Treatment for Incontinence

Treatments for Urinary Incontinence

More than 2 million men experience urinary incontinence, a condition in which the muscle (sphincter) that holds the neck of the bladder closed is unable to retain urine in the bladder. This may occur when the sphincter is too weak, the bladder is not emptied regularly, or if the bladder muscles contract strongly. Urinary incontinence in men is typically related to a medical condition that involves the prostate gland, such as prostate cancer, benign prostatic hyperplasia, or prostatitis, and some of the treatments associated with these conditions, including surgical procedures, drugs, and radiation therapy.

For example, urinary incontinence is infrequently a side effect of radiation therapy for prostate cancer, a side effect of prostatectomy for prostate cancer or BPH, and following TURP for BPH. Urinary incontinence can appear in several forms. The most common type of incontinence men experience after treatment for prostate cancer is stress incontinence, which is the accidental release of urinary when pressure is applied to the bladder, as when someone coughs or lifts a heavy object. Urge incontinence is characterized by a bladder that contracts at the wrong time, making men feel like they have to urinate even if their bladder is empty. In men who have overflow incontinence, leakage occurs when the bladder does not empty properly. This can be associated with BPH or narrowing of the urethra. Total incontinence is defined as a complete inability of the sphincter to hold back urine.

Medications for Urinary Incontinence

Medications in several different categories can be helpful in alleviating mild to moderate urinary incontinence. Men can use medications alone or in combination with other strategies.

• Alpha-1-adrenergic blocking agents: These drugs are prescribed to treat BPH, which presses against the urethra and may cause incontinence. Drugs include doxazosin mesylate (Cardura), tamulosin (Flomax), and terazosin hydrochloride (Hytrin). Side effects include dizziness, fatigue, and headache.

• Anticholinergic agents (some also referred to as antimuscarinics): These drugs decrease involuntary bladder muscle contractions and are helpful with urge incontinence. Examples include darifenacin (Enablex), fesoterodine (Toviaz), flavoxate (Urispas), hyoscyamine sulfate (Levbid), oxybutynin chloride (Ditropan XL), propantheline (Pro-Banthine), solifenacin succinate (Vesicare), tolerodine (Detrol), and trospium chloride (Sanctura). Side effects may include blurry vision, constipation, dry mouth, and headache.

• 5-alpha reductase inhibitors: These drugs are also used to treat BPH. The two current drugs in this category are dutasteride (Avodart) and finasteride (Proscar). Side effects include breast enlargement, erectile dysfunction, and low sperm count.
• Tricyclic antidepressants: These medications block nerve impulses and reduce urinary muscle spasms, and are effective for stress incontinence. Examples include desipramine hydrochloride (Norpramin), doxepin hydrochloride (Sinequan), imipramine (Tofranil), and nortryptyline (Pamelor). Side effects include appetite changes, blurry vision, dizziness, and dry mouth.

Herbal and Natural Remedies

A number of natural and herbal remedies may be helpful as complementary treatment for urinary incontinence. Many of the remedies have been shown to be beneficial in promoting and maintaining urinary tract health and may also help those who suffer with urinary incontinence. Some of the more promising herbal and natural remedies for urinary incontinence include pollen, probiotics, saw palmetto, stinging nettle, and uva ursi, among others.

Collagen Injections

In mild cases of urinary incontinence, collagen injections may correct the problem. Collagen is a protein that can be injected around the bladder neck to fill out the neck and reduce bladder pressure and improve the function of the urinary muscles. Collagen injections may need to be repeated after several months to achieve bladder control.

Collection Devices

Occasionally men chose to use an external collection device, which is a combination of a condom-like object that is placed over the penis and held in place with Velcro. A tube goes from the device to a collection bag that can be worn strapped to the leg. Collection devices are usually used along with penile clamps and should not be tried immediately after surgery.

Catheters

Catheters are considered a short-term treatment option for urinary incontinence. Long-term use of a catheter can cause irritation and increases the risk of infection. There is also the possibility of loss of bladder muscle control if a catheter is used too long, which will make regaining urinary continence even more difficult to achieve.

Penile Clamps and Rings

Use of penile clamps and rings is typically reserved for severe cases of urinary incontinence. Penile clamps (e.g., Cunningham clamp) is a V-shaped casing with a cushion that is placed over the penis to prevent urine from leaking. Compression rings fit around the penis and are inflated to prevent leakage. Both of these devices must be removed every 2 to 3 hours so men can empty the bladder. Improper use of clamps and rings can result in damage to penile and urethral tissue and cause pain, swelling, and obstruction. They also can hinder the development of muscle control men need to regain urinary continence.

