Urinary Incontinence

Incontinence of urine can have a very profound affect on your daily life. It can cause you to become homebound and constrained. It can cause depression and be very embarrassing. Patients often do their best by adapting to their situation by restricting fluid intake, planning their day according to the availability of a nearby bathroom, and having to carry pads or diapers with them. Patients dealing with incontinence will also be dealing with a very high cost of diapers and appliances.

Urinary incontinence can be classified into two separate categories according to its cause. The first is known as the overactive bladder or OAB and the second is known as stress urinary incontinence.

 

 Types of Incontinence

  • Urge Incontinence – Leakage associated with an overwhelming need to urinate also known as overactive bladder or OAB (Gotta go, gotta go!)
  • Stress Incontinence – Leakage during physical activity that increases intra-abdominal pressure, i.e. lifting, exercising, sneezing, and coughing
  • Mixed Incontinence – Combination of the above
  • Orgasmuria – a subtle form of stress urinary incontinence is the leakage of urine that only occurs during sexual activity and orgasm

 

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.

 

Stress Incontinence 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

Orgasmuria is 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.

Overactive Bladder

OAB is defined by having several urinary symptoms including urgency with or without incontinence, frequency of urination during the day and at night (nocturia). This is condition is often referred by urologists as lower urinary tract symptoms abbreviated to LUTS.

Overactive Bladder is a common medical condition that affects up to 542 million Americans and Europeans. In the US 16.6% of the adult population suffers from OAB. Of those 6.1%or 12.2 million will have severe OAB, which we define as “Wet” involving accidental leakage of urine. OAB is not a natural part of aging and should be treated– you can do something about it. It is not a result of drinking too much fluid and neither does it exist because you have a weak bladder. The risk of having an OAB increases with age. At 60 or older approximately 5% of men are incontinent due to OAB. Certain medical conditions such as diabetes are linked to OAB and frequent urination at night (nocturia).

In a study published in the March 2008 issue of the journal Diabetes Care diabetes is positively associated with irritative lower urinary tract symptoms (LUTS) and nocturia but not benign prostatic hyperplasia (BPH).” The researchers found that diabetes was associated with irritative LUTS and nocturia “consistently across racial groups.” Furthermore, “The relationship between irritative LUTS and diabetes was greater in black men.”

If you often experience a strong uncontrollable urge to urinate with barely any time to make it to the bathroom, or if your sleep is disturbed 2 or more times a night with the need to rush to the bathroom, you may be suffering from OAB and you should contact a health care professional for treatment.

 

 How the Bladder works

  • Bladder collects urine
  • The sphincter – a circular muscle at the level of the prostate – controls the flow of urine
  • The sphincter muscle wraps around the urethra
  • A healthy sphincter stays closed until one relaxes it to urinate

In men, the urinary sphincter muscle is located below the prostate. This muscle surrounds the Urethra. When the sphincter muscle tightens, it holds urine in the bladder. When it relaxes, the bladder muscle also known as the detrusor contracts and the urethra opens, allowing urine to flow outside the body. Usually these contractions are under your own control but when the muscle in your bladder receives sudden messages to contract before you are ready to urinate, it’s called overactive bladder. As a man ages, the prostate size increases, narrowing the bladder opening. This chronic condition causes the bladder muscle to thicken inwardly, thus decreasing the inner volume of the bladder. In addition the detrusor becomes stiffer with decreased flexibility and compliance and increased resistance to stretching. Thus a man with an enlarged prostate will often urinate with a slower narrower, weaker stream, smaller volumes of urine and with more frequency. Stretching of the thickened detrusor muscle will provoke a sudden urge to urinate. This is also known as urgency.

 

 Symptoms

The overactive bladder has various symptoms.

  • Involuntary loss of urine.
  • Continuous leakage when the bladder is full.
  • Making 8 or more trips to the bathroom in a 24hour period.
  • Inability to stop leakage long enough to reach a toilet (urgency incontinence).
  • Leaking or wetting accidents (urinary incontinence).

 

 Causes

  • Enlargement of the prostate also known as benign prostate hypertrophy (BPH).
  • Aging of the bladder.
  • Combination of factors or in some patients often unknown.
  • Urinary Tract infections such as cystitis, prostate infections and certain medications may cause temporary OAB.
  • Diseases like Parkinson’s disease, stroke and diabetes could cause OAB.
  • DESD: Detrusor external sphincter dyssynergia may result in incontinence. It is mostly seen with patients with spinal cord injury and multiple sclerosis.

