden and compelling desire to pass urine that is difficult to defer and is accompanied by involuntary leakage.

UUI is typically associated with either bladder outlet obstruction (BOO) or overactive bladder (OAB) syndrome, also called detrusor overactivity, causing urinary urgency and frequency.

UUI is one of the components that may be seen with lower urinary tract symptoms (LUTS) in men. The etiologies of LUTS are discussed in detail separately. (See "Lower urinary tract symptoms in males", section on 'Etiologies of LUTS'.)

Causes of BOO or overactive bladder include:

Benign prostate hypertrophy (BPH)

Neurologic conditions affecting the brain (stroke, normal pressure hydrocephalus) that can also cause UUI (see 'Patients with neurologic disease' below)

Medications that can increase bladder contractility or exacerbate obstructive effects (table 1)

Although the specific mechanisms that cause UUI are poorly understood, UUI is partly related to uninhibited bladder contractions. These contractions may be due to a defect in afferent sensory signaling from the urinary tract or central processing of these signals, and/or due to detrusor muscle dysfunction (figure 1).

Stress urinary incontinence — Stress urinary incontinence (SUI) occurs in the absence of a bladder contraction and is due to inadequate urethral sphincter function, either from mechanical damage to the urethral sphincter or from physiologic effects that limit sphincter function.

Causes of SUI include:

Prostate surgery – Prostate surgery is the most common cause of SUI.

Radical prostatectomy to treat prostate cancer can result in damage to the external urethral sphincter during surgical dissection because the sphincter is closely approximated to the prostatic apex (figure 2).

Following radical prostatectomy, it is common for men to initially experience SUI; however, this typically improves or resolves over 6 to 12 months [14-17]. Up to 40 percent of men report some degree of long-term urinary incontinence after radical prostatectomy, but for the majority of men, symptoms are mild and do not require treatment [18]. The rate of persistent, bothersome urinary incontinence following radical prostatectomy is approximately 5 to 10 percent [18-22]. (See "Radical prostatectomy for localized prostate cancer", section on 'Surgical treatment'.)

Transurethral resection of the prostate (TURP) for benign prostatic enlargement to remove obstructing prostate tissue can cause damage to the external urethral sphincter (especially as a result of multiple such resections), but that is uncommon. (See "Surgical treatment of benign prostatic hyperplasia (BPH)".)

Spinal cord injury or disease that impairs sphincter function. This is described separately, (See "Anatomy and localization of spinal cord disorders", section on 'Autonomic fibers' and "Chronic complications of spinal cord injury and disease", section on 'Bladder dysfunction'.)

Medications that impair sphincter function (table 1).

Mixed incontinence — Mixed incontinence, a combination of SUI and UUI, is not common among men. It may be seen when both the bladder and urinary sphincter have impaired function, such as in patients with neurologic disorders (eg, spina bifida, spinal cord injury) or sometimes after prostate surgery or radiation. Additionally, mixed urinary incontinence may occur when a patient with either UUI or SUI that has been stable for years has a new causative factor or medication that causes the other type of incontinence to occur.

Overflow incontinence — Overflow incontinence occurs when urine is retained in the bladder due to incomplete emptying after an attempt to urinate. Overflow incontinence is one of the less common causes of incontinence; however, identifying it early on leads to the recognition of associated urinary retention that may result in damage to the bladder and kidneys [23].

The retention of urine leading to overflow incontinence can be due to BOO or detrusor underactivity, also known as impaired detrusor contractility or underactive bladder.

Causes of BOO or detrusor underactivity include:

BPH

Urethral stricture disease

Neurologic disorders (see 'Patients with neurologic disease' below):

Neuropathy and lower spinal cord (cauda equina) pathology can cause detrusor underactivity

Higher spinal cord lesions can cause sphincter hyperactivity and outflow obstruction

Medications that can decrease bladder contractility/cause detrusor underactivity (table 1)

Postoperative urinary retention (may be occult) (see "Overview of post-anesthetic care for adult patients", section on 'Inability to void')

Acute urinary retention is described separately. (See "Acute urinary retention", section on 'Etiologies'.)

Post-void dribbling — Post-void dribbling (PVD) is dribbling of urine retained in the urethra after the bladder has emptied. It causes wetness soon after the patient has completed urinating but not at other times.

PVD may occur along with other LUTS and be caused by factors that cause LUTS; it also occurs independently of LUTS. As an isolated symptom, PVD is most commonly idiopathic, although rarely it is due to a urethral stricture or diverticulum or to hypospadias.

