Urinary incontinence after prostate treatment (IPT) is usually an iatrogenic problem caused by an intervention for prostate disease. The current evidence for this malady is detailed in the “Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline,” which was initially published in 2019 and amended in 2024.^1,2 The authors participated in a panel discussion at the 2025 AUA Annual Meeting. While this was only a sampling of the material included in the published guideline, it gave the audience an idea of how to manage various cases of urinary incontinence.

The initial case reviewed risk factors for incontinence in patients undergoing radical prostatectomy (RP). Prior to RP, clinicians should counsel patients undergoing RP that urinary incontinence is common but generally resolves by 12 months, sexual arousal incontinence and climacturia are possibilities, and clinicians should discuss all known risk factors (current age, prostate size, membranous urethral length, and possibly BMI) for postoperative urinary incontinence. Pelvic floor muscle exercises or pelvic floor muscle training should be initially offered to all patients after RP and particularly for patients seeking treatment for IPT.

Figure. Urethral cuff erosion.

Surgical and nonsurgical management options, including pads, other collection devices, and occlusion clamps, should be discussed with all patients with stress urinary incontinence (SUI). A shared decision-making model should be employed to discuss risks, benefits, and expectations focusing on the degree of bother. In patients who choose surgery for IPT, a cystoscopy should be performed and urodynamic testing may be employed if there is a management question.

Patients with primarily urgency urinary incontinence or urgency predominant mixed urinary incontinence should be treated as if they have overactive bladder.³ The definitive treatment of SUI or stress predominant mixed urinary incontinence is surgical.

Surgical Management

If conservative measures fail, all patients with bothersome SUI should be considered for an artificial urinary sphincter (AUS). Prior to implanting an AUS, clinicians should confirm that patients have adequate physical and cognitive capabilities to operate the device and are aware of its risks, particularly mechanical failure, infection, and erosion.

Male slings should be considered in patients with mild to moderate SUI. Expectations of success and risks of failure should be discussed with all patients undergoing a male sling. It is important to note that male slings should not routinely be performed in patients with severe SUI. This guideline does not make a distinction between adjustable and fixed slings.

Adjustable balloon devices can be offered to patients with mild SUI after prostate treatment. These devices are now Food and Drug Administration approved for this indication, but experience with them is still quite limited.

Radiation Therapy Impacts

Because of the increase in surgical management of high-risk prostate cancer, more patients now undergo salvage radiation therapy (RT) after initial treatment with RP. We discussed a case of a patient with IPT who undergoes salvage RT and develops worsening urinary incontinence. The current IPT guidelines state that an AUS should be offered over male slings or adjustable balloons in patients undergoing surgery of IPT with a history of primary, adjuvant, or salvage RT. Specifics regarding patient selection and counselling when placing an AUS were also discussed. All patients undergoing an AUS should be aware that reoperations are common. As far as surgical technique, a single cuff, perineal surgical approach is preferred at the time of initial AUS surgery.

Complications After Surgery

Complications, such as recurrent or persistent incontinence, are common after placement of AUS and patients undergoing these procedures should be told about them. In patients who experience recurrent or persistent incontinence after AUS or sling, clinicians should again perform a history, physical, and any appropriate investigations to help determine the cause.

In patients with persistent or recurrent incontinence after male sling placement or an AUS, an AUS should be considered. This guideline provides 2 algorithms for evaluating sling failure and AUS failure. A mechanical failure of an AUS is a special case which can easily be confirmed in a patient with recurrent incontinence by measuring the volume in the reservoir using cross-sectional imaging. A low reservoir volume means device failure.

Special Situations

An infection or erosion of an AUS necessitates removal of the device followed by a 3- to 6-month period of healing before reimplantation (Figure). The current guideline contains statements discussing risk factors for cuff erosion as well as diagnosis and intraoperative management of urethral erosion. We will discuss a case of cuff erosion. Decision-making during the explant of the AUS and further management were also discussed. In these cases, if an AUS is reimplanted, the surgical technique may be different from an initial placement as placement of a transcorporal urethral cuff may be necessary depending on the size of the urethra at the new surgical site. The guideline also contains sections on treatment for climacturia, IPT after urethral reconstructive surgery, treatment of IPT with a symptomatic vesicourethral stenosis, and role of urinary diversion.

The full unabridged version of this guideline is available online at auanet.org.