Stress urinary incontinence (SUI) is most effectively and most frequently managed with insertion of either a transobturator mesh sling or artificial urinary sphincter (AUS).¹ Men with severe SUI or any SUI in the context of prior radiation are likely best served with AUS insertion–this much is clear.² The challenge lies in accurately grading men with self-reported mild–moderate SUI and then in determining the ideal management strategy for each patient. Many men conceptually prefer the sling because of its simple design and passive function. Therefore, preoperatively identifying those patients who are less likely to have long-term satisfaction with slings is of utmost importance in minimizing failed surgeries.

Urodynamic testing provides confirmation of SUI and offers precise quantification of SUI severity in the form of Valsalva leak point pressure (VLPP). Preoperative VLPP <100 cmH₂O (severe SUI) has been proposed a threshold predictive of sling failure for post-prostatectomy SUI.³ However, the resource and time requirements, patient discomfort, and costs of urodynamics limit the attractiveness of its routine use in assessment of SUI severity.

The 24-hour pad test provides a “real-world” assessment of SUI severity by quantifying the volume of daily urine leakage. However, this test has 2 major limitations. First, the amount of leakage a man experiences in a 24-hour period varies significantly based on his level of physical activity and oral intake. Second, many patients find it logistically challenging and cumbersome to reliably collect their pads for 24 hours and bring the pads to the urology clinic. These limitations have deterred us from using this test in our routine practice.

Patient-reported average pad per day (PPD) usage is the simplest and quickest way to quantify SUI. However, this test also has 2 major limitations. First, PPD usage varies with the type of pad used, the patient’s threshold for changing pads, and the patient’s level of physical activity and oral intake. Second, relying solely on patient-reported history with no objective measurements lacks the precision ideally used in surgical decision making.

In 1996, Kowalczyk first described the standing cough test (SCT) as a means to determine a patient’s candidacy for tandem AUS cuff placement.⁴ The SCT is performed with a full bladder and 4 deep coughs while the provider monitors for leakage. As male SUI guidelines recommend cystourethroscopy prior to surgical intervention,² we recommend performing the SCT immediately after cystourethroscopy to confirm that the bladder is full. While we no longer place tandem AUS cuffs, we appreciated the practicality and reproducibility of the SCT. We began incorporating the SCT into our routine clinical practice in 2014. We subsequently created the Male SUI Grading Scale (MSIGS) to quantify the degree of leakage using in-office SCT (see Appendix). We have validated MSIGS and found it to correlate closely with 24-hour pad weights.⁵

Once validated, we sought to retrospectively assess the value of MSIGS as a predictor of successful SUI surgery. We retrospectively analyzed the cases of 203 men who had undergone sling placement at our institution with 11–75 months of followup.⁶ Multivariable analysis identified MSIGS score as an independent predictor of sling success (p <0.001). We then developed a nomogram that incorporated MSIGS, PPD and history of pelvic radiation.⁶ We internally validated the nomogram and confirmed that it performed superiorly to PPD and history of pelvic radiation alone in predicting sling failure in males.

After accumulating more data, we again tested the value of MSIGS in predicting SUI surgical success, focusing on men with mild-moderate SUI (MSIGS 0–3). As expected, men with mild SUI (MSIGS 0–1) had significantly higher rates of sling success (≤1 PPD and no subsuquent incontinence procedure) than men with moderate SUI (MSIGS 2–3; 78% vs 63%, p=0.02).⁷ Moreover, we found that men with moderate SUI were significantly more likely to succeed with AUS than with slings (80% vs 63%, p=0.02). Therefore, we use these data to counsel patients with moderate SUI towards AUS placement.

As a tertiary referral center, many patients present to our clinic specifically requesting sling placement. However, 34% of men presenting to our practice with self-reported mild-to-moderate SUI by PPD actually exhibit severe SUI on SCT.⁸ Moreover, men with self-reported moderate SUI who are “upstaged” to severe SUI by MSIGS have low sling success rates (33%).⁹ Therefore, we subsequently changed our practice to require objective confirmation of mild SUI severity on SCT before offering a sling, regardless of self-reported SUI severity. Just as the female SUI guidelines advise visual confirmation of leakage prior to offering surgical interventions,¹⁰ we advise visual confirmation and quantification of leakage to guide preoperative decision making.

While certainly imperfect, MSIGS has become an important pillar of our SUI evaluation because of its practicality. The SCT adds minimal time and no cost to a standard clinic visit. It does not rely on the patient to collect pads or keep a diary, so it can be performed consistently on essentially all patients. MSIGS accurately assesses the severity of male SUI and predicts sling success, even in men with reported mild–moderate SUI. By consistently using this tool, urologists can minimize unsuccessful sling placements and maximize patient satisfaction.

Disclosures: Dr. Allen Morey receives honoraria for being a guest lecturer/meeting participant for Boston Scientific and Coloplast Corp. No other authors have disclosures to present.