Conservative or behavioral management is generally recommended during the first year after prostatectomy [33]. Pelvic floor muscle training (PFMT) is the most commonly used conservative management and is a first-line treatment that is used to restore pelvic floor or bladder function after radical prostatectomy. Treatment regimens are not yet standardized, however. Generally, PFMT is a pelvic floor muscle (PFM) contraction with various positions (lying, sitting, and standing) using tools (biofeedback, pelvic floor electrical stimulation) to increase the strength and endurance of the pelvic floor. Repeated contractions are thought to improve urinary control, through an increased support for the detrusor muscle and urethral sphincter [34]. For the accurate contraction of the PFM, the patient must learn the technique by use of specialized methods. Floratos et al. [35] reported that PFMT, using intensive verbal instructions and electromyographic biofeedback, showed objectively 91% of the overall continence rate at 6 months. If the patient did not receive instructions for PFMT, the effect was significantly lower [36]. The long-term effects of early postoperative biofeedback-PFMT are reported to be a continence rate of 96.1% among patients at postoperative month 12 [37]. In a prospective randomized controlled trial among patients with PPI for at least 1 year, PFMT with or without biofeedback and pelvic floor electrical stimulation resulted in improvement in incontinence episodes [38]. However, PFMT cannot be applied to every patient after radical prostatectomy, because patients need to be motivated and have their pelvic floor neurologically intact. Additionally, PFMT has limited benefit in patients with severe urinary incontinence. Behavioral management, such as reduction of bladder irritants, reduction of fluid intake, timed voiding, and bladder training, have also been recommended [39], but not enough evidence is available yet.

An effective pharmacologic treatment with acceptable side-effects is needed to compensate for the gap between conservative management and surgical management. Although currently there is no pharmacologic treatment approved for SUI in men, some studies of the effect of duloxetine in male SUI, which was proved to be an effective and safe treatment for women with SUI, have been reported. Duloxetine, a combined serotonin/norepinephrine reuptake inhibitor, increases the activity of the striated urethral sphincter and the effects on the excitability of pudendal motor neurons by stimulating the Onuf's nucleus [40,41]. Filocamo et al. [42] made a comparison between PFMT and duloxetine with PFMT only in the treatment of PPI and demonstrated a facilitative effect of duloxetine on early continence recovery. In a randomized, placebo-controlled, double-blind trial, which included 31 patients, 80 mg of duloxetine daily for 3 months was effective in the treatment of incontinence symptoms and improved quality of life in patients with mild to moderate PPI [43]. Larger studies investigating the efficacy and side effects of duloxetine are needed before widespread use of pharmacologic treatment.

Various substances (collagen, Teflon, silicone macroparticles, autologous fat, autologous chondrocytes, and dextranomer/hyaluronic acid copolymer) have been used for decades as bulking agents. Injection of urethral bulking agents in the urethral submucosa works by adding bulk, increasing coaptation at the level of the bladder neck and distal sphincter, and increasing the urethral lumen's resistance to flow. These are minimally invasive, cheaper treatment modalities for PPI, after conservative treatment, that do not limit future antiincontinence surgery [44]. Problems with these agents include the need for multiple injections, deterioration of effect over time, and modest success rates with low cure rates. The collagen injection success rates for PPI range from 36 to 69%, with 4 to 20% of patients reporting being dry [45-48]. Agents currently used include dextranomer/hyaluronic acid copolymer (Deflux), pyrolytic carbon microspheres (Durasphere), and polydimethylsiloxane (Macroplastique). These new agents show a slower migration without compromising the other organs, and short-term data are good. However, satisfactory long-term results required reinjections, and a high rate of complications occurred in some cases [49-51]. Bugel et al. [52] reported that Macroplastique injection showed a rapid deterioration after initial improvements, with success rates of 40% at 1 month and 26% at 12 months. Recently, autologous fibroblasts and myoblasts were introduced to reconstitute the deficient urethral sphincter, and their effects and safety have been reported [53].

Injection therapy may be useful for short-term improvement in patients with PPI who are in too poor of health for invasive surgical treatments.

Interest in the male suburethral sling procedure, which is based on the concept of passive external urethral compression, as a treatment option for PPI has been recently revived. Although long-term outcomes are unknown, the sling, which is used as a permanent material instead of a resorbable material, performs reasonably well in the intermediate term. Sling surgery is adequate for patients with mild to moderate degrees of SUI who have not had previous radiation therapy, who have adequate detrusor contractility, or who demand a less invasive procedure or a nonmechanical device, as opposed to a device such as the artificial urinary sphincter (AUS) [54]. The advantages of sling surgery compared with the AUS include no mechanical parts, no need for manual dexterity or device training, a cognitive status that enables activating and deactivating the urethral cuff, immediate efficacy, and reduced overall cost. Whereas reported revision rates owing to recurrent incontinence are quite low, longer follow-up is needed before definitive comparisons to the AUS can be made.