 

Diagnosing OAB

The diagnosis of OAB depends largely on patient self-described symptoms of frequency, nocturia, and urgency. Many patients avoid discussing the issue with their physicians and delay in seeking care. When taking a history, age, onset, description, nocturia, prior therapy, history of neurological disorders and patients’ expectations are the main topics to discuss with the doctor. In addition a simple physical exam of the abdomen and pelvic area is necessary to complete the initial evaluation. A voiding diary is very important and provides useful information. The volume of each void is key. The diary also allows for baseline and comparative assessment of a treatment. The night and first morning voids are most likely to demonstrate the bladder’s ability to store urine. Special questionnaires are also very useful to measure the severity and bother from OAB and these can also be used to evaluate efficacy and progress from a given treatment option.

What to expect at an office visit

  • History
    • Spinal or neurologic disease
    • History of BPH
  • Physical Exam
    • Neurologic exam
  • Urinalysis
  • Postvoid Residual
  • Urodynamics, Cystoscopy

 

What else can be needed for the diagnosis?

Imaging (x-rays) is rarely necessary. It is indicated if a kidney evaluation is needed, however a kidney ultrasound study may be just as good as an x-ray, without the getting radiation. The doctor may request a MRI of the spine if a neurological problem is suspected. A urodynamic test is indicated when the cause of the incontinenece is not entirely clear, to confirm or rule out a a diagnosis.

 

Urodynamics

 

What is Urodynamics?

This is a study of the Urinary Bladder. It involves a series of tests that measure the function and pressure in the bladder as well as the flow of urine through the urethra (passage through which urine is passed out of the body). It provides extremely important information on how much urine the bladder can hold, if there is a blockage, if the bladder is overactive, and bladder strength.

 

Who may need the Test?

Doctors may recommend Urodynamic testing for patients with Urinary Incontinence (leakage or loss of control of urine) or difficulty passing urine—frequency, urgency, incomplete bladder emptying, night time urinating, etc.

It also can also differentiate between the need for medical or surgical treatment.

 

The procedure and what to expect

Upon arrival you will be asked to empty your bladder into a commode that will measure how fast your urinating.

 

Next, while lying on a table, a small, flexible, lubricated catheter will be placed into the bladder through the urethra. Anesthetic jelly is used. Another small catheter will be placed in the rectum(anus). These 2 catheters will be connected to the computer.

 

Three small sticky pads will be placed to measure the activity of the valve below the bladder—to see if it is opening and closing appropriately.

 

Lastly, you will again be asked to sit on a commode and your bladder will be filled with sterile water while the computer monitors function. You may be asked to cough or strain down to see if urine escapes or leaks. This is part of the test. Once you are full or feel like you have to urinate, you will be asked to empty your bladder and then the test is complete.

 

The test takes 30-45 minutes. At the end of the test, the catheters will be removed and you will be given antibiotics for a few days.

Preparing for the Test

  • No need to fast and you can take your usual medications.
  • Please come with a full bladder and do not urinate upon arrival.
  • Try to empty your bowels before the test.
  • If you have a catheter, you do not have to come with a full bladder.
  • *** Please notify us if you take antibiotics before going to a dentist or if you have had Hip, Knee Replacements or Heart valve Replacements***

 

YOU WILL NEED ANTIBIOTICS PRIOR TO THE TEST!

 

After the test

You will be advised to drink plenty of water for 24 hrs to flush out the bladder. Infection is very rare. If you should experience any symptoms like fever or persistent pain when passing urine, please seek medical attention. You make experience a little discomfort or slight bleeding that should settle within 48 hrs.

Non-Surgical Treatment of Urinary Incontinence

Male Incontinence Severity Level Guidelines

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

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.

 

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
  • Male sling

 

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 (Success rates for collagen ~ 17% after prostatectomy)
  • Carbon beads
  • Autologous fat

Advantages:

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

Disadvantages:

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

 

Surgical Options for Male Stress Incontinence

Male Slings

Male sling is a device designed to support the muscles around the Urethra to its proper anatomical position for optimal sphincter function, restoring urinary control. It is highly effective, minimally invasive procedure to correct mild to moderate incontinence (one to two pads a day with normal daily activities).

  • 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
  • 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.

 

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 associated with orgasm.

 

InVance™ Male Sling

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

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

 

 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

 

 

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.

 

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 27 years experience with over 5000 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. Finally proximal placement of the artificial sphincter urethral cuff is compromised by using the same scrotal incision for the penile implant, which negatively affects the success of the sphincter: the patient will continue to leak urine.

 

Penile Implant and Artificial Urinary Sphincter in Patient After Prostate Cancer Surgery

Dr. Eid discusses a patient that has conquered prostate cancer and has now cured his ED and urinary incontinence with an inflatable penile prosthesis (IPP) and an artificial urinary sphincter (AUS).

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, proximal (close to the bladder) 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.