More than being dry: what bothers men with stress urinary incontinence after prostate cancer therapy

We thank Geretto et al. (1) for their thoughtful comments. They highlight the importance of patient counseling regarding urinary incontinence (UI) following surgical treatment for prostate cancer, particularly as it pertains to expected clinical outcomes. We could not agree more. As they note, clinicians likely underestimate the significance of UI. As our study shows, the individuality of experience and subsequent treatment choice makes a one-size-fits-all approach to counseling challenging. Indeed, others have shown that leakage means different things to different people, and even some with low volume of leakage can experience significant bother, which was borne out again in our pilot (2). As a matter of clinical practice, we recommend counseling focused on the patient’s individualized goals, which can even be at odds with one another. Directed discussion on risk, benefit, and alternatives with the individual patient in mind considering how different approaches may meet their goals will yield more effective discussions than a focus on “objective” measurements such as number of pads.

The editorial comments by Geretto et al. note that objective data on dryness achieved by the various options for surgical treatment of UI is lacking. Unfortunately, this objective knowledge gap will likely persist as any retrospective assessment of treatment of men with UI with sling versus artificial urinary sphincter (AUS) will be strongly influenced by selection bias. Guideline-directed treatment favors AUS in the setting of severe UI and those patients who have undergone radiation (3). Certainly, a randomized study examining various treatment options among patients with various characteristics would be helpful to provide more robust data. However, even objective measures of UI may not be the ultimate solution, as these objectives measures may not correlate with patient satisfaction or quality of life. This is a critical part of understanding the patient perspective and can hopefully help us to push the thinking in this field towards patient-centered, rather than surgeon-centric, outcomes. In addition, we would argue—as supported by our pilot data—that dryness is only one outcome and we should expand our thinking in evaluating stress urinary incontinence (SUI) outcomes.

Geretto et al. concluded by noting that improvement in prostatectomy technique should be a focus of future direction. Certainly, any advancement in technique to improve urinary and sexual outcomes for men with prostate cancer, not the least of which being more men on active surveillance, is welcome. Many of the men struggling with incontinence were dry after their prostatectomy, but it was radiation in the adjuvant or salvage setting that worsened any continence outcome, even years after primary treatment (4,5). Overall, a vast majority of men who have UI will not pursue surgical treatment; while this may be due somewhat to patient choice, significant barriers to obtaining UI treatment remain. In light of this and the number of men currently living with unassessed, undertreated or untreated UI, we believe the focus in this area should be multipronged, including increased outreach and earlier counseling on UI, as well as realization of UI that may happen years after prostatectomy.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Andrology and Urology. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2023-03/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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