Functional incontinence — Functional incontinence occurs when comorbid physical conditions impair the patient’s mobility so that a patient cannot get to a bathroom in time, thus is incontinent of urine. The impaired mobility may be temporary (eg, an injury limiting ambulation) or permanent [7,24,25]. Typically a patient can indicate if limited mobility is the reason for his incontinence, unless the patient has cognitive impairment (eg, dementia).

Incontinence after prostate treatment — Urinary incontinence after prostate treatment (including radical prostatectomy) is discussed elsewhere. (See "Urinary incontinence after prostate treatment".)

INITIAL EVALUATION

History and examination — A focused history is often sufficient to identify the most probable type of urinary incontinence. Symptoms occurring with urination help to narrow the differential diagnosis and focus the examination.

Certain antecedent or comorbid conditions help to guide the determination of the type of incontinence, including recent prostate surgery, medication changes, and comorbid neurologic disease. (See 'Further evaluation and diagnosis' below.)

Patients should be asked if they have these symptoms suggesting a specific type of incontinence:

Urge urinary incontinence (UUI) – A sense of urgency; precipitants such as running water or hand-washing or exposure to a cold environment; along with hesitancy, straining to void, and an intermittent or slow stream

Stress urinary incontinence (SUI) – Incontinence with physical exertion, coughing, sneezing, laughing, or lifting or with gravitational change (arising from bed)

Overflow incontinence – A sense of incomplete emptying, pelvic discomfort, bedwetting

Post-void dribbling (PVD) – Incontinence that is limited to the postvoid setting and without symptoms of UUI

Urinary tract infection (UTI) – Burning, frequency, and/or fever

Constipation that could contribute or be comorbid with urinary incontinence

Questionnaires can facilitate gathering information to determine the type of incontinence. A table of typical responses to a questionnaire to distinguish between the two most common causes of incontinence, SUI and UUI, is shown in a form (form 1).

A number of other self-assessment instruments can be used as part of the initial evaluation of a patient with urinary incontinence to assess precipitants/associated symptoms, severity, and the bother of incontinence. These tools may also be used to monitor treatment effectiveness [26]. (See 'Tools to measure treatment effectiveness' below.)

Components of physical examination to evaluate urinary incontinence include:

Rectal examination to assess prostate size and consistency for a gross estimate of the degree of benign prostatic hyperplasia (BPH) that could cause bladder outlet obstruction (BOO).

Abdominal examination after voiding to:

Assess for a palpable bladder that may be present with incomplete emptying

Assess for an abdominal mass that could cause pressure on the bladder

We use the same indications for prostate-specific antigen (PSA) testing for men with incontinence as for asymptomatic men, although some clinicians may consider testing at a somewhat younger age. Benefits and risks of PSA testing should be discussed (see "Screening for prostate cancer", section on 'Approach to screening'). In a man with incontinence, PSA may help to identify benign prostatic enlargement or prostate cancer that could affect treatment and can serve as a baseline PSA for a patient who will take a medication that alters PSA (eg, an alpha reductase inhibitor). (See "Lower urinary tract symptoms in males", section on 'History, physical, and initial testing'.)

Identifying urgent or reversible causes — Information gathered during focused history and examination is used to determine if there is an urgent concern (eg, overflow incontinence due to urinary retention that needs immediate treatment to relieve bladder pressure) or a potentially reversible cause that should be identified and addressed [27].

Urinary retention — A patient with overflow incontinence due to urinary retention may describe a sensation of incomplete emptying (eg, bladder feeling full despite having just voided or passing urine right after having just voided). Sometimes, there may be nocturnal enuresis (bedwetting) due to pelvic floor relaxation at night combined with a very full bladder, or UTIs (due to bacteria retained in the bladder with the urine). Some men with slowly progressive urinary retention may have minimal symptoms. These patients may report increased abdominal girth (due to the distended bladder), or vague abdominal discomfort.

Examination findings may include a palpable bladder on abdominal examination right after voiding and/or an enlarged prostate that could cause BOO.

Post-void residual (PVR) should be measured if poor bladder emptying is suspected. Ultrasound measurement is preferred over urinary catheterization, which is more uncomfortable and carries a risk of infection or urethral trauma. (See "Acute urinary retention", section on 'Prompt diagnosis of retention'.)

PVR ≥200 mL suggests overflow incontinence; a patient whose PVR is <200 mL does not have overflow incontinence [28]. If the PVR is >300 mL, a catheter should be placed right away so that the bladder and kidneys are not at risk of damage due to excessive urinary volume. In addition, a serum creatinine and renal ultrasound should be obtained and a referral to urology placed. Specifics are described separately. (See "Acute urinary retention", section on 'Bladder decompression'.)

