Stress Urinary Incontinence in Males

What is Stress Urinary Incontinence?

Stress Urinary Incontinence (SUI) is the sudden involuntary loss of urine related to stress maneuvers such as coughing, sneezing, straining, exercising or even moving from sitting to standing. Both men and women can be affected by this issue. In men, SUI more commonly occurs after radical prostatectomy for prostate cancer; though less common, SUI can also occur after other types of prostate surgery or prostate radiation. SUI can be very bothersome and negatively affect a patient’s quality of life. Further, depending on the severity of SUI, men may incur increasing financial burden to have enough incontinence pads or adult diapers.

How Can SUI Be Treated?

Prior to and soon after prostate surgery, patients will be encouraged to perform pelvic floor muscle exercises to strengthen the muscles that are important for urinary continence. For bothersome SUI that persists despite pelvic floor muscle strengthening, there are two surgical management options: placement of a male urethral sling and insertion of an artificial urinary sphincter. Of note, for mild SUI or for those who are not interested in surgery or not safe surgical candidates, patients may be prescribed an incontinence clamp.

Artificial Urinary Sphincter Implantation

Artificial urinary sphincter (AUS) implantation is the standard treatment for moderate to severe stress urinary incontinence. The AUS allows you to control your bladder with a hand-operated pump to compress and release a cuff around the urethra. The goal of the AUS is to reduce urine leakage during activities such as sneezing, coughing, running, or lifting weights. The AUS consists of:

  • An inflatable cuff placed around the urethra

  • A reservoir to store liquid and keep the pressure in the system, placed into the belly

  • A valve or pump to control the cuff, placed into the scrotum

    The AUS can have complications, such as erosion/urethral injury, mechanical failure, or infection, which requires its removal.

When is an AUS Recommended?

AUS is generally recommended in case of moderate to severe urinary incontinence, or if sling implantation has failed to cure or improve your condition. AUS has a long-lasting effect and improves your quality of life. You should be able to control the pump manually. Before the surgery is scheduled, the doctor or nurse will sit down with you to discuss how the device works and to make sure you feel comfortable using it. The doctor will do some tests to make sure that there are no contraindications for getting an AUS. As part of this assessment, you may need a work-up including a urodynamic study (bladder pressure test), a cystoscopy (direct visualization of the urethra with a camera), and a pad test.

How is the AUS Implanted?

You will typically be asleep (general anesthesia) for this procedure. The bladder is emptied. The surgeon will insert a catheter to make sure that your bladder is completely empty during surgery. An incision is made between the scrotum and the anus to place the cuff around the urethra, and another one in the lower abdomen to insert the reservoir. The AUS is placed. The cuff is placed around the urethra. Finally, the pump is positioned in the scrotum without any other incision and is connected to the other two elements of the device. The cuff is left open until the doctor activates it a few weeks later in the outpatient clinic.

How to Prepare for the Procedure

Before surgery, the doctor will ask for a urine sample. This will be tested to make sure you do not have a urinary tract infection. If you have an infection this should be treated with antibiotics before scheduling the surgery. Your doctor may prescribe antibiotics before, during, and after the operation even if there is no infection, in order to prevent an infection. Your doctor will advise you in detail about how to prepare for the procedure. If you need general anesthesia, you must not eat, drink, or smoke after midnight before surgery. If you are taking any prescribed medication, discuss it with your doctor. You may need to stop taking it several days before surgery. Your doctor will advise you on when you can start taking it again.

After the Procedure

You can usually leave the hospital the same day after implantation of an artificial urinary sphincter. You will likely leave the hospital with a bladder catheter in place. You are usually instructed to remove your catheter the day after surgery. After you leave the hospital, your body still needs time to fully recover from surgery. Because of this, the AUS will not be activated until your lower urinary tract has completely healed. This means that in the weeks after the procedure, you will continue to have urine leakage. During this time, you may also experience pain in the pelvic area, or feel pain when you urinate. Your doctor can prescribe medication to deal with these symptoms. Your doctor will schedule an appointment to activate the device 6 weeks after surgery. Your wound will be checked as well.

During the Recovery Period your Doctor May Recommend to:

  • Consume enough liquid, especially water, to provide at least 2 liters of urine output

  • Not lift anything heavier than 10 pounds

  • Not do any heavy exercise

  • Take showers instead of baths

  • Avoid thermal baths, or going to the sauna

  • Prevent constipation by adapting your diet

  • Avoid sexual activity

  • Avoid activities that can traumatize the operation site, such as cycling and horseback riding

POST AUS PRECAUTIONS

Lifetime Precautions for Artificial Urinary Sphincter Patients

1. The artificial urinary sphincter is placed around your urethra. Thus, if a catheter or any other device is placed into urethra, the sphincter could be irreversibly damaged.

2. For the rest of your life, you should notify any medical caregivers that you have an artificial sphincter in place. For example, if you are having a dental procedure, you will likely need additional antibiotics.

3. You should instruct all providers NOT to place a urethral catheter unless a urologist is consulted, and the device is properly deactivated in the open position.

4. Avoid prolonged sitting on hard surfaces. If you must, consider bringing a cushion with you.

It’s recommended that you obtain a medic alert-type bracelet indicating that you have an artificial urinary sphincter.

When Should I Consider a Male Urethral Sling?

Slings can be considered in case of mild to moderate urinary stress incontinence. They are also recommended when other surgical treatments are not possible, or if you do not want to undergo implantation of an AUS. A sling may be an option after other procedures have failed. There are a variety of male urethral slings. Each type of sling has specific characteristics, results, and possible complications. Ask your doctor about his or her experience with the sling suggested to you.

How are Slings Implanted?

You will typically be asleep (general anesthesia) for this procedure. An incision will be made in the perineum to expose the urethra. The sling will be placed around the urethra, with each arm of the sling coming through a natural opening in the pelvis (See Fig 2). Two small incisions will be made on either groin to aid in placement of the sling. For further description of this procedure, you can watch a video by clicking this link: https://youtu.be/r-NmuZ1OVRo

After the Procedure

You will be discharged with a catheter in place. You will be instructed to follow up in clinic approximately 3 days after surgery for catheter removal and to ensure that you can urinate. For 4 weeks after surgery, do not lift anything heavier than 10 pounds, avoid heavy exercise, take showers instead of baths and no swimming. Prevent constipation by adapting your diet. Additionally, for at least 3 months, you should avoid activities which can traumatize the operation site, such as cycling and horseback riding.