Artificial Urinary Sphincter After Prostatectomy: Restoring Control After Male Stress Incontinence

Urinary leakage after prostate surgery can be frustrating, embarrassing and restrictive. When persistent leakage is caused by weakness of the urinary sphincter, an artificial urinary sphincter (AUS) is often the most reliable surgical treatment—particularly for moderate or severe stress urinary incontinence.

However, not every man who leaks after prostatectomy has the same problem. Before inserting an AUS, it is essential to establish why the leakage is occurring. An AUS treats sphincter weakness; it does not directly treat an overactive bladder.

Why can incontinence occur after prostatectomy?

Urinary continence normally depends on several structures working together:

The external urinary sphincter closing the urethra
Healthy supporting tissues around the urethra
A bladder that stores urine at a safe pressure
Coordinated bladder and sphincter function
Adequate pelvic-floor muscle control

During radical prostatectomy, the prostate and part of the internal continence mechanism are removed. Although every effort is made to preserve the external sphincter, it may be weakened by surgical dissection, altered support, scarring or nerve injury.

Radiotherapy, previous urethral surgery, bladder-neck contracture and urethral stricture may further affect continence and tissue quality.

Stress incontinence or overactive bladder?

This distinction is critical because the treatments are different.

Stress urinary incontinence

Stress incontinence typically causes leakage with:

Coughing or sneezing
Standing from a chair
Walking or exercising
Lifting
Bending
Changing position
A full bladder
Sexual activity

The leakage is usually caused by inadequate closure of the urinary sphincter. This is the type of incontinence that an AUS is designed to treat.

Overactive bladder

Overactive bladder generally causes:

A sudden, difficult-to-defer need to urinate
Frequent urination
Waking several times at night
Leakage before reaching the toilet
Leakage triggered by running water, arriving home or putting the key in the door

These symptoms may result from involuntary bladder contractions, reduced bladder capacity, bladder irritation, infection, obstruction or changes in bladder function that existed before the prostate operation.

Some men have mixed incontinence, with both stress leakage and urinary urgency. An AUS may improve the stress component while urgency, frequency or urge leakage persists and requires separate treatment.

Assessment before considering an AUS

A careful evaluation helps confirm that sphincter weakness is the principal cause of leakage and identifies conditions that should be treated before implantation.

Assessment may include:

A detailed symptom and surgical history
Physical examination
Urinalysis and urine culture
A bladder or voiding diary
Pad-use assessment or a formal pad-weight test
Measurement of urinary flow and residual urine
Cystoscopy to examine the urethra, sphincter region and bladder neck
Urodynamic studies in selected patients

Any urinary infection, bladder-neck contracture or urethral stricture should usually be treated and shown to be stable before an AUS is inserted.

The role of urodynamic studies

Urodynamics evaluates how the bladder stores and empties urine. It may help identify:

Genuine stress urinary incontinence
Detrusor overactivity or overactive bladder contractions
Poor bladder compliance or unsafe storage pressures
Reduced bladder capacity
Weak bladder contraction
Bladder-outlet obstruction
Mixed stress and urgency incontinence

Urodynamics is not necessarily required for every straightforward case. Current guidelines support its selective use when the diagnosis is uncertain or when the findings could change management.

It is particularly useful when a man has:

Marked urgency or urge leakage
Difficulty emptying his bladder
An elevated residual urine volume
Previous radiotherapy
Previous surgery for a urethral stricture or bladder-neck contracture
Neurological disease
Unexplained or mixed urinary symptoms
Leakage that does not follow a typical stress-incontinence pattern

Finding detrusor overactivity does not automatically exclude AUS surgery. It allows the patient and surgeon to set realistic expectations and determine whether bladder-directed treatment should be given before or after the procedure.

What is an artificial urinary sphincter?

An AUS is a fluid-filled hydraulic device with three main components:

Urethral cuff: placed around the urethra to keep it gently closed.
Control pump: positioned inside the scrotum, where it can be felt and operated through the skin.
Pressure-regulating balloon: usually placed in the lower abdomen or pelvis.

