Urinary Incontinence Treatment Options

Life, as you know it does not have to change because you have an overactive bladder. Various treatment options are available.

Overactive Bladder

Medications:

Certain medications have been known to decrease symptoms of an overactive bladder. These medications have to be prescribed by your doctor and work by enhancing the ability of the bladder to store urine. Examples of this type of medication are: Detrol LA, Ditropan XL, Vesicare, Enablex and Santura. Medications such as Hytrin, Flomax, Cardura, and Uroxatral relax the muscle of the bladder neck and prostate reducing resistance to flow of urine and the work that the bladder muscle needs to do for urination to occur. With time, and because the force needed to urinate is reduced, the detrusor bladder muscle becomes thinner and more elastic, thus increasing the bladder capacity to store urine.

Procedures:  

Any procedure that reduces urinary obstruction, generally caused by prostate enlargement, may also alleviate symptoms of OAB. These are described in the BPH section of this web site: Microwave (thermo) therapy, Green Light Laser and trans urethral resection of the prostate.

Stress Urinary Incontinence:

Stress urinary incontinence is caused by damaged or weakened urethral sphincter in the setting of a bladder that is able to store urine adequately. The sphincter is the muscle that controls the flow of urine. When damaged, the sphincter loses the ability to squeeze and close the urethra, resulting in leakage.

After Removal of Prostate: stress urinary incontinence occurs most often after prostate cancer surgery, but can also rarely occur after trans-urethral prostate surgery and radiation therapy for prostate cancer. In the process of removing the prostate cancer, parts of the muscle tissue that help control urine flow may be damaged. Differences in the length of the urethra located between the tip of the prostate and the sphincter muscle, also determines which patients are more likely to be incontinent after prostate cancer surgery. Patients with a longer segment of the urethra in this specific anatomical area will have a greater likely hood in being continent. Patients with a very short segment of this urethra are at risk of developing incontinence following the cancer operation. In some cases scar tissue forms at the point where the bladder was reconnected to the urethra, obstructing urine flow as well as preventing proper function of the sphincter muscle. After removal of the prostate, it is not unusual to have partial incontinence. For most this is a temporary condition, which in the majority of cases resolves within a year or so. If the incontinence continues beyond 18 months to 2 years, it is unlikely to improve on its own and a doctor should be consulted. A narrowing of the connection of the bladder with the urethra also known as a stricture may develop after prostate cancer surgery. Narrowing of urinary stream, urinary infections and inability to completely empty the bladder may subsequently occur. This can also lead to frequent urination and in some cases overflow incontinence.  

Orgasmuria, a subtle form of stress urinary incontinence is the leakage of urine that only occurs during sexual activity and orgasm. This is noted in up to 30% of men following prostate cancer surgery. This condition is very disturbing for many men and most will refrain from sexual activity because of this condition. However it can be easily fixed with a male sling.

Treatment options

• Absorbent products: Absorbent pads, diapers and garments can deal with incontinence.
• Medication: No FDA approved medication for stress incontinence in men. Antidepressants/Antihistamine effect on bladder
• Devices
• Behavioral modification
• Biofeedback
• Injectables
• Surgery

Devices

Clamps: Cunningham clamp, C3-clamp

Advantages

• Non-medical, non-surgical
• Easy to use
• Works well

Disadvantages

• Bulky
• Pressure necrosis
• Generally not a turn on

Catheters

Advantages

• Works

Disadvantages

• Attached to a bag
• Increased risk of infection

Behavioral modification

• Decrease fluid intake
• Void frequently
• Avoid caffeine, alcohol
• Avoid activity that increases intraabdominal pressure

Pelvic floor rehabilitation

a.k.a. biofeedback Means of teaching Kegel exercises Objective way to measuring pelvic floor strength

Bulking agents

Collagen, carbon beads, autologous fat

Success rates for collagen ~ 17% after prostatectomy

Advantages

• Relatively safe
• Office or outpatient
• Long term data available

Disadvantages

• Skin test: delayed hypersensitivity
• Expensive
  
• Low cure rate
• Repeat treatments

top of page

Surgical options for male stress incontinence

• InVance Male Sling
• AdVance Male Sling
• Artificial Urinary Sphincter (AUS)
  

Male Slings

Male sling is a device designed to support the muscles around the Urethra.  It is highly effective, minimally invasive procedure to correct mild to moderate incontinence (one to two pads a day with normal daily activities). The male sling from American Medical System (AMS) is a safe and effective surgical solution for mild to moderate incontinence. The sling is placed inside the body. It places pressure upon the urethra, reducing the possibility of urine leakage and providing urinary control. It works on its own and requires no manipulation from you.

It offers many benefits to men suffering from urinary incontinence. It is an outpatient procedure performed under spinal or general anesthesia. Recovery is very rapid allowing you to resume non-strenuous activities within a few days.

Finally, 20 to 30% of men following prostate cancer surgery seen in my practice have leakage of urine with orgasm. This can be a very frustrating symptom, which can interfere with a healthy sexual life. The male sling will alleviate and for some completely eliminate the urinary incontinence associate with orgasm.

