Published 2019; Amended 2024

Unabridged version of this guideline [pdf]
Guideline Amendment Summary [pdf]
Evaluation Algorithm [pdf]
Surgical Management Algorithm [pdf]
Sling Failure Algorithm [pdf]
AUS Failure Algorithm [pdf]

To cite this guideline:

Breyer BN, Kim SK, Kirkby E, Marianes A, Vanni AJ, Westney OL. Updates to Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline (2024). J Urol. Published online July 27, 2024. doi:10.1097/JU.0000000000004088

Jaspreet S. Sandhu, MD; Benjamin N. Breyer, MD; Craig Comiter, MD; James A. Eastham, MD; Christopher Gomez, MD; Daniel J. Kirages, PT; Chris Kittle; Alvaro Lucioni, MD; Victor W. Nitti, MD; John T. Stoffel, MD; O. Lenaine Westney, MD; Kurt McCammon, MD

Benjamin N. Breyer, MD; Alex J. Vanni, MD; O. Lenaine Westney, MD

Staff and Consultants

Sennett K. Kim; Erin Kirkby, MS; Alexis Marianes, PhD; M. Hassan Murad, MD

Purpose

This Guideline on incontinence after prostate treatment (IPT) is intended to facilitate care decisions and aid clinicians in the management of patients who have incontinence after undergoing treatment of localized prostate cancer and benign prostatic hyperplasia (BPH). The multiple treatments that exist for patients with IPT are discussed and evaluated herein.

Methodology

The systematic review utilized to inform this Guideline was conducted by a methodology team at the Mayo Clinic Evidence-Based Practice Research Program. The scope of the topic and the discussion of the final systematic review used to develop Guideline statements was conducted in conjunction with the Incontinence after Prostate Treatment Panel. A research librarian conducted searches in Ovid MEDLINE (from 2000 to December 21^st, 2017), Cochrane Central Register of Controlled Trials (from 2000 to December 21st, 2017) and Cochrane Databases of Systematic Reviews (from 2000 to December 21st, 2017). Searches of electronic databases were supplemented by reviewing reference lists of relevant articles. Panel members identified additional references through 12/31/2018. In 2023, the Incontinence after Prostate Treatment Guideline was updated through the AUA amendment process in which newly published literature is reviewed and integrated into previously published Guidelines. The methodologist searched Embase (1996 to June 2023), EBM Reviews – Cochrane Central Register of Controlled Trials (May 2023), EBM Reviews – Cochrane database of Systematic Reviews (2005 to June 2023), Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations and Daily (2019 to June 2023).

GUIDELINE STATEMENTS

Pre-Treatment

1. Clinicians should inform patients undergoing localized prostate cancer treatment of all known factors that could affect continence. (Moderate Recommendation; Evidence Level: Grade B)
2. Clinicians should counsel patients regarding the risk of sexual arousal incontinence and climacturia following localized prostate cancer treatment. (Strong Recommendation; Evidence Level: Grade B)
3. Clinicians should inform patients undergoing radical prostatectomy that incontinence is expected in the short-term and generally improves to near baseline by 12 months after surgery but may persist and require treatment. (Strong Recommendation; Evidence Level: Grade A)
4. Prior to radical prostatectomy, clinicians may offer patients pelvic floor muscle exercises or pelvic floor muscle training. (Conditional Recommendation; Evidence Level: Grade C)
5. Clinicians should inform patients undergoing radical prostatectomy or transurethral resection of the prostate after radiation therapy of the high rate of urinary incontinence following these procedures. (Moderate Recommendation; Evidence Level: Grade C)

Post-Prostate Treatment

6. In patients who have undergone radical prostatectomy, clinicians should offer pelvic floor muscle exercises or pelvic floor muscle training in the immediate post-operative period. (Moderate Recommendation; Evidence Level: Grade B)
7. In patients with bothersome stress urinary incontinence after prostate treatment, clinicians may offer surgery as early as six months if incontinence is not improving despite conservative therapy. (Conditional Recommendation; Evidence Level: Grade C)
8. In patients with bothersome stress urinary incontinence after prostate treatment despite conservative therapy, clinicians should offer surgical treatment at one year post-prostate treatment. (Strong Recommendation; Evidence Level: Grade B)

