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Urology & Nephrology Surgeries


Male Urinary Incontinence

Urinary incontinence (UI) is the accidental leakage of urine. The prevalence of UI in males increases with age, but UI is not an inevitable part of aging.

UI is a treatable problem. To find a treatment that addresses the root of the problem, you need to talk with your health care provider. The three forms of UI are

  • stress incontinence, which is the involuntary loss of urine during actions—such as coughing, sneezing, and lifting—that put abdominal pressure on the bladder
  • urge incontinence, which is the involuntary loss of urine following an overwhelming urge to urinate that cannot be halted
  • overflow incontinence, which is the constant dribbling of urine usually associated with urinating frequently and in small amounts

What causes UI in men?

For the urinary system to do its job, muscles and nerves must work together to hold urine in the bladder and then release it at the right time.

Nerves carry signals from the brain to the bladder and sphincter. Any disease, condition, or injury that damages nerves can lead to urination problems.

Nerve Problems

Any disease, condition, or injury that damages nerves can lead to urination problems. Nerve problems can occur at any age.

  • Men who have had diabetes for many years may develop nerve damage that affects their bladder control.
  • Stroke, Parkinson's disease, and multiple sclerosis all affect the brain and nervous system, so they can also cause bladder emptying problems.
  • Overactive bladder is a condition in which the bladder squeezes at the wrong time. The condition may be caused by nerve problems, or it may occur without any clear cause. A person with overactive bladder may have any two or all three of the following symptoms:
    • urinary frequency—urination eight or more times a day or two or more times at night
    • urinary urgency—the sudden, strong need to urinate immediately
    • urge incontinence—urine leakage that follows a sudden, strong urge to urinate

 

  • Spinal cord injury may affect bladder emptying by interrupting the nerve signals required for bladder control.

Prostate Problems

The prostate is a male gland about the size and shape of a walnut. It surrounds the urethra just below the bladder, where it adds fluid to semen before ejaculation.

  • BPH: The prostate gland commonly becomes enlarged as a man ages. This condition is called benign prostatic hyperplasia (BPH) or benign prostatic hypertrophy. As the prostate enlarges, it may squeeze the urethra and affect the flow of the urinary stream. The lower urinary tract symptoms (LUTS) associated with the development of BPH rarely occur before age 40, but more than half of men in their sixties and up to 90 percent in their seventies and eighties have some LUTS. The symptoms vary, but the most common ones involve changes or problems with urination, such as a hesitant, interrupted, weak stream; urgency and leaking or dribbling; more frequent urination, especially at night; and urge incontinence. Problems with urination do not necessarily signal blockage caused by an enlarged prostate. Women don't usually have urinary hesitancy and a weak stream or dribbling.
  • Radical prostatectomy: The surgical removal of the entire prostate gland—called radical prostatectomy—is one treatment for prostate cancer. In some cases, the surgery may lead to erection problems and UI.
  • External beam radiation: This procedure is another treatment method for prostate cancer. The treatment may result in either temporary or permanent bladder problems.

Prostate Symptom Scores

If your prostate could be involved in your incontinence, your health care provider may ask you a series of standardized questions, either the International Prostate Symptom Score or the American Urological Association (AUA) Symptom Scale. Some of the questions you will be asked for the AUA Symptom Scale will be the following:

  • Over the past month or so, how often have you had to urinate again in less than 2 hours?
  • Over the past month or so, from the time you went to bed at night until the time you got up in the morning, how many times did you typically get up to urinate?
  • Over the past month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
  • Over the past month or so, how often have you had a weak urinary stream?
  • Over the past month or so, how often have you had to push or strain to begin urinating?

Your answers to these questions may help identify the problem or determine which tests are needed. Your symptom score evaluation can be used as a baseline to see how effective later treatments are at relieving those symptoms.

Physical Examination

A physical exam will check for prostate enlargement or nerve damage. In a digital rectal exam, the doctor inserts a gloved finger into the rectum and feels the part of the prostate next to it. This exam gives the doctor a general idea of the size and condition of the gland. To check for nerve damage, the doctor may ask about tingling sensations or feelings of numbness and may check for changes in sensation, muscle tone, and reflexes.

EEG and EMG

Your doctor might recommend other tests, including an electroencephalogram (EEG), a test where wires are taped to the forehead to sense dysfunction in the brain. In an electromyogram (EMG), the wires are taped to the lower abdomen to measure nerve activity in muscles and muscular activity that may be related to loss of bladder control.

Ultrasound

For an ultrasound, or sonography, a technician holds a device, called a transducer, that sends harmless sound waves into the body and catches them as they bounce back off the organs inside to create a picture on a monitor. In abdominal ultrasound, the technician slides the transducer over the surface of your abdomen for images of the bladder and kidneys. In transrectal ultrasound, the technician uses a wand inserted in the rectum for images of the prostate.

Urodynamic Testing

Urodynamic testing focuses on the bladder's ability to store urine and empty steadily and completely, and on your sphincter control mechanism. It can also show whether the bladder is having abnormal contractions that cause leakage. The testing involves measuring pressure in the bladder as it is filled with fluid through a small catheter. This test can help identify limited bladder capacity, bladder overactivity or underactivity, weak sphincter muscles, or urinary obstruction. If the test is performed with EMG surface pads, it can also detect abnormal nerve signals and uncontrolled bladder contractions.

No single treatment works for everyone. Your treatment will depend on the type and severity of your problem, your lifestyle, and your preferences, starting with the simpler treatment options. Many men regain urinary control by changing a few habits and doing exercises to strengthen the muscles that hold urine in the bladder. If these behavioral treatments do not work, you may choose to try medicines or a continence device—either an artificial sphincter or a catheter. For some men, surgery is the best choice.

Surgical Treatments

Surgical treatments can help men with incontinence that results from nerve-damaging events, such as spinal cord injury or radical prostatectomy.

  • Artificial sphincter: Some men may eliminate urine leakage with an artificial sphincter, an implanted device that keeps the urethra closed until you are ready to urinate. This device can help people who have incontinence because of weak sphincter muscles or because of nerve damage that interferes with sphincter muscle function. It does not solve incontinence caused by uncontrolled bladder contractions.

Surgery to place the artificial sphincter requires general or spinal anesthesia. The device has three parts: a cuff that fits around the urethra, a small balloon reservoir placed in the abdomen, and a pump placed in the scrotum. The cuff is filled with liquid that makes it fit tightly around the urethra to prevent urine from leaking. When it is time to urinate, you squeeze the pump with your fingers to deflate the cuff so that the liquid moves to the balloon reservoir and urine can flow through the urethra. When your bladder is empty, the cuff automatically refills in the next 2 to 5 minutes to keep the urethra tightly closed.

Artificial sphincter

  • Male sling: Surgery can improve some types of urinary incontinence in men. In a sling procedure, the surgeon creates a support for the urethra by wrapping a strip of material around the urethra and attaching the ends of the strip to the pelvic bone. The sling keeps constant pressure on the urethra so that it does not open until the patient consciously releases the urine.
  • Urinary diversion: If the bladder must be removed or all bladder function is lost because of nerve damage, you may consider surgery to create a urinary diversion. In this procedure, the surgeon creates a reservoir by removing a piece of the small intestine and directing the ureters to the reservoir. The surgeon also creates a stoma, an opening on the lower abdomen where the urine can be drained through a catheter or into a bag.

Urinary diversion



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