Men and Urinary incontinence

The stigma associated with urinary incontinence often keeps men from seeking medical assistance and it is much more common than is often thought, though less prevalent than in women. Men of all ages can be affected.

The incidence of urinary incontinence among men at the age of 50 compared to women of the same age is lower. As age increases, male incidence increases. It is not, however, simply a function of ageing, it is directly related to other illnesses such as enlarged prostate, prostate cancer, and neurological conditions such as multiple sclerosis, Parkinson’s disease, and Alzheimer’s. To a lesser extent, the incidence of diabetes and overweight as well as other risk factors increase the incidence of urinary incontinence in men.

The treatments below are suggested for those patients with non-complicated incontinence, that is without recurring incontinence, or incontinence associated with pain, haematuria, recurrent infection, voiding problems, prostate irradiation, or radical pelvic surgery. For patients presenting with these symptoms, immediate referral to a urologist is recommended.

DIAGNOSTIC ASSESSMENT

Male incontinence can be broken down into symptom groups which may aid in assessment. Men with post-micturition dribble may be helped by pelvic floor muscle exercise and urethral milking. Stress urinary incontinence (SUI) in men is seen mostly after prostatic surgery and urge incontinence (UUI) often involves prostatic enlargement or benign prostatic hypertrophy (BPH), obstruction or other surgical procedures such as bowel resection. The term mixed incontinence applies when both symptoms are present.

A thorough history should be taken to determine the nature of the incontinence, noting any previous surgical procedures, and other relevant illnesses or medications.

Physical examination should include abdomen/bladder for stone, diverticulum or tumours, rectal for faecal impaction, sacral neurological and central nervous system to include mental status and other neurological factors. Urinalysis should be performed to rule out infection and haematuria. Treat any infections and reassess.

Quality of life should be assessed to determine impact of incontinence on the individual and at the same time, assess mobility and toilet access.

STRESS URINARY INCONTINENCE (POST-PROSTATECTOMY)

Stress urinary incontinence in men is generally experienced after prostate surgery, though it is not unknown in other circumstances, and presents with the involuntary loss of urine with activity such as coughing, running, jumping, etc. Each man will differ. Some will experience only a small amount of sporadic urine loss, possibly short term, while others may experience constant, long term leakage. Many will recover continence completely given proper treatment.

Treatment alternatives

Lifestyle

Review lifestyle for food and fluid intake, weight reduction and smoking. Overweight people have greater abdominal pressure. Smokers cough more, which can result in an increased incidence of leakage.

  • Do not drink too much or too little. Reducing fluid intake to decrease urine may produce further irritation of the bladder and promote infection.
  • Avoid caffeine and fizzy drinks, which may irritate the bladder, as may alcohol.
  • Review current medication for interaction or iatrogenic effects.

Pelvic Floor Muscle Exercise

Pelvic floor muscle exercise is the most effective treatment for post-prostatectomy urinary incontinence. Combined with bladder retraining and voiding diaries, many will achieve full continence, provided there has been no damage to the urethral sphincter during surgery. Biofeedback and electrical stimulation aid in the execution of pelvic floor muscle exercises and ideally should be recommended by a physiotherapist or continence professional. Research has been done to examine the role of biofeedback and electrical stimulation in post prostatectomy urinary incontinence and has been shown in many cases to be beneficial.

Bladder Retraining

Bladder retraining may also be useful after prostatic surgery, if the man is experiencing urgency and urge incontinence. Increasing amounts of urine are held in the bladder for controlled amounts of time to increase the capacity of the bladder. The goal is to break the cycle of frequency, urgency, and urge incontinence. A continence advisor or specialist physiotherapist can help with this training.

Medical Devices

Absorbent incontinence products for men are made in the form of pouches, drip collectors and pads. Most disposable products use technology to turn urine into a gel like substance so it is retained in the pad and reduces the chance of leakage. A recent study has examined the effectiveness of various absorbent incontinence products for men.

Catheters may be used as a temporary measure, after surgery, or as a long term solution in certain circumstances. Catheters may be intermittent or indwelling and are connected either to a drainage bag held on the person or to a valve which allows the catheter to be emptied in a vessel on a regular basis.

Male condom or sheath collection devices should be fitted by a specialist device professional and fit loosely over the penis either emptied by a bag or a valve.

