Male stress urinary incontinence: assessing patient-reported outcomes

Male stress urinary incontinence (SUI) is caused by intrinsic sphincter deficiency (ISD) from a variety of etiologies – prostatic surgery as the being the most common. SUI may sometimes be associated with overactive bladder symptoms. Based on the severity of symptoms and the associated level of bother, the patient may seek treatment. A treatment plan is elaborated after careful patient evaluation involving a combination of voiding diary, quality of life (QOL) questionnaires, flowmetry, urethrocystoscopy and urodynamics. The therapeutic options include conservative methods, such as pelvic floor exercises, or surgical modalities such as injectables, adjustable balloon therapy, slings and the artificial urinary sphincter (AUS). The success is defined by objective or subjective outcome measures. This retrospective study presents a global assessment of patient satisfaction and QOL in 37 men at a follow-up of 7 to 60 months after AUS.1 The investigators demonstrated an overall high QOL level based on a survey of patient-reported outcomes (PRO) composed of 4 questionnaires: International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), Post-Operative Patient Global Impression of Improvement (PGI-I), Incontinence Impact Questionnaire-Short Form (IIQ-SF) and Urogenital Distress Index (UDI-SF). Out of 34 patients, 31 would have an AUS placed again and recommend it to a friend with a similar problem. The authors concluded that the insertion of AUS positively impacted QOL and patient satisfaction.1 The economic burden of male SUI has been steadily increasing in the last 2 decades, with most of the increase occurring in the ambulatory surgery setting.2 Many patients are counselled for and chose a surgical intervention with hopes of cure. As incontinence is not alife-threatening, the patient must decide if the expected benefits outweigh the possible risks and complications of the surgery. His decision is therefore based on how severely his condition affects his QOL. It is crucial for the surgeon to establish realistic expectations, because they are direct determinants of a patient’s satisfaction following the intervention. Another consideration is the limited lifespan of a mechanical device, such as the AUS. The increasing risk of mechanical revision with long-term follow-up may signifi-cantly change patient satisfaction over time.3 The purpose of using PRO in incontinence research is to measure the impact of an intervention on the overall health status from a patient’s perspective. In clinical trials, these tools are ideally administered before and after treatment in a prospective fashion. Despite the wide availability of QOL questionnaires, there is little consensus about their applicability to guide treatment decision.4 Due to the retrospective nature of this study, we cannot compare the preoperative and postoperative scores of the QOL questionnaires. However, the desire to undergo surgical treatment can be used as a surrogate of significant QOL impairment before the intervention. Future clinical studies should prospectively measure PRO and correlate them with objective outcomes in homogeneous populations of patients to avoid any possible bias.