Incontinence

 

Radical prostatectomy is a very effective way to treat organ confined prostate cancer, and the cure rates are very high. However, we know that one of the potential side effects of the surgery can be persistent urinary incontinence (involuntary loss of urine). While the vast majority of men who undergo a radical prostatectomy will resolve their urinary incontinence completely, there is a small percentage of men in whom the urinary incontinence will persist and never correct itself. For these men there ARE effective treatment options, and at Urology Centers of Alabama we have specialists who perform these treatment procedures. The surgeries are minimally invasive requiring only small incisions and the hospital time is also minimal. MALE SLING The use of synthetic slings to treat urinary incontinence has been a common practice in female patients for many years. We also offer this treatment option to men who suffer from persistent post prostatectomy incontinence, and the results are quite good. The male sling is a ribbon of sterile, synthetic mesh that is placed below the urethra and supports and repositions the urethra. Placement of the sling allows the patient’s natural sphincter (the circular, muscular valve that prevents leakage of urine) to function more effectively and to maintain continence. The most ideal candidate for the male sling would be a man who has incontinence following radical prostatectomy is of a mild-to-medium degree of severity. The degree of severity of a patient’s incontinence can be ascertained by performing a test where pads that have been used by the patient are weighed before and after usage to establish the degree of leakage. This testing is painless and simple and is done in the convenience of the patient’s own home. The male sling procedure itself is most often performed on an out-patient basis with the patient going home the same day as the surgery. Through a small incision in the patient’s perineum (the area under the scrotum and between the legs) the sling is placed into position beneath the urethra. Tensioning the sling allows the repositioning and support of the urethra. The surgery takes about 35 to 45 minutes. Risks of infection and serious bleeding are both less than 1%. A catheter is placed into the bladder at the time of surgery and will be maintained for about 24 hours after surgery. All of our male sling patients are given a prescription for antibiotics and a prescription for pain medicine following their surgeries. The efficacy of the male sling is quite good and in the ideal patient cure rates (no further leakage, no further pads) approach 90%. Patient satisfaction with the male sling has been found to be very, very high. Unfortunately, there are some men who will have not only urinary incontinence but also erectile dysfunction following their radical prostatectomy. Some of these men would have had erectile difficulties even before their prostate cancer surgery. For the man who does have erectile dysfunction and incontinence, a combination procedure utilizing the male sling and an inflatable penile implant is possible. In fact, some of the very first combination sling plus penile implant surgeries were performed at Urology Centers of Alabama. The safety, efficacy, high patient satisfaction, and low risk of this combination procedure has been well documented. For the right patient the combination of a male sling and a penile implant may represent the ideal treatment option. Following radical prostatectomy some men may suffer from climacturia; this is the leakage of urine that occurs during sexual activity and orgasm. Some studies have indicated that climacturia can be present in up to 40% of men who undergo a radical prostatectomy, and patients and their spouses find climacturia to be a very distressing and very bothersome situation. We have found that men who have the male sling placed will almost always completely resolve their climacturia. Therefore, use of the male sling can benefit the patient in several different ways. ARTIFICIAL URINARY SPHINCTER Developed in 1972, the artificial urinary sphincter has long been a very effective way to treat urinary incontinence in men. The artificial sphincter is a synthetic cuff that is placed around the urethra, and also has a small pump shaped like the end of the pinky finger. The pump is placed under the skin in the scrotum. The entire device is completely contained in the body and no one would know that a patient has an artificial sphincter. The cuff of the sphincter compresses the urethra and that is what prevents leakage. When a patient needs to urinate, they will experience the normal sensation to void. They would then squeeze the scrotal pump and this allows the cuff to open and the patient to void. After voiding, the device automatically resets itself. Surgery to place the artificial sphincter is performed in less than an hour, and the risks of infection or serious bleeding are quite low. For the man with a more severe degree of urinary incontinence the artificial sphincter is the treatment of choice. Like the male sling, the artificial sphincter can be placed at the same time as a penile implant for the treatment of both erectile dysfunction and post- prostatectomy incontinence. The male sling and the artificial sphincter provide very good treatment options for men with incontinence. Which surgery is best for you will be determined when you have your consultation with the prosthetic surgeon. Any kind of preoperative testing to help decide which surgery is best is painless and is performed in the comfort of the Urology Centers office. We strongly encourage all men with urinary incontinence that does not resolve after radical prostatectomy to speak to their prostate cancer surgeon. There are excellent treatment options for these patients. In this day and age, there is no need for any man with incontinence after radical prostatectomy to not seek effective treatment.