Evaluation of Incontinence after Prostate Treatment

9. Clinicians should evaluate patients with incontinence after prostate treatment with history, physical exam, and appropriate diagnostic modalities to categorize type and severity of incontinence and degree of bother. (Clinical Principle)
10. In patients with urgency urinary incontinence or urgency predominant mixed urinary incontinence, clinicians should offer treatment options per the American Urological Association Overactive Bladder Guideline. (Clinical Principle)
11. Prior to surgical intervention for stress urinary incontinence, clinicians should confirm stress urinary incontinence by history, physical exam, or ancillary testing. (Clinical Principle)
12. Clinicians should inform patients with incontinence after prostate treatment of management options for their incontinence, including surgical and non-surgical options. (Clinical Principle)
13. In patients with incontinence after prostate treatment, clinicians should discuss risk, benefits, and expectations of different treatments using the shared decision-making model. (Clinical Principle)
14. Prior to surgical intervention for stress urinary incontinence, clinicians should perform cystourethroscopy to assess for urethral and bladder pathology that may affect outcomes of surgery. (Expert Opinion)
15. Clinicians may perform urodynamic testing in patients prior to surgical intervention for stress urinary incontinence in cases where it may facilitate diagnosis or counseling. (Conditional Recommendation; Evidence Level: Grade C)

Treatment Options

16. In patients seeking treatment for incontinence after radical prostatectomy, clinicians should offer pelvic floor muscle exercises or pelvic floor muscle training. (Moderate Recommendation; Evidence Level: Grade B)
17. Clinicians should discuss the option of artificial urinary sphincter with patients who are experiencing mild to severe stress urinary incontinence after prostate treatment. (Strong Recommendation; Evidence Level: Grade B)
18. Prior to implantation of artificial urinary sphincter, clinicians should ensure that patients have adequate physical and cognitive abilities to operate the device. (Clinical Principle)
19. In patients who select artificial urinary sphincter, clinicians should preferentially utilize a single cuff perineal approach. (Moderate Recommendation; Evidence Level: Grade C)
20. Clinicians should discuss the option of male slings with patients as treatment options for mild to moderate stress urinary incontinence after prostate treatment. (Moderate Recommendation; Evidence Level: Grade B)
21. Clinicians should not routinely implant male slings in patients with severe stress incontinence. (Moderate Recommendation; Evidence Level: Grade C)
22. Clinicians may offer adjustable balloon devices to non-radiated patients with mild to severe stress urinary incontinence after prostate treatment. (Conditional Recommendation; Evidence Level: Grade C)
23. Clinicians should manage patients with stress urinary incontinence after treatment of benign prostatic hyperplasia the same as patients that have undergone radical prostatectomy. (Moderate Recommendation; Evidence Level: Grade C)
24. In patients with stress urinary incontinence after primary, adjuvant, or salvage radiotherapy who are seeking surgical management, clinicians should offer artificial urinary sphincter over male slings or adjustable balloons. (Moderate Recommendation; Evidence Level: Grade C)
25. In patients with incontinence after prostate treatment, clinicians should counsel patients that efficacy is low and cure is rare with urethral bulking agents. (Strong Recommendation; Evidence Level: Grade B)
26. Clinicians should consider other potential treatments for incontinence after prostate treatment as investigational, and patients should be counseled accordingly. (Expert Opinion)

Complications after Surgery

27. Clinicians may counsel patients regarding risk factors for artificial urinary sphincter erosion. (Conditional Recommendation; Evidence Level: Grade C)
28. Clinicians should counsel patients that artificial urinary sphincter will likely lose effectiveness over time, and reoperations are common. (Strong Recommendation; Evidence Level: Grade B)
29. In patients with persistent or recurrent urinary incontinence after artificial urinary sphincter or sling, clinicians should again perform history, physical examination, and/or other investigations to determine the cause of incontinence. (Clinical Principle)
30. In patients with persistent or recurrent stress urinary incontinence after sling, clinicians should recommend an artificial urinary sphincter. (Moderate Recommendation; Evidence Level: Grade C)
31. In patients with persistent or recurrent stress urinary incontinence after artificial urinary sphincter, clinicians should discuss artificial urinary sphincter revision with the patient. (Strong Recommendation; Evidence Level: Grade B)
32. In patients presenting with infection or erosion of an artificial urinary sphincter or sling, clinicians should perform explantation and reimplantation should be delayed. (Clinical Principle)
33. After explanting an eroded device, clinicians may manage artificial urinary sphincter urethral cuff erosion intra-operatively with urethral catheter alone, in situ urethroplasty, or anastomotic urethroplasty. (Expert Opinion)

