Urinary Incontinence in Men
Inability to hold onto urine is known as urinary incontinence. It can be debilitating and badly affect enjoyment of life. If severe, it can cause frustration, embarrassment and fear of leaking and odour, which can cause some men to become housebound. There are many things that can be done to help, and it is important that you seek medical advice if affected, as there is very rarely a situation that can’t be improved.
Different types of incontinence
There are difference types of urine incontinence, and these are managed and treated differently.
Stress urinary incontinence (SUI)
Stress urinary incontinence occurs when urine leaks during straining or physical activity, such as coughing, sneezing, lifting or exercising. This is a common cause of incontinence following prostate cancer surgery. This type of incontinence is due to partial damage to the external urinary sphincter (see diagram). It varies in severity from mild to total urinary incontinence.
Total urine incontinence
This is a form of incontinence where all the urine produced drains out, with no control at all. It is considered a severe form of stress incontinence, where the external urinary sphincter is not working at all.
Urgency Incontinence (UI)
Urgency incontinence occurs associated with a feeling of urgency (a powerful feeling that you must urinate straight away). A patient will typically leak urine if they don’t quite make it to the toilet in time. This type of incontinence is normally caused by an underlying bladder problem (which itself may be due to other causes such as long term prostate obstruction or neurological problems).
This typically presents as an ongoing urine dribble. It is due to poor emptying of the bladder that has been present for some time.
Nocturnal (night time) incontinence
This is a quite rare form of incontinence in adults and always needs investigation.
Causes of urinary incontinence
Some of the causes for urine incontinence in men are listed below:
- Radical prostatectomy for prostate cancer
- Radiotherapy for prostate cancer
- Other forms of prostate surgery for benign prostate problems
- Severe benign prostate conditions
- Severe diabetic problems
- Previous stroke
- Parkinson’s disease
- Multiple sclerosis
- Pelvic trauma
- Unknown cause (sometimes urgency incontinence occurs with no obvious cause)
How is urinary incontinence assessed?
Your urologist is trained and experienced in assessing urine incontinence.
The aim of the assessment and investigations is to work out:
- the type of incontinence you have
- how severe this is, and how badly it is affecting you.
- which treatment options are likely to help you the most.
You will often be asked to complete an evaluation before you come. This may include a bladder diary (see below) and a questionnaire.
We will then talk with you about your medical history, the specific problems you have, and how these affect you. Sometimes it is very obvious what has caused your problems, but further investigations may be required to help with diagnosis and planning of treatment.
Other tests that may need to be done after your consultation
Digital rectal examination
The prostate is examined to get an idea of its size, and to check for any other problems.
Urine flow rate
You will be asked to come to the appointment with a full bladder, and to urinate into a flow machine. This is just like a bucket, and measures the flow of your urine. It is just like urinating into a urinal.
Ultrasound scan of your bladder
After you have done the flow rate, your bladder will be scanned with an ultrasound (completely painless) to see if there is any urine remaining in the bladder after you have voided.
Ultrasound of the prostate
Occasionally, it is helpful to know the precise size of the prostate. This can be done by performing an ultrasound scan of the prostate. This is mildly uncomfortable, but is not painful. A small probe (about the size of two fingers) is inserted into the rectum to perform the scan.
Blood tests for glucose and kidney function
These tests can help to check that the kidneys are working well, and that blood glucose is not too high (sometimes a cause of waterworks symptoms)
PSA (prostate specific antigen) blood test
This test is helpful in predicting if your symptoms are likely to progress in the future. We know that a PSA above 1.4 predicts a higher chance of worsening symptoms in the future.
By sending a sample of urine to the laboratory, your urologist is able to check for the presence of infection or blood in the urine
This is only performed occasionally. Flexible cystoscopy is a short procedure, usually performed under local anaesthetic, which allows visual inspection of the urethra and bladder. It is sometimes helpful in working out the cause of waterworks symptoms if this is not otherwise clear. It is mildly uncomfortable, but should not be painful. A local anaesthetic jelly (there is no needle) is used to numb and lubricate the urethra and the telescope is inserted, along with some fluid into the bladder to fill it. The inspection only takes a few minutes.
Pad weight tests
This is a useful method of working out how much urine you lose in a 24-hour period. You will be asked to wear incontinence pads and weight them before you put them on and then again when you remove them. The weight if the pads can be converted to urine volume.
