Millions of American suffer from urinary incontinence (loss of bladder control). It has been estimated that up to 18 percent of men will experience loss of bladder control during their life and that $10 billion is spent in the United States every year on pads and other incontinence related products. Also, in previous surveys, only 1 of 10 people with an incontinence problem sought help for their problem. The most common reasons for not seeking help included thinking that loss of bladder control is a "normal" part of aging (not true), that nothing could be done about the problem (also not true), or the incontinent person was too embarrassed to seek help. With current methods of evaluation and treatment, almost all bladder control problems can be either eliminated or significantly improved.
Types of Urinary Incontinence
There are four basic types of urinary incontinence: The first type is called Stress Incontinence, which is the loss of urine with coughing, straining, lifting, or other strenuous activity. In men, the most common cause of Stress Incontinence is damage to the valve muscle after prostate surgery (especially after prostate cancer surgery).
The second type is called Urge Incontinence. This type of leakage occurs when the man feels the urge to urinate, but cannot get to the bathroom "in time". Urge Incontinence is usually caused by an "overactive" bladder. This over activity in men is usually caused by an enlarged prostate "blocking" the flow of urine. It is also known that after prostate surgery, about 25% of men will continue to experience urge incontinence due to an overactive bladder.
The third type of incontinence is called "Mixed Incontinence" which is the combination of stress and urge incontinence (the man experiences urine loss with coughing and straining and must also rush to get to the bathroom to avoid leakage). Mixed incontinence is commonly seen in men after cancer surgery on the prostate who had some damage to the valve muscle combined with an overactive bladder (probably related to a change in the nerves that control the bladder).
The fourth type of incontinence is called "Overflow Incontinence". In this situation, the bladder never empties and with frequent "dribbling" of urine as the urine overflows. The most common cause of overflow incontinence in men is long-standing blockage to the flow of urine from the prostate where the bladder muscle eventually becomes stretched out and unable to contract. Also, some men with diabetes may have damage to the nerves that control the bladder resulting in loss of the bladder's ability to contract and retention of urine. With overflow incontinence, it is important to empty the bladder on a regular basis (usually with a program of clean intermittent self-catheterization.
Defining the exact cause of each of these types of incontinence is critical in directing successful treatment. The cause of incontinence is determined by performing special tests (called "urodynamics") of the bladder and valve muscle. The urodynamics tests require special equipment and arc performed by urologists with special training in bladder control problems. The tests are not painful, require no special preparation, and are done in the office with the person fully awake. With these tests, the exact cause of the incontinence can be defined and further treatment options can be discussed.
Types of Treatment Available
Pelvic Floor training / Biofeedback Various types of medical, or non-surgical, treatments are available and may be useful depending on the results of tile urodynamic evaluation. For Stress Incontinence, these treatments include biofeedback. For "urge" or "mixed" incontinence, biofeedback, "bladder training", and medications called anticholinergics to "relax" the bladder be helpful.
Medications to Improve Control Medications to help "tighten" the valve muscle (called "alpha stimulators"), may be useful in men with mild Stress Incontinence. Medications to relax the bladder (called anticholinergics) may help relax the overactive bladder.
Surgical Treatments
When non-surgical treatments are not effective, various types of surgical procedures are available to help restore control For stress incontinence, the most common form of surgery is called an artificial urinary sphincter (AUS). This procedure involves insertion of an artificial valve which can be highly effective in certain situations depending on the results of the urodynamic studies.
Components and Function The AUS consists of three components: the cuff goes around the urethra, the pump which goes inside the scrotum, and the balloon which holds the fluid for the device. The balloon is available in different pressure ranges and is filled with a fluid which is very safe even if it leaks out of the device. The device works hydraulically with the cuff around the urethra staying closed at all times. When the person wants to urinate, the pump is squeezed and the cuff opens. Automatically, in 3-5 minutes, the cuff closes again. The refilling of the cuff is controlled by a resistor mechanism inside the pump.
Technique of Implantation in the Male The AUS insertion is performed in the hospital operating room with either a general or spinal anesthetic. Two small incisions are made: one in the groin area and the other between the scrotum and the rectum. The proper size cuff is placed around the urethra and the robing from the cuff is passed up to the groin area. The small pressure regulating balloon (which is about the size of a golf ball) is placed beneath the abdominal muscles and the pump which controls the device is tunneled down into the scrotum just beneath the skin. All connections between the 3 components are made in the groin area and the incisions are closed. At the conclusion of the operation, the cuff is "locked open" until pain and swelling in the scrotum resolves (usually 4-6 weeks).
Recovery Period Usually only an overnight hospital stay is required and there is minimal postoperative pain. Most men return to work 2-3 weeks after surgery. At about 4-6 weeks after surgery, the AUS is activated in the office to allow urinary control to be restored.
Results and Complications We have published a long-term study which demonstrated excellent long-term results with the AUS in men followed for a minimum of 3.5 years (mean follow-up of 7.2 years) after AUS insertion. Since 1987, there have been very few mechanical complications requiring surgical correction and the infection rote requiring removal of the device is close to 1 percent. Overall patient satisfaction is very high with a significant improvement in the quality of life after the AUS placement.
It is important to remember that if you or someone you care for has urinary incontinence that with appropriate evaluation and treatment by a knowledgeable physician, bladder control can almost always be restored.
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