 

Urinary incontinence in women can be troublesome and embarrassing, but it is treatable. There are several types of incontinence, but the most common are urinary urge incontinence, stress incontinence, and mixed incontinence. Incontinence is a very common condition and the prevalence does increase as one ages. Urinary urge incontinence involves the involuntary loss of urine usually associated with a sudden urge that cannot be suppressed. Some of the causes may be related to infection, hormone status, childbirth, or previous pelvic surgeries. It can be exacerbated by certain types of foods/beverges. As with any medical problem, a thorough history is vital. The physician needs to know all the medications that the patient uses as well as toilet habits. A voiding diary is thus extremely useful. Physical exam involves assessing the vaginal area and pelvic floor. It is important to rule out infection, bladder cancer and other inflammatory causes. Sometimes, a cystoscopy is done to rule out hematuria. If the incontinence is not straight forward, further testing called urodynamics is performed to assess bladder filling and emptying. Treatment involves both behavior and pharmacological changes. Behavior changes may include weight loss, smoking cessation, dietary changes, and pelvic floor muscle therapy. The pharmacologic therapy for UUI involves a trial of medications that are known as anticholinergics. It is important that the patient is aware of the side effects of medications. If the medications are not helpful or cannot be taken, then other surgical modalties are investigated. These may include sacral nerve stimulation, posterior tibial nerve stimulation or botulinum toxin injections for refractory UUI. These treatment options are minimally invasive and patient friendly. Stress incontinence is the involuntary loss of urine usually associated with increased abdominal pressure. For example, coughing, sneezing, exercising. It can develop as a result of obesity, childbirth, pelvic surgeries. As with the UUI, a thorough history is crucial. Nonsurgical treatment options include pelvic floor strengthening. Surgical options include periurethral bulking agent which can be done in the office. The minimally invasive “sling” or “tape “ procedure is safe and effective. So although incontinence is embarrassing, it can be treated and therefore should be brought to your physician’s attention.

 

Blood in the urine Difficulty urinating Frequent urination Painful urination Spraying of the urinary stream Discharge from the urethra Diagnosis includes a detailed history and physical including onset of symptoms and severity. Your doctor may also choose to evaluate your urethra with a variety of office tests including Post-void residual volume: determining how well you empty your bladder Urinary flow rate: strength of urinary stream Retrograde urethrogram: x-ray performed while instilling dye into urethra Cystoscopy: looking into urethra and bladder with a small telescope

 

Various treatment options exist, each with their own advantages and disadvantages. Urethral dilation: gently stretching the stricture with sequential dilators. Usually performed in the office with local anesthesia, however recurrence rate is high. Endoscopic Incision: the stricture is cut using a special cystoscope while under general anesthesia in the operating room. Typically performed on outpatient basis, and no formal skin incision is needed. Success rate is typically pretty good, but depends on location of the stricture and length of the stricture. Each subsequent incision carries higher recurrence rate. Open urethroplasty: removing the diseased segment and replacing with healthy tissue. The technique used depends on location and length of the stricture, as well as surgeon experience. For longer strictures, a tissue graft is usually needed to bridge the gap. The tissue used for grafting can include local penile skin or even buccal mucosa from inside the cheek. Success rates are typically very good with low recurrence rates, especially with surgeons with experience in performing these procedures.