Our Services
Incontinence Treatment
There are a number of types of incontinence (leaking of urine) and this determines the type of treatment needed. Urge urinary incontinence is having the sense of needing to urinate and not making it to the bathroom in time. This type of incontinence tends to be associated with neurologic disorders, diabetes or the result of an enlarged bladder for a prolonged time. A separate type of incontinence is male stress urinary incontinence (SUI). This incontinence is leaking urine with cough, sneeze, laugh, lifting or any movement that can increase abdominal pressure. Male stress urinary incontinence occurs in around 4-40% of men following prostate cancer treatments. Men may have mixed incontinence with features of both as well. Following some prostate treatments or spinal cord injuries, men may experience total incontinence, with leaking of urine all the time and very little to no control of the leakage.
All types of urinary incontinence are associated with decreased quality of life and significant bother for patients. Men may have severe incontinence requiring Depends or multiple pads per day, or the incontinence may be minor requiring only changing clothes intermittently. Treatments need to be directed at the underlying cause and with a clear focus on the type of incontinence that is predominant.
Stress urinary incontinence is a potential side effect following prostatectomy. Many men experience incontinence initially following surgical removal of the prostate, but most men regain control over the first 6 months. Stress urinary incontinence is not normal for men. Therapy like Kegel exercises can improve and speed recovery of continence. This is more successful when performed with biofeedback or a physical therapist. Approximately 4% of men will have significant stress urinary incontinence that leads them to seek a cure. A larger percentage of men will have stress incontinence that is either not bothersome (usually 1-2 pad per day or less) or they are unaware options exist to improve their continence. Men who undergo radiation therapy or brachytherapy (seed placement) followed by surgical removal of the prostate often have stress incontinence or total incontinence due to their treatments. Total incontinence can be seen rarely following transurethral resection of the prostate (TURP) as well. Even in the most severe cases, therapy exists that can help the patient regain control.
When a patient comes in for an appointment to discuss urinary incontinence, they can expect the initial step to be an assessment of their history and medication that may be associated with incontinence. Often a post-void residual (PVR) will be obtained and a urinalysis. This is simply having a patient empty their bladder and then using a non-invasive ultrasound measuring the amount of fluid left in the bladder. Initial attempts to control incontinence may involve medication, but stress incontinence and total incontinence rarely respond well to medication. There are several tests that can be performed that may clarify the causes and type of incontinence as well.
- Cystoscopy- a small camera is carefully passed along the urethra (urinary channel) and into the bladder. This can provide useful information on the anatomy of the bladder, potential for scar tissue in the urethra, and ensure there are no bladder tumors or stones that may be contributing to the leakage. Often during this process, if considering a male sling, we will ask the patient to close their sphincter muscle to ensure the sphincter does coapt (bring the sides together) well.
- Urodynamics- this is a test where very small catheters are placed in the bladder and the rectum to measure pressure as the bladder fills. The bladder catheter will help fill the bladder with fluid and measure for bladder wall contraction which may be felt as an urge to urinate to the patient. Urodynamics can also ensure the patient’s bladder is able to generate a normal contraction to expel the urine, an aspect that is potentially important in some male sling cases.
Urge incontinence
Urge incontinence is leakage that is associated with the sudden onset or need to urinate.
Causes of urge incontinence include:
- Diabetes
- BPH or enlarged prostate
- Spinal cord injury or trauma
- Nerve injury, at times associated with back injuries
- Bladder stones
Treatments for urge incontinence include:
- Bladder Botox injections
- Through a cystoscopy, botox is delivered into the bladder wall
- This helps decrease the sensation of the bladder which can allow the patient to store more urine and obtain more warning before the need to urinate
- Side effects of botox include possible urinary retention or difficulty urinating, bleeding and a need for repeat botox procedures
- Interstim placement
- A small electrode is inserted in the back to stimulate the sacral nerves, changing how the bladder is sensed
- There is initially a test week followed by permanent device placement
- This device does have a battery that may need to be replaced in the future
- Risks of the procedure include infection, rarely pain in an atypical location or inability to attain an MRI
- Posterior Tibial Nerve Stimulation
- An in-office procedure where a small needle is inserted around the tibial nerve at the ankle
- This provides a 30 minute treatment session once weekly to adapt the nerves sensing the bladder
- This has few risks or side effects, but does require frequent visits to the office
Male Stress Urinary Incontinence
Incontinence associated with lifting, standing from a seated position, sneezing, laughing or any activity that causes the abdominal muscles to contract and increase pressure in the abdomen.
