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Male Stress Urinary Incontinence

What is Male Stress Urinary Incontinence?

Men who leak urine when they are doing activities that increase intra-abdominal pressure (eg. laughing, sneezing, lifting heavy objects) are said to have stress urinary incontinence. The sphincter, which acts as a tap for the bladder, is usually damaged as a result of prostate surgery.

  • It happens more commonly in men who had their prostate removed because of cancer (up to 60% have mild leakage, and 2-3% have severe leakage).

  • It can happen in about 1% of men who had a transurethral resection of the prostate (TURP or prostate ‘reboring’ surgery) for benign enlargement of the prostate.

  • About 5% of patients undergoing radiotherapy treatment for prostate cancer may get mild to moderate incontinence.

What other problems can occur in these patients?

Bladder neck contracture

  • About 5 – 7% of men after radical prostatectomy may develop scarring of the anastomosis (where the bladder neck was joined to the urethra) called a bladder neck contracture. This can cause a weak flow and straining during urination. Often, this has to be surgically released endoscopically and the scarring has to stabilise before incontinence surgery can proceed. This is to prevent repeated passage of instruments in the urethra over where the compression device is, resulting in erosion of the device.

  • A bladder neck contracture can also mask stress incontinence and the leakage would become worse or apparent after the scarring is released.

Bladder dysfunction

  • Men after radical prostatectomy can also develop bladder dysfunction and can sometimes develop an overactive bladder or an underactive bladder. Hence, the urinary incontinence may not solely be due to stress leakage, and may have an urge leakage component, which has to be treated with medications as well.

Incontinence during sexual activity

  • Men can also get urinary incontinence during sexual activity and this can be very embarrassing and distressing for the couple. Helpful tips include watching your fluid intake and emptying your bladder before sex, and wearing a condom.

How is a diagnosis of stress incontinence made?

  • For patients contemplating incontinence surgery, a urodynamics study is recommended. This is to assess the severity of the leakage and help in deciding which surgery is more suitable. It can also assess for bladder dysfunction (see above).

  • Sometimes, a 24-hour pad weight test can be helpful to quantify the amount of leakage.

What are the treatment options?

Conservative

  • Pelvic floor exercises were first described by Dr Arnold Kegel in the 1940s and they aim to strengthen the pelvic floor muscles and improve bladder neck support. A trained physiotherapist can assist in this.  Often, men are instructed to start doing these exercises even before their prostate surgery.

  • Lifestyle: Watch fluid intake.

  • Absorbent products – pads, diapers.

  • External collection devices - condom catheters, penile clamps.

  • Internal collection devices - intermittent or long-term catheter.

Surgery

Continence can continue to improve up to one year after radical prostatectomy. Therefore, patients are often advised to wait till then before considering surgery. Men who have combined surgery and radiotherapy treatments, have an increased risk of complications from incontinence surgery.

Urethral bulking agents

  • Success rates are much lower than the other options.

  • Can be done under local anaesthesia or sedation.

  • This involves the injection of bulking agents into the urethra, creating wall-to-wall apposition and hence increasing the outlet resistance.

  • Examples of agents that can be used are collagen (now no longer manufactured), Macroplastique (silicon particles in a viscous gel) and Bulkamid (hydrogel with synthetic polymer).

  • Considered in patients who have high anaesthetic risks.

Cystoscopic view of urethra: after injection

Advance male sling

  • Relatively new concept and product.

  • Involves surgical placement of a synthetic mesh sling under the urethra, with the arms of the sling exiting through a small incision in each inner thigh.

  • Only suitable for mild to moderate stress incontinence (not for severe stress incontinence).

  • Advantages compared to the artificial urinary sphincter:

    • Shorter operation time and less invasive

    • Shorter hospital stay and faster recovery

    • No deactivation time post-op; patients see results immediately

    • No device activation required

    • Less risk of erosion

Artificial urinary sphincter (AMS 800)

  • The gold standard operation for severe stress incontinence.

  • High success rates with long-term durability.

  • Consists of 3 components which are interconnected:

    • A pump which is implanted in the scrotum

    • An inflatable cuff around the urethra

    • A balloon reservoir implanted in the lower abdomen

  • During urination, the pump is squeezed to move fluid out of the cuff that is compressing the urethra, and back into the reservoir.

  • After 2 -3 minutes of urination, the fluid automatically returns from the reservoir to the cuff, squeezing the urethra closed again.

  • Not suitable for those with:

    • Poor hand dexterity or mental capacity to know how to use the device

    • High anaesthetic risks

    • Known allergy to rifampicin, minocycline or other tetracyclines (antibiotics impregnated into the device)

    • Unresolved overactive bladder or poor bladder compliance (‘stiff’ bladder that does not stretch) – risk of building up pressure in the bladder by closing off the urethra and damaging the kidneys