Special Situations

34. Clinicians should discuss urinary diversion with patients who are unable to obtain long-term quality of life due to incontinence after prostate treatment. (Expert Opinion)
35. In patients with bothersome incontinence during sexual activity, clinicians should offer treatment. (Moderate Recommendation; Evidence Level: Grade C)
36. In patients with stress urinary incontinence following urethral reconstructive surgery, clinicians may offer artificial urinary sphincter and counsel that complication rates are higher. (Conditional Recommendation; Evidence Level: Grade C)
37. In patients with incontinence after prostate treatment and erectile dysfunction, clinicians may offer a concomitant or staged procedure. (Conditional Recommendation; Evidence Level: Grade C)
38. In patients with symptomatic vesicourethral anastomotic stenosis or bladder neck contracture, clinicians should treat the patient prior to surgery for incontinence after prostate treatment. (Clinical Principle)

Background

IPT causes emotional and financial distress to patients afflicted with this condition by delaying patients’ re-entry into society, inhibiting relationships, and carrying an economic burden for families and stakeholders. It is a condition that has gained visibility not only due to the extensive use of surgery for prostate cancer but also given the proliferation of men’s continence products available to the lay public. 

Given that IPT is caused by treatment of the prostate, it is by definition iatrogenic. As such, it is perhaps preventable or predictable. Understanding the nature of IPT is crucial for patients and clinicians during recovery and extended survivorship following prostate treatment. Clinicians benefit from being able to assess which patients will likely experience further symptom recovery versus those who will not. This allows clinicians to set clear and reasonable expectations regarding the short-, medium-, and long-term sequelae of IPT.

Although most clinicians are familiar with the more commonly known term “post-prostatectomy incontinence,” this Guideline uses the term “IPT”, as a more inclusive term that covers the management of patients who have incontinence after undergoing treatment of localized prostate cancer and BPH. Evaluation of the patient, risk factors for IPT which should be discussed with all patients prior to treatment, assessment of the patient prior to intervention, and a stepwise approach to management are covered in this Guideline. Possible maneuvers to decrease rates of IPT, with specific focus placed on patients with SUI, are also explored. The multiple treatments that exist for patients with IPT are discussed and evaluated, including physical therapy, medications, and surgery. Algorithms for patient evaluation, surgical management, and device failure are provided for practitioners. While no clear convention for severity grading is accepted, for the purposes of this Guideline the following definitions are being used based on patient reported pads per day usage. Patient reported outcome measures, standing cough test, and daily pad weights can also be employed. Social continence is considered one or fewer pads per day that is tolerable to the patient.^{1, 2} Mild, moderate, severe incontinence is considered 1-2, 2-4, 5 plus pads per day reported by the patient, respectively.^3-5

Methodology

The systematic review utilized to inform this Guideline was conducted by a methodology team at Mayo Clinic Evidence-Based Practice Research Program. Determination of the Guideline scope and review of the final systematic review to inform Guideline statements was conducted in conjunction with the Incontinence after Prostate Treatment Panel. The update search performed in 2023 was conducted by an independent methodologist.

Panel Formation

The IPT Panel was created in 2017 by the American Urological Association Education and Research, Inc. (AUAER). This Guideline was developed in collaboration with the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU). The Practice Guidelines Committee (PGC) of the American Urological Association (AUA) selected the Panel Chair, who in turn appointed additional panel members with specific expertise in this area, in conjunction with SUFU. Funding of the Panel was provided by the AUA with contributions from SUFU; panel members received no remuneration for their work.

