Managing post-prostatectomy stress urinary incontinence.

The need for supervision by a health-care professional in patients undertaking pelvic-fl oor exercises is well recognised for women with stress urinary incontinence caused by urethral hypermobility, though the evidence base is scarce. Failure to off er such supervision, for example by mere provision of leafl ets on pelvic-fl oor muscle exercises, risks leaving women uncertain as to precisely which muscles are being referred to, and ambivalent about the need to undertake the exercises for several months. A similar approach has been adopted for men, with the International Consultation on Incontinence recommending an initial phase of supervised pelvic-fl oor muscle training for men with stress urinary incontinence after radical prostatectomy, allocating a grade B recommendation in the Oxford Centre for Evidence-Based Medicine scheme. In The Lancet, the Men After Prostate Surgery (MAPS) study assessed a structured pelvic-fl oor muscle training programme compared with standard care, in which exercises could be undertaken but formal teaching was excluded. Separate study groups included men after radical prostatectomy or after transurethral resection of the prostate (TURP) who reported incontinence on screening and baseline questionnaires. The primary outcomes were self-reported incontinence at 12 months, and incremental cost per quality-adjusted life year (QALY). Although men in both intervention groups were more likely to be doing exercises than those in the control groups, this did not translate into less incontinence. After radical prostatectomy, the proportion of men with incontinence was 76% (148 of 196, intervention) versus 77% in the control group (151 of 195, adjusted risk ratio [RR] 0·97, 95% CI 0·87–1·09, p=0·64). After TURP the proportion was 65% (126 of 194) versus 62% (125 of 203, adjusted RR 1·06, 95% CI 0·91–1·23, p=0·47). QALYs were almost identical. The formal training of pelvic-fl oor muscle exercises was dominated (ie, not as good as the control) because it was more costly and was not eff ective. The absence of a clear advantage for formal training for these exercises in men, and the high rates of self-reported urinary incontinence, are important fi ndings. The MAPS study did not question the appropriateness of recommending pelvic-fl oor muscle exercises after prostatectomy, and men were generally compliant with the advice received. However, attendance for pelvicfl oor muscle training is costly to both patient and health provider, so to be worthwhile requires demonstration of improved continence rates or quality of life. The results of MAPS show that formal training achieves only a higher proportion of men reporting that they are performing pelvic-fl oor muscle exercises at 1 year. Stress urinary incontinence in men is deemed a low prevalence problem, when set alongside the high prevalence in women. Yet for men after TURP in MAPS, for whom urgency urinary incontinence was the major issue, 10% (251 of 2590, the total original population) were still incontinent a year after surgery, and severe incontinence was reported by 4% (97 of 2590). The values are even more substantial for radical prostatectomy: 58% (429 of 742, the total original population) of patients reported incontinence at 6 weeks after radical prostatectomy (primarily stress incontinence), of whom 73% (299 of 411, the total assigned to study groups) were still incontinent at 12 months. This fi nding means an incontinence rate of at least 40% (299 of 742) after radical prostatectomy, and a severe incontinence rate of 20% (152 of 742). These values show the importance of frank discussion of continence issues with patients before surgery. Most lay people would regard a state of continence as having no involuntary loss of urine. However, Published Online July 8, 2011 DOI:10.1016/S01406736(11)61034-9