Artificial Urinary Sphincter (AUS)
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An artificial urinary sphincter is used for more severe male urinary incontinence as defined by Dr. Engel as pad usage of three or more soaked pads per day. As with the AdVance Male Sling, its most common application is in the setting of post-prostatectomy incontinence. With proper patient selection, one should likewise expect success rates well above 90% in non-radiated patients, somewhat less in those having received radiotherapy. In cases of extreme incontinence, the definition of success may be reduction of pad usage to perhaps one or maybe two non-soaked pads per day, but the goal is always to eliminate the need for incontinence pads or diapers completely.
The artificial urinary sphincter (AUS) has been used for well over twenty years, but modifications that have significantly decreased mechanical failure and infection rates over the years, have been made. This is a permanent device, with only the rare need to revise the system due to mechanical dysfunction. The most common reason to have to perform corrective surgery would be urethral atrophy, a condition that can occur over time. In such cases, a patient may have a perfect result only to leak to some degree a year or two later. Here, only the cuff around the urethra is changed to a smaller size – a relatively simply procedure.
The AUS is a system consisting of three pieces: a cuff similar to a blood pressure cuff filled with water that is wrapped around the urethra, a small pump placed into the scrotum that the patient squeezes once or twice when he wants to urinate, and a water balloon or reservoir placed inconspicuously behind the pubic bone. This reservoir is what pressures the system. How the system works is the the cuff stays inflated until water is pumped out of it back to the reservoir. This gives the patient approximately one minute to urinate, after which time the cuff automatically re inflates. Urinating in this way simply becomes part of their routine and is almost never complained about.
Placement of Artificial Sphincter
A: Bulbar urethra exposed. B: Space created behind urethra. C: Sphincter cuff in place.
D: Pump placement in scrotum.
Artificial Sphincter Functioning
The video below immediately starts with a squeeze of the pump placed in the scrotum. This opens the sphincter and gives the patient over one minute to urinate. The video then demonstrates the gradual automatic closing of the sphincter to complete continence.
Patients must be aware of the possible complications of an artificial urinary sphincter, but generally the two most feared are infection of any part of the system or erosion of the urethra. In both cases, the system will need to be removed to allow for healing, and both complications are somewhat more common in radiated patients. The procedure itself is performed in a hospital – George Washington in Dr. Engel’s case. The patient will stay overnight and go home the next day, and in all cases the patient will begin antibiotics well before the procedure to limit infection risk. Patients will be asked to shower twice a day for several days before the procedure. The patient will go home with the sphincter deactivated to allow for healing, and will come to Dr. Engel’s office in six weeks to have the sphincter activated. It is at that time that the patient will likely be dry. It is this moment that is one of the most gratifying moments in practice for Dr. Engel as in some cases patients will have suffered from severe urinary incontinence for several years before seeking help.