Department of Urology

Illnesses We Treat

Male Urinary Incontinence

What does this mean?

Men with urinary incontinence have difficulty controlling the passage of urine. It is normal for most men to have a small amount of leakage, especially right after urinating. However, when the leakage becomes more severe, many will seek the opinion of a urologist.

Causes:

Urinary incontinence is caused by three main problems:

• A weak urinary sphincter or stress incontinence
• An overactive bladder or urge incontinence
• A bladder that does not contract or overflow incontinence

• Nerve problems - spinal cord injury, stroke, Parkinson’s disease, multiple sclerosis, diabetes.
• Prostate problems - enlarged prostate or benign prostatic hyperplasia (BPH), after prostate surgery or radiation therapy.

Evaluation – what to expect:

• History and physical – your doctor will ask you many questions regarding your medical history, including medications you are taking, past surgeries and major illnesses. A physical exam also provides important information. Usually, a rectal exam is performed to evaluate the size and consistency of the prostate gland.
• Urinalysis and urine culture are performed to look for a urinary tract infection
• Uroflow and PVR – These are tests of how well you are able to empty your bladder. You will be asked to urinate in a special machine that measures the flow rate and afterward, the amount of urine left in your bladder will be checked with a bladder scanner.
• 24 hour pad test – by collecting your urinary pads over a 24 hour period, your doctor can determine how much urine loss you are having
• Ultrasound –Abdominal ultrasound is a test used to evaluate the shape of the kidneys and urinary bladder. Transrectal ultrasound is used to evaluate the prostate.
• Urodynamics - Video urodynamics is a test where a small catheter is placed in the bladder, which is filled with a water-based dye that can be seen on x-ray. Pressures in the bladder are measured during filling and voiding and x-rays are taken at various points in the study. A bladder stress test is performed to see if the sphincter is weak.
• Cystoscopy is an endoscopic look inside the bladder.

Management and treatment:
Treatment is based mostly on the severity of the incontinence and how much it affects your lifestyle. Sometimes, symptoms can be alleviated by simple measures like diet changes, decreases in fluid intake or exercises to increase the pelvic muscle strength. When these things don’t work, many men will choose to try medications or even surgery.

• Behavioral therapy - Bladder training or timed voiding is scheduled bathroom trips instead of waiting for the urge to urinate. Kegels or pelvic floor exercises to strengthen the muscles involved with continence can be moderately helpful for men with lower degrees of incontinence, especially right after prostate surgery. For men who have difficulty locating their pelvic floor muscles to do the exercises, a dedicated biofeedback regimen with a nurse or physiatrist can sometimes be helpful.
• Medications for stress incontinence:
• Sudafed, which is used to treat cold symptoms, has been prescribed to treat the condition. However, the dosage required to obtain the desired effect is often very high and can be accompanied by unwanted side effects like elevated blood pressure.
• Imiprimine, a drug that is used in the treatment of depression, is mildly effective in stress incontinence
• Newer medications more specific to the treatment of stress incontinence are on the horizon but are not yet FDA approved
• Medications for urge incontinence:
• anticholinergics - these drugs work by relaxing the bladder and decreasing involuntary bladder contractions. With the trade names of Ditropan® XL, Detrol® LA and Oxytrol®, which differ mostly upon their delivery systems, these drugs are effective in about 60 percent of patients. Their most common side effects are dry mouth and constipation. They should not be used in patients with certain types of glaucoma or in Alzheimer’s disease.
• Alpha-blockers - these drugs work by relaxing the muscle fibers in the prostate and bladder neck in men who have BPH, allowing better flow of urine. Common drugs are Flomax®, Hytrin®, Cardura® and Uroxatral®.
• 5-alpha reductase inhibitors – drugs such as Proscar® and Avodart® work by shrinking the prostate in men with large, obstructing glands.
• Catheters - In men who cannot empty their bladders spontaneously, either because of a weakened bladder or an obstruction, clean intermittent catheterization can be performed. A small tube is used to drain the urine at regular intervals throughout the day. Alternatively, and indwelling catheter can be placed which is changed once a month. In men who have total incontinence because of a weak sphincter, a condom catheter can be placed over the penis to drain the urine.
• Neuromodualtion or Interstim® therapy - is a technique used in the treatment of refractory urgency, frequency and urge incontinence. A pacemaker-like device is inserted to stimulate the nerves leading to the bladder and pelvic floor muscles. A test stimulation is performed before the device is implanted to see if there is a benefit.
• Botox injection - Botox therapy has been used for the treatment of refractory urge incontinence. Most of the studies so far have been on patients with neurologic problems and it is not yet FDA approved for use in the bladder although there will soon be clinical trials.
• Periurethral injections - This is a procedure in which collagen or a similar agent is injected into the urinary sphincter through a cystoscope. It is relatively easy to do, but it is more likely to produce improvement in symptoms rather than cure. Also, most patients will require multiple injections to improve and will need maintenance injections at least once a year. Because collagen can produce an allergic reaction in some patients, it is necessary to perform a collagen skin test at least one month prior to injection.
• Male sling - In men with post-prostatectomy incontinence, the placement of a piece of synthetic material underneath the urethra that compresses it against the pubic bone is a surgical option. It is a procedure that does not require an overnight stay in the hospital. Generally, men with lower degrees of incontinence are good candidates for the sling.
• Artificial Urinary Sphincter - Also for men with post-prostatectomy incontinence, this is the most time-tested surgery. A device is implanted which circumferentially compresses the urethra and keeps it closed until you are ready to urinate. By squeezing a pump, which sits in the scrotum, the cuff is emptied for long enough for you to urinate, and then it refills to close the urethra again.

For more information or to make an apppointment please contact:

Nicole B. Fleischmann, M.D.
Thomas Grimaldi, M.D.
Department of Urology
5 East 98th St., Box 1272
New York, NY 10029
Tel: (212) 241-4812