Preparing for male stress urinary incontinence treatment

Urinary incontinence is any unexpected leaking of urine from your bladder that you cannot control. There are many types of urinary incontinence.

Stress urinary incontinence is leaking caused by the stress, or pressure, that you put on your bladder when you:

• Sneeze
• Cough
• Lift something
• Laugh

Other types of urinary incontinence are:

Urge urinary incontinence

This happens when you have a strong urge to urinate (pee). You may not be able to wait until you get to a restroom. This is also called overactive bladder leading to incontinence.

Overflow incontinence

You cannot empty your bladder, causing a backup of urine. Small amounts of urine leave the bladder in an uncontrolled way.

The urethra is the tube that carries urine from the bladder to the penis. The male urethra has 2 sphincters that control the flow of urine.

If one sphincter is damaged, the other is often strong enough to stop major leaks. If both sphincters are damaged, urine can flow freely out of the bladder. This leads to stress urinary incontinence.

The most common causes of damaged sphincters are:

Radical prostatectomy

This is the most common cause of severe stress urinary incontinence. Incontinence can slowly get better in the early months after prostate surgery. This improvement often stops after about 6 to 12 months.

Transurethral surgery

Incontinence is common after a transurethral resection of the prostate (TURP) or prostate enucleation (TUBE). This can be temporary. For some patients it is permanent.

Radiation therapy

This most often follows treatment for prostate cancer. Any major radiation therapy in the pelvis can damage the sphincters. Transurethral procedures or traumatic catheterization after radiation treatment can lead to incontinence. Successful treatment of a severe stricture (narrowing) at the membranous urethra (external sphincter) can also lead to incontinence.

Radiation therapy effects can happen years after the 1st therapy.

External trauma

Major pelvic trauma can lead to urinary incontinence if both sphincters are damaged. This is rare.

Stress urinary incontinence can cause urine leaks during physical activity, such as:

• Changing position to stand
• Coughing
• Sneezing
• Reaching for an object
• Physically straining

Some people with very severe incontinence will leak at all times. You may feel like you cannot keep doing normal activities of daily life. This can lead to embarrassment and, in some cases, depression.

Some people with severe leakage suffer from skin irritation and breakdown.

First, you must decide on your treatment goals and how much the condition is bothering you.

Treatment plans can have:

Observation

If mild stress incontinence does not bother you, you and your doctor may decide that you do not need to treat it right away. This approach is called observation.

Your care team can help you find things to change without medicine or surgery. These could be changes to your lifestyle, such as not drinking a lot of fluid during key times of the day.

If you also have urge incontinence, you may want to avoid:

• Alcohol
• Caffeine
• Spicy food
• Other inflammatory items

Products like urinary pad liners and adult diapers can also help. They absorb urine and stop leakage from reaching your clothing.

Pelvic floor physical therapy

You may be sent to see a pelvic floor physical therapist. They diagnose and treat pelvic floor dysfunction.

Pelvic floor physical therapy is a common 1st step before trying surgery. It often involves a series of exams, teaching sessions, and at-home exercises to help lessen incontinence.

Condom catheter

A thin plastic device is worn over the penis like a condom. It collects leaked urine in a drainage bag. This is a noninvasive treatment. This means it does not go into the body.

It can be hard to put on and keep on a condom catheter. It can also cause skin irritation and breakdown from urine leakage.

Incontinence penile clamp

This is a noninvasive tool used to limit urinary incontinence. They can be worn temporarily. They are most often worn during physical activity. The penis is gently sandwiched between two soft pads. This stops urine from leaving the penis during activity.

The device is often moved up or down the shaft every 2 hours. Do not use it at night while sleeping.

Foley catheter drainage of the bladder

A catheter is put in to drain the bladder. It is placed through the urethra or through the suprapubic region (above the pubic bone). A suprapubic catheter is often put in during a short surgery.

These tubes need to be changed each month. Incontinence often gets better but is not cured.

Catheter placements raise the risk of a urinary tract infection (UTI). A urethral catheter also can cause urethral erosion. This is when the underside of the penis is worn away by the tubing.

These are not great long-term solutions. They are often only for people who cannot or do not want more involved surgery.

Male urethral sling

This is a surgical option for mild to moderate stress urinary incontinence (those who use less than 3 pads each day).

An incision (cut) is made under the scrotum. Then, 2 small incisions are made in the groin. A special mesh sling is put in. It is used to change the position of the urethra. This lessens incontinence.

You may have a catheter put in during the surgery. The catheter is removed the day after surgery. Most patients are discharged on the day after surgery.

The sling works right away after catheter removal. It does not need activation.

A urethral sling does not stop you from having an artificial urinary sphincter placement later. You should not get a urethral sling if you have severe incontinence or have had pelvic radiation therapy.

Artificial urinary sphincter

An artificial urinary sphincter can be a good choice for those who have:

• Moderate to severe stress urinary incontinence
• Had radiation therapy

It is put in using 2 incisions — 1 below the scrotum and 1 in the groin.

There are 3 parts that work together to keep urine from leaking out of the bladder:

• Artificial sphincter: This is a cuff that wraps around the urethra. When filled with fluid, it expands to gently squeeze the urethra. This lessens the amount of urine leaking out of the bladder.
• Fluid reservoir: This is placed in the pelvis. It holds the fluid that fills the artificial sphincter.
• Activation pump: This small pump is placed in the scrotum. It moves fluid between the reservoir and the sphincter.

To urinate, you press the activation pump in the scrotum. The pump moves fluid from the cuff to the reservoir. This opens the urethra so that urine can flow freely from the bladder and out of the penis. The pump then moves the fluid back into the cuff so that it expands again.

