As with all clinical situations, the evaluation of postprostatectomy incontinence begins with a complete history and physical examination. The history should include detailed information about the urinary leakage. When did the leakage occur after surgery, and was any leakage present prior to surgery? The events occurring during leakage (activity, urgency or no sensation) as well as associated urinary symptoms (force of stream, complete emptying) are important factors. Day and nighttime pad usage should be documented to measure the severity of leakage. A pad-weight test may also more accurately quantify urine leakage. Any associated neurologic symptoms or history of previous incontinence therapy should be obtained. The physical examination should include focus on the neurologic status of the perineum and lower extremities. Rectal examination should be performed to rule out recurrence in cancer cases, and to assess the size of the prostate in patients following TURP. A urinalysis and residual urine should be obtained in all patients, and PSA testing should be considered in all patients with a history of prostate cancer to rale out recurrence.
Cystourethroscopy should be performed to inspect for urethral strictures or bladder neck contractures. Gross inspection of the distal urethral sphincter may reveal abnormalities, but cy stoscopic examination does not determine sphincter function. In cases of incontinence following TURP, distortion or absence of the verumontanum suggests sphincteric injury and the presence of residual adenoma can be confirmed. Bladder pathology (tumors, stones, or diverticuli) can be detected. An important feature in performing cystoscopy is to assess the length of the urethra between the external sphincter and the bladder neck. If the urethrovesical anastomosis is at the level of the external sphincter without sufficient urethral length, a transurethral route for injection therapy may be difficult (53).
Radiologic evaluation may consist of retrograde urethrography (RUG) or voiding cystourethrography (VCUG). These studies are capable of identifying anatomic causes of incontinence (stricture or bladder neck contracture). The bladder neck is visualized during VCUG and should remain closed during filling. Straining films may detect leakage of urine across the bladder neck. The VCUG also permits the identification of bladder trabeculation, diverticuli, vesicoureteral reflux, or residual urine. As with cystoscopy, these studies offer anatomic information alone and do not assess bladder or sphincteric function. Perhaps the greatest utility of VCUG is in combination with urodynamic studies, videourodynamics.
Urodynamic evaluation is essential to determine the etiology of incontinence following prostatectomy, and should be performed in all patients for whom invasive therapy is considered or in patients who fail conservative treatment. The appropriate urodynamic investigation should allow determination of bladder and urethral function during filling as well as assess bladder contractility and the presence of obstruction during voiding. To delineate these functions, a multichannel pressure flow study is the most appropriate test. This study requires the presence of a rectal catheter to allow determination of true detrusor pressure, and the presence of simuultaneous uroflow to measure flow velocity during voiding. The use of electromyography of the pelvic floor in indicated in cases complicated by potential neurologic dysfunction. In routine cases it will add little to the diagnosis of postprostatectomy incontinence. Urethral pressure profilometry will provide information concerning urethral closing pressure and functional urethral length. There are no established normal values in male patients and the shape and magnitude of the urethral pressure profile varies greatly with individual techniques (54). Videourodynamics provides the most complete evaluation, combining the anatomic detail of VCUG with the functional assessment of pressure-flow studies.
During the filling phase of the pressure-flow study, information concerning detrusor compliance or instability as well as cystometric capacity is obtained. At 200, 250, and 300 mL volume, the patient is asked to strain. If urinary leakage occurs during straining in the absence of a rise in true detrusor pressure, sphincteric weakness is documented. As stated previously, the exact value of the VLPP is less important in males as is making the diagnosis of stress incontinence. The filling phase of the urodynamic study is critical, as one should determine the whether the bladder is stable with normal storage pressures and that the sphincter is competent during straining maneuvers. During the voiding phase, information regarding bladder contractility or the presence of bladder outlet obstruction is present. As in cases of outlet obstruction related to benign prostatic hyperplasia (BPH), the voiding phase of the pressure flow study will distinguish between obstruction (high detrusor pressure, low urinary flow) and impaired contractility (low detrusor pressure, low urinary flow). The authors routinely perform pressure-flow studies followed by flexible cystoscopy in the evaluation of incontinent patients following prostatectomy.
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