Men may experience urinary incontinence (UI) after surgery for benign prostatic hyperplasia (BPH) or radical prostatectomy (RP). Conservative interventions, such as pelvic floor muscle training (PFMT), electrical stimulation and lifestyle modifications, may be undertaken to manage the symptoms of UI following prostate surgery. However, the value of the approaches to conservative management of UI after prostate surgery remains uncertain. The objective of this Cochrane systematic review was to assess the effects of conservative interventions for managing UI after prostate surgery.

We searched the Cochrane Incontinence Specialised Register on 22 April 2022 for randomised controlled trials (RCTs) and quasi-RCTs of adult men (aged 18 or over) with UI following prostate surgery for prostate cancer or lower urinary tract symptoms/benign prostatic obstruction. The key interventions were: PFMT plus biofeedback; electrical or magnetic stimulation; and combinations of conservative treatments. The comparator against all these key interventions was versus no treatment, sham treatment, or verbal and written instructions. The primary outcomes were subjective cure or improvement of UI (patient-reported as defined by trialists) and condition-specific quality of life (assessed using validated questionnaires). 

Two review authors independently screened all retrieved titles and abstracts for eligibility, followed by full-text screening; a third review author acted as arbitrator in cases of disagreement. The same two reviewers independently extracted all data and critically appraised included studies using the Cochrane ‘Risk of bias’ tool. Where feasible, random-effects meta-analyses were performed in RevMan Web. When meta-analyses were not appropriate, we performed narrative syntheses based on the synthesis without meta-analysis (SWiM) guidance. The GRADE approach was used to assess the certainty of key outcomes and comparisons.

Twenty-five studies including a total of 3079 participants were identified for inclusion following the screening process. Twenty-three of these studies assessed men who had previously undergone RP or radical retropubic prostatectomy (RRP). 

Four included studies compared PFMT plus biofeedback versus no treatment, sham treatment or verbal/written instructions. Men undertaking PFMT plus biofeedback may experience greater subjective cure of incontinence from 6 to 12 months (1 study; n = 102; low-certainty evidence) but may be less likely to be objectively cured between 6 to 12 months (2 studies; n = 269; low-certainty evidence). It is not certain if undertaking PFMT and biofeedback has an effect on either surface or skin-related adverse events (1 study; n = 205; very low-certainty evidence) or muscle-related adverse events (1 study; n = 205; very low-certainty evidence). No studies in this comparison reported on condition-specific quality of life, participant adherence to the intervention or general quality of life.

Eleven included studies compared combinations of conservative interventions with no treatment, sham treatment or verbal/written instructions. There may be little difference in the number of men being subjectively cured or improved of incontinence between 6 and 12 months (RR 0.97, 95% CI 0.79 to 1.19; 2 studies; n = 788; low-certainty evidence) and there is probably little difference in condition-specific quality of life between combinations of conservative treatments and control (MD -0.28, 95% CI -0.86 to 0.29; 2 studies; n = 788; moderate-certainty evidence). Additionally, there is probably little difference in men’s general quality of life between 6 and 12 months (MD -0.01, 95% CI -0.04 to 0.02; 2 studies; n = 742; moderate-certainty evidence). Between 6 and 12 months, there is little difference in objective cure or improvement in incontinence between combinations of conservative treatments and control (MD 0.18, 95% CI -0.24 to 0.60; 2 studies; n = 565; high-certainty evidence). However, it is not certain whether participants undertaking combinations of conservative treatments have increased adherence to the intervention between 6 and 12 months (RR 2.08, 95% CI 0.78 to 5.56; 2 studies; n = 762; very low-certainty evidence). In terms of the number of surface or skin-related adverse events, there is probably no difference between combinations and control (2 studies; n = 853; moderate-certainty evidence). However, it is not certain whether combinations of treatments increase the risk of men experiencing muscle-related adverse events (RR 2.92, 95% CI 0.31 to 27.41; 2 studies; n = 136; very low-certainty evidence).

No studies comparing electrical or magnetic stimulation versus no treatment, sham treatment or verbal/written instructions were identified.

The certainty of evidence assessed using GRADE was mixed, ranging from low-certainty to high-certainty. The evidence was mainly downgraded due to small sample sizes within studies and the risk of bias, as most of the included studies were at high risk of bias for at least one domain.

Although 25 studies were identified for this systematic review, the value of conservative interventions for managing UI after prostate surgery remains uncertain. There is a need for large, high-quality and adequately powered RCTs to address this evidence gap.

Continence 7S1 (2023) 100974
DOI: 10.1016/j.cont.2023.100974