This device is not ideal for people with:

• Neurologic diseases
• Other conditions that affect hand dexterity and strength

Incontinence often gets better but is not cured. Most people still use at least 1 pad each day.

This procedure has a higher complication and revision surgery rate compared to the urethral sling.

You and your urologist will talk about your condition and your goals. To help make the best decision, your urologist may need more details. These can only be collected through testing.

Some of the tests you might need are:

Bladder volume index/post-void residual

This test uses a small ultrasound probe. It measures residual (leftover) urine in your bladder after you have urinated.

Cystoscopy

This procedure is done in the office. Lidocaine jelly is put into the urethra. Your surgeon then places a small, flexible telescope into the urethra and bladder. There is little to no pain and it only takes a few minutes.

Urodynamics

This test fills your bladder with saline using a small catheter. It checks the size of your bladder and the pressure within your bladder. This is an outpatient procedure. You will not need sedation (anesthesia).

You will need to do pre-operative testing before surgery. These tests may be:

• Electrocardiogram (ECG/EKG): Checks if your heart is healthy enough for surgery.
• Blood test: Checks if your supporting organs (kidney, liver, and intestines) are working the right way. Checks that your blood levels (hemoglobin, hematocrit) are high enough.
• Chest X-ray: Checks if your lungs are healthy enough for surgery.
• Medicine review: Makes sure your blood pressure is controlled. Also checks to see if medicines that can lead to bleeding (Coumadin, aspirin, clopidogrel) are stopped before surgery.

You will need to stop using tobacco products before surgery. These could be:

• Cigarettes
• Chewing tobacco
• Vaping products
• Nicotine gum

You may need to do a urine test on the day of surgery to confirm this.

In the weeks before your surgery date, you will get general details of the time and location of your surgery. You will get a phone call within 2 business days of your surgery date to tell you the exact time to come.

Call 319-384-8008 if:

• It is less than 2 business days before surgery and you have not gotten a phone call
• You have questions

This varies based on the type of surgery.

For suprapubic tube placement, the procedure takes under 1 hour. For a male sling or artificial urinary sphincter placement, the procedure often lasts 1 to 2 hours.

It will also take about 1 hour to:

1. Give you anesthesia
2. Position you for surgery
3. Wake up

Complications vary based on the type of procedure. Major complications are rare for urethral surgery.

Bleeding

This is common after urethral surgery. There is often a small amount of blood from the incision. You may also have mild bruising in the scrotum and perineum.

Infection

All patients get antibiotics before surgery. This has been shown to lower the risk of surgical-site infection. Infections after urology procedures can happen in the incision or in the urine. They are often seen 3 days after surgery. You may have fever, chills, and redness around the wound.

Infections after a prosthetic material has been put in the body is very concerning. If the device is infected, we will need to remove and replace it later.

Urethral erosion

This often happens with an artificial urinary sphincter. It involves slow erosion or wearing down of the urethral tissue by the device. This can lead to:

• The device not working as it did before
• Pain in the pelvis or perineum
• Redness
• UTIs

Device malfunction

Over time, parts of the artificial urinary sphincter device can break down and stop working. If this happens, you will need another surgery to replace part or all of the device.

Neurologic injury or positioning injury

When positioning you for surgery, the care team places pads at pressure points on the body. Your arms and legs are placed in a way that does not lead to nerve injury.

Neurologic injuries can still happen. Most injuries will heal in the days or weeks after surgery. Some may need more intense rehabilitation. Almost all injuries will heal with time and rehab. Neurologic injuries are more common:

• After longer operations
• In patients with obesity

Persistent incontinence

Most patients will see major improvement in the degree of their urinary incontinence. Some may not.

Most patients stay 1 night in the hospital.

For both an artificial urinary sphincter and a male sling, you will have a single midline incision in the perineum under the scrotum. This is often around 7 cm in length. All sutures will dissolve on their own as your body heals.

If you are getting a male sling, you will have 2 tiny incisions in the groin.

If you are getting an artificial urinary sphincter, you will have a slightly larger incision on 1 side of the upper scrotum or groin.

You will have a catheter to drain your bladder. Most patients will have their urethral catheter taken out the day after surgery.

Pain medicine

Most patients only need a few days of narcotic (morphine-based) medicines after discharge.

Stool softeners

Surgical anesthesia, pain, and pain medicines slow down the intestinal tract. Stool softeners help to maintain regular bowel habits.

Antibiotics

Most patients only need antibiotics at the time of surgery. You will not be prescribed antibiotics at discharge.
 

1st post-operative visit: You will return to the clinic 2 to 3 weeks after surgery. Your care team will check to see if you are healing well.

2nd post-operative visit: If you had an artificial urinary sphincter placed, you will return 6 weeks after surgery for device activation. At that visit, your care team will go over proper cycling of the device. They will make sure that you understand how to use the device.

If you had a urethral sling placed, your clinic visit will be 2 to 3 months after surgery.

Other office visits: If you had an artificial urinary sphincter placed, you will return 3 to 4 months later. The care team will monitor your health and review proper operation of the device.

If you had a sling placed and can empty your bladder well, you will return to the clinic 1 year after surgery.

If you have new or worsening urinary symptoms between normal visits, contact us right away. We can decide if you should be seen sooner.

New or worsening symptoms may be:

• Decreased urinary stream
• UTIs
• Urinary retention
• Straining to urinate or not able to empty your bladder
• Sudden worsening of urinary incontinence
• Fever or chills
• Pain in your pelvic, scrotum, or perineum

These surgeries improve incontinence. They do not always “cure” the urinary leakage.

If you had a urethral sling placed, you will often know your new level of dryness after the catheter is taken out.

If you had an artificial urinary sphincter placed, you will need to wait 6 weeks before the device is activated.

If your incontinence gets worse after surgery, return to the clinic for an evaluation.