After relieving the urinary retention, any causes contributing to urinary retention should be addressed (eg, eliminating or decreasing dosages of medications (table 1) that can cause detrusor underactivity or sphincter dysfunction, or relieving constipation that can cause obstruction). If there is BOO due to BPH, this should be addressed as described separately. (See "Medical treatment of benign prostatic hyperplasia".)

Urinalysis — A urinalysis should be obtained to assess for irritants (eg, infection or blood) in the bladder. If bladder infection is suspected (eg, due to fever, dysuria), a urine culture should also be obtained.

Infection – If a UTI is detected by urine testing, it should be treated. (See "Acute simple cystitis in adult and adolescent males", section on 'Treatment'.)

If incontinence persists, eradication of the UTI should be confirmed; after eradication of the UTI, evaluation for other types of incontinence should be done.

Blood – If urinalysis reveals hematuria, further evaluation should be done. This is described separately. (See "Etiology and evaluation of hematuria in adults".)

If incontinence persists after hematuria is addressed, evaluation for other types of incontinence should be done.

Causative medications — If a patient taking a potentially causative medication (table 1) is experiencing incontinence, the medication should be discontinued or decreased if possible, even if the patient has taken the medication for years before the onset of incontinence. Relieving any contribution that a medication is making may alleviate the incontinence even if there are many contributing factors.

Functional limitations — A patient who describes being incontinent due to difficulty getting to a toilet in a timely way because of limited functional mobility is experiencing functional incontinence. The onset may be abrupt (eg, an injury to a leg temporarily preventing walking) or more gradual (eg, inability to ambulate far enough to reach a bathroom due to worsening arthritis). The patient can typically describe a temporal relationship between declining mobility and onset of incontinence, although a patient with cognitive impairment may not give this history.

Functional incontinence may be addressed by providing alternative receptacles or planning to void without waiting for the bladder to be as full. Acceptable alternatives may include a male urinal, commode, or condom catheter. For men who need more time to access the bathroom, timed voiding (planned visits to the bathroom) prior to a definite need to urinate may address functional incontinence. For patients with a functional limitation due to cognitive impairment/dementia, reminders to void regularly (queueing) may be beneficial.

Other reversible causes

Caffeine and alcohol consumption – If a patient notes that intake of caffeine or alcohol is temporally associated with incontinence, these should be eliminated from the patient’s diet; or, a trial of abstinence can be attempted regardless of an obvious temporal association.

Constipation – If the patient describes constipation or stool impaction is detected on rectal examination, constipation should be treated, as it may be contributing to incontinence. (See "Management of chronic constipation in adults".)

Obesity – Pressure from the weight of the abdomen may press on the bladder, leading to SUI that may resolve with weight reduction. (See "Obesity in adults: Overview of management", section on 'Approach to therapy'.)

If intercurrent treatment is needed while pursuing weight loss, approaches to treating SUI may be used. (See 'Stress urinary incontinence' below.)

Indications for referral — Men who have symptoms, signs, or past history suggesting "complicated" incontinence should be referred to a specialist in urology prior to attempting therapy for the incontinence. These include:

Concern for a urologic cancer (eg, hematuria, prostate nodule, induration, or asymmetry, or elevated PSA)

Prior pelvic surgery/invasive procedure or radiation of the prostate or urethra

PVR >300 mL (see "Acute urinary retention", section on 'Bladder decompression')

Neurologic disease (see 'Patients with neurologic disease' below)

Recurrent bladder or prostate infections

Pelvic pain

Severe incontinence requiring multiple heavy pads or incontinence briefs each day

FURTHER EVALUATION AND DIAGNOSIS — After identifying and addressing urgent or reversible causes including overflow incontinence and functional incontinence, history and findings can be used to determine other causes of incontinence. The temporal relationship between a potentially causative event (eg, prostate surgery associated with stress urinary incontinence [SUI]) and the presence of certain associated symptoms often suggest a particular type of incontinence (eg, SUI, urge urinary incontinence [UUI], mixed, or post-void dribbling [PVD]) that is confirmed by additional symptoms and findings on history and examination. (See 'History and examination' above.)

After prostate surgery, radiation, or urethral trauma — Patients with incontinence that occurs after prostate surgery, radiation, or urethral trauma may have had damage to the urethral sphincter that can produce SUI. These patients are typically evaluated and managed by their urologist. (See "Radical prostatectomy for localized prostate cancer", section on 'Urinary incontinence'.)

Patients with SUI describe incontinence with exertion that increases intraabdominal pressure (eg, physical activity, coughing, sneezing, laughing, lifting) because the increase in intraabdominal pressure can increase pressure on the bladder that the malfunctioning sphincter cannot withstand, resulting in urinary incontinence.

