Male Urinary Leakage

Male Urinary Incontinence and Post Prostatectomy Incontinence

Urinary incontinence is the accidental leakage of urine. This usually causes problems when it occurs at inconvenient times or “all the time” for some.

Urinary leakage can occur with men just like with women. The impact leakage has on any individual is significant and may affect social function. Urinary leakage can lead to avoidance of certain activities and situations due to fear of embarrassment. Leakage can also lead to increased spending on diapers and pads that do not treat the cause of the leakage only the symptom of leakage. Erlanger Urology specializes in the treatment of all causes of male urinary leakage. There are many medical and surgical options available to allow you or your loved one to control urinary leakage and to get you back to enjoying life.

What Causes Incontinence after Prostate Removal?

The bladder and the urethra control urination. When your kidneys produce urine, they empty it into the bladder to hold until urination. The bladder is muscular and shaped like a balloon. When you urinate, the muscles of the bladder wall contract and force urine out of the bladder into the urethra. Muscles that surround the urethra then relax and allow the urine to flow through it and out of the penis.

Because the prostate gland surrounds the urethra, it can cause different issues with urination. If the prostate becomes enlarged, it can obstruct the urethra, inhibiting flow. This is a natural part of male aging, as the prostate becomes larger with age, making urination a slower, longer process.

But when the prostate is either removed or destroyed with radiation, this disrupts the way the bladder holds urine and can lead to urine leakage. Radiation can decrease the bladder’s capacity and cause the bladder to spasm, leading to urine leakage. Surgery can also damage the nerves that are involved in bladder control. If the bladder neck sphincter (the muscle that is normally closed to prevent urine leakage) is damaged during prostate surgery, this can lead to incontinence.

How Common is Incontinence after Prostate Surgery?

Urinary incontinence is common in men who’ve had prostate surgery/removal or radiation. At six weeks after surgery, almost two thirds of men can expect to have some degree of incontinence, as defined by using a pad. These numbers drop with time, but after a year around 20 percent of men can still have some degree of incontinence. This tends to be higher in men who are inactive. The numbers keep dropping as bladder function and control are regained. In three years, less than 10 percent of men who’ve had prostate removal surgery are incontinent.

Are there Different Types of Incontinence after Prostate Surgery?

There are three different types of incontinence:

• Stress incontinence is the most common type of urine leakage men experience after prostate surgery. Leakage occurs when a person coughs, sneezes, or laughs.
• Urge incontinence is the type that occurs most often after radiation treatment. This incontinence involves the need to urinate frequently with occasional episodes of leakage.
• Overflow incontinence happens when the bladder doesn’t empty as it normally should. Signs of overflow incontinence are taking a long time to urinate, a dribbling stream with little force, getting up often during the night to go to the bathroom, and the feeling that you can’t pass enough urine to feel your bladder is drained.

How Long Does it Take to Recover from Incontinence after Prostate Surgery?

Since the cause is usually tied to damage to the bladder and/or the urethra, particularly the sphincter muscles that control each, complete recovery can take anywhere from six months to 18 months. In patients who had normal continence prior to prostate surgery, the vast majority will regain full function within 12-13 months after surgery.

I just Underwent Prostate Cancer Surgery and I Leak. What Should I do Now?

Treatment for urinary leakage related to prostate cancer depends on how long ago your procedure was and how much you are leaking.  Typically, most people leak urine after the catheter is removed after the prostate removal. The good thing is that most people will regain urinary control over time.  Only about 1 in 10 men will have significant leakage that affects lifestyle 1 year after the prostate is removed.

One of the first options to improve urinary control is in the form of pelvic floor exercises (PFE) or Kegel’s. PFE can be performed by tensing the muscle used to start and stop urination. Practice makes perfect and the effectiveness of these exercises are improved when assisted by a pelvic floor physical therapist that can be recommended for you.  Pelvic floor exercises may help you regain control of your urinary function earlier after your prostatectomy compared to if you did not do the exercises. Once you are several months to a year out from your procedure the exercises have less benefit so it’s in your best interest to start them early.

What is Considered Normal for the Number of Times per Day a Person Urinates?

This varies dramatically depending on how much the person drinks during the day, but a healthy person may urinate anywhere from 4 to 10 times per day. The average amount is from 6-7 times in a 24-hour period.

I had my prostate procedure performed 3-9 months ago, I am still having significant leakage. What are my options for treatment now?

Within a year from the surgery, it is beneficial to continue to perform PFE because there is no harm to doing them.  Your urologist will assess your leakage by pad use, degree of wetness, pad weights over a 24-hour period, and voiding diary.  A small camera may be placed into your bladder to assess the sphincter and make sure there is not a blockage in the urethra. Often times you can have more than one type of leakage, especially if you are leaking at night. If you are identified as having urge leakage, medications and lifestyle changes may resolve your leakage.  If the main component of your leakage occurs with cough, sneeze or activity then there are multiple options.

Therapies are directed at treating the cause of the urinary leakage versus managing the leakage.   Pads, diapers, clamps, and condom catheters may be used but do not really affect the volume of leakage. These options are temporary solutions and can be used if you have been experiencing slow improvements in your urinary control or are too unhealthy to trial other therapies.  The cost of diapers and pads can be significant; moving towards definitive therapy of your leakage may be in your best interest and will be discussed by your urologist.