This is a test to assess bladder function and urine outflow. It helps in making a diagnosis about the cause of your incontinence problems if this is not entirely clear, and can help guide treatment decisions. The test takes about 30 minutes and is done as a day case. It is not painful.
Soft, thin plastic tubes are inserted into your waterpipe (urethra) to record pressure readings during the test. The bladder is filled with fluid, and then you will be asked to urinate. At the end of the test the catheters will be removed.
The next step – treating your problem:
This is reasonably straightforward and can help in a number of people. It involves careful consideration of fluid volume intake, and timing of intake and voiding. It doesn’t produce a cure, but can help reduce the severity of your symptoms. This approach will be disussed with you in detail if it applies to your condition.
Bladder retraining (for urgency incontinence)
This approach works well for some people with incontinence due to an overactive bladder (urgency incontinence). For this to be most successful, a program of retraining needs to be undertaken under the supervision of a specialist physiotherapist. If this approach is likely to help your situation, Nick will discuss this with you in detail and refer you to a physio.
Pelvic floor physiotherapy (mainly for stress urinary incontinence)
This kind of treatment works best for stress urinary incontinence, and is integral to recovery of urinary continence after prostate surgery. Again, it needs careful supervision from an expert pelvic floor physiotherapist experienced in these issues. If you are likely to need prostate cancer surgery, it is likely that your urologist will refer you to a physiotherapist before surgery, and afterwards.
Medication (for urgency incontinence)
If the methods above have not helped with urgency incontinence, tablet treatment can be tried. These tablets help to settle the bladder and reduce its activity if it is overactive. There are many different tablets on the market, which are as generally effective as each other, but have different side effect profiles. Some people find these very helpful, but quite a large number of patients will stop taking them Trade names include Vesicare (solifenacin), Enablex (darifenacin) Detrusitol (tolterodine), and generic oxybutynin. Oxybutinin is also available as a patch that is applied to the skin.
Surgical Sling (for stress urinary incontinence)
Troublesome stress incontinence occurs rarely after surgery on the prostate or urethra, but when it does, it may need surgical treatment if other measures (such as pelvic floor physiotherapy) have not worked. Examples of operations that can cause incontinence are radical prostatectomy or other prostate procedures such as TURP/Holmium laser surgery etc. Radiotherapy to the pelvis (for example, for prostate cancer) can also cause urine incontinence. Slings are suitable for mild and moderate degrees of stress incontinence that have not responded to conservative treatment. Slings generally produce a significant improvement in symptoms in about 80% of men.
There are two different forms of sling, and Nick Brook will discuss these with you in detail, including which is most suitable for your urine incontinence.
Artificial urinary sphincter (AUS)
The artificial urinary sphincter is a surgical device that controls urine in men who are otherwise incontinent of urine. It is used in severe incontinence that has not respond to other treatments, or in those who are not suitable for insertion of a sling to control continence. An example of its use is in men with severe incontinence after radical prostatectomy or TURP, or after radiotherapy for prostate cancer.
For more information on the artificial urinary sphincter (AUS), including detailed information about the indications and animation video of the procedure, please follow this link:
Artificial urinary sphincter (AUS) in men
Absorbent products – pads
There are many different continence products available. These aim to manage rather than treat your condition, but can be very helpful in helping you to cope with incontinence. A list of some vendors in South Australia is given below. This is not an exhaustive list and is provided as a guide only.
Occasionally, catheters may be the best option for managing incontinence. An example is an older man with overflow incontinence and many medical problems that would make surgery unsafe. There are problems with long-term catheters, such as infection, but these can be managed with appropriate measures.
External collection devices
Again, these devices tend to be used when other options are not possible. The collection device takes the form of a sheath placed on the penis, connected to a drainage bag. With careful attention, these devices can help greatly.
Nerve stimulation (for urgency incontinence)
Nerve stimulation is used in the setting of incontinence caused by an overactive bladder (urgency with urgency incontinence). There are two options. The first is non-surgical and involves repeated visits to clinic to have a small needle placed near the tibial nerve in the ankle. This is called Percutaneous Tibial Nerve Stimulation (PTNS). A device is used to stimulate this nerve with a small current for a period of time. The needle is removed and then you go home, to have the procedure repeated over a number of weeks.
The second involves a two-stage surgical operation to implant a device in the lower back, which stimulates the nerves that run to the bladder. This device provides on-going nerve stimulation and is called Sacral Nerve Stimulation, or Sacral Neuromodulation.
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