Most men with SUI will report that they are dry when lying down, because there is not a gravitational effect causing leakage if their sphincter relaxes. Continuous leakage with standing up against gravity is called gravitational SUI; this implies severe injury to the urethral sphincter.

The management of postoperative SUI is described below. (See 'Stress urinary incontinence' below.)

Patients with urgency — Patients with UUI typically feel a sense of urgency to urinate that may be brought on by precipitants such as running water, hand washing, or exposure to a cold environment. They may experience hesitancy, straining to void, a sensation of incomplete emptying, or an intermittent or slow stream. They may be on a medication (table 1) that was initiated or increased that could increase bladder contractility and cause overactive bladder (OAB). Examination may reveal an enlarged prostate consistent with benign prostatic hyperplasia (BPH). (See 'Urge urinary incontinence' above.)

UUI is often associated with other urinary symptoms that may include frequency and nocturia. A combination of any of these symptoms is referred to as lower urinary tract symptoms (LUTS). The evaluation of UUI and other LUTS is described separately. (See "Lower urinary tract symptoms in males", section on 'Overactive bladder'.)

Patients with neurologic disease — Diseases of the brain or of the spine can cause urinary incontinence through effects on the bladder and/or the urinary sphincter.

Patients with an underlying neurologic disease as the etiology for incontinence will have other neurologic signs or symptoms [29]. For most patients with a neurologic etiology for urinary incontinence, the neurologic diagnosis will already be established; it is unusual for urinary incontinence to be the presenting feature of a neurologic disorder.

Brain diseases that can lead to incontinence, most commonly UUI, include:

Parkinson disease – Etiologies and treatments are described separately. (See "Clinical manifestations of Parkinson disease", section on 'Autonomic dysfunction' and "Palliative approach to Parkinson disease and parkinsonian disorders", section on 'Autonomic dysfunction'.)

Stroke – Most commonly, detrusor hyperactivity is the cause of incontinence after stroke. Evaluation is described separately. (See "Complications of stroke: An overview", section on 'Urinary incontinence'.)

Normal pressure hydrocephalus – Specifics are discussed separately. (See "Normal pressure hydrocephalus", section on 'Urinary incontinence'.)

Spinal cord conditions cause incontinence through a variety of mechanisms, including SUI. In patients with neurologic disorders, SUI may occur with transfers (eg, from a wheelchair to bed) as these activities typically cause increased intraabdominal pressure. Spinal cord conditions that can lead to incontinence include traumatic injury. The evaluation and management of incontinence in this setting is described separately. (See "Chronic complications of spinal cord injury and disease", section on 'Bladder dysfunction'.)

Multiple sclerosis affects both the brain and spinal cord and can produce concurrent types of incontinence. Specifics related to the evaluation and management of incontinence in patients with multiple sclerosis is discussed separately. (See "Manifestations of multiple sclerosis in adults", section on 'Bowel and bladder dysfunction' and "Symptom management of multiple sclerosis in adults", section on 'Bladder dysfunction'.)

Isolated post-void dribbling — A man who describes completing urination and then having some dribbling right after urination is experiencing PVD. PVD differs from a slow dribbling stream during urination that may occur due to BPH and may be accompanied by urinary hesitancy and other symptoms of UUI.

A man with PVD may give a history of a procedure through the penis (eg, transurethral resection of the prostate [TURP] or cystoscopy) prior to the onset of the symptom, although the absence of such a procedure does not rule out the possibility of PVD; most patients with PVD do not have such a history.

Hypospadias with a very proximal position of the urethral opening may be detected on examination of a patient with PVD. If the patient is uncircumcised or partially circumcised, the foreskin should be replaced in position after retracting it for the examination to avoid paraphimosis (retracted foreskin that cannot be returned to normal position). (See 'Post-void dribbling' above.)

Other patients — Patients with either overflow incontinence or functional incontinence have typically been identified early on in the evaluation. (See 'Initial evaluation' above.)

Mixed urgency and stress incontinence — A diagnosis of mixed incontinence is typically made by detecting symptoms of both SUI and UUI. Both types may develop at the same time; or, alternatively, a man may develop a second type of incontinence after he has controlled one type, and thus may describe incontinence as occurring at different times and with different activities than before. (See 'After prostate surgery, radiation, or urethral trauma' above and 'Patients with urgency' above.)