Several techniques for sling surgery have been introduced. Three representative sling designs, which differ in the materials used, the methods of fixation, and the position of the support, are the bone-anchored sling (BAS), the transobturator sling, and the adjustable retropubic sling.

Adjustable continence balloons, which are one of the most recent treatments, create passive compression of the urethra by two balloons located on either side of the urethra. The ProACT (Uromedica, Plymouth, MN, USA) is an adjustable continence therapy option and is a minimally invasive modality with a cost that is remarkably less than that of the AUS. The ProACT implantation is performed under general or spinal anesthesia through a perineal incision. The balloons are placed, one on each side of the urethra, right above the pelvic floor at the former level of the prostate after radical prostatectomy. Fluoroscopic guidance or transrectal ultrasound is used for visualization. Tubing runs from each balloon to titanium ports placed on the back of the scrotum. The balloons are filled with sterile water through these ports. At 1 month and thereafter, the balloons are refilled with 1-ml increments of this solution (maximum of 8 ml) until continence is reached. Postoperative readjustment is very simple, and only local anesthesia is necessary.

Prospective single-center study to evaluate the results of ProAct demonstrated a decrease in the median 24-hour urinary leakage (352.5 vs. 11 ml, p<0.001), a decrease in the median number of pads used per day (4.75 vs. 2.25, p=0.001), and an overall dry rate of 50% [71].

Of the 170 patients reported by Hubner and Schlarp [72], one-third became pad free. The mean number of postoperative adjustments of the balloon was 3 to 5, with some patients requiring 6 to 8 refillings. Although the success rate approximates the male sling surgery, the benefit must be weighed against the frequent need for balloon refilling and the high complication rate. The most common perioperative complications were urethral or bladder perforation, necessitating termination of the implant on the perforated side. Other complications were temporary urinary retention and device explantation as the result of balloon failure, infection, erosion, or migration. The ProACT system is not recommended for patients with prior external beam radiation therapy, because of a higher complication rate and an unsatisfactory success rate [73].

The AUS is, despite the new surgical treatment options, still the gold standard and the most effective long-term surgical treatment of male incontinence. The AUS consists of three components: the cuff, which goes around the proximal bulbar urethra; the pump, which goes inside the scrotum; and the reservoir (balloon), which holds the fluid for the device. A 4.5-cm cuff was the first cuff size, with the introduction of a 4.0-cm cuff in 1994. Currently, a 3.5-cm cuff is also available. Hudak and Morey [74] reported that the 3.5-cm cuff has become the predominant size, which is used for primary and revision AUS placement.

AUS has the largest body of literature reporting long-term success. The success and high patient satisfaction rates seem to outweigh the need for periodic revision, high cost, and surgical invasiveness. The success rate of the AUS procedure is still the best, when compared with that of all other available surgical treatment options for PPI. The success rates for AUS range from 59 to 90% [75-82] (Table 1). Continence rates with the AUS can vary with the definition of continence, the method of evaluation, and the length of follow-up. Nevertheless, high subjective rates of satisfaction, from 87 to 90%, are consistently reported, even without total continence [83,84].

A potential downside of the AUS is the need for periodic revisions. Revision and explantation rates, owing to mechanical failure, urethral atrophy, infection, and erosion, vary considerably among the studies, with reports of 5 to 45% and 7 to 17%, respectively [80,82]. Lai et al. [79] reported that 270 patients underwent AUS implantation, with an infection rate of 5.5%, cuff erosion rate of 6%, and an atrophy rate of 9.6%. Overall, 25% of patients required revision at 5 years. In another long-term report, Kim et al. [78] reported that 36% of patients required surgical revision or removal within 10 years, and most events occurred within the first 48 months. Revisions include replacement of the malfunctioning part, cuff replacement, repositioning or downsizing owing to urethral atrophy, and a second or tandem cuff or transcorporal cuff placement. An increased revision rate was reported for patients who received pelvic radiation but was not found in a recent series, and previous radiation therapy is therefore not a contraindication for AUS implantation [75]. AUS also showed improvement in preoperative urodynamic abnormalities in patients with PPI and concomitant urodynamic bladder dysfunction, such as detrusor overactivity, hypersensitivity, and mild loss of compliance [85].