Incontinence

Incontinence in men can be due to a variety of reasons, and are broadly categorized into bladder or sphincter problems.

Bladder problems may arise from long-standing prostate problems, giving rise to symptoms such as frequency, urgency and leakage when unable to ‘hang on’. Neurological problems can also cause bladder over-activity. Treatments may include tackling the underlying problem, or managing the bladder symptoms with anticholinergic tablets, or Botox injections into the bladder. Very rarely, complex bladder surgery may be required to increase its capacity.

Sphincter problems usually arise from previous surgery or radiotherapy eg for prostate cancer. Up to 1:5 men may need to use pads after a radical prostatectomy, but very few (< 1%) have incontinence after surgery for benign prostate disease (TURP, laser prostatectomy etc). Post-prostatectomy incontinence may improve spontaneously up to a year after the cancer surgery, but then usually tends to ‘plateau’ and remain the same. At this point it is useful to have an assessment by a reconstructive urologist, who can assess the degree of leakage and the impact on quality of life. A number of effective treatments are available, including tablet therapy, injections around the urethra, a Male Sling procedure or an Artificial Urinary Sphincter (AUS) (see below). To establish a clear diagnosis as to the type of incontinence, it is usually necessary to undergo a bladder pressure test (urodynamic studies), which measures the pressures in the bladder during filling and emptying. This information is then used to chose the best treatment to resolve the incontinence problem (see below). [collapse title="Male Sling"]The male sling procedure was developed to help men with urinary incontinence due to sphincter weakness or insufficiency in the setting of prior pelvic surgery including post-TURP (transurethral resection of the prostate) and post-radical prostatectomy.

One of the advantages of the male sling is that it can be performed with a fairly short recovery and minimal complications, and requires only a small incision in the perineum (between the scrotum and the anus). Most patients are discharged the morning after surgery.

Pre-operative Investigations and preparation

Following consultation in the outpatient department, you may be asked to complete a 24-hour pad diary as well undergo urodynamics testing. The latter is a 20-minute test and involves passing a catheter tube into the bladder and measuring bladder pressures during filling and emptying. Occasionally a cystoscopy (a look inside the bladder with a fine telescope) is also required, and all patients are required to attend the hospital for pre-assessment – routine pre-operative checks such as blood tests etc.

The Operation

The operation is usually carried out under a general anaesthetic and takes approximately 45 minutes. An incision is made in the skin of the perineum (the area between the scrotum and anus), and the urethra (water-pipe) identified. A synthetic mesh-like surgical tape is sutured onto the urethra, and passed out through two or four very small holes made in the adjacent skin. The tape is then pulled through to compress the urethra and lift it into a new position. The incision is closed with dissolvable sutures (stitches) and a catheter tube placed in the bladder to drain the urine overnight. The catheter is removed the next morning. Pain usually subsides quickly and once you have passed urine you are discharged from hospital with standard tablet painkillers.

Complications

Complications are rare but may occur. They include prolonged bleeding from the wound, blood clot, infection of the mesh or surrounding area, temporary inability to pass urine necessitating the catheter to remain for a week, or recurrent leakage (see success rate below). The normal pattern and feeling of passing urine may not return for a few weeks after surgery.

Success Rate

In appropriately selected patients, cure rates (ie pad-free) of 80% can be achieved1. However the Male sling is a fairly new procedure, and there is no data beyond 6 years. There have been no serious problems during this period. However there have been numerous long-term studies with good results for similar surgery in women.

1. Collado Serra A et al. AdVance/AdVance XP transobturator male slings: preoperative degree of incontinence as predictor of surgical outcome. Urology. 2013 May;81(5):1034-9.[/collapse]

Urodynamic Studies+-

Urodynamic studies are an accurate way of measuring bladder pressures and function, and are carried out by passing a fine tube (catheter) into the bladder, and a small sensor in the rectum (back passage). Your bladder is slowly filled with fluid, and the pressure trace recorded on computer. We will ask you various questions during bladder filling, and afterwards you will be asked to pass urine into a special toilet that measures the flow.

There will be a nurse or radiographer present to explain each step, and the procedure should take 30 minutes or so. At the end of the procedure, Mr Rees will examine the traces, give you an explanation as to the cause of your symptoms, and formulate a treatment plan.

There are very few risks to this procedure, but inserting the catheter may be a little uncomfortable (but not painful). Afterwards, there is sometimes some stinging when you first pass urine, and if so this will settle quickly. Rarely, an infection may develop in the urine, requiring antibiotic treatment.

Urinary Incontinence in Women+-

Urinary incontinence is common, especially in women. It may occur at any age but it is more likely to develop as you get older.

There are different types of urinary incontinence:

Stress incontinence

Stress urinary incontinence is the most common type of incontinence. It occurs when the pressure in the bladder becomes too great for the bladder outlet to withstand. This is usually caused by weak pelvic floor muscles. With stress incontinence, urine leaks when you cough, laugh, sneeze or when you exercise (such as when you jump or run). Stress incontinence is common in women who have had several children as the pelvic floor muscles are often weakened by childbirth. It can also be a problem in overweight people and with increasing age.

Urge incontinence (unstable or overactive bladder)

Urge incontinence is the second most common cause of leakage. Patients experience an urgent desire to pass urine and urine leaks before they have time to get to the toilet. In this condition, the bladder muscle contracts too early and the normal control is reduced. In most cases, the cause of urge incontinence is not known. It seems that the bladder muscle gives wrong messages to the brain and the bladder may feel fuller than it actually is. Sometimes urge incontinence can occur because of problems with the nervous system (the brain, spinal cord and other nerves in the body).

Mixed incontinence

Some people have a combination of stress and urge incontinence.