Did You Know You Don't Have to Choose Between Incontinence and Erectile Dysfunction?

Stress urinary incontinence and erectile dysfunction (ED) are common side effects after any level of prostate cancer treatment, including radical prostatectomy and radiation therapy for prostate cancer. While many patients prefer to treat bothersome incontinence first, over ED, this is no longer a polarizing choice, and there are effective surgical management solutions for both.

Artificial urinary sphincters (AUS) are a surgical procedure in which an inflatable cuff is placed around the urethra a pump is placed in the scrotum that works to stop the flow of urine when needed. An inflatable penile prosthesis (IPP) is a device that is placed in the penis to help with erections.

These devices can be placed one after the other (AUS, then IPP) or at the same time, and are recommended for moderate to severe cases of stress incontinence and ED following prostate treatment when more conservative measures have failed. Each method comes with its own pros and cons.

Sequential AUS and IPP Placement

This has long been considered the gold standard for treatment in moderate-to-severe cases of SUI, and when first-line treatments (like pills and vacuum devices) for ED haven’t been working. First, the AUS is placed, then the IPP is placed a time later.

Placing the devices one after the other like this tends to be chosen more often, partly because the time between surgeries lets the wounds heal more quickly and can make it easier to learn how the first device works before adding the second. A swollen scrotum can make it harder to master two devices at a time.

Another reason this surgery option is favored is that many patients may find SUI more bothersome and inconvenient than ED, so having the AUS implant first would be more helpful to them. This method has also had fewer complication rates compared to the synchronous device placement process. If there were to be any complications, these would mostly include infections after the surgery, which may infect both devices. This would lead to a more intense re-implant process.

It’s important to speak with a specialist in these areas who does these surgeries a lot, so that the best decision for one’s unique case can be made. Sometimes, these procedures are covered by health insurance, so it may also be helpful to speak with one’s health insurance company to see if this is a feasible option.

Synchronous AUS and IPP Placement

Placing both the AUS and IPP at the same time is a newer concept (available in the past several decades), and is considered more time-effective, given there is only one surgery and one recovery period to think about. This method was first tested because researchers wanted to cut down on surgery time, which would hopefully reduce the chances of infection, since patients were spending less time in the operating room.

Due to the number of devices placed at once, though, there may be more swelling in the scrotum, making it hard to figure out each pump system while recovering. Several studies comparing the two methods have stated the synchronous method may have higher post-surgery complication rates; however, most of these incidents were incision site and urinary tract infections that can be easily treated with antibiotics.

This method has been preferred by patients in several studies, often with higher satisfaction rates. However, patients may find it difficult to get their health insurance to support the cost of this specific procedure, so it’s important to check with both one’s urologist and provider, and with health insurance representatives to come up with the best option for care.

Key Takeaways

• There are several options to treat both stress urinary incontinence and ED following treatment for prostate cancer.
• All options should be discussed with a urologist, so that the best option for each is chosen.
  • Think about and discuss time constraints, health insurance coverage, cost, and the surgeon's confidence.
• It may be helpful to speak with a healthcare provider if SUI and ED are bothersome after prostate cancer treatment.

Resources:

Breyer, B. N., Kim, S. K., Kirkby, E., Marianes, A., Vanni, A. J., & Westney, O. L. (2024). Updates to incontinence after prostate treatment: AUA/Gurs/Sufu Guideline (2024). Journal of Urology, 212(4), 531–538. https://doi.org/10.1097/ju.0000000000004088

Chung, E. (2024). A narrative review on synchronous concurrent versus delayed sequential surgery in the artificial urinary sphincter and penile prosthesis implantation. Translational Andrology and Urology, 13(8), 1650–1656. https://doi.org/10.21037/tau-23-22

Dalimov, Z., & Simhan, J. (2024). Simultaneous implantation of the penile prosthesis and artificial urinary sphincter: Review of current evidence. International Journal of Reconstructive Urology, 2(1), 84–91. https://doi.org/10.4103/IJRU.IJRU_14_24

Tu, H. Y., & Sandhu, J. S. (2017). Combined artificial urinary sphincter and penile implant surgery: Good or bad idea? The Journal of Sexual Medicine, 14(5), 643–644. https://doi.org/10.1016/j.jsxm.2017.03.253

Ungerer, G., Köhler, T. S., Helo, S., Ziegelmann, M. J., & Elliott, D. (2026). Cuff conundrum: Inflatable penile prosthesis surgery in men who have transcorporal artificial urinary sphincters. The Journal of Sexual Medicine, 23(2). https://doi.org/10.1093/jsxmed/qdaf353

Yafi, F. A., Peak, T., Mitchell, G., Sangkum, P., & Hellstrom, W. J. G. (2016). 151 synchronous dual AUS/IPP insertion through a single penoscrotal incision. The Journal of Sexual Medicine, 13(Supplement_1), S71. https://doi.org/10.1016/j.jsxm.2016.02.157