Stress Urinary Incontinence in Men
Definition of Stress Urinary Incontinence
The International Continence Society (ICS) defines urinary incontinence as "the complaint of any involuntary loss of urine". Stress urinary incontinence is urine leakage, which is associated with increased abdominal pressure and insufficient urethral sphincter mechanism. The main symptom of stress urinary incontinence is the loss of urine on exertion, sneezing or coughing [Hampel 2007].
Epidemiology of Male Urinary Incontinence
In older male patients (over 60 years), the prevalence of urinary incontinence is 19% (compared to 37% in older women). Only a minority, however, suffers from pure stress incontinence. Urge incontinence or mixed forms are much more frequent.
Causes of Male Urinary Stress Incontinence
The incidence of urinary incontinence after radical prostatectomy is 0.5 to 87% in the literature. The high difference of the prevalence is due to different studies (by the surgeon or independent observer), different time intervals after surgery, and different definitions of urinary incontinence. In the long-term, about 10% of patients required more than one pad per day due to urinary incontinence after prostatectomy. Risk factors for postoperative incontinence are: advanced age, previous TURP and advanced tumor stage.
There are several reasons for postoperative incontinence. Direct damage to the external sphincter or its innervation is caused by deep sutures of the pelvic floor in the case of bleeding or by tumor infiltration. Protective factors for postoperative continence are bilateral nerve sparing, low tumor stage, young healthy patients and no previous prostate surgery (TURP).
Postoperative hypermobility of the membranous urethra has been identified as another factor for sphincter weakness after radical prostatectomy. This finding has led to the development of the suburethral slings [Gozzi, 2008] and modifications of the surgical technique were published [Rocco, 2009]. Occasionally, urge incontinence may develop after radical prostatectomy.
TURP and Prostatectomy for BPH:
Directly after removal of the prostatic adenoma (TURP or simple prostatectomy), the patient loses the prostatic component of the bladder closure mechanism. The urethral pressure profile resembles that of women. Postoperative detrusor overactivity is also a reason for urinary incontinence. An intact urinary sphincter may soon compensate above mentioned factors with the help of behavioral therapy (adjusting drinking habits and micturition), physiotherapy and anticholinergic medication [Hampel 2007].
Persisting urinary incontinence is rare after surgical treatment of BPH. Causes are de novo urge incontinence, stricture of the urethra or bladder neck, neurological disorders, iatrogenic sphincter injury or already preoperative existing sphincter deficiency. Iatrogenic sphincter injury is the cause for long term urinary incontinence of 0.5% of patients after TURP [Rassweiler 2006].
Pelvic fracture may lead to a distraction injury of the membranous urethra with stress urinary incontinence and erectile dysfunction.
Neurological diseases, weakening of the urinary sphincter with age.
Signs and Symptoms of Male Stress Urinary Incontinence
The severity of stress incontinence is classified by Stamey:
- Grade 1: loss of urine with sudden increases of abdominal pressure: e.g. coughing, sneezing or laughing.
- Grade 2: loss of urine with lesser degrees of stress: e.g. walking or standing up.
- Grade 3: loss of urine without any relation to physical activity or position, e.g. while lying in bed.
Other symptoms: urge symptoms (frequency, nocturia), residual urine or urinary retention, weak urinary stream and recurrent urinary tract infections.
Diagnostic Work-Up of Male Stress Urinary Incontinence
Quantification of urinary incontinence (classificaiton by Stamey, pad use). Ask for distress due to urinary incontinence, previous surgeries, medications (alpha blockers, clonidine), neurological and urological diseases.
Urine sediment and urine culture to rule out urinary tract infection.
Ultrasound imaging of the bladder:
Urodynamic study is the best diagnostic tool to differentiate between urge incontinence, stress urinary incontinence or mixed forms.
Cystoscopy is important for the assessment of the residual sphincter function. Furthermore cystoscopy identifies strictures of the urethra, bladder neck or the anastomosis after prostatectomy.
Conservative Treatment of Male Urinary Incontinence
Management of Urinary Incontinence:
Management of urinary incontinence with condom urinal or usage of absorbent pads. Some men may prefere the use of a suprapubic catheter.
Physiotherapy with pelvic floor exercises aims at strengthening the sphincter muscle. The pelvic floor exercises may be more efficient with biofeedback. After radical prostatectomy, improvement in urinary incontinence may be expected up to one year after surgery. Randomized trials showed a significant effect of physiotherapy to achieve early continence, for long-term results physiotherapy has only minor contribution [MacDonald 2007].
Anticholinergic medication is effective in mixed urinary incontinence and urge incontinence. Specific medication against stress urinary incontinence uses duloxetine, a serotonin and norepinephrine reuptake inhibitor. Duloxetine is not approved for usage in men, it may be offered as "off-label" treatment [Schlenker, 2006]. A therapeutic trial is only useful for mild stress incontinence, many contraindications have to be respected.
Surgical Treatment of Male Stress Urinary Incontinence
Useful long-term results exist only for the artificial sphincter, all other treatment options are less invasive but still have to proof to be reliable in the long term.
Bulking agent injections:
Different materials (bulking agents) can be used to support the weakened sphincter in its closing function. Injections produce a submucosal cushion and provide a limited efficiancy in mild urinary incontinence. Bulking agents like collagen have the disadvantage that it is absorbed and the effect wears off. Nonabsorbable materials may loose their effect by dislocation. Autologous myoblasts and fibroblasts obtained good results in initial studies [Mitterberger 2008] [Strasser, 2007], but the results could not be reproduced and the studies are challenged academically.
The ProACT device consists of two small implantable balloons which increase the pressure on the membranous urethra [Huebner 2007].
Non-adjustable male slings:
Bone anchored bulbourethral sling (InVance) [Guimaraes 2009], retrourethral sling without bone anchorage (Advance) [Gozzi 2008].
Male sling system (Advance) for the treatment of stress urinary incontinence after radical prostatectomy. With kind permission of American Medical Systems, www.americanmedicalsystems.com, Minnetonka, USA.
Adjustable sling systems:
Argus system [Romano, 2006], Reemex system.
Artificial urinary sphincter:
The artificial urinary sphincter is the treatment of choice, if there is a complete absence of sphincter function or after failure of above mentioned treatment options, see fig. artificial sphincter AMS 800.
The artificial sphincter AMS 800 has three components: pressure-regulating balloon, urethral cuff and pump control. With kind permission of American Medical Systems, www.americanmedicalsystems.com, Minnetonka, USA.
Good results can be expected in relation to urinary continence. The disadvantages are the relatively high risk for surgical revisions (up to 50% within 5 years). Mechanical failure, cuff erosion of the urethra and infection are the most common complications [Hussain 2005]. To operate the artificial sphincter, the patient should have a certain manual dexterity and intellectual insight [fig. control of the AMS 800 artifical urinary sphincter].
Control of the artificial urinary sphincter AMS 800: the pressure-regulating balloon provides constant filling of the urethral cuff. The activation of the control pump in the scrotum leads a short-term evacuation of the urethral cuff and allows micturition. The urethral cuff is filled again after 3–5 min by the pressure-regulating balloon. With kind permission of American Medical Systems, www.americanmedicalsystems.com, Minnetonka, USA.
It is important to deactivate the artificial urinary sphincter before performing transurethral manipulations, see fig. deactivation of artificial urinary sphincter.
Deactivation of artificial sphincter AMS 800 (left) after activating of the control pump. Activation of the artificial sphincter (right). With kind permission of American Medical Systems, www.americanmedicalsystems.com, Minnetonka, USA.
Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
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