In 2023, the Incontinence after Prostate Treatment Amendment Panel was created by the AUA to review new literature and provide updates herein.

Searches and Article Selection

A comprehensive search of several databases from 2000 to December 21st, 2017 was completed. Databases included Ovid MEDLINE Epub Ahead of Print, Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. The search strategy was designed and conducted by an experienced medical reference librarian with input from the Guideline methodologist. Controlled vocabulary supplemented with keywords was used to search for studies on IPT. The search was restricted to studies published in English and available in full text in the peer reviewed literature.

In 2023, the Incontinence after Prostate Treatment Guideline was updated through the AUA amendment process in which newly published literature is reviewed and integrated into previously published Guidelines. The methodologist searched Embase (1996 to June 2023), EBM Reviews – Cochrane Central Register of Controlled Trials (May 2023), EBM Reviews – Cochrane database of Systematic Reviews (2005 to June 2023), Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations and Daily (2019 to June 2023).

Data Abstractions

Two reviewers independently selected studies and extracted data using standardized, pilot tested forms created in a systematic review software management system (Distiller SR, Evidence Partners, Ottawa, Canada). Disagreements were resolved by discussion between the two reviewers. Two main types of data were abstracted: baseline characteristics (study design, objective, inclusion and exclusion criteria, sample size, age, body mass index [BMI], intervention, period of follow up), and outcome data (number of patients who were incontinent and those with incontinence improvement, mean pads per day, quality of life [QoL], and complications).

Risk of Bias Assessment

The Newcastle Ottawa scale, which evaluates cohort selection, comparability and outcomes assessment, was used for non-randomized controlled trials (RCTs). The Cochrane risk of bias tool which evaluates random sequence generation, allocation concealment, blinding, and attrition was used for evaluation of RCTs.

Data Synthesis

When meta-analysis was appropriate, methodologists utilized the random-effects model a priori because of the anticipated heterogeneity across study populations and settings. Otherwise, outcomes were evaluated using narrative and descriptive approaches.

Determination of Evidence Strength

The categorization of evidence strength is conceptually distinct from the quality of individual studies. Evidence strength refers to the body of evidence available for a particular question and includes individual study quality in addition to consideration of study design; consistency of findings across studies; adequacy of sample sizes; and generalizability of samples, settings, and treatments for the purposes of the Guideline. Investigators graded the strength of evidence for key comparisons and outcomes for each Key Question, using the approach described in the Agency for Healthcare Research and Quality Evidence-based Practice Center Methods Guide for Comparative Effectiveness and Effectiveness Reviews.⁶ Strength of evidence assessments were based on the following domains:

• Study limitations, based on the overall risk of bias across studies (low, medium, or high)
• Consistency of results across studies
• Directness of the evidence linking the intervention and health outcomes
• Precision of the estimate of effect, based on the number and size of studies and confidence intervals for the estimates (precise or imprecise)
• Reporting bias, based on whether or not the studies defined and reported primary outcomes and whether or not we identified relevant unpublished studies (suspected or undetected)

The AUA employs a 3-tiered strength of evidence system to underpin evidence-based guideline statements. Table 1 summarizes the GRADE categories, definitions, and how these categories translate to the AUA strength of evidence categories. In short, high certainty by GRADE translates to AUA A-category strength of evidence, moderate to B, and both low and very low to C.

The AUA categorizes body of evidence strength as Grade A (well-conducted and highly-generalizable RCTs or exceptionally strong observational studies with consistent findings), Grade B (RCTs with some weaknesses of procedure or generalizability or moderately strong observational studies with consistent findings), or Grade C (RCTs with serious deficiencies of procedure or generalizability or extremely small sample sizes or observational studies that are inconsistent, have small sample sizes, or have other problems that potentially confound interpretation of data). By definition, Grade A evidence is evidence about which the Panel has a high level of certainty, Grade B evidence is evidence about which the Panel has a moderate level of certainty, and Grade C evidence is evidence about which the Panel has a low level of certainty.

