Treatment of Stress Urinary Incontinence (SUI)
Treatment of stress urinary incontinence (SUI):
Products that absorb urine
These include diapers and pads. Although they are very helpful, many men are dissatisfied with the smell and inconvenience.
Currently there are no approved medications for male SUI.
Many men discover that there are strategies they come up with on their own to minimize leakage. These include purposeful dehydration, keeping the bladder relatively empty by urinating frequently, and avoiding foods and other products that cause bladder stimulation. A short and incomplete list of these include:
- Caffeine (coffee, tea, soda pop, chocolate)
- Spicy foods (jalapeno and other peppers)
- Citric acid foods (grapefruit, etc)
- Tomato-based foods (pasta sauce, etc)
These include clamps [pic of Cunningham clamp] that “squeeze” the penis and avoid leakage and condom catheters [pic]. In the latter, the patient uses a device similar to a condom that goes over the penis and the patient urinates into it, then it drains to a bag. Although these devices are fairly easy to use and may be satisfying for some men, they have certain risks and most men find them very awkward to use.
These are catheters that go inside the bladder [pic of catheter]. They work very well but have a very high rate of infection and many men find them uncomfortable.
These are various materials (collagen, carbon beads, coaptite) that are injected into the urethra to push the tissue together and so cause some “obstruction” that may help the incontinence. Although they are generally safe, they rarely cure the problem and usually have to be repeated periodically to maintain continence.
Surgery for SUI mainly falls into two categories: slings and sphincter.
Slings are appropriate for men with mild-moderate incontinence (less than 3 pads per day).
Slings “boost” up the urethra, restoring support to the urethra that may be lost after prostatectomy. It is performed with an incision in the perineum (the area between the scrotum and anus) and two tiny incisions in the groin.
- Benefits: no moving parts, continence is restored immediately
- Risks/downsides: temporary urinary retention (requiring use of a catheter) is common, not as reliable as artificial urinary sphincter (AUS; see below) [link to section on AUS] for more severe incontinence, does not work as well in certain situations (after radiation, immobile urethra)
Artificial Urinary Spincter (AUS)
What is an AUS?
This is a device that has a cuff that goes around the urethra, a pump in the scrotum, and a balloon in the abdomen.
The cuff is “closed” most of the time, preventing leakage. When the patient “cycles” the device, using the pump in the scrotum, the cuff opens up and allows the patient to urinate. Over a minute or so, the cuff refills with fluid, thus causing continence again.
Does the AUS work well?
Yes, very well. Satisfaction rates for patients in most studies is well above 90%. Many patients describe it as “life-changing”.
Does my insurance pay for it?
Most insurances companies, including Medicare, cover the device and surgery.
What are the risks?
As with any surgical procedure, there are potential risks. The most significant is infection. Just like having a knee or hip prosthesis, having an AUS means there is a “foreign body” in place and an infection can be quite serious (just like with a hip or knee).
Implants are safe for getting an MRI if needed.
It is important to tell other health care providers that you have an AUS. For example if you are having a dental procedure you will likely need additional antibiotics. Also, if you ever need a urinary catheter, the cuff needs to be “deactivated” so the cuff is not injured. This is typically done by a Urologist or experienced physician.
What can I do to avoid infection?
Infection rates with modern implants are quite low, around 1%.
There are certain conditions that do increase the risk of infection:
- Spinal cord injury
- Diabetes (especially if the blood sugars are consistently high)
- Redo surgery or in the setting of extensive scarring
- Taking chronic steroids such as prednisone
One of the great advances of modern AUS is the use of coating that hold in antibiotics to prevent bacteria from getting on the device.
We use many techniques to minimize infection in patients, both before the operation and during the operation. It is critical that surgeons are very meticulous in technique and are aware of the many things that can be done to prevent infections.
How is the device put in?
The devices are typically put in either through a very small incision on the upper part of the scrotum, or with two incisions (one in the perineum (the area between the scrotum and anus) and one in the groin or abdomen).
Do I need to stay in the hospital?
The procedure may be done as an outpatient or with an overnight stay. If done as an outpatient, the patient needs to return to clinic the next day to have dressings etc removed.
Where is done?
The procedure is done in the operating room, either in the hospital or at a surgery center.
Do the devices ever fail?
These devices are mechanical and so eventually they will fail. With modern devices, they usually last 7-10 years and may last even more than 20 years. When they fail, an additional surgery is required to replace the device (very similar to the original surgery).
Over time, the urethra under the cuff will get thinner (“atrophy”) and so the cuff will not be able to close the urethra as well. If this happens, the device should be replaced in a different location.
Who should do the surgery?
As with other specialized surgeries, the patient should be careful about who they choose to perform it. With AUS, surgeons often do less than 5 per year and may not have specialty training in implant and penile surgery. As with most things, the patient should enquire about the experience of the surgeons performing these cases and only go to someone who is comfortable with all aspects of these cases.
What do I need to do to prepare for the procedure?
You will need to meet with the physician to make sure that you are a suitable candidate for this procedure.
Most patients require only a short workup, including cystoscopy (look inside bladder with a small camera) and urine flow studies. These can be done on the day of the consultation. For those with more complex issues, more studies may be required to make sure you are getting the right procedure for your problem.
We must make sure that laboratory studies, including urine culture, are normal. If there are abnormalities or something in your health history that may compromise your ability to receive anesthesia, you may need to visit your regular doctor or a specialist (cardiologist, anesthesiologist) to make sure your health is optimized so you get the best possible outcome.
You will need to shower with a special antibiotic soap for several days before the operation and we will provide this in clinic.
Figure 1 - AUS cuff placed into the perineum (space between the anus and the scrotum) around the urethra
Figure 2 - A view of the AUS via a scope in the urethra that shows the device squeezing the urethra shut.