Pharmacological and Surgical Interventions (under certain conditions)

If basic management has failed and incontinence markedly disrupts quality of life, further interventions should be considered and referral to a urologist is advised. This includes procedures such as male slings and bulking agents, or artificial sphincter.

URGE INCONTINENCE

Urge incontinence is defined as an involuntary loss of urine with a strong desire to void. As with stress urinary incontinence, urge incontinence should be initially treated with non-invasive means. The greatest risk factor for urge incontinence is organ enlargement (eg BPH) and prior surgery.

Treatment alternatives

Lifestyle

  • Do not drink too much or too little. Reducing fluid intake to decrease urine may produce further irritation of the bladder and promote infection.
  • Avoid caffeine and fizzy drinks that act as a bladder stimulant, as may alcohol.
  • Reduce weight, which causes extra abdominal pressure, and stop smoking which causes increased coughing and resultant leakage.
  • Incontinence protection may be used during diagnosis and treatment, if the treatments are not entirely effective, and to increase confidence during stressful periods.

Pelvic Floor Muscle Exercise

There is some evidence, that in some cases, strengthening the pelvic floor may aid in minimising the incidence of leakage in men with urge incontinence. Biofeedback and electrical stimulation aid in the execution of pelvic floor muscle exercise and ideally should be recommended by a physiotherapist or continence professional.

Bladder Retraining

Bladder retraining is a highly effective tool in treating urge incontinence. The capacity of the bladder is slowly increased in small, incremental, controlled steps. Patient compliance and self-motivation are important as well as adhering to the slow pace of training to ensure maximum success.

Medical Devices

Men who experience a sudden urge to urinate may wear absorbent incontinence products designed for men/male anatomy. These products are either disposable or reusable and come in a number of shapes and styles which include drip collectors, pouches and sock like pads. Each product varies as to absorbency and comfort. It is best to consult a continence advisor to assess daily needs and determine the most appropriate mix of products for the individual patient.

Other products for urine collection and inhibiting urine flow may also be used to contain leakage in certain cases. Catheters and devices to aid men with pelvic floor muscle exercise or to inhibit stress urinary incontinence may be suited to some patients for whom other methods of treatment are not indicated. Catheters may be used as a temporary measure, after surgery, or as a long term solution. Catheters may be intermittent or indwelling and are connected either to a drainage bag held on the person or to a valve which allows the catheter to be emptied in a vessel on a regular basis. Indwelling suprapubertal catheters may be surgically introduced through the abdomen rather than via the urethra. Patients or carers may be trained to change and clean these. Male condom or sheath collection devices should be fitted by a specialist device professional and fit loosely over the penis either emptied by a bag or a valve.

Other Interventions (under certain conditions)

If the above treatments are not effective after approximately 3-4 months, reassess and consider further intervention and referral. The options available from a specialist physiotherapist include further physical techniques such as electro-stimulation and biofeedback.

Pharmacological intervention is also available in the form of antimuscarinic or anticholinergic drugs. Neuromodulation, autoaugmentation, bladder augmentation and urinary diversion may also be used.

MIXED INCONTINENCE

The term mixed incontinence is used when symptoms of both urge and stress urinary incontinence are present. It is advised by the International Continence Committee of the WHO that the symptoms of the predominant condition be treated first. However, the first-line treatments for both urge and stress urinary incontinence are the non-invasive measures of lifestyle intervention, bladder retraining and pelvic floor muscle exercise. If there is a failure or limited success with these techniques, drugs may be administered for the most prominent symptoms remaining. Failing that, referral for further investigation should follow.

POST-MICTURITION DRIBBLE

Post-micturition dribble is treated with a combination of pelvic floor muscle exercise to strengthen the sphincter and urethral milking after voiding.

OTHER FORMS OF INCONTINENCE

There are other forms of incontinence which may not fall into the above categories.

  • Overflow incontinence: As the name implies, there is a constant flow of urine, as if the bladder is ‘overflowing’. This is often caused by a mechanical obstruction such as faecal impaction, prostate enlargement, nerve damage, or urethra abnormatlities.
  • Functional incontinence: The inability to reach the toilet to urinate either due to disability (physical or mental) or infirmity.