Guideline sources The following summarized guidelines for the evaluation and management of urinary incontinence in men (UI) are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2022) and the American Urological Association (AUA/SUFU 2019; 2012). 1 2 3 Guidelines 1. Diagnostic investigations History and physical examination: elicit a complete medical history including symptoms and comorbidities, medications, and perform a focused physical examination in the evaluation of male patients with urinary incontinence. A Show 2 more Assessment of PVR: As per EAU 2022 guidelines, measure post-void residual in the assessment of urinary incontinence. A As per AUA 2012 guidelines, measure post-void residual urine volume in patients with stress urinary incontinence when considering invasive therapy. E Show 2 more Urodynamic testing: https://web.pathway.md/diseases/recUr5LcI9gz7fNQZ 1/5 6/29/23, 3:48 AM Urinary incontinence in men Pathway As per EAU 2022 guidelines, obtain urodynamic testing for urinary incontinence when considering invasive treatment. B As per AUA 2012 guidelines, consider obtaining multi-channel urodynamic testing in patients with both symptoms and physical findings of stress urinary incontinence considering invasive, potentially morbid, or irreversible treatments. C Show 12 more Bladder electromyography: obtain EMG in combination with cystometry/cystometrogram with or without pressure flow studies in patients with relevant neurologic disease at risk for neurogenic bladder or in patients with other neurologic disease and elevated post-void residual or urinary symptoms. B 2. Medical management Antimuscarinic agents: offer antimuscarinic agents or mirabegron in adult patients with urge urinary incontinence failed conservative treatment. A Duloxetine: offer duloxetine in patients with stress urinary incontinence. B Inform patients about the possible adverse events of duloxetine. A 3. Nonpharmacologic interventions Lifestyle modifications: offer lifestyle modifications for improving urinary incontinence, although evidence is lacking. B Incontinence pads: advise using pads and/or penile sheaths as a palliative option for the management of urinary incontinence. B Bladder training: offer bladder training as a complementary treatment for urinary incontinence. B Prompted voiding: offer prompted voiding in patients with urinary incontinence where appropriate. A 4. Therapeutic procedures Intravesical injection of botulinum toxin: Offer bladder wall injections of onabotulinumtoxin A (100 U) in patients with overactive bladder/urge urinary incontinence refractory to medical therapy. B Inform patients about the limited duration of response, risk of UTI, and possible prolonged need for clean intermittent self-catheterization (ensure that they are willing and able to do so). A Sacral nerve stimulation: offer sacral nerve stimulation in patients with urge urinary incontinence refractory to medical therapy and willing to undergo surgical treatment. B Artificial urinary sphincter: offer artificial urinary sphincter implantation in patients with moderate-to-severe stress urinary incontinence. Inform patients that there is a high risk of https://web.pathway.md/diseases/recUr5LcI9gz7fNQZ 2/5 6/29/23, 3:48 AM Urinary incontinence in men Pathway complications, mechanical failure, and the need for explantation, although a cure can be achieved. A Perform artificial urinary sphincter implantation only in expert centers. B Noncircumferential compression device: offer adjustable continence therapy (ProACT) only in expert centers. B Show 2 more 5. Surgical interventions Augmentation cystoplasty: Offer augmentation cystoplasty in patients with overactive bladder/urge urinary incontinence refractory to all other treatment options and able and willing to perform self-catheterization. B Inform patients undergoing augmentation cystoplasty of the high risk of complications, the risk of having to perform clean intermittent self-catheterization, and the need for life-long surveillance. A Urinary diversion: offer urinary diversion only in patients with overactive bladder/urge urinary incontinence refractory to less invasive therapies and willing to accept a stoma. B 6. Specific circumstances Patients undergone prostatectomy (preoperative counseling): Counsel patients undergoing radical prostatectomy regarding the following: all known factors that could affect continence B risk