What Every Man Should Know

What Every Man Should Know

Urinary Incontinence is the accidental leakage of urine. This condition affects people of all ages in the United States. It is estimated that approximately 25 million adults nationwide suffer from this medical problem. Therefore, if you or a loved one are affected by urinary incontinence, you should know that you are not alone. It is not an inevitable part of the aging process. Urinary incontinence is a treatable condition in the large majority of circumstances.

Although women have a higher chance of experiencing incontinence, the loss of bladder control is relatively common among men. Studies suggest that 5 to 15% of men living at home above the age of 60, and 2 to 15 % of men between the ages of 15 to 64, are affected by incontinence. Among younger men, the condition is often related to prostate cancer surgery. Approximately half of all men who undergo prostate removal surgery because of prostate cancer will experience leakage of urine during the first six weeks after surgery. At the end of the first year, about 20% will continue having a significant problem with leakage, or stress urinary incontinence.

As men age, the prostate gland grows. It is estimated that 17 million men have an enlarged prostate, or symptoms of Benign Prostate Hyperplasia (BPH). This is a medical term that simply means a non-cancerous enlargement of the prostate. The prostate gland wraps around the urethra (the bladder outlet), so an enlarged prostate can constrict or block the urethra. This is known as prostatic obstruction. Prostatic obstruction can compromise the bladder’s ability to effectively empty, causing chronic retention of urine. This contributes to urgency and frequency because the bladder still signals that it needs emptying. If left untreated, the bladder can become distended, worsening its ability to contract and completely empty. It is possible to have prostatic obstruction even if the prostate is not enlarged.

Men can also experience overactive bladder (OAB), with the sudden and urgent need to urinate, having to urinate frequently, and even having to get up at night to go to the bathroom. This affects approximately 33 to 34 million adults in the U.S., men as well as women. Among these, around nine million have accidents, or episodes of urgency urinary incontinence, because they are not able to reach the bathroom before losing control of their bladder. OAB in older women often results in incontinence, whereas men are more likely to be bothered by frequency of urination. This can be further aggravated by an enlarged prostate. For this reason, men may be prescribed a combination of drugs aimed at treating symptoms of OAB and BPH.

Incontinence and problems with urination in themselves are not diseases; they are symptoms that can have many causes. It is important to understand that there’s no reason why incontinence or any difficulty with urinating has to be accepted as if it were something that has no remedy. There are many solutions. The first step is to become educated, in order to be able to understand the condition and evaluate the resources available to address it.

You should seek treatment for your bladder control problem when you are not able to control your bladder or bowel as you once did or when the frequency or urgency to urinate is interfering with the quality of your life.

Side Male Anatomy
The Most Important Thing Is To Understand

By gaining understanding of your problem, you will be able to:

  • Know how to talk about your symptoms and get the most accurate diagnosis from your doctor.
  • Choose among treatment options and discuss them with your doctor.
  • Ask questions and understand the answers you get from your healthcare provider.
  • Be in a better position to protect your health and quality of life, hold the job that you want to keep, and maintain your relationships with friends and family.

Knowledge Is Power
In order to understand the causes of urinary incontinence or problems with urination, it is necessary to learn a little bit about how the bladder and the urinary system work:

  • Normally, the bladder is like a bag that has two functions. One is to store urine. The second is to contract and squeeze out the urine when you are ready to empty the bladder. The sphincter muscle is responsible for maintaining the closure of the urethra and surrounds the exit to the bladder at its connection with the urethra. The urethra is the tube that passes through the prostate and then through the penis where it ultimately exits near the tip at the meatus.
  • Sometimes this mechanism suffers damage at some point. If the damage to the sphincter is severe enough, or if the bladder becomes overactive and contracts
    at the wrong time, urine can leak out of the bladder, causing incontinence.
  • If the prostate gland increases in size as a man grows older, it can block the flow of urine. This prostatic obstruction may cause symptoms of sudden urgency to urinate, frequent