Pads

Absorbant pads and undergarments are among the most common ways to deal with urinary incontinence. Incontinent pads and undergarments, which are readily available from pharmacies and retail stores, are often worn right after surgery.

Lifestyle and Diet Modifications

Several lifestyle and dietary factors can reduce the risk as well as the symptoms associated with urinary incontinence. Being overweight places excess pressure on the bladder, and so losing weight can be helpful. Following a high-fiber diet that is rich in fresh fruits and vegetables, legumes, and whole grains is recommended to avoid constipation, as straining and excess pressure in the bowels can worsen urinary incontinence. Beverages that increase urinary frequency, such as alcohol, coffee, and other drinks that contain caffeine should be significantly limited or eliminated. Men who experience frequent nighttime urination should avoid drinking liquids at least 2 to 3 hours before going to bed.

See also

Lifestyle and Urinary Tract Infections

Exercise, BPH and Urinary Tract Infections

7 Natural Ways to Treat Urinary Incontinence

Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation can be used to retrain and strengthen weak urinary muscles and improve bladder control. Treatment involves inserting a probe into the anus, through which a mild electrical current is passed. This causes the muscles to contract. While the current is on, the patient is supposed to squeeze the muscles. After the muscle contracts, the current is turned off for up to 10 seconds, and the cycle is repeated. Treatment sessions usually last 20 to 30 minutes.

Behavioral Therapy

Behavioral therapy for male urinary incontinence includes several strategies, and men can use one or more along with other options as part of a program. Types of behavior therapy are:

• Biofeedback, which involves use of a simple device that records electrical signals that are produced when the urinary muscles contract. These signals are transformed into sounds or visual signs that patients can use to help them activate weak muscles on demand, relax tense muscles, and learn better muscle coordination.
• Bladder retraining, in which patients keep a diary of their urination and leakage episodes. This information can be analyzed by a physician to help patients learn how to empty the bladder before leakage occurs.
• Kegel exercises (pelvic floor muscle exercises), which consists of contracting and relaxing the muscles that make up part of the pelvic floor. These exercises are very effective at strengthening muscle tone in cases of urinary incontinence caused by poor muscle tone.

At the University of Alabama-Birmingham, researchers reported that a behavioral therapy program combining pelvic floor muscle training, bladder control methods, biofeedback, and pelvic floor electrical stimulation reduced the number of incontinence episodes by 55 percent among men who were still experiencing urinary incontinence from 1 to 17 years after prostatectomy. This was significantly better than the 24 percent reduction seen in a control group. The eight-week study evaluated 208 men, who were divided into three groups: controls (no intervention), behavioral therapy (bladder control methods and pelvic floor muscle training); or behavioral therapy plus biofeedback in the office and daily pelvic floor electrical stimulation at home.

Sixteen percent of the men in the intervention groups achieved complete urinary continence. Among the remaining men who participated in either of the behavioral therapy portions of the study, the reduction in urinary incontinence was 50 to 59 percent, although the men still averaged two episodes per day. The value of this study is that it demonstrated that men who still had urinary incontinence a year or more after prostatectomy could improve continence using behavioral intervention. (Goode 2011)

Artificial Urinary Sphincter

An artificial urinary sphincter is a device that prevents urinary leakage when the urinary sphincter no longer functions. This treatment option is typically reserved for severe incontinence that has not responded to other therapies. The device consists of three parts that are filled with saline: an inflatable cuff that is placed around the urethra, a balloon that is placed under the belly muscles, and a pump, which is implanted in the scrotum. The cuff is connected to the pump, which is implanted in the scrotum and is activated by pressing or squeezing a button. When the pump is turned on, the fluid in the cuff empties into the balloon, the urethra opens, and urine can leave the bladder. The cuff then automatically reinflates (refills with fluid) within about 90 seconds, and the urethra is closed, preventing any urinary leakage.

Before surgery, your doctor will advise you to stop taking any drugs that may increase the risk of bleeding (e.g., ibuprofen, warfarin), and you will need to fast for 6 to 12 hours.