Medications and procedures can be offered to effectively treat the cause of the leakage. Duloxetine, originally used to treat depression, has been known to help stress urinary leakage. Its use is off-label, and has the side effects of nausea, GI upset and insomnia.

Urethral bulking is a minimally invasive outpatient procedure, which has shown to be effective for stress-related leakage. While asleep a small scope is placed into the bladder and a bulking agent is placed into the sphincter to allow it to close better.  This is an option only in select cases of mild urinary leakage 6-12 months after their prostate cancer surgery.

It Has Been 1 Year or More Since my Prostate Cancer Procedure and I Am Still Bothered by My Leakage. What Can I do?

After one year of stress urinary leakage, the healing from the prostate surgery is likely done and increases in urinary control without treatment is very unlikely. Surgical management to correct the urinary leakage is the gold standard.  The procedural options include placement of a urinary sphincter, or sling placement.

Placement of an artificial urinary sphincter (AUS) is the gold standard for treatment of stress urinary leakage.  This device is very successful at treating all degrees of stress urinary leakage, mild to severe.  The AUS is a mechanical implant that has several components including an inflatable ring placed around your urethra that acts as your urinary control mechanism, a pump placed in your scrotum that controls opening of the ring and a balloon that is placed behind your abdominal wall that holds salt water to inflate the ring.

All the components are placed within your body and are completely concealed. When you want to urinate the pump is pressed and the inflatable ring deflates allowing urine to freely pass out of your system. Over time the ring reinflates with the salt water allowing no further leakage to occur when active.  The device is usually implanted while you are completely asleep and involves a less than 23-hour hospital stay.  Risks of infection of the implant requiring removal, bleeding, erosion, and urinary retention are quite uncommon and can be discussed further during your consultation.

If you are found to have mild to moderate urinary leakage based on your pad use you may be a candidate for urethral sling placed. The urethral sling is a piece of mesh that acts as a hammock compressing and elevating the urethra back into a more normal position. The advantage of the sling is that there are no moving parts and there is no chance it can fail due to malfunction. The sling is placed through a small 4-5 cm incision between your scrotum and anus.  Placement requires placement while you are completely asleep and involves a less than 23-hour hospital stay.  Risks of infection, bleeding, erosion, thigh pain, and urinary retention are quite uncommon and can be discussed further during your consultation.

There are two types of slings produced for male urinary incontinence the AMS Advance Sling and the Coloplast Virtue Sling. The Virtue sling differs from the Advance sling because it has four arms instead of two arms. The theorized benefit of the Virtue Sling is that it compresses the urethra better and it is placed outside the muscle over the urethra lessening the chance of erosion; however, there has been no head to head trials comparing the two for effectiveness.

How is Incontinence Treated after Prostate Surgery?

Prostate surgical methods are improving with the goal of limiting damage to the sphincter muscles around the urethra. Surgeons try to save as much of the area around the bladder and the urethra sphincter muscles as possible. The process of placing radioactive seeds into the prostate has also advanced to where it is more precise and causes less damage to the bladder.

Still, urinary incontinence is a likely side effect after prostate surgery. Here are some of the treatment methods for addressing it.

• Pelvic floor exercises — Also called Kegel exercises, these exercises target the muscles you squeeze when trying to stop urinating. These can become weakened after surgery, so strengthening them can help limit incontinence.
• Supportive care — These are behavior modifications, such as avoiding caffeine, alcohol, spicy foods, drinking less fluid, and not drinking before bedtime. Changing medications can help, as can weight loss and becoming more active.
• Medication — Various medications can increase bladder capacity and decrease the frequency of urination. Other medications are in the pipeline to specifically target urinary leakage.
• Artificial sphincter — This is a three-part device consisting of a pump, a pressure-regulating balloon, and a cuff that encircles the urethra and prevents urine from leaking.
• Bulbourethral sling — A sling is made from a synthetic material or from the patient’s tissue and is used to create the urethral compression necessary to control the bladder.
• Other surgery, injections, and devices — There are other options, such as surgery to place rubber rings around the tip of the bladder to hold urine, and these keep evolving. Our Urologists can discuss the latest options with you that fit your situation.

I Have Undergone Radiation after my Prostate Cancer Surgery. Does that Change my Chances of Improving my Leakage through Surgery?

Yes, it usually does. The effectiveness of urinary slings to treat urinary leakage after prostate surgery with radiation is around 50%. Artificial urinary sphincters work well in the setting of radiation but your surgeon may have to place the AUS in a different position or perform other maneuvers to minimize the chance of device erosion which is higher after radiation.

What is the Next Step?

Many men undergo prostate cancer treatments live a different kind of life after treatment due to the side effects of urinary leakage and erectile dysfunction.  Unfortunately, many men may suffer alone with the avoidance of social situations and intimacy due to the emotional impact these conditions have. Seeking professional help from urological experts who can manage the complex side effects of prostate cancer surgery may allow you to return to normal function.

Erlanger Men’s Health offers state-of-the-art treatments for persistent urinary leakage and ED after surgery. We provide a comfortable setting where your quality of life issues will be managed at your pace. Our mission is to help you re-engage in social situations and normal activity that may be avoided due to urinary leakage.