Post-prostatectomy male stress urinary incontinence (SUI) is a common and debilitating complication. This video showcases the application of the Bulkamid urethral bulking agent system to address male SUI, exhibiting an off-label use since its approval is exclusive to women. To our knowledge, this video marks the inaugural publication demonstrating the application of Bulkamid in males with SUI. The agent is injected using a semi-rigid 20-gauge needle guided by cystoscopy close to the native external urinary sphincter. Our video makes the case that the use of Bulkamid agents presents as a feasible and efficacious alternative for treating male SUI, particularly in patients who are unsuitable or unagreeable to traditional surgical interventions.

Surgical setup included bulkamid – 4 milliliters – a 5.5 mL hysteroscope, as well as a rigid needle with a 20-gauge tip.
A rigid needle was primed with bulkamid agent between half to 1 CC’s. 
While navigating the scope through the urethra initially proved difficult due to the penile prosthesis, the scope could then be advanced to the bulbar urethra, which demonstrated diffusely pale urethral tissue, consistent with previous radiation treatments. The patient also had a stable, mild bladder neck contracture.
Bulking agent injection:
The scope was then pulled to the external sphincter, and at the 8 o’clock position, 1 CC of bulk amid was injected. This procedure was repeated at the 4 o’clock position with an additional 1 CC of bulk amid.
The sphincter was observed with adequate urethral coaptation with these two injection sites. The scope was subsequently removed.

Post-op follow up showed reduced Stress Urinary Incontinence. Patient endorses using 4 - 5 ppd prior to surgery, is now using 1 - 2 ppd.
Patient denies difficulty voiding and remains with a low PVR.

Urethral bulking agents in men are feasible, it is an alternative procedure with relatively low risks, to be performed in highly selected patient population, Optimal bulking agent volume and technique to be refined, more studies to prove efficacy and safety.