MANAGEMENT

Patient expectations of treatment — Regardless of the type of urinary incontinence, discussing the patient’s goals and expectations of treatment is key because a multicomponent approach focused on the aspects of urinary incontinence that are most bothersome to the patient is important for successful management. Treatment aimed at simply decreasing the number of incontinence episodes (the focus of the majority of treatment trials) may not be sufficient to improve the quality of life for patients most bothered by the timing, volume, or inconvenience of urinary incontinence. For example, for some men, a period of continence sufficient to complete a meeting, take a car ride, or attend a sporting event is a major goal, whereas for other men, avoiding side effects from medications or a surgical procedure is more important.

Adjunctive measures — Men with any type of incontinence may be using adjunctive measures during evaluation and initiation of treatment. Men should be counseled that leakage is not a normal part of aging and that goals of treatment include minimizing or eliminating the need for the use of pads or catheters as a self-management strategy.

Although some men may continue to use these measures over the long term as well, these should not be the only treatments, because chronic use is associated with risk. Adding treatments to correct the underlying cause(s) of incontinence may decrease the need for adjunctive measures and thus modulate the associated risks.

Adjunctive measures include:

Protective pads and undergarments – Protective pads and garments made of absorptive materials that collect expelled urine may be effective to limit visible aspects of incontinence (thus eliminating embarrassment); there are risks to chronic use.

Chronic exposure to urine-soaked pads can result in contact dermatitis and skin breakdown that is uncomfortable and can predispose to infection. This risk may be mitigated by measures that minimize urinary leakage and by ensuring regular changes of pads or garments when leakage occurs. (See "Prevention of pressure-induced skin and soft tissue injury", section on 'Minimize excess temperature and moisture'.)

Information on pad varieties and other urinary incontinence supplies is available from medical supply companies and United States-based urinary incontinence patient advocacy groups, such as The Simon Foundation and the National Association for Continence.

External catheters – External urinary catheters (also called condom catheters or sheath drainage systems) are associated with less morbidity compared with indwelling catheters [30]. Men may find them preferable to pads. Successful use of an external catheter requires adherence of the condom sheath to the penis. (See "Placement and management of urinary bladder catheters in adults", section on 'External'.)

Use of external catheters may not be possible in some patients who are not able to keep catheters in place (eg, due to skin infections) or are not physically able to place catheters (eg, obesity, neurologic impairment).

In men with bladder dysfunction who use an external catheter, urodynamic testing should be obtained to determine that bladder storage pressures remain low to avoid progressive renal damage. Other complications of these catheters are described separately. (See "Complications of urinary bladder catheters and preventive strategies", section on 'External catheters'.)

Penile clamps – Penile clamps can be used in men with stress urinary incontinence (SUI) who have adequate bladder storage function (ie, normal bladder capacity and normal compliance). These clamps can cause discomfort if used constantly, so many men find they work best for short-term use (eg, dinner, going to a movie, etc).

Indwelling or intermittent catheters – Use of indwelling or intermittent catheters should be avoided whenever possible, because they place the patient at risk for complications. (See "Complications of urinary bladder catheters and preventive strategies".)

However, in certain limited instances of incontinence or associated conditions (eg, acute urinary retention), a bladder catheter is required. (See "Placement and management of urinary bladder catheters in adults".)

Nonpharmacologic therapy — Nonpharmacologic therapies for urge urinary incontinence (UUI), SUI, and mixed incontinence include:

Pelvic floor muscle exercises, which are done using the same techniques for men and for women (see "Patient education: Pelvic floor muscle exercises (Beyond the Basics)")

Lifestyle modification, particularly weight loss and fluid consumption (see "Female urinary incontinence: Treatment", section on 'Lifestyle modification')

Bladder training (table 2) (see "Female urinary incontinence: Treatment", section on 'Bladder training')

Biofeedback to supplement pelvic muscle exercises (see "Female urinary incontinence: Treatment", section on 'Supplemental modalities')

Managing specific types of incontinence

Stress urinary incontinence — The management of SUI is typically coordinated by a urologist.

Nonpharmacologic therapy – nonpharmacologic therapy is generally used for initial management of SUI along with adjunctive measures. (See 'Nonpharmacologic therapy' above and 'Adjunctive measures' above.)

In systematic reviews, meta-analyses, and randomized trials, results differ as to whether there is benefit of nonpharmacologic therapies (eg, pelvic floor muscle therapy/biofeedback either pre- or postoperatively) for postsurgical urinary incontinence [7,31]. As an example, trials of men with incontinence six weeks after radical prostatectomy or transurethral resection of the prostate (TURP) detected no differences in frequency or volume of urinary incontinence between men who received one-to-one pelvic floor muscle training versus control [32]. In contrast, among men with incontinence for more than one year after radical prostatectomy, patients receiving eight weeks of either behavioral therapy alone (pelvic floor muscle training and bladder control strategies), or behavioral therapy plus biofeedback and pelvic floor electrical stimulation, had a 55 and 51 percent reduction, respectively, in the number of incontinence episodes compared with a 24 percent reduction in those assigned to observation [33].