The cuff remains closed during normal activities and prevents urine from leaking. To urinate, the patient squeezes the scrotal pump. This temporarily transfers fluid out of the cuff, allowing the urethra to open. The cuff then automatically refills over the following few minutes.

The device is entirely internal. Nothing normally remains outside the body.

Who may benefit from an AUS?

An AUS may be considered when:

Stress incontinence persists despite pelvic-floor rehabilitation
Leakage significantly affects work, exercise, travel, sleep, relationships or quality of life
Incontinence is moderate or severe
The patient has undergone prostatectomy or other prostate treatment
The urethra and bladder neck are open and stable
Urinary infection has been excluded
Bladder storage and emptying are sufficiently safe
The patient understands that the implant may eventually require revision
The patient has enough hand strength and dexterity to operate the pump

Guidelines recommend discussing AUS surgery with men experiencing persistent stress incontinence after prostate treatment, including selected men with mild leakage who prefer this option.

Surgery is usually deferred while natural recovery is still occurring. Incontinence that remains troublesome at approximately six months and is not improving may justify earlier discussion, while definitive surgery is commonly considered by 12 months after prostatectomy.

When may an AUS be unsuitable?

An AUS may not be appropriate when there is:

Active urinary infection
An untreated or unstable urethral stricture
Recurrent bladder-neck obstruction
Active urethral erosion
Inability to operate the scrotal pump
Severe cognitive impairment
An unsafe, poorly compliant bladder that has not been addressed
A continuing need for frequent urethral catheterisation or instrumentation

Previous pelvic radiotherapy does not necessarily prevent AUS implantation. However, radiated tissues may heal less reliably and have a higher risk of erosion, infection and future revision.

What happens during and after surgery?

The operation is performed under anaesthesia. The cuff is commonly placed around the bulbar urethra through an incision in the perineum, with the pump positioned in the scrotum and the balloon placed in the lower abdomen or pelvis.

The AUS is normally left deactivated while the tissues heal. It is commonly activated approximately four to six weeks later, depending on the patient’s recovery and the surgeon’s protocol.

Until activation, urinary leakage is expected to continue.

Patients are then taught how to:

Locate and operate the pump
Empty the bladder without repeatedly squeezing the pump
Recognise whether the device has cycled normally
Explain the implant to other healthcare providers
Seek assistance if catheterisation or urinary procedures are required

How successful is an AUS?

The AUS is regarded as the standard surgical treatment for moderate-to-severe male stress incontinence after prostatectomy. Most men experience a substantial reduction in leakage and improvement in quality of life.

“Success” does not always mean being completely pad-free. Many men achieve social continence, generally described as using no more than one small security pad per day. Results vary according to previous radiotherapy, urethral surgery, tissue quality, severity of leakage and how success is defined.

An AUS is a mechanical implant rather than a permanent cure. Device survival decreases over time, and some men will eventually require revision or replacement.

Possible complications

Potential complications include:

Bleeding, bruising or haematoma
Temporary urinary retention
Wound or device infection
Difficulty locating or operating the pump
Persistent stress leakage
Ongoing urgency or urge incontinence
Urethral cuff erosion
Urethral tissue thinning or atrophy
Mechanical malfunction or fluid leakage
Pump or component migration
Pain
Need for revision, replacement or removal

Infection and erosion generally require removal of part or all of the device. A new AUS may sometimes be inserted after the urethra has healed, but repeat surgery can be more complex.

Warning signs of cuff erosion or device infection

Urethral erosion occurs when the cuff gradually damages or enters the urethral wall. It may develop months or years after implantation.

Seek prompt urological review if you notice:

New pain or burning during urination
Blood in the urine
Recurrent urinary infections
Increasing perineal, urethral or scrotal discomfort
New swelling, redness, warmth or discharge around an incision
Fever or feeling generally unwell
Difficulty passing urine
A noticeably weaker urinary stream
Sudden urinary retention
A sudden return or marked worsening of leakage
The pump becoming unusually difficult to operate
Part of the device becoming visible through the skin or urethra

Fever, urinary retention, marked swelling, severe pain or an exposed implant requires urgent medical assessment.