The surgical procedure to implant the device takes about 30 minutes, after which men can expect to have a urinary catheter in place until they leave the hospital. It takes about 6 to 8 weeks to achieve urinary continence after surgery, and during that time men will still experience leakage. They also will be taught how to use the pump.

Getting an artificial urinary sphincter is generally safe, although because it is a surgical procedure there are some risks. These include infection at the site of the incision (in the scrotum), blood clots in the legs that may travel to the lungs, damage to the urethra or bladder, urine leakage that may get worse, difficulty emptying the bladder (which may require a catheter), and failure, wearing away, or infection that requires a surgical procedure to remove the device. An artificial urinary sphincter does not always eliminate urinary leakage, and over time some or all of the urinary incontinence may return. If this occurs, a new artificial sphincter will need to be implanted. (Staskin 2007) Generally, however, research indicates that 85 to 97 percent of men who had severe urinary incontinence following prostate surgery and who had an artificial urinary sphincter device had little (1 to 3 pads daily) or no leakage. Most studies report that 80 percent of men say their quality of life improved after receiving the artificial urinary sphincter. (Johns Hopkins prostatebulletin.com)

Male Suburethral Sling

For men who have mild to moderate urinary incontinence associated with a weak sphincter, especially following prostatectomy or TURP, a male suburethral sling may provide relief. A suburethral sling is also known as a bulbourethral sling because it is implanted under the bulbous urethra. One advantage of the male sling is that it requires a relatively short recovery time and only one small incision in the groin.

Before undergoing the surgery to place the sling, men may be asked to undergo a urodynamic study to determine their urinary tract function, as well as a 24-hour pad test to identify how many pads are used and the amount of urine leaked. Prior to surgery, men should refrain from using aspirin or any medications that may thin the blood. A fast from midnight before the day of the surgery is required.

The sling is composed of polypropylene mesh and it elevates and applies gentle compression against the urethra to reduce urine leakage. This procedure can be done on an outpatient basis, and most men recover completely from placement of the sling within 4 to 6 weeks, during which time men need to refrain from heavy lifting. Men can expect to experience some pain in the immediate post-operative period. Some patients achieve complete elimination of urinary incontinence after placement of the sling, while others see an improvement but still experience some leakage.

Complications associated with placement of a urethral sling are rare, but they may include bleeding, infection, erosion of the sling, an inability to urinate, or recurrent leakage. After the procedure, men typically need to have a catheter until swelling subsides.

Botox for Incontinence

The Food and Drug Administration has approved Botox (onabotulinumtoxin A) for treatment of urinary incontinence that is the result of a neurologic condition, such as multiple sclerosis or a spinal cord injury, in adults who have not responded to or who cannot tolerate anticholinergic medications. Currently, the FDA approval does not extend to other causes of urinary incontinence.

Botox is the trade name for botulinum toxin, a protein produced by the bacterium Clostridium botulinum, and the most potent neurotoxin discovered thus far. The most popular uses for Botox include relaxing facial wrinkles, although it has also been approved to treat excessive sweating, chronic migraines, and other conditions.

The newest approval was partly based on the success seen in two placebo-controlled Phase III clinical studies involving 691 patients with urinary incontinence related to multiple sclerosis or spinal cord injuries. In both studies, patients who received Botox experienced a significant reduction in the frequency of incontinence episodes when compared with patients who received placebo.

The treatment involves injecting Botox into the bladder, which causes the bladder to relax and to increase its storage capacity. Doctors inject Botox with the assistance of a cystoscope, which allows them to see the interior of the bladder before they make the injection. The Botox injection is effective in reducing urinary incontinence for up to 10 months before retreatment is necessary.

Botox injections are not without side effects. The most common adverse reactions reported following initial injection were urinary tract infections (49%), urinary retention (17%), fatigue (6%), constipation (4%), and muscle weakness (4%).

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References

Cleveland Clinic: http://my.clevelandclinic.org/services/sling_procedure/hic_male_sling_procedure_for_urinary_incontinence.aspx

Goode PS et al. Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for persistent postprostatectomy incontinence: a randomized controlled trial. JAMA 2011 Jan 12; 305(2): 151-59

Johns Hopkins. Prostate Disorders

Johns Hopkins: www.prostatebulletin.com

Staskin DR, Comiter CV. Surgical treatment of male sphincteric urinary incontinence: the male perineal sling and artificial urinary sphincter. In Wein AJ et al. Campbell-Walsh Urology. Philadelphia: Saunders Elsevier, 2007.