For some men with SUI, a penile clamp to mechanically hinder involuntary passage of urine may be used, although only intermittently [30]. A patient who uses a penile clamp should be ambulatory, have good bladder storage function, and be able to place and remove the clamp himself. Use of a penile clamp by a patient with sensory abnormalities should be avoided, because tissue damage from the clamp can occur with prolonged use, and a patient with sensory impairment may not recall that the clamp is in place or realize that it is causing damage.

Pharmacotherapy for SUI – For men with SUI who do not respond to lifestyle interventions or pelvic floor muscle exercises after at least three months, we suggest the addition of duloxetine, a serotonin norepinephrine reuptake inhibitor (SNRI).

Duloxetine – Duloxetine, an SNRI, is approved for the treatment of SUI in many European countries. In the United States, there are no medications approved for SUI; duloxetine is approved to treat major depression and neuropathic pain.

Duloxetine acts by stimulating pudendal motor neuron alpha-adrenergic and 5-hydroxytryptamine-2 receptors, which can improve urinary symptoms.

A systematic review found limited evidence to support the efficacy of any single medication for male urinary incontinence, and only one well-performed randomized trial [34]. In this trial of 112 men with postprostatectomy SUI, after 16-week follow-up those randomly assigned to duloxetine along with pelvic muscle exercises were more likely to report improved incontinence-related quality of life compared with those assigned to pelvic muscle exercises alone, and 39 (versus 27) patients were dry [35]. This beneficial effect of duloxetine quickly disappeared after discontinuation. Patients were more likely to discontinue duloxetine compared with placebo (15 versus 2 percent) during the study period, with nausea being the most commonly cited reason [35].

Procedural and surgical interventions for SUI – The most common interventions for male SUI are transurethral bulking agents, perineal slings, and the artificial urinary sphincter. For men experiencing incontinence following radical prostatectomy, watchful waiting supplemented with nonpharmacologic therapy for a period of at least 6 to 12 months is generally recommended to allow for spontaneous resolution of SUI symptoms [36,37].

Selecting among these therapies depends upon the severity of the incontinence and whether the patient is healthy enough to undergo one of the surgical procedures, which have greater efficacy than the transurethral bulking agent procedure. For men who choose to have surgery for SUI, the main treatment decision is between surgical placement of a perineal sling and an artificial urinary sphincter. The choice is based on patient preference; data suggest that most men prefer a sling [38]. These therapies may be trialed sequentially, as a single prior injection of bulking agents does not appear to affect the postoperative results of male perineal slings [39] or artificial urinary sphincters [40], and previous sling placement does not appear to adversely affect the outcome of artificial urinary sphincter placement [41].

Transurethral bulking agents – Various substances can be injected into the submucosal tissues of the urethra or bladder neck to improve SUI symptoms.

For select men with mild SUI or those who are not candidates for more invasive surgery, transurethral bulking agents may be a reasonable treatment option. The success rates in men are lower (<25 percent) than those reported in women, presumably due to increased scarring at the bladder neck following prostate surgery. In men, multiple injections (up to four) are usually required to achieve satisfactory results, which generally last one year or less, at which point an additional injection is required [42]. However, repeated injections of bulking agents may make other subsequent surgery more difficult.

Perineal sling – Sling techniques involving urethral repositioning have been adapted for use in men. The slings typically use synthetic mesh to mobilize and compress the urethra, likely by extending the functional length of the membranous urethra, to achieve continence. Contemporary male slings are placed transversely through the obturator foramen [43-45]. Additionally, a “quadratic” sling is available that combines transobturator fixation with an anterior prepubic component [46].

Slings may be preferred in men with limited manual dexterity who may have difficulty manipulating an artificial urinary sphincter or in those with more mild incontinence [47,48].

Studies of perineal sling placement for incontinence occurring after prostate surgery showed evidence of efficacy; however, long-term data are limited. In a prospective study of 44 patients at median follow-up of two years, 55 percent had no wet pads and another 23 percent reduced the number of pads used by >50 percent. Failure rate was 23 percent within six months; failure was associated with body mass index (BMI) of ≥30, prior irradiation, and prior high-intensity focused ultrasound. A retrospective study found similar results. Postoperative complications, including urinary retention, infections, and urethral erosion, occurred in 14 percent of patients and necessitated sling removal in 9 percent. The International Consultation on Incontinence (ICI) and the United Kingdom National Institute for Health and Clinical Excellence (NICE) have concluded that evidence supports the safety and efficacy of male slings for postprostatectomy SUI [36,49-51].

