Urinary incontinence is certainly not a life-threatening situation. However, it certainly effects lifestyle in a dramatic manner. For many it means wearing damp undergarments, diapers, having skin irritation or diaper rash.
Even though the cause of the urinary leakage may be multi-fold, and in and of itself not a life-threatening disorder, the effects of this disorder can be most severe on the individual's lifestyle. It may limit his or her physical activity, social relationships, sexual attitudes, ability to do spontaneous activities without careful planning, and in severe circumstances may lead to a lonesome, hermit-like existence.
Modern medicine has been able to help many of these patients through drug therapy, exercise programs, and biofeedback techniques. There is, however, a significant group of patients in whom, no matter how much knowledge medical science may have, surgical reconstruction and noninvasive techniques will still lead to leakage of urine to such a severe degree that something must be done.
In 1973, American Medical Systems, Minnetonka, MN, developed an effective artificial sphincter that initially went around the neck of the bladder in both men and women, but later was found to be better positioned around the portion of the urethra in men beneath the lower end of the prostate and that part of the urethra that feeds into the penis (the proximal bulbar).
Many modifications have been developed, but, in general, the device as we see it today is effective, has few mechanical problems, is easy to implant by an experienced, knowledgeable surgeon, and can better the life of an individual who has no control of urine.
In my 25 years of experience it has always amazed me how so few men and women have taken advantage of this technology. There are many men who have had radical surgery for prostate cancer who are urine incontinent wearing diapers, who have tried multiple drugs and devices with no success. There are men who have had transurethral resections of the prostate for benign disease, and in that small group who have had the severest complication of urinary incontinence many therapies and procedures have failed.
In addition, women can have similar urinary incontinence problems that no form of medical, minimally invasive, or surgical procedures other than the implantation of an artificial incontinence device will be helpful. Some of these women have had multiple operations for stress incontinence-- leaking urine when they laugh, sneeze, cough, run or jump, and they now basically have a pipe-like urethra that has no contractile abilities and is a direct exit to the outside world from their bladder. These are the type of people, and there are others as well, who would benefit from surgical implantation of an artificial sphincter. Before this device is implanted the patient must obviously have severe symptoms and have failed all other pharmacological, biofeedback, and other surgical approaches. Their bladder must be large enough so that it can hold enough urine in-between voiding. You would not want to put a sphincter in somebody who had to run to the bathroom every 15 minutes. The bladder has to be neurologically intact, not contracting on a regular basis and causing urgency and a need for frequent urination. The bladder must be infection free and prior to the implant the patient must be able to empty the bladder completely. If these criteria are met then the patients are candidates for the implantation of the artificial sphincter.
In women the procedure is done around the neck of the bladder usually from a lower abdominal approach, but not entering the peritoneal or abdominal cavity. In men, in most cases, the procedure is done through a very simple 3 to 4 inch incision between the scrotum and rectum. After entering the deep structure of the perineum the urethra is found and is freed (circumscribed) for approximately 1 � to 2 inches.
A donut-like cuff is then placed around the urethra at its proximal bulbar portion. This is attached to a pump mechanism place in males in the scrotal compartment next to the testicle, and in the females in the labia majora. In addition, the pump is attached to a small cylinder holding 25 cc (about 2 � tablespoons) of salt water that is placed through the same incision retroperitoneal (behind) and above the pubic bone, but not in the abdominal cavity. This reservoir pushes fluid into the donut cuff around the urethra or bladder neck (female) compressing these structures and acting as an artificial sphincter or valve.
As the bladder fills and the patient develops an urge to void compression two or three times of the pump mechanism in the labia and/or scrotum pushes the 1.5 to 2 cc fluid that is compressing the urethra in the donut cuff back into the reservoir such that the patient has 2 � to 3 minutes to void and empty his or her bladder. As soon as voiding is complete the reservoir by virtue of its pressure and elasticity pushes fluid, 1.5 to 2 cc, into the donut cuff compressing the urethra or bladder neck and again giving urinary control until the next voiding sensation.
This procedure can be done my most qualified, experienced urological surgeons in less than one hour and requires at most a 24 hour hospital stay. Many can be done as an in and out admission. It is extremely important the reservoir be placed in the abdominal retroperitoneal area and not in the subcutaneous (under the skin).
This is done so that if a patient coughs, sneezes, jumps, runs or increases his or her abdominal pressure the increased pressure which would normally cause the bladder to push urine out is equally exerted on the reservoir which will increase equivalently the pressure in the donut cuff allowing for enough resistance to offset the temporary increased pressure. The device after surgery is made nonfunctional by pressing a small valve or button on the top of the pump in the scrotum or labia.
This is done to allow the urethra or the bladder neck to heal, improve its blood supply, and be capable of tolerating the increased pressures that will occur when the device is activated and the cuff is continuously filled with saline and exerting pressure on the urethra or bladder neck. Many surgeons are advising their patients to deactivate the device each night since most incontinent men or women are non-incontinent in the reclining sleeping position. In the morning the device can be activated and functioning during the daily activities.
My opinion is that the device after surgery should be deactivated for six to eight weeks to allow this healing process to occur, and the patient should be cystoscoped to be sure at six to eight weeks that the urethra is well healed, there are no tears in the urethra, and the donut cuff is not visible inside the urethra. In those circumstances then can the device be activated and function as designed.
The surgery is done by a urologic surgeon, the postoperative course is relatively benign, and even the complications are few if the above recommendations are followed. There is always a small chance of infection and erosion, and yes, not matter how good a mechanical device may be, some time in the future there may be a mechanical problem as well. On the other hand, mechanical problems could take more than a decade to occur, are frequently easy to correct, and give an individual with a relatively hopeless incontinence situation another decade or more of dryness, health, activity, and comfort, and the ability to fulfill one's lifestyle.
Additional resources on incontinence are available from MayoClinic.com:
http://www.mayoclinic.com/health/urinary-incontinence/DS00404
