**3. Diagnostic evaluation**

A comprehensive assessment typically begins with a detailed medical history, physical examination, and an objective assessment of symptoms.

The medical history should focus on the type, timing, and severity of incontinence throughout the day, the presence or absence of nighttime and gravitational incontinence, and the presence of incontinence-triggering situations (e.g., straining, coughing, or sneezing). The history should also assess any preexisting LUTS, details regarding the prostatectomy procedure, comorbidities, prior radiotherapy, interventions for urethral strictures or incontinence, and the oncological status [41].

The physical evaluation should include an abdominal, neuro-urological, and perineal examination, as well as a digital rectal examination. Furthermore, manual dexterity should be assessed before an artificial urinary sphincter (AUS) implantation, which requires manipulation of the activating pump [42].

Micturition time charts and bladder diaries are standardized tools for measuring and monitoring symptom severity, evaluating the frequency, number of incontinence episodes, voided volumes, and 24-h urinary output [43]. Available validated questionnaires include the International Consultation on Incontinence-Short Form [44]

#### *Post-Prostatectomy Urinary Incontinence DOI: http://dx.doi.org/10.5772/intechopen.114136*

and the UCLA/RAND-Prostate Cancer Index Urinary Function Score [45], which are the most frequently used. Patients' subjective perception of how much they leak is unreliable; therefore, objective measures should be required for evaluation [46]. Pad count appears to be a poor measure of the degree of UI due to limitations such as different sizes, pad absorbency, and degree of saturation [47, 48]. On the other hand, pad weight is recognized as the most accurate metric for UI assessment [47]. Evidence indicates that the 24-h and 48-h pad weighing tests are the most accurate for quantifying and diagnosing UI severity [47, 49].

The primary diagnostic should be performed before scheduling initial conservative treatment, including urinalysis to rule out infection and bladder ultrasound to assess postvoid residual urine volume [41].

If this attempt fails and surgical treatment is planned, a more invasive diagnosis should be performed [41]. Urethrocystoscopy aims to rule out urethral pathologies, such as bladder neck stenosis or urethral stricture, that may complicate a future surgical approach. Urethroscopy can also be used to perform the *repositioning test,* which consists of applying gentle mid-perineal pressure parallel to the anal canal while a 0° cystoscope is positioned distally of the sphincter region, and a view of the entire circumference of the external urinary sphincter is obtained. The test yields a positive result when the sphincter autonomously and reflexively closes concentrically, exhibiting complete closure during the repositioning of the posterior urethra [50]. This evaluation is essential in determining the patient's residual sphincter function and determines suitability for potential retrourethral sling implantation [50].

A urodynamic test is required if the patient has neurogenic disorders or OAB symptoms, especially to assess detrusor function [51]. However, the use of urodynamics in therapeutic decision-making is still debated. As reported by some authors, a higher preoperative Valsalva Leak Point Pressure (VLPP) (>70 cm H2O or > 100 cm H2O) better predicts successful outcomes for male sling implantation [52, 53]. In contrast, Han et al. found no negative impact of an impaired preoperative VLPP on functional outcomes after male sling placement [54]. In patients undergoing artificial urinary sphincter implantation due to intrinsic sphincter deficiency, there was no correlation between preoperative urodynamic findings and surgical outcomes [55]. Recent evidence indicates that the urodynamic study might not be relevant in all PPUI patients [56].

Urethrocystography may be a valuable supplementary diagnostic tool in cases suspicious of urethra abnormalities to rule out or better characterize a urethral stricture or bladder neck contracture [57].