Artificial urinary sphincter – The artificial urinary sphincter is the most effective long-term treatment for men with severe SUI or with previous pelvic radiation therapy [52].

The artificial urinary sphincter consists of three silicone components: a cuff, a balloon reservoir, and a pump. Each of these components is attached to a length of silicone tubing and connected together during the surgical implant procedure.

Success rates (use of ≤1 pad daily) have ranged from 59 to 90 percent at follow-up intervals ranging from one to eight years [36]. Patient satisfaction with this technique is high, even among men with severe SUI [53-55].

However, surgical revision of the artificial urinary sphincter is often required to maintain long-term continence. Surgical revision may be needed due to urethral erosion, infection, mechanical malfunction of the device (eg, leaking of fluid), or urethral atrophy. A common cause of late urethral erosion is Foley catheter trauma. Therefore, after artificial urinary sphincter placement, it is vital that urethral instrumentation be kept to a minimum, as such instrumentation may weaken the urethra at the cuff site and cause erosion of the cuff. If urethral catheterization is required, the artificial urinary sphincter must be deactivated and the smallest catheter possible (usually 12 French) should be utilized for not more than 48 hours preferably. Deactivation often requires involvement of a urologist, although teaching the patient to deactivate the device may allow the patient to take responsibility for deactivating it prior to Foley catheter placement. If urethral erosion occurs, the cuff must be surgically removed and a Foley catheter placed for a period of two weeks to allow the urethra to heal. Another cuff may then be placed at a later time. There is a risk of subsequent urethral stricture in the setting urethral erosion.

Another cause of artificial urinary sphincter failure is postoperative wound infection, which occurs in <3 percent of patients [56] and typically requires removal of the entire device. Artificial urinary sphincters are more likely to fail in patients with compromised urethras (from prior artificial urinary sphincter placement, radiation therapy, or urethroplasty) [57].

Urge urinary incontinence — For men with UUI, nonpharmacologic therapy (see 'Nonpharmacologic therapy' above) is typically used for initial management along with adjunctive measures. If symptoms persist, pharmacotherapy is added, and procedural or surgical treatment is an option for significant incontinence refractory to pharmacotherapy.

These treatments for UUI are described in detail separately. (See "Lower urinary tract symptoms in males", section on 'Isolated overactive bladder' and "Lower urinary tract symptoms in males", section on 'Initial management'.)

Mixed incontinence — In men with mixed incontinence, a combination of therapies for UUI and SUI is indicated. Treatment should be individualized according to the etiologies and the relative severity of the UUI versus the SUI.

Generally, the type of incontinence that started more recently is treated first, followed by symptom reassessment. A urologist may obtain urodynamic testing to aid in management decisions, particularly in men with prior pelvic radiation or those with neurologic disorders, as these conditions may reduce bladder storage capacity, resulting in chronically elevated bladder pressures that can lead to upper urinary tract damage over time. (See 'Indications for referral' above.)

Post-void dribbling — A man with retained urine in the urethra causing post-void dribbling (PVD) should be advised to avoid compressing the urethra during voiding, such as from undergarments or pants.

Following micturition, the patient should manually "milk" the perineal urethra to expel retained urine. Pelvic floor exercises may also be used. However, there is no direct evidence of efficacy with these interventions.

Tools to measure treatment effectiveness — Self-assessment instruments for urinary incontinence may be used to measure patient-reported outcomes (PROMS). Additionally, comparing results during or after treatment with those obtained during initial evaluation of incontinence may help the patient and clinician assess treatment effectiveness [26].

Self-assessment instruments include:

To assess precipitants/associated symptoms, severity, and bother of incontinence:

Michigan Incontinence Symptom Index (M-ISI) – This self-scoring form is useful for patients with symptoms of SUI, UUI, or mixed incontinence. Questions cover the frequency of urinary incontinence with various activities, how many pads are used, and how much interference with daily activities and social embarrassment the incontinence causes [58].

International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI Short Form M) – The International Consultation on Incontinence Questionnaire-Short Form provides brief questions about the occurrence and severity of incontinence by asking about incontinence frequency, volume, precipitants, and how much it interferes with daily life. A long form is also available, as are forms to evaluate other urinary symptoms the patient may be experiencing.

To assess severity:

Sandvik questionnaire – The Sandvik questionnaire can be used to assess how often leakage occurs and the approximate amount [59]:

-How often do you experience urinary leakage (less than once monthly, few times monthly, few times weekly, or daily/nightly)?

-How much urine do you lose each time (drops, small splashes, or more)?