AUA Nomenclature: Linking Statement Type to Evidence Strength

The AUA nomenclature system explicitly links statement type to body of evidence strength, level of certainty, magnitude of benefit or risk/burdens, and the Panel’s judgment regarding the balance between benefits and risks/burdens (Table 2). Strong Recommendations are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken because net benefit or net harm is substantial. Moderate Recommendations are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken because net benefit or net harm is moderate. Conditional Recommendations are non-directive statements used when the evidence indicates that there is no apparent net benefit or harm or when the balance between benefits and risks/burden is unclear. All three statement types may be supported by any body of evidence strength grade. Body of evidence strength Grade A in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances, and that future research is unlikely to change confidence. Body of evidence strength Grade B in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances, but better evidence could change confidence. Body of evidence strength Grade C in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances, but better evidence is likely to change confidence. Body of evidence strength Grade C is only rarely used in support of a Strong Recommendation. Conditional Recommendations also can be supported by any evidence strength. When body of evidence strength is Grade A, the statement indicates that benefits and risks/burdens appear balanced, the best action depends on patient circumstances, and future research is unlikely to change confidence. When body of evidence strength Grade B is used, benefits and risks/burdens appear balanced, the best action also depends on individual patient circumstances, and better evidence could change confidence. When body of evidence strength Grade C is used, there is uncertainty regarding the balance between benefits and risks/burdens, alternative strategies may be equally reasonable, and better evidence is likely to change confidence.

Where gaps in the evidence existed, the Panel provides guidance in the form of Clinical Principles or Expert Opinions with consensus achieved using a modified Delphi technique if differences of opinion emerged.⁷ A Clinical Principle is a statement about a component of clinical care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature. Expert Opinion refers to a statement, achieved by consensus of the Panel, that is based on members' clinical training, experience, knowledge, and judgment for which there is no evidence.

Peer Review and Document Approval

An integral part of the Guideline development process at the AUA is external peer review. The AUA conducted a thorough peer review process to ensure that the document was reviewed by experts in the treatment of IPT. In addition to reviewers from the AUA PGC, Science and Quality Council (SQC), and Board of Directors (BOD), the document was reviewed by representatives from AUA and SUFU as well as external content experts. Additionally, a call for reviewers was placed on the AUA website from January 14 to 28, 2019 to allow any additional interested parties to request a copy of the document for review. The Guideline was also sent to the Urology Care Foundation to open the document further to the patient perspective. The draft Guideline document was distributed to 49 external peer reviewers. All peer review comments were blinded and sent to the Panel for review. In total, 33 reviewers (9 AUA PGC, SQC, and BOD reviewers; 22 external reviewers; and 2 public reviewers) provided comments. At the end of the peer review process, a total of 476 comments were received. Following comment discussion, the Panel revised the draft as needed. Once finalized, the Guideline was submitted for approval to the AUA PGC, SQC and BOD as well as the governing bodies of SUFU for final approval.

In 2024, as a part of the amendment process, the AUA conducted a thorough peer review process. A call for peer reviewers was posted on February 7^th, 2024 and the draft Guideline document was distributed to 85 peer reviewers, 32 of whom submitted comments. The Amendment Panel reviewed and discussed all submitted comments and revised the draft as needed. Once finalized, the Guideline was submitted to the AUA PGC, SQC, and BOD for final approval in addition to the approval bodies of collaborators SUFU and the Society of Genitourinary Reconstructive Surgeons (GURS).

Clinicians should inform patients undergoing localized prostate cancer treatment of all known factors that could affect continence. (Moderate Recommendation; Evidence Level: Grade B)

Clinicians should counsel patients regarding the risk of sexual arousal incontinence and climacturia following localized prostate cancer treatment. (Strong Recommendation; Evidence Level: Grade B)

Clinicians should inform patients undergoing radical prostatectomy that incontinence is expected in the short-term and generally improves to near baseline by 12 months after surgery but may persist and require treatment. (Strong Recommendation; Evidence Level: Grade A)

Prior to radical prostatectomy, clinicians may offer patients pelvic floor muscle exercises or pelvic floor muscle training. (Conditional Recommendation; Evidence Level: Grade C)

Clinicians should inform patients undergoing radical prostatectomy or transurethral resection of the prostate after radiation therapy of the high rate of urinary incontinence following these procedures. (Moderate Recommendation; Evidence Level: Grade C)