This is most commonly seen following removal of the prostate and is known as post-prostatectomy incontinence. The number of men who end up with post-prostatectomy incontinence depends on the definition of incontinence used. If less than 2 pads daily is considered continent, a smaller number of men (around 2-4%) have incontinence. If no pads daily is considered continent, up to 60% of men may have post-prostatectomy incontinence. If the incontinence bothers a patient, no matter how little the volume of fluid leaking, it is worth discussing potential treatment options.
- Peri-urethral injections
- Injection of a bulking agent around the urethra to increase the pressure of the urethra and attempt to minimize leakage
- Often requires multiple procedures and only useful to treat very minimal incontinence
- Advance Trans-obturator male sling
- A two armed sling to reposition the urethra following prostate cancer treatment
- Provides a back-stop for the urethra to close with cough, sneeze or activity
- Success rates of 54-80% for improvement, around 50% dry
- Risks of the procedure include urinary retention, perineal pain, infection, erosion, and recurrent incontinence.
- Able to treat mild to moderate incontinence
Virtue male sling - can decrease leaking of urine with stress maneuvers like coughing, laughing, standing or at the time of orgasm. Helps restore continence following prostate surgery.
- Virtue Quadratic sling
- A four arm sling to reposition the urethra and provide a compression mechanism to further increase resistance and decrease post-prostatectomy incontinence
- Success rates of 70-79% for improvement, around 50% dry as well
- Risks of the procedure include urinary retention, perineal or scrotal pain, infection, and recurrent incontinence.
- Able to treat mild to severe incontinence
Artificial urinary sphincter (AUS) restores urine control following prostate cancer treatments.
- Artificial urinary sphincter
- Internal device that is not seen from outside the body
- Creates a new closure of the urethra to minimize incontinence
- Opens when a patient squeezes a pump placed in the scrotum
- This is not painful to perform
- Success and cure rates over 80%
- Able to treat all levels of incontinence
- Risks of the procedure include infection or erosion of the device requiring removal, mechanical failure of the device, urethral atrophy, and recurrent incontinence.
- Around 25% of the patients require revision of the device within 10-12 years
Multiple factors are important to determine the correct procedure and to maximize benefit. It is important to realize that no procedure can guarantee a patient will be 100% dry. Many patients do end up without the need for pads. Important factors are:
- Patient factors- many patients will choose a male sling over the artificial urinary sphincter if the chooses appear to have equal chances of success
- Time following prostatectomy- improvements may be seen naturally over the first 12 months following prostate removal
- Degree of incontinence
- This may be quantified by number of pads, pad weight
- Prior radiation therapy
- Increases chance of residual incontinence following male sling or artificial urinary sphincter
- Prior surgery
- Having a prior artificial sphincter or sling may change the likelihood of success with repeat treatment or attempts at an alternative treatment
Total urinary incontinence
Complete loss of urine with little ability to control urine flow.
Typically seen following rare cases of transurethral surgery of the prostate or radiation therapy combined with prostate removal.
This type of incontinence is typically best treated with an artificial urinary sphincter. Success rates depend on the cause of the incontinence.
Climacturia
This type of incontinence is loss of urine at the time of orgasm.
Not a very common problem but may be seen after prostate removal.
This type of incontinence responds well to physical therapy or considering a male urethral sling.
You don’t have to continue leaking. There are treatments available and it is not considered normal to have incontinence as men age. Please schedule a visit with Dr. Lowe to determine which options may be right for you.
OTHER SPECIALTIES AT LOWE UROLOGY
Patient Instructions
Dr. Lowe’s Pre-Operative Instructions for AUS surgery
Questions to ask your surgeon prior to male sling (Virtue, Advance) or Artificial Urinary Sphincter surgery
- How many slings or artificial sphincters have you done over the last 3-4 years? How many do you typically do per year?
- What type of device do you think is best for me?
- Are there other options I should consider prior to surgery?
- What training have you received regarding placement of male slings or artificial sphincters?
- Will I need to stay in the hospital overnight?
- Will I need to keep a catheter in following surgery?
- When should I expect to stop leaking? Will I be completely dry following surgery (typically we cannot guarantee being completely dry, but important to have a clear expectation)?
AUS= artificial urinary sphincter
It is important that patients do not eat or drink anything, even coffee or water, starting at midnight the night before artificial urinary sphincter (AUS) surgery. However, all medications can be taken with a sip of water.
Please stay on low dose aspirin prior to surgery.
Please arrive at the surgery center two hours before your scheduled surgery time. If your scheduled surgery time is the first of the day, please arrive at 6:00am.
This procedure can be done safely with one to two small incisions in about one hour and normally requires a 24 hour hospital stay. Incisions will be located just above the penis and over the perineum (figure B), the area between the anus and scrotum.
A 
B 
For more information, and to see stories of men who have had this treatment, visit www.MaleContinence.com.