What is male incontinence?
Incontinence refers to the leakage of urine from the bladder resulting in social or physical harm to the patient. It is more common in women due to the shorter urethra, physiologic changes with aging, and those due to childbirth. It may also occur in men and can be associated with aging, bladder dysfunction, neurological conditions, and injury. The most common condition in men resulting in unwanted leakage of urine is prostate surgery. The prostate surgery to remove the entire prostate for prostate cancer referred to as radical prostatectomy results in urinary incontinence in 5-15% of men. This can vary from one light pad per day in the underwear to near-total urinary leakage.
What are the treatment options for men with urinary incontinence?
Options of treatment for men with incontinence ranges from pelvic floor exercises to operative correction. For some men padded absorbable underwear is all that is required. This may be true for older men who leak because of an aging external sphincter mechanism.
- Pelvic floor exercises: These are often referred to as Kegel Exercises and involve a sequence of flexion and relaxation of the muscles which surround the urethra and anus. The proper muscle can be identified by stopping the urine mid-stream and recalling this maneuver in-between urination. A common program would be to hold this muscle closed for 2 seconds and repeat for 10 repetitions, several times per day.
- Medications: There are occasions where male leakage is caused or made worse by a sudden need to urinate which causes incontinence before one can reach the bathroom or drop his pants in time to direct the urine into the toilet. This is referred to as Urge Incontinence. Certain neurological conditions make this worse like those due to diabetes, stroke, and some spinal injuries. Medication directed toward relaxation of the bladder like oxybutynin, tolterodine and mirabegron are commonly used.
- Male sling: A mesh-like tape placed below the mid urethra in women has been a successful and low-risk procedure to help treat female stress incontinence (USI) for several decades. A similar technique for men was developed around 2005 and is now a good option for some types of incontinence. The best candidates are men with stress incontinence (associated with coughing, sneezing, or exercise) and a leakage volume of about 3 pads per day or less. This is an out-patient surgery done with the patient under general anesthesia. A 4 cm incision is made in the perineum (the flat part of the bottom beneath the scrotum) and the bulbar portion of the urethra is dissected free and mobilized. A curved instrument is placed through a small puncture in the inner thigh and directed through an opening in the pelvic bone and then adjacent to the urethra. A ribbon of sterile mesh is attached to the instrument and it is withdrawn bringing the mesh into position under the urethral bulb. Tension is applied to exert an appropriate amount of pressure to the urethra resulting in suspension and control of leaking. The incisions are closed with absorbable suture and a small catheter is left in the bladder overnight.
- Artificial Urinary Sphincter (AUS): This the best option for men who have urinary stress incontinence to a more severe degree, leaking over 3 pads per day. It may be done as the initial procedure but sometimes is done when any of the above methods fail. It is over 90% successful in alleviating the need for urinary pads. The position and anesthesia are similar to the sling as described above, however, the urethra is mobilized just beyond the bulb. No mesh is inserted and instead, an inflatable cuff is inserted around the urethra and then connected to a small pumping device just under the scrotal skin. These components are then connected by sterile tubing to a 30 ml saline reservoir placed below the rectus muscle above the pubic bone. The inflated reservoir transmits fluid to the cuff and inflates it, causing the urethra to close and stopping any leakage. To urinate the patient locates the pump under the scrotal skin and compresses it, forcing fluid from the cuff to the reservoir and opening the urethra to allow urination. After about 30 seconds the cuff gradually refills and prevents further leakage until pumped open again. This procedure is done under general anesthesia and takes about 90 minutes to perform, it requires overnight admission to the hospital. Antibiotics are used to prevent infection and a small urinary catheter is removed the morning after the procedure. The unit is deactivated for 6 weeks during the healing process, then activated in the Dr’s office.
- Other implantable devices: Manufacturing companies are working to engineer a device that can be placed near or underneath the sphincter area to help compress the urethra and treat male leaking. Clinical trials are ongoing and look for these to become an option as well.
- What are the success rates with the sling and the Artificial Urinary Sphincter (AUS)? When patients are appropriately selected (for instance no prior radiation treatment, no underlying neurological problems and leaking less than 4 pads per day) the sling is over 80 percent successful to eliminate or greatly reduce the number of pads used per day.
- What are the risks of the sling? Other than a small risk of bleeding or infection, as with all surgery, the risks are small. Most patients will experience a tingling or burning discomfort of the scrotum for 3-6 weeks after surgery. This is mild and temporary. The biggest risk is continued leakage – although 80 percent success, 20 percent of patients will still need to wear a pad in their underwear. Either immediately or with time.
- What are the risks of the AUS? About a 5 percent risk of infection or erosion and a 5 percent risk of malfunction. With time, some men experience urethral atrophy and leaking may return. A revision or replacement of the AUS is may be necessary after 10 – 15 years.
- How will I feel when I go home after the sling? You will have a small catheter in place to be removed the next morning. Many patients do this themselves. You will likely have good immediate control of your urination. As mentioned above some tingling or mild burning discomfort of the scrotum is common. You may have some bruising of the scrotal skin or thighs.
- How will I feel after the AUS? You will have the small catheter removed in the hospital before discharge. Leaking will then be present until activation 6 weeks later in the office. You will have some swelling and tenderness of the scrotum where the small pumping device is placed. The area may get black and blue for about 7 days. Small clips in the incision above the pubic bone are removed 7 days after the procedure and you will be taught to position the scrotal pump daily. After healing you will not really notice the pump except when using it to open the sphincter cuff.
- When should I be concerned or notify my doctor in the post-operative period? Fever more than about 100.5 degrees, bleeding around the incision or into the urine, Inability to urinate, shortness of breath, chest pain or pain in the calves of your legs.