24-hour pad weight – The weight of incontinence pads used over a 24-hour period provides a quantitative assessment of the degree of incontinence the man is experiencing. It can also help to determine the impact of a treatment regimen to help guide management decisions. As an example, if a medication measurably reduces the volume of urinary incontinence, dose titration may be reasonable, rather than discontinuing the medication for lack of efficacy. (See "Female urinary incontinence: Evaluation", section on 'History'.)

Bladder diary – A three-day bladder diary can be used to document the frequency of urinary incontinence episodes (form 2). This can also help quantify the severity of urinary incontinence if the history obtained is unclear.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Urinary incontinence in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Urinary incontinence in males (The Basics)" and "Patient education: Neurogenic bladder in adults (The Basics)" and "Patient education: Pelvic floor muscle exercises (The Basics)")

Beyond the Basics topics (see "Patient education: Pelvic floor muscle exercises (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Classification – Types of male urinary incontinence include urge urinary incontinence (UUI), stress urinary incontinence (SUI), mixed urinary incontinence that includes UUI and SUI, overflow incontinence, post-void dribbling (PVD), and functional incontinence. A patient may have more than one type of urinary incontinence. The etiology of each type of incontinence may be multifactorial with a variety of contributing pathophysiologic mechanisms. (See 'Causes/classifications of incontinence' above.)

History and examination – A focused history is often sufficient to identify the most probable type of urinary incontinence. Symptoms occurring with urination also help to narrow the differential diagnosis and focus the examination. Recent prostate surgery, medication changes, and comorbid neurologic disease are particularly relevant factors for determining the type of incontinence. (See 'History and examination' above.)

Identifying urgent or reversible causes – In the initial evaluation, information gathered during history and examination determines if there is an urgent concern (eg, urinary retention) or a potentially reversible cause (eg, infection, medications (table 1), and others) that should be identified and addressed. (See 'Identifying urgent or reversible causes' above.)

Indications for referral – Men who should be referred to an urologist include those with concern for a urologic cancer, prior prostate or other pelvic surgery, radiation, post-void residual (PVR) >200 mL, neurologic disease, recurrent urologic infections, pelvic pain, or severe incontinence with multiple pads or incontinence briefs daily. (See 'Indications for referral' above.)

Further evaluation and diagnosis – Further evaluation and diagnosis of the type of incontinence is based on the medical history and specific symptoms. This in turn will direct the most appropriate management. (See 'Further evaluation and diagnosis' above.)

A sense of urgency to urinate typically indicates UUI, which may be accompanied by other symptoms. (See 'Patients with urgency' above.)

The evaluation and treatment of UUI is discussed separately. (See "Lower urinary tract symptoms in males", section on 'Isolated overactive bladder' and "Lower urinary tract symptoms in males", section on 'Initial management'.)

Prostate surgery, radiation, or urethral trauma can damage the urethral sphincter and produce SUI. Symptoms of SUI include incontinence with exertion and, in severe cases, gravitation incontinence. (See 'After prostate surgery, radiation, or urethral trauma' above.)

Men with SUI are typically evaluated and managed by their urologist. The patients are typically treated with lifestyle interventions or pelvic floor muscle exercises; duloxetine may be added if incontinence persists. Invasive treatments are reserved for men with SUI who do not respond to medical management. (See 'Stress urinary incontinence' above.)

Neurologic disease of the brain or spinal cord can cause urinary incontinence due to effects on the bladder and/or the urinary sphincter. (See 'Patients with neurologic disease' above.)

Dribbling after completing urination (PVD) as an isolated symptom is usually idiopathic; patients can be instructed to manually "milk" the perineal urethra to expel retained urine. Pelvic floor exercises may also be used. (See 'Isolated post-void dribbling' above and 'Post-void dribbling' above.)

Management – Management strategies differ based on the type of incontinence. (See 'Managing specific types of incontinence' above.)

Nonpharmacologic therapy – Nonpharmacologic therapies that may be used include pelvic floor muscle exercises; lifestyle modification, particularly weight loss and fluid consumption; bladder training (table 2); and biofeedback to supplement pelvic muscle exercises. (See 'Nonpharmacologic therapy' above.)

Adjunctive measures – Men with incontinence may be using adjunctive measures (eg, pads or catheters) and should be counseled that leakage is not a normal part of aging and that goals of treatment include minimizing or eliminating the need for pads or catheters due to the risks of complications associated with their use. (See 'Adjunctive measures' above.)

Tools to measure effectiveness – Several instruments are available for initial evaluation and to assess effectiveness of treatment of incontinence. (See 'Tools to measure treatment effectiveness' above.)

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References

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