Incontinence is the involuntary leaking of urine. It is a common condition that many men struggle with, but there is hope for successfully treating this disorder. If you are dealing with the frustration and embarrassment that incontinence can bring, contact a urologist at City of Hope.
Our highly skilled team of urologists uses leading-edge techniques to treat all types of male incontinence, which include:
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The physicians in our Division of Urology and Urologic Oncology are leading experts in treating patients with all types of urologic disorders and cancers. Just as no two patients are alike, male incontinence requires a unique treatment plan tailored to each individual to attain the best possible outcomes.
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Urinary incontinence is the loss of bladder control, resulting in the accidental leakage of urine from the body. For example, a man may feel a strong, sudden need, or urgency, to urinate just before losing a large amount of urine, called urgency incontinence.
In a normal male, the bladder neck and the prostate are closed at rest, as are the muscles of the external sphincter. When the prostate is removed, the bladder neck will no longer be closed at rest and since the prostate has been removed, only the external sphincter is left to control urine. In some men, this is not enough to hold urine back when coughing or sneezing.
When the bladder has a hard time emptying and more urine is made than it can hold, this is called overflow incontinence. Overflow incontinence is usually caused by a blockage or narrowing caused by scar tissue. It also may happen when the bladder muscle is not strong enough to get all the urine out.
Signs of overflow incontinence include
Urge incontinence is also known as an overactive bladder. This condition occurs when the bladder muscle contracts too often without warning and you cannot control it. This can be caused by a prostate infection or bladder irritation from radiation therapy.
With this type of incontinence, even a small amount of urine in the bladder can trigger a strong need to pass urine. Because you cannot hold a normal amount of urine, you have to go to the bathroom a lot and may wet yourself if you don’t get there right away. You may feel as if you have a weak bladder or that liquids go right through you. You may even wet the bed at night.
As a man ages, it is not uncommon for the prostate to increase in size, causing the bladder to work harder to eliminate urine. When the bladder has to work harder to empty it becomes more irritable, leading to frequent urination, getting up at night to urinate and having the sudden urge to urinate. In severe cases, the urge to urinate can be so drastic that it actually causes a man to leak urine on the way to the bathroom.
In other cases, the nerves that supply the bladder are damaged. When the bladder loses these nerves, it exhibits a similar pattern of irritability that gets worse overtime. In these cases, the symptoms tend to be worse than in those with an enlarged prostate. The bladder can become thickened and it may not be able to hold as much urine. The process of urinating may not be coordinated, so as the bladder squeezes to empty, the sphincter also squeezes.
Diagnosing stress urinary incontinence involves several steps. In order to determine the best option for treatment, it is important to know the severity of the incontinence. Methods to determine the severity include:
Pad Weights: In order to give an exact measure of the degree of leakage, we may ask patients to save all pads used for 24 hours in a zip-lock bag. These pads are then measured and compared to the weight of a dry pad. The weight difference shows the exact volume of leakage. This is an important step in determining the best treatment choice.
Cystoscopy: Cystoscopy involves placing a camera into the urethra in order to ensure there are no urethral strictures. If there are strictures, they must be treated before an incontinence procedure can be performed.
Bladder capacity measurement: At the time of the cystoscopy, patients fill their bladder as full as possible, then urinate into a container to measure how much urine the bladder can hold. Any residual urine in the bladder is also measured. This is key, as a patient with a larger bladder has better outcomes with a sling versus a urinary sphincter.
Diagnosing urge urinary incontinence is slightly different than stress urinary incontinence and focuses on finding the source of the bladder’s overactivity.
Urodynamics: This is essentially a stress test for the bladder. For this procedure, a catheter is placed in the urethra, another in the rectum and electrodes are attached to the pelvis. The bladder is then filled with warm saline and tested to see how well the bladder fills. Then, with the catheters in place, patients urinate and the strength of the stream and bladder are measured. The test can show us if the bladder is able to store urine normally, if it is working too hard to empty or if it is just oversensitive.
Cystoscopy: This test involves placing a camera into the urethra in order to ensure there are no urethral strictures. If there are strictures, we will need to treat them before an incontinence procedure can be performed. This is particularly important if you have had a previous procedure done for your prostate.
Flow and postvoid residual (PVR) measurement: These are noninvasive tests that may be performed instead of an urodynamic evaluation. Patients come in with a full bladder and then urinate into a funnel to empty the bladder and measure the strength of the urine stream. Doctors then measure the remaining urine in the bladder. This test is helpful in determining how well you urinate and lets us know if we can start medications safely.
Male sling: The goal of the male sling is to help pull the urethra into the body in order to enhance the function of the external sphincter. It is important to have a functioning sphincter before having a sling placed. There are currently two male slings on the market, the first is made by AMS and is called the Advance Sling. This sling wraps around the inferior pubic rami at the level of the bulbar urethra.
The second is made by Coloplast and is called the Virtue Sling. The virtue also has arms that wrap around the inferior pubic rami, but it also features prepubic arms. The goal of the secondary arms is to add compression to the urethra.
Results of these two slings is similar, however, there have been no comparative trials.
Artificial urinary sphincter: The artificial urinary sphincter has been around since the 1970s, so there have been multiple modifications to this device. However, the function has always been the same; to mimic the actions of the natural sphincter.
To implement the artificial urinary sphincter, incisions are placed in the perineum (the area between the anus and the scrotum) and low abdomen. Then, a cuff full of fluid is placed around the urethra to obstruct it. Next, a small balloon that holds fluid is placed in the abdomen. Finally, a pump sits in the scrotum that controls where the fluid goes. When a man needs to urinate, the pump in the scrotum is pressed, the fluid in the cuff moves from the cuff to the balloon, the urethra is opened and the urine is able to pass.
Prostate removal: In a normal male, the bladder neck and the prostate are closed at rest, as are the muscles of the external sphincter. When the prostate is removed, the bladder neck will no longer be closed at rest and with the prostate gone, the external sphincter is left to control urine. In some men, this is not enough to hold the urine back when coughing or sneezing.
Transurethral resection of the prostate (TURP): After a procedure for enlarged prostate, there can be several causes to stress incontinence. First, if there is damage to the sphincter muscle, then there can be stress urinary incontinence. Generally, this incontinence will not get better over time.
A second reason that incontinence may occur after a TURP is because the bladder is not used to having such a small amount of resistance and the sphincter muscle is not strong enough to control the urine. In this case, most patients improve over time. Reasons that people may not get better include older age and a long history of bladder issues prior to surgery.
Once the cause of the leakage is determined, doctors can directly target the best treatment option. Treatment options include:
Medications: Anticholinegics are a class of medications that target the bladder receptors responsible for contraction. A new class of medication called mirabegron targets and activates the receptors in the bladder responsible for relaxation. These are the best oral medications for an overactive bladder.
Botox injection: In patients who fail oral medication, a different option is Botox injection. Botox prevents the muscles of the bladder from contracting. The improvements from this treatment are not permanent and often require repeat injections.
Neurmodulation: Interstim is a device implanted into the low back that sends pulses of electricity along the nerves that supply the bladder. This device is effective in some patients who have failed oral therapy. When this treatment is successful, the results last for quite some time.
In addition there is a form of neuromodulation called tibial nerve stimulation. Here, rather than a continuous pulse to the nerves of the bladder, we target a nerve that is all the way down in the leg near the ankle. Patients opting for this treatment come in periodically and often require maintenance treatments to maintain success.
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