Pelvic floor muscle exercises, also called “Kegel exercises,” for the physician who popularized them, consist of intermittent voluntary contractions of the urethral sphincter muscle. If patients are unable to generate a urethral sphincter muscle contraction, aides including biofeedback might be helpful. PFME have been studied in the setting of post-prostatectomy incontinence and appear to be beneficial at hastening return of continence. A randomized control trial to evaluate the effect of PFME in men who had undergone RP used urinary continence at 3 months after surgery as the primary endpoint [53]. In this study, 88 % of the men in the treatment group achieved complete continence, measured by 24-h pad weight, significantly greater than 56 % of the men who achieved continence at 3 months in the placebo group. At 1 year, the difference between the two groups was only 14 %. Subsequently Filocamo et al. [54] randomized 300 consecutive patients who had undergone RP for clinically confined prostate cancer and showed an earlier return to continence with 74 % of the men performing PFME being dry, measured by pad usage, compared to 30 % in the untreated group at 3 months. While this difference was statistically significant, the difference at 1 year (98.7 % vs. 88 %) was not. Most men regain continence after RP; it appears that PFME can reduce time to continence, at least in the first postoperative year. Goode et al. [55] studied the effect of PFME on patients presenting with persistent post-prostatectomy urinary incontinence, defined as incontinence present after the first postoperative year. These authors randomized 208 men to one of three arm—one underwent 8 weeks of behavior therapy (PFME and bladder control strategies), the second included behavior therapy plus (addition of biofeedback and pelvic floor muscle stimulation), and a control arm (no treatment). They noted a 55 % decline in mean incontinence episodes at 8 weeks in the behavior therapy arm compared to 24 % in the control arm, a statistically significant improvement. Furthermore, they noted no significant improvement over behavior therapy with the addition of biofeedback and pelvic floor muscle stimulation. As such, a trial of pelvic floor exercises appears prudent for all men presenting for management of urinary incontinence after RP.

Biofeedback has been evaluated to determine if it improves recovery of continence over PFME alone. Burgio et al. [56], studied the use of preoperative biofeedback assisted behavioral training to decrease post-RP incontinence. Participants were taught pelvic floor muscle control and received instructions in daily PFME. Patients were taught to contract the sphincter muscles during 2 to 10-s periods separated by 2–10 s of relaxation depending on initial ability. The main outcome measurements were duration of incontinence as derived from bladder diaries, severity of incontinence, distress from incontinence, and pad use. The Hopkins Symptom Checklist was used to measure psychological distress and the Medical Outcomes Study Short Form Health Survey (SF-36) was used to assess impact on QoL. They concluded that preoperative behavioral training could hasten the recovery of urine control and decrease the severity of incontinence following RP. A similar study done by Wille et al. [57], questioned the benefit of early biofeedback after RP, the outcomes measured included a 20-min pad test (an objective measure) and a urine symptom questionnaire.

Goode et al. [55] found that the addition of biofeedback to behavior therapy did not improve continence compared to behavior therapy alone, suggesting that if patients can perform PFME regularly, biofeedback has no role as adjunct therapy.

Surgical treatments, endoscopic or open, are usually not entertained for men with stress urinary incontinence until conservative treatments have failed. Given the natural history of urinary function recovery after RP, it is prudent to wait at least a year after surgery before undergoing evaluation and treatment for urinary incontinence. Surgical management remains the mainstay for the correction of post-RP SUI. Common surgical procedures currently used are endoscopic bulking agents, the artificial urinary sphincter, and a variety of male slings. Table 12.2 lists selected reports with the various modalities as well as the success rate.

Urethral bulking agents have been used in female SUI and have also been applied to male SUI, particularly in the setting of post-RP SUI. Glutaraldehyde cross-linked collagen has been approved by the Food and Drug Administration for the treatment of intrinsic sphincter deficiency since 1993. In males with post-RP SUI, the technique consists of endoscopic injection of collagen in the submucosa overlying or just distal to the urethral sphincter at four sites circumferentially until the urethra coapts. Collagen injection can be repeated after 4 weeks.

Cummings et al. [60] reviewed their initial series of glutaraldehyde cross-linked collagen used as an injectable bulking agent for the therapy of post-radical prostatectomy stress incontinence. Preoperative severity of incontinence was measured as mild (1–2 pads/day), moderate (3–4 pads/day) or severe (more than 4 pads/day or total incontinence). These authors reported that 58 % of patients had a “good” or “improved” result at a mean follow-up of 10.3 months. Smith et al. [61] reviewed their series of men with post-RP SUI who underwent injection of glutaraldehyde cross-linked collagen and stratified the patients as being “totally dry” or “socially continent” if they used no more than 1 pad daily. Their analysis of men who underwent collagen injection revealed that 8.1 % of the men were dry and 38.7 % of the men achieved social continence after a median of 4 injections. In a more recent review, Westney et al. [62] calculated pad usage before and after therapy. Treatment effect was stratified into quartiles of improvement of 0 % to 25 %, 26 % to 50 %, 51 % to 75 %, and 76 % to 100 %. 17 % of patients gained complete continence. Published success rates with urethral bulking agents is difficult to compare because of varying number of injections and multiple outcome measures used in studies, but ranges from 17 % to 38 % [60–62].

