Incontinence (involuntary loss of urine) may be a devastating problem, resulting in embarrassment, loss of intimacy, and even social isolation. We describe it to our patients as a “social cancer”.
Incontinence comes in several varieties but the most common are:
This is defined as leakage associated with activity. This type of incontinence, or involuntary loss of urine, in men usually occurs after prostate surgery for cancer but occasionally may occur after other events such as injury, transurethral resection of the prostate (TURP), or a prostatectomy for prostate cancer. Typically there has been injury to the urinary sphincter muscle, the valve that gives one the ability to control their urination. Leakage then occurs when the patient uses their abdominal muscles, for example sneezing, coughing, laughing, abending over, athletic activities, etc.
If a man is diagnosed with stress incontinence, various successful treatments are available.
Treatment options for stress incontinence
Men presenting for evaluation for stress incontinence are generally familiar with collection devices. These include collection pads and adult diapers (DependsTM). Other options for treatment in this general category include penile clamps and condom catheters. A penile clamp is a “C-clamp” that is clipped over the penis to compress the urethra shut and prevent leakage. A condom catheter is a condom that is inserted over the penis, and connects a bag to collect urine. These are not “treatment options” that focus on a cure, but most patients will say they are a form of “damage control.”
Pelvic floor physical therapy is a non-invassive method to improve continence. There are specialized physical therapist who can work with a patient to strength the sphincter muscle and improve continence. Most men are familiar with “kegel exercises” to improve continence, but more exercises exist to strengthen these natural muscles. A pelvic floor physical therapist can guide your through these exercises. Pelvic floor physical therapy is most beneficial for continence that occurs early after a prostatectomy, or for continence that is mild.
Surgical therapies exist for the treatment of male stress incontinence. These are split between two general categories, slings and an artificial urinary sphincter. Slings are most commonly used with mild degrees of incontinence (less than 1-2 pads per day). A sling is inserted through a small opening in the skin. It is composed of a piece of mesh that compresses or re-positions the urethra such that the body’s sphincter can act more effectively.
An artificial urinary sphincter is a mechanical device that is inserted through a small incision on the skin. It has three components: an inflatable cuff that compresses the urethra to prevent leakage, a pump to relax to cuff during voiding, and a fluid reservoir that contains saline which fills all components of the device. The device is location beneath the skin and is not recognizable in a public shower. The success rates are greater than 90%, and the satisfaction rates are high.
Also known as overactive bladder, this is when the man gets an irrepressible urgency to urinate and cannot get to a bathroom in time. Men can also get urgency without incontinence, which is the feeling of urinary urgency but the man is able to suppress it (sometimes barely!). These are very common problems, with a wide variety of causes. Common causes include: infection, medications, prostate growth, bladder over-activity or sensitivity of the bladder muscles, sensitivity to certain foods or substances, and neurologic injury or diseases. Occasionally, urgency or urge incontinence can be the sign of a more serious underlying condition such as bladder cancer.
Urgency and urge incontinence are NOT normal and need to be evaluated. Evaluation includes a patient’s history and examination, an analysis of the urine, and often additional testing such as cystoscopy (looking into the bladder with a very small camera, it is not a painful procedure) and/or urodynamics (an outpatient “EKG” test of the bladder muscles done in clinic).
Treatment options for urge incontinence
Treatment options are tailored to treat the exact dysfunction that is found on urodynamics. General options include behavoral therapy (minimizing fluid intake, avoiding caffeine, smoking cessation), medications to “relax an overactive bladder,” botox injections to relax the bladder muscle, and neuromodulation. Neuromodulation focusses on decreasing the “nerve inputs” to the bladder. Two options for neuromodulation include posterior tibial nerve stimulation, and interstim device placement (“bladder pacemaker”).
This is typically a constant leakage that occurs when a patient is unable to efficiently empty their bladder. Urine builds up and “spills” out, like a reservoir spilling over a dam. This can be due to obstruction (such as prostate or scarring in the urethra) and/or loss of bladder function or sensation. It can be dangerous and requires investigation to make sure no other problems are occurring. Treatments generally include catheters and/or surgery to relieve any blockage that is present.