Urinary Incontinence in Men
In a 1996 study, the number of Americans experiencing urinary incontinence was estimated to be 13 million. Of these, 85% were women, and 15% men. More current studies show that this number has increased. The increase is thought to be due to the increase in diagnosis and treatment of prostate cancer. As a symptom, rather than a specific disease, urinary incontinence is classified as a quality of life issue. In other words, one man's misery is another's inconvenience! It is important to remember, that incontinence is not a normal part of the aging process.
Classification
Stress Incontinence: Stress incontinence occurs when the pressure inside of the bladder is greater than that within the urethra. This occurs during periods of activity, which involve straining, such as heavy lifting or exercise, or with a change in position, coughing or laughing. The most common cause of stress incontinence in men, is surgery utilized to treat prostate cancer (radical prostatectomy). Other less common causes include surgery for benign prostatic disorders, pelvic trauma, or any other process resulting in damage to the urethral sphincter.
Urge Incontinence: When the overwhelming need to urinate results in the loss of urine prior to reaching the bathroom, the condition is known as urge incontinence. The causes are many, and include infection, BPH (benign prostatic hyperplasia), as well as disorders of the nervous system, including stroke, multiple sclerosis, spinal chord injury, and Parkinson's disease, just to name a few. Other common causes may include constipation, medications (diuretics), alcohol and caffeine use, as well as the condition often referred to as the "overactive bladder". Treatments for prostate cancer, including external beam radiation as well as brachytherapy may also contribute to this condition.
Overflow Incontinence: This condition is usually caused by the inability to empty the bladder, resulting in "water over the dam". The most common cause is prostatic obstruction secondary to benign or malignant processes. Less common causes include bladder outlet obstruction due to urethral strictures, as well as bladder dysfunction secondary to diabetes.
Total Incontinence: This type of incontinence is fortunately unusual, and is usually the result of severe sphincter damage due to surgery or pelvic injury.
Functional Incontinence: When another condition makes it impossible for an individual to make it to the bathroom on time, incontinence may result. An individual may be bed ridden, or have a severe problem with ambulation due to arthritis or other orthopedic condition. Likewise, if there are cognitive deficits, an individual may have problems in recognizing that they need to go the bathroom.
Diagnosis
The physician will make a diagnosis based primarily on the history, as related by the patient or the caregiver. A physical exam is also completed during which the bladder will be palpated, and the genitals examined. The prostate will also be examined by rectal exam. In most cases, a post void residual urine volume will be determined, by either ultrasound, or rarely catheterization.
Laboratory testing will include a urine analysis, as well as a culture. It may also include testing for bladder cancer.
At the end of the visit, the patient will often be asked to keep a voiding diary. In these cases, we will ask that you keep note of the time and type of fluids ingested, as well as the volume. You will be asked to record the time of each void, the volume, and whether or not there was any leakage, or urgency involved. Once this information is in hand, the decision will be made to go on to more sophisticated testing including pad weight test, cystoscopy, or urodynamics.
Treatment
Once the diagnosis as to the cause of the incontinence is known, treatment will be discussed. Options for treatment include the following:
Medication: Urge incontinence is the most common type of incontinence to be treated medically. Depending on the condition, medications known as antimuscarinics may be recommended. These drugs include commonly advertised mediations including Detrol LA™, Vesicare™, Enablex™, Ditropan XL™, Oxytrol™, and Sanctura™. Other drugs, including tricyclic antidepressants (imipramine) have also found a use in the treatment of urge incontinence. Research using novel agents such as Botulinum Toxin (Botox™) has resulted in the potential for this becoming a mainstream treatment for certain conditions causing urge incontinence. Attempts at developing medications to treat stress incontinence have been largely unsuccessful. Clearly, if a condition such as diabetes is thought to be the etiology of the incontinence, the treatment is specific to the condition.
Behavioral: In many instances, pelvic floor training can be used as a primary treatment, and most certainly as an adjunct to any of the other treatments for incontinence. Often a visit to a physical therapist will help to identify and to strengthen the weak areas in the pelvic floor. The therapist may utilize biofeedback, as well as electrical stimulation.
The use of Kegel exercises may also be recommended. The Kegel exercises can be done at any time and place, and involve exercising the muscles that make up the pelvic floor. These are the same muscles used to prevent one from passing gas as well as to stop the flow of urine. Various routines exist. Almost all recommend squeezing the muscle for 3 seconds, followed by 3 seconds of relaxation. If this is repeated 30 times, 3 or 4 times per day, one may see significant changes in the ability to prevent stress incontinence.
Timed voiding (every 2 or 3 hours) as well as wise fluid management will help tremendously with individuals who have functional incontinence.
Surgery: In cases when the incontinence is severe, or in instances when it is mild, yet other treatments have been unsuccessful, surgery may be recommended. In cases of overflow incontinence, when the diagnosis is obstruction by the prostate, the recommendation may be to have a portion of the prostate removed with the end result being a lower residual urine volume, better flow and less incontinence. Procedures including the transurethral resection of the prostate (TURP), and Green Light Photosensitive Vaporization of the Prostate™ can be very effective.
In cases where the incontinence is due to prostate cancer surgery, options include the placement of the AMS 800 Artificial Urethral Sphincter™, or the male sling procedures (AdVance™ and InVance™). These devices are manufactured by American Medical Systems (www.AmericanMedicalSystems.com)
The artificial urethral sphincter (AUS) remains the "gold standard" for the treatment of stress and total urinary incontinence due to prostate surgery of any type. It is a three-piece prosthetic device that includes a cuff that encircles the urethra, a pump that controls the device, and a pressure reservoir that is placed inside the pelvis.
The surgery usually requires a one-night stay in the hospital, and is done under general or regional anesthesia. The device is implanted in about 1 hour, but cannot be activated for 6 weeks. This waiting period allows for the urethra to "toughen up" under the cuff, as well as time for the tenderness in the scrotum to pass so that the individual can operate the pump without severe pain. Once activated, the sphincter is relaxed by squeezing the pump 3-4 times. The individual can then urinate completely. The sphincter closes automatically.
Complications can include infection, erosion, tissue atrophy and sphincter malfunction, all of which may require either a minor or major revision. Your physician can discuss these issues with you in detail if the need arises.
Sub urethral slings have been used in the treatment of stress incontinence in women, for years. They have only recently become popular for men. Most attempts at placing these slings have been unsuccessful. Recent advances by American Medical Systems have resulted in the development of the AdVance sling. This mesh sling is place through a small incision in the skin between the rectum and the scrotum. Much like its counterpart in women, the sling is held in place by the patient's own tissue and the serrations along the edges of the mesh. While the sling may not cure total incontinence, it will work in men utilizing a significant number of pads per day (7-8). Complications may include infection, or erosion. The procedure is done either as an outpatient, or an overnight stay in the hospital.
Interstim™ is an implantable neuromodulator that is manufactured by the Medtronic, Corporation. It is a unique approach to the treatment of urge incontinence that involves placement of electrodes in the 3rd sacral foramen, which in turn stimulate the nerves that supply the bladder. The end result may be a drop in the number of incontinent episodes of up to 50% or more. It is a reversible treatment, in that it can be implanted on a test basis, and removed if it is not successful. If successful, a battery powered intermittent pulse generator is implanted and may last between 6 and 10 years before needing a change.
Bulking agents including collagen were heralded with great expectation for the treatment of incontinence in men. In recent years they have fallen out of favor, as the results were poor and not very durable.
Our practice is able to provide almost every available treatment for the management of urinary incontinence in men. Speak to your physician about these treatments, as well as complications that may arise from their use.