A 75-year-old man comes for follow-up 6 months after radical prostatectomy for prostate cancer. He continues to have occasional episodes of involuntary loss of urine with activities such as straining or lifting heavy objects. The patient was an avid golfer but stopped after the surgery due to urinary leakage. He has no dysuria, nocturia, or hematuria. The patient did not undergo radiation therapy. He has a history of hypertension and type 2 diabetes mellitus.
The blood pressure is 130/80 mm Hg and pulse is 68/min. The abdomen is soft and nontender without palpable masses. There is decreased sensation to light touch and pinprick on bilateral feet. Ankle reflexes are absent and muscle strength is normal. Post-void residual volume is low.
Prostate-specific antigen level is undetectable and urinalysis findings are within reference range.
Which of the following is the best next step in managing this patient?

Question

A 75-year-old man comes for follow-up 6 months after radical prostatectomy for prostate cancer.  He continues to have occasional episodes of involuntary loss of urine with activities such as straining or lifting heavy objects.  The patient was an avid golfer but stopped after the surgery due to urinary leakage.  He has no dysuria, nocturia, or hematuria.  The patient did not undergo radiation therapy.  He has a history of hypertension and type 2 diabetes mellitus.
The blood pressure is 130/80 mm Hg and pulse is 68/min.  The abdomen is soft and nontender without palpable masses.  There is decreased sensation to light touch and pinprick on bilateral feet.  Ankle reflexes are absent and muscle strength is normal.  Post-void residual volume is low.
Prostate-specific antigen level is undetectable and urinalysis findings are within reference range.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

Urinary incontinence is a common complication after radical prostatectomy for localized prostate cancer and is usually due to urethral sphincter injury. Some studies show that up to 50% of patients can develop stress incontinence within 2 months of surgery, but the incidence dramatically decreases to ~10% by 2 years post surgery. As a result, nonsurgical treatment is initially preferred. Pelvic floor exercises with biofeedback can significantly accelerate recovery and decrease incidence of post-surgical urinary incontinence. Patients who fail conservative therapy (usually <1%) may require surgery with artificial sphincter placement or sling procedure. (Choice A) MRI of the lumbosacral spine can evaluate for neurogenic bladder due to spinal cord lesions. Patients usually develop lower extremity weakness with bowel/bladder incontinence. This patient's normal muscle strength makes this less likely. The absent ankle reflexes can be due to normal aging (most common after age 70) and are not clinically significant. (Choice C) Retrograde urethrogram can detect urethral strictures due to bladder neck contracture or distal urethral narrowing post prostatectomy. Patients usually develop urinary retention with decreased urinary stream or overflow incontinence. The post-void residual is usually increased. (Choice D) Sildenafil can improve erectile dysfunction after radical prostatectomy. However, it is not useful for urinary incontinence. (Choice E) Tolterodine is an antimuscarinic drug for urge incontinence due to benign prostatic hyperplasia. However, this patient's prostatectomy makes this unlikely. No medications have yet been approved in the United States for the treatment of stress incontinence. Educational objective: Urinary incontinence is a common complication after radical prostatectomy for localized prostate cancer and is usually due to a damaged urinary sphincter. Pelvic floor exercises with biofeedback can significantly accelerate recovery and decrease the incidence of postprostatectomy stress incontinence. __________ References: Contribution of early intensive prolonged pelvic floor exercises on urinary continence recovery after bladder neck-sparing radical prostatectomy: Results of a prospective controlled randomized trial. (http://www.ncbi.nlm.nih.gov/pubmed/17487874) Effectiveness of early pelvic floor rehabilitation treatment for post-prostatectomy incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/16002204)

A 75-Year-Old Man Comes for Follow-Up 6 Months After Radical