In patients who have undergone radical prostatectomy, clinicians should offer pelvic floor muscle exercises or pelvic floor muscle training in the immediate post-operative period. (Moderate Recommendation; Evidence Level: Grade B)

In patients with bothersome stress urinary incontinence after prostate treatment, clinicians may offer surgery as early as six months if incontinence is not improving despite conservative therapy. (Conditional Recommendation; Evidence Level: Grade C)

In patients with bothersome stress urinary incontinence after prostate treatment despite conservative therapy, clinicians should offer surgical treatment at one year post-prostate treatment. (Strong Recommendation; Evidence Level: Grade B)

Clinicians should evaluate patients with incontinence after prostate treatment with history, physical exam, and appropriate diagnostic modalities to categorize type and severity of incontinence and degree of bother. (Clinical Principle)

In patients with urgency urinary incontinence or urgency predominant mixed urinary incontinence, clinicians should offer treatment options per the American Urological Association Overactive Bladder Guideline. (Clinical Principle)

Prior to surgical intervention for stress urinary incontinence, clinicians should confirm stress urinary incontinence by history, physical exam, or ancillary testing. (Clinical Principle)

Clinicians should inform patients with incontinence after prostate treatment of management options for their incontinence, including surgical and non-surgical options. (Clinical Principle)

In patients with incontinence after prostate treatment, clinicians should discuss risk, benefits, and expectations of different treatments using the shared decision-making model. (Clinical Principle)

Prior to surgical intervention for stress urinary incontinence, clinicians should perform cystourethroscopy to assess for urethral and bladder pathology that may affect outcomes of surgery. (Expert Opinion)

Clinicians may perform urodynamic testing in patients prior to surgical intervention for stress urinary incontinence in cases where it may facilitate diagnosis or counseling. (Conditional Recommendation; Evidence Level: Grade C)

In patients seeking treatment for incontinence after radical prostatectomy, clinicians should offer pelvic floor muscle exercises or pelvic floor muscle training. (Moderate Recommendation; Evidence Level: Grade B)

Clinicians should discuss the option of artificial urinary sphincter with patients who are experiencing mild to severe stress urinary incontinence after prostate treatment. (Strong Recommendation; Evidence Level: Grade B)

Prior to implantation of artificial urinary sphincter, clinicians should ensure that patients have adequate physical and cognitive abilities to operate the device. (Clinical Principle)

In patients who select artificial urinary sphincter, clinicians should preferentially utilize a single cuff perineal approach. (Moderate Recommendation; Evidence Level: Grade C)

Clinicians should discuss the option of male slings with patients as treatment options for mild to moderate stress urinary incontinence after prostate treatment. (Moderate Recommendation; Evidence Level: Grade B)

Clinicians should not routinely implant male slings in patients with severe stress incontinence. (Moderate Recommendation; Evidence Level: Grade C)

Clinicians may offer adjustable balloon devices to non-radiated patients with mild to severe stress urinary incontinence after prostate treatment. (Conditional Recommendation; Evidence Level: Grade C)

Clinicians should manage patients with stress urinary incontinence after treatment of benign prostatic hyperplasia the same as patients that have undergone radical prostatectomy. (Moderate Recommendation; Evidence Level: Grade C)

In patients with stress urinary incontinence after primary, adjuvant, or salvage radiotherapy who are seeking surgical management, clinicians should offer artificial urinary sphincter over male slings or adjustable balloons. (Moderate Recommendation; Evidence Level: Grade C)

In patients with incontinence after prostate treatment, clinicians should counsel patients that efficacy is low and cure is rare with urethral bulking agents. (Strong Recommendation; Evidence Level: Grade B)

Clinicians should consider other potential treatments for incontinence after prostate treatment as investigational, and patients should be counseled accordingly. (Expert Opinion)

Clinicians may counsel patients regarding risk factors for artificial urinary sphincter erosion. (Conditional Recommendation; Evidence Level: C)

Clinicians should counsel patients that the artificial urinary sphincter will likely lose effectiveness over time, and reoperations are common. (Strong Recommendation; Evidence Level: Grade B)