It should be noted that most authorities do not consider urethral bulking agents as a durable treatment for male SUI, particularly post-RP. In fact, the most recent International Consultation on Incontinence [63], a consensus meeting of incontinence experts, regarded urethral bulking agents as showing only modest success rates with low cure rates for male SUI.

Urethral compression procedures were introduced in 1972 when Kaufman published a series of manuscripts evaluating three different types of urethral compression techniques designed to improve continence after RP. The procedures consisted of using the penile crura with or without a buttress to compress the bulbar urethra. In his early description of this procedure he reported his success rates as excellent if there was no leakage, marked improvement in those with some leakage but no appliance and poor if a clamp was necessary. His final procedure, a silicone gel compressive implant placed just under the bulbar urethra, had a success rate, defined as dry without protection, of 63 % in 21 men with short-term follow-up [64]. These procedures, along with the success of the pubovaginal sling for female SUI, led to multiple types of male urethral slings. A male sling based on the needle suspension procedures for incontinence in females was subsequently introduced. This sling consists of three synthetic bolsters placed under the bulbar urethra and suspended above the rectus fascia in the lower abdomen via sutures through the retropubic space. Schaeffer et al. [65] reviewed their results of this bulbourethral sling for PPI. Pad usage was measured daily and the patients were stratified into dry, improved (>50 % reduction in pad usage), and wet. The success rate, defined as being completely dry, in 64 men was 56 %. Clemens et al. [66] reviewed a series of patients undergoing the same procedure and introduced a satisfaction rate (“Would you undergo the procedure all over again?”) as an outcome measure and reported a satisfaction rate of 90.2 %.

A bone-anchored variant of the male sling was reported in 2001 [67]. Initial success with this technique, defined as being dry or needing a pad for security without any episode of incontinence, was reported to be 87.5 % in 14 men followed for a mean of 12 months. Comiter [68] prospectively evaluated 21 men who underwent the bone-anchored sling surgery. Patients were stratified per their pad usage as well as their score on the UCLA/RAND Incontinence score. In this study, 76 % of men followed for a mean of 12 months demonstrated success, defined as the need for no pads.

Ullrich and Comiter [69] evaluated 22 patients with preoperative and postoperative pad usage and preoperative and postoperative urodynamic parameters, as well as UCLA/PCI questionnaire. Pad usage decrease from 4.6 to 0.74 and they found no significant change in maximum flow rate or detrusor pressure at maximum flow rate. In terms of satisfaction, they found that 73 % of patients report no or a very small problem after male sling surgery. Rajpurkar et al. [70] utilized a similar classification to assess cure in their series of 46 patients. They classified patients as “cured” if they were dry, “improved” if they were using 1–2 pads/day and “failed” if they utilized >2 pads/day. In addition to using the UCLA/PCI questionnaire, they reported patient satisfaction rates of 70 %.

More recently, Fischer et al. [71] evaluated the male perineal sling in 62 men and attempted to determine preoperative parameters that could predict success. Patients completed multiple validated questionnaires including the I-PSS (International Prostate Symptom Score), UCLA/RAND Prostate Cancer Index urinary function score, ICIQ-SF (International Consultation on Incontinence short form), IIQ-7 (Incontinence Impact Questionnaire short form), PGI-I (Patient Global Impression of Improvement), and the UDI-6 (Urogenital Distress Index short form). Success was defined by the PGI-I, patient perception of their lower urinary tract condition, as very much or much improved. Failure was defined as a little better, no change, a little worse, or much worse. As defined by the PGI-I, these authors reported a success rate of 58 %. The successes and failures as defined by the PGI-I were then compared to their pad weights and the results of the postoperative questionnaires. They found that the patients’ perception of success correlated with the 24 h pad weight as well as all the questionnaires. This study suggests that a global question is a reasonable way to measure outcomes.

A transobturator version of the male sling is now being used extensively in the USA and Europe [72]. This sling is made of polypropylene and is placed through a perineal incision and tensioned via trocars passed through a transobturator route. Initial results with this sling are comparable to initial results with the bone anchored sling. Published success rates with male slings range from 38 % to 76 % depending on outcome measures used [66–72].