InVance™ Male Sling

• Effective treatment for mild to moderate incontinence
• Minimally invasive, 45-minute outpatient procedure
• Continence is immediately restored
• Nothing to operate
• Device is completely hidden inside the body
• 88% satisfaction rate¹

1. Onur R, et al. Efficacy of a new bone-anchored perineal male sling in intrinsic sphincter deficiency. International Incontinence Society. Oct. 5-9, 2003. 33rd annual meeting, Florence, Italy. Abstract 399.

How does it work:

Sling creates gentle compression on the urethra for urinary control.

Procedure:

• Spinal or general anesthesia can be used
• Small incision under the scrotum
• Miniature titanium screws placed into the pubic bone on each side of the urethra
• Sling positioned to exert gentle pressure on urethra
• Sling secured to screws
• Incision closed
  

AdVance™ Male Sling

Sling restores urethra to its proper anatomical position for optimal sphincter function, restoring urinary control

Procedure:

• Spinal or general anesthesia can be used
• Three small incisions: 1 under the scrotum, 2 over groin creases
• Specially designed surgical tools are used to position the sling
• Sling is gently tightened
• Incision closed

Mechanism of Action

Artificial Urinary Sphincter (AUS)

The Artificial Urinary Sphincter is placed inside the body to provide urinary control. The sphincter is closed unless the control pump, which is located inside the scrotal sac, is squeezed. This opens the sphincter cuff temporarily for a few minutes allowing urination. The cuff then closes automatically. It has proved to be highly effective in treating male incontinence following prostate surgery. Most men are left dealing with only very minor leaks, usually resulting from exertion or strenuous exercise. You can stay dry by using a pad a day or less to manage these minor leaks. It is not 100% effective in all patients and they may require additional protection. Placement of a second urethral cuff will improve incontinence in most cases. 

The Artificial Urinary Sphincter 800, produced by American Medical System has been used successfully for almost 30 years. It is an outpatient procedure, performed under spinal anesthesia. The procedure lasts about 45-90 minutes. Shaped like a doughnut the device is implanted around the neck of your bladder. The fluid filled ring keeps your urinary sphincter shut tight until you are ready to urinate. To urinate you press a valve implanted under your skin that causes the ring to deflate and allows urine from your bladder to be released.

 As with any procedure, you may experience some temporary pain afterwards. This is considered normal and can be usually treated with oral medication. Recovery time varies from patient to patient. You can resume normal physical activity within a few days of the procedure or as directed by your doctor. The device can typically be used 6to 8 weeks after the procedure. Once the sphincter is activated you can control your own urination by squeezing the control pump whenever you need to empty the bladder. 

According to peer reviewed recent publications in the Journal of Urology (December 1996):

• 90% of patients reported satisfaction with their sphincter 800
• 92% would have the sphincter 800 placed again
• 96% would recommend the sphincter 800 to a friend

Complications include malfunction of the device, which means that the surgery will need to be repeated and infection, but infection is uncommon. In a clinical study of people with an urinary sphincter 800:

• Less than 5% experienced an infection
• Less than 4% experienced cuff erosion into the urethra
• Less than 5% experienced device failure

All these problems can be successfully treated when addressed in a timely manner. 

Artificial Urinary Sphincter (AUS)

The Gold Standard for treatment of moderate to severe incontinence 60 minute outpatient procedure 92% of patients would have the device placed again 96% of patients would recommend it to a friend Device is placed completely in the body, providing simple, discreet control

For men who suffer from incontinence and impotence following prostate cancer surgery:

Should one do both the Artificial Urinary Sphincter and the Penile Implant at the same time?

In my 18 years experience with over three thousand penile prosthesis and sphincters, I believe that it is not prudent, nor advantageous for the patient to have both done simultaneously. Performing both together will increase operating time. It is well established that the longer the surgery, the higher the risk of infection. Should an infection occur in one device, the other will most likely also get infected. In addition a much greater amount of edema and post-operative swelling will occur after the procedure when both implants are combined. This will delay the use of both implants and may compromise the placement of the penile sphincter control pump and impact overall outcome. 

What to do first a Penile Implant or the Artificial Urinary Sphincter and why? 

When considering both implants, the penile and artificial sphincter, the penile implant should always be performed first. The reason for this is that once the penile implant is inserted, placement of the urethral cuff or cuffs becomes much easier. Also the sphincter is a more delicate device and insertion of a urethral catheter (usually needed to perform the penile implant) should be avoided. Finally if the sphincter is done first, then it will need to be deactivated temporarily at the time of penile prosthesis placement in order to allow the penile implant pump to heal in the scrotum. The patient will be incontinent again during this process. The best option therefore is to do the penile implant first, wait three months and then perform the artificial urinary sphincter.    

A prosthesis specialist should be consulted to determine if you are the right candidate for these procedures. If you suffer from any of the symptoms of incontinence, you should consult with a Urologist who specializes in prosthetic surgeries to determine the best possible treatment option for you.