In patients with persistent or recurrent urinary incontinence after artificial urinary sphincter or sling, clinicians should again perform history, physical examination, and/or other investigations to determine the cause of incontinence. (Clinical Principle)

In patients with persistent or recurrent stress urinary incontinence after sling, clinicians should recommend an artificial urinary sphincter. (Moderate Recommendation; Evidence Level: Grade C)

In patients with persistent or recurrent stress urinary incontinence after artificial urinary sphincter, clinicians should discuss artificial urinary sphincter revision with the patient. (Strong Recommendation; Evidence Level: Grade B)

In patients presenting with infection or erosion of an artificial urinary sphincter or sling, clinicians should perform explantation and reimplantation should be delayed. (Clinical Principle)

After explanting an eroded device, clinicians may manage artificial urinary sphincter urethral cuff erosion intra-operatively with urethral catheter alone, in situ urethroplasty, or anastomotic urethroplasty. (Expert Opinion)

Clinicians should discuss urinary diversion with patients who are unable to obtain long-term quality of life due to incontinence after prostate treatment. (Expert Opinion)

In patients with bothersome incontinence during sexual activity, clinicians should offer treatment. (Moderate Recommendation; Evidence Level: Grade C)

In patients with stress urinary incontinence following urethral reconstructive surgery, clinicians may offer artificial urinary sphincter and counsel that complications rates are higher. (Conditional Recommendation; Evidence Level: Grade C)

In patients with incontinence after prostate treatment and erectile dysfunction (ED), clinicians may offer a concomitant or staged procedure. (Conditional Recommendation; Evidence Level: Grade C)

In patients with symptomatic vesicourethral anastomotic stenosis (VUAS) or bladder neck contracture, clinicians should treat the patient prior to surgery for incontinence after prostate treatment. (Clinical Principle)

In the future, refinements to therapies that create IPT will occur, decreasing incidence. The Panel expects continued enhancements in diagnostics and treatment options that will continue to improve patient continence and decrease the prevalence of IPT. Since most papers are single center experiences, the Panel expects and hopes to have increased multicenter research collaboration. Clinical trials of lifestyle interventions, medications, and surgeries will be needed to estimate therapeutic benefit while comparative effectiveness research can help determine which therapy to use and when. Patient reported outcome measures, which are very important in the treatment of QoL surgery have also become more prevalent; as such, the Panel expects these to also improve in use and quality, allowing clinicians to fully address patient concerns.

Refining which patient populations with SUI and BNC/VUAS will benefit from synchronous BNC/VUAS treatment and AUS placement rather than staged procedures will improve the QoL of many patients.

Newer treatments will encompass not only improvements in surgical products such as AUS and male slings, but will also include continued research into muscle injections, stem cells, and newer treatments for urgency and urge incontinence.

Developments regarding surgical products will likely include improvements to the current AUS, possibly improving the patient’s ability to use the pump. It may also include a more automated system controlled from an external device with no manual dexterity needed. With newer technologies, the Panel hopes to see automatic adjustments in cuff pressures or fluid volumes that would allow increased pressures improving continence with any increase in abdominal pressure. Dynamic pressuring could lead to less leakage and less wear on the urethra.

Male slings have continued to evolve from bone anchored slings to the current products on the market, including some that are adjustable. As clinicians learn more about etiology, continued development and improvements will increase efficacy of newer products.

The ATOMS® adjustable transobturator sling is currently approved for use in Europe and Canada; however, it is currently under review by the FDA. New evidence demonstrates that the ATOMS® adjustable sling is safe and effective for men with mild to severe SUI. However, patients with prior RT and prior surgery for urethral stricture had significantly worse continence rates, complication rates, and satisfaction rates compared to those who did not have these risk factors.^{2, 198}

Some advances in the treatment of male SUI are expected to parallel those with female SUI. Regenerative medicine may shape future treatments attempting to restore normal function with either autologous muscle-derived cells or multipotent mesenchymal stem cells injected into the sphincter. While cell-based therapies have yet to produce long-term clinical improvement, hope exists that cellular regenerative therapies such as stem cells or low-intensity shockwave will lead to effective non-surgical therapies.

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