This is an original study evaluating the use of pelvic floor physical therapy and duloxetine for stress urinary incontinence (SUI) after holmium laser enucleation of the prostate (HoLEP). Clinically significant SUI is a known complication of HoLEP with the highest incidence in the first few months after the procedure [1].  Pelvic floor physical therapy has been shown to be beneficial for patients with SUI after radical prostatectomy [2]. There is very limited data on PFPT use for SUI after holmium laser enucleation of the prostate (HoLEP). Furthermore, evidence exists to support the use of duloxetine to treat post prostatectomy SUI in patients who have failed to achieve continence with Kegel exercises and/or PFPT [3]. Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor with specific affinity for the 5HT receptor in Onuff’s nucleus resulting in increased external urethral sphincter tone and sphincter muscle hypertrophy over time. To our knowledge there is not readily available data that has been published on using duloxetine for persistent SUI refractory to PFPT after HoLEP. 

The aim of this study was to characterize the use of PFPT and duloxetine for SUI after HoLEP at a high volume center. We hypothesized that PFPT would lead to a higher rate of men with post HoLEP SUI returning to continence. Our primary outcome was the ability to achieve continence. A secondary aim of this study was to evaluate the effectiveness of duloxetine as an adjunct therapy for men who failed to achieve continence after PFPT. We hypothesized that duloxetine would allow some men to achieve continence who failed to become continent with PFPT alone.

A retrospective chart review was performed on patients that underwent HoLEP and were referred to PFPT for SUI between 1/1/2014 and 6/30/2022. Patient demographics were recorded including age, prostate specimen weight, degree of incontinence measured in pads per day prior to referral, urinary retention prior to HoLEP and if there was a component of urge urinary incontinence. The ability to achieve continence, defined as 0 pads per day or one pad per day for safety was recorded. Time to continence was estimated using follow up notes. Patients who failed to become continent with PFPT alone and went on to receive duloxetine were identified. At PFPT patients were taught how to perform Kegels using biofeedback, given an at home exercise regimen and taught to be conscious of bearing down during activities of daily living.

107 patients were identified who were referred to PFPT after HoLEP for SUI. Of those, 84 patients attended at least one PFPT session. Patients were referred to PFPT an average of 47 days after their procedure. An overview of patient demographics and results can be seen in Table 1. Notably patients who did not attend PFPT used fewer pads per day at the time of referral. The median number of PFPT sessions attended was 2. 61 patients (72.6%) who attended PFPT achieved continence after an average of 81 days. Of patients who did not attend PFPT, 16 (84.2%) achieved continence after an average of 119 days. 

72 patients were identified who attended PFPT after HoLEP for SUI and had not previously been prescribed duloxetine. 45 of these patients (62.5%) achieved continence with PFPT alone. Of the 27 patients who did not achieve continence with PFPT alone, 19 were prescribed duloxetine in conjunction with continued PFPT. Of the patients who failed to achieve continence with PFPT alone and were prescribed duloxetine, 8 (42.1%) were able to achieve continence.

There was no significant difference in ability to achieve continence when comparing patients who attended PFPT to those who were referred but did not attend. However, it is important to consider that the patients who did attend PFPT were using significantly more pads per day prior to referral than the patients who did not attend (average of 3.2 vs 2.0). Incontinence in the first 3 months after HoLEP is often transient and may resolve without intervention [1]. One of the weaknesses of this analysis is the lack of a control group with a similar degree of incontinence as the group that received PFPT. It is therefore difficult to characterize the degree of improvement that PFPT provided for the patients that attended. However, given that patients who attended PFPT had significantly worse incontinence prior to referral and achieved continence at a similar rate it is reasonable to infer that PFPT provided some benefit. When considering time to continence the difference between the two groups was not significant. The group who attended PFPT was followed more closely. As the time to continence was estimated using follow up notes, the group that did not attend PFPT may have an increased reported time to continence since they were not followed as often. Of patients who were not able to achieve continence with PFPT alone, 42.1% were able to become continent with the addition of duloxetine. In these patients with refractory incontinence duloxetine likely provided some benefit.

PFPT represents a low risk intervention that may provide some benefit for patients with SUI after HoLEP, especially those patients requiring 3 or more pads per day. Duloxetine appears to assist with achieving continence for patients unable to achieve continence after HoLEP with PFPT alone. Further studies are needed to determine which patients with SUI after HoLEP who would most benefit from PFPT and duloxetine.

Hout M, Gurayah A, Arbelaez MCS, Blachman-Braun R, Shah K, Herrmann TRW, Shah HN. Incidence and risk factors for postoperative urinary incontinence after various prostate enucleation procedures: systemic review and meta-analysis of PubMed literature from 2000 to 2021. World J Urol. 2022 Nov;40(11):2731-2745. doi: 10.1007/s00345-022-04174-1. Epub 2022 Oct 4. PMID: 36194286.
Milios JE, Ackland TR, Green DJ. Pelvic floor muscle training in radical prostatectomy: a randomized controlled
Kotecha P, Sahai A, Malde S. Use of Duloxetine for Postprostatectomy Stress Urinary Incontinence: A Systematic Review. Eur Urol Focus. 2021 May;7(3):618-628. doi: 10.1016/j.euf.2020.06.007. Epub 2020 Jun 27. PMID: 32605820.