Surgical options for urinary leakage in men

Urinary incontinence takes many forms, including these three main types:

• Stress incontinence — due to leakage with activities, such as lifting, climbing stairs or strenuous activity
• Urge incontinence — related to leakage associated with the feeling or urge to urinate
• Mixed incontinence — a combination of the stress and urge incontinence

Stress urinary incontinence is a possible side effect of prostate cancer surgery and can have negative effects on a patient's quality of life. Up to 10% of men may experience some degree of stress incontinence after their surgery.

Stress incontinence in men

Stress incontinence in men after prostate surgery is due to multiple factors related to the patient's anatomy, prostate cancer and the surgery performed. Ultimately, this leads to a weakened sphincter muscle and laxity of the pelvic floor. The sphincter muscles control the release of urine, and the urethra is the small tube that empties the bladder. A prostatectomy procedure removes some of the control provided by the prostate and bladder, making the patient reliant solely on the external sphincter muscle.

Normally, the sphincter remains closed as the bladder fills with urine until you can reach a restroom. The weakened muscles and relaxed pelvic floor have trouble holding urine, so any movement that exerts a force on the abdominal and pelvic muscles puts pressure on the bladder and can cause leakage. This force could be sneezing, bending over, lifting or even laughing.

Stress incontinence symptoms that begin after prostate surgery may resolve on their own with time and pelvic physical therapy. Usually, patients can see continued improvement for 12 months after surgery and try nonsurgical treatments, such as physical therapy, before considering surgical treatment options, such as male urethral slings and artificial urinary sphincters.

Male urethral slings

Male urethral slings are indicated for men with mild to moderate stress urinary incontinence, which is defined as using one to four pads per day. The surgeon uses a synthetic mesh material to create a sling, or hammock, to support and pull the urethra and pelvic floor back toward their original locations. Some slings also provide compression support for the sphincter muscles.

A cystoscopy test will be needed before the surgery to confirm that the sphincter muscles are working.

Male urethral slings are performed as an outpatient procedure, and patients can go home the same day. Heavy lifting and strenuous exercise are restricted for about six weeks. Patients need to be careful climbing ladders and squatting for about three months after surgery because significant hip flexing can loosen the sling.

About 80% of men with male urethral slings see an improvement in their symptoms after surgery, with the majority of them no longer needing pads after surgery.

Artificial urinary sphincters

This surgical procedure is more invasive than male urethral slings and appropriate for men with severe stress incontinence, which is defined as using more than four pads per day. It's also a good option for patients who have damage to sphincter muscles from radiation therapy or a failed male urethral sling.

Artificial urinary sphincters placement has multiple components. A small cuff is placed around the urethra. This replaces the sphincter muscle's function. Tubes connect the cuff to a pressure-regulating balloon placed in the lower pelvic region and a pump in the scrotum. The pump is manually operated to open the cuff on the urethra and allow urine to be released from the body.

Some patients can go home the same day as surgery, while others will require an overnight hospital stay to recover.

After surgery, the artificial urinary sphincter isn't activated for about a month while the body heals. During this time, heavy lifting and exercise are restricted. Patients return to the clinic and are taught how to properly use the device. With proper training and consistent use, artificial urinary sphincters are effective at treating symptoms of severe stress urinary incontinence in men.

Talk with your health care team if you're experiencing urinary incontinence symptoms or are concerned about your prostate or urinary health.

David Yang, M.D., is a urologist in Mankato, Minnesota.