Important precautions after AUS implantation

Always tell healthcare providers about the AUS

A urethral catheter must not be inserted while the cuff is activated. Forcing a catheter through a closed cuff may damage the urethra and cause erosion.

Before catheterisation, cystoscopy or any procedure through the urethra:

The AUS must be identified
The cuff must be fully deactivated
The smallest appropriate catheter should be used
Prolonged urethral catheterisation should be avoided when possible
The treating team should contact a urologist if they are unfamiliar with the device

Patients should consider carrying a medical alert card or wearing medical identification stating:

“Artificial urinary sphincter present, deactivate before urethral catheterisation.”

Protect the urethra and implant

Patients should also:

Avoid operating the pump until instructed after surgery
Follow restrictions on lifting, exercise, cycling and sexual activity during healing
Avoid unnecessary urethral instrumentation
Report urinary infections promptly
Attend follow-up if leakage increases or the device behaves differently
Tell their urologist about future pelvic procedures
Never repeatedly squeeze the pump in an attempt to overcome urinary obstruction

What if the AUS fails?

The first step is to determine the reason. Recurrent leakage may be caused by:

Mechanical device failure
Loss of fluid from the system
Incomplete cuff closure
Urethral tissue thinning beneath the cuff
Cuff erosion
Device infection
A urethral or bladder-neck obstruction
Overactive bladder rather than sphincter failure
Incorrect device use

Assessment may include examination of the pump, urinalysis, cystoscopy, imaging, pad testing and sometimes repeat urodynamics.

Depending on the cause, options include:

Teaching or correcting pump technique
Treating overactive bladder separately
Revising or replacing a malfunctioning component
Replacing the entire AUS
Changing cuff size or position
Moving the cuff to a healthier section of urethra
Tandem-cuff or transcorporal techniques in carefully selected complex cases
Removing the device when infection or erosion is present
Allowing the urethra to heal before considering reimplantation
Considering a male sling in selected men with mild recurrent stress leakage
External collecting devices, continence clamps, absorbent products or long-term catheter options when further implant surgery is unsuitable

Men with prior radiotherapy, erosion or multiple urethral operations may require individualised reconstructive planning.

A final perspective

An artificial urinary sphincter can be life-changing for men with persistent stress urinary incontinence after prostatectomy. Its success depends on more than inserting a device: the correct cause of leakage must first be established.

Stress incontinence, overactive bladder, obstruction and poor bladder emptying can coexist. A careful history, objective assessment, cystoscopy and selective urodynamic testing allow treatment to be tailored to the individual patient.

Patients should understand that an AUS requires manual operation, lifelong precautions and possible future revision. With appropriate patient selection, careful surgery and ongoing follow-up, it remains one of the most effective treatments available for male post-prostatectomy stress incontinence.

So, if you suffer with post prostatectomy urinary incontinence, come see your Brisbane based functional urologist, Jo Schoeman to discuss this option.

References

American Urological Association, GURS and SUFU. Incontinence after Prostate Treatment: Clinical Guideline, amended 2024.
Breyer BN, Kim SK, Kirkby E, et al. Updates to Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline Amendment 2024. Journal of Urology. 2024.
European Association of Urology. EAU Guidelines on Non-neurogenic Male Lower Urinary Tract Symptoms—Disease Management.
European Association of Urology. EAU guidance: What happens when the artificial urinary sphincter fails?.
Johnson A, Abraham N, Chughtai B. Artificial urinary sphincters for moderate post-prostatectomy incontinence: current research and proposed approach. Journal of Clinical Medicine. 2023.
Desai TJ, Rozanski AT. Artificial urinary sphincter erosion and infection: a contemporary review of perioperative considerations and management. Translational Andrology and Urology. 2024.
Continence Foundation of Australia. Male urinary incontinence.

This information is intended for general education and does not replace individual medical assessment. Suitability for an AUS should be discussed with a urologist experienced in male continence and reconstructive surgery.