of sexual arousal incontinence and climacturia B expected incontinence in the short-term that generally improves to near baseline by 12 months after surgery but may persist and require treatment. A Patients undergone prostatectomy (evaluation): elicit history, perform a physical examination, and obtain an appropriate diagnostic evaluation to categorize the type and severity of incontinence and degree of bother in patients with incontinence after prostate treatment. B Show 3 more Patients undergone prostatectomy, pelvic floor muscle training: As per EAU 2022 guidelines, offer pelvic floor muscle training alone or in combination with biofeedback and/or electrostimulation to speed up recovery from urinary incontinence in patients undergoing radical prostatectomy. B As per SUFU/AUA 2019 guidelines, consider offering pelvic floor muscle exercises or pelvic floor muscle training before radical prostatectomy. C As per SUFU/AUA 2019 guidelines, offer pelvic floor muscle exercises or pelvic floor muscle training in the immediate postoperative period in patients after radical prostatectomy and in patients seeking treatment for incontinence after radical prostatectomy. B Patients undergone prostatectomy, transobturator slings: https://web.pathway.md/diseases/recUr5LcI9gz7fNQZ 3/5 6/29/23, 3:48 AM Urinary incontinence in men Pathway As per EAU 2022 guidelines, offer nonadjustable transobturator slings in patients with mild- to-moderate post-prostatectomy urinary incontinence. Inform patients that severe incontinence, prior pelvic radiotherapy, or transurethral surgery may worsen the outcome of nonadjustable male sling surgery. B As per SUFU/AUA 2019 guidelines: Consider placing male slings as a treatment option in patients with mild-to-moderate stress urinary incontinence after prostate treatment. C Do not place male slings routinely in patients with severe stress incontinence. C Perform explantation and delay reimplantation in patients presenting with infection or erosion of a sling. B Patients undergone prostatectomy (artificial urinary sphincter): consider placing an artificial urinary sphincter in patients with bothersome stress urinary incontinence after prostate treatment. B Ensure that patients have adequate physical and cognitive abilities to operate the device before artificial urinary sphincter implantation. C Show 4 more Patients undergone prostatectomy (noncircumferential compression device): consider offering adjustable balloon devices in patients with mild stress urinary incontinence after prostate treatment. C Patients undergone prostatectomy (periurethral injection of bulking agents): do not offer periurethral injection of bulking agents in patients with post-prostatectomy urinary incontinence. D Patients undergone prostatectomy (surgery): consider performing surgery as early as 6 months if incontinence is not improving despite conservative therapy in patients with bothersome stress urinary incontinence after prostate treatment. C Perform surgical treatment at 1 year after prostate treatment in patients with bothersome stress urinary incontinence despite conservative therapy. B Show 2 more Patients undergone prostatectomy (management of persistent/recurrent incontinence): elicit history, perform a physical examination, and/or obtain other investigations to determine the cause of incontinence in patients with persistent or recurrent urinary incontinence after artificial urinary sphincter or sling implantation. B Show 2 more Patients undergone prostatectomy (management of erectile dysfunction): Consider offering a concomitant or staged procedure in patients with incontinence after prostate treatment and erectile dysfunction. C Consider offering treatment in patients with bothersome climacturia. C References 1. Mauro Gacci, Vasileios I Sakalis, Markos Karavitakis et al. European Association of Urology Guidelines on Male Urinary Incontinence. Eur Urol. 2022 Oct;82 4 387 398. Open https://web.pathway.md/diseases/recUr5LcI9gz7fNQZ 4/5 6/29/23, 3:48 AM Urinary incontinence in men Pathway 2. Jaspreet S Sandhu, Benjamin Breyer, Craig Comiter et al. Incontinence after Prostate Treatment: AUA/SUFU Guideline. J Urol. 2019 Aug;202 2 369 378. Open 3. J Christian Winters, Roger R Dmochowski, Howard B Goldman et al. Urodynamic studies in adults: AUA/SUFU guideline. J Urol. 2012 Dec;188 6 Suppl):2464 72. Open https://web.pathway.md/diseases/recUr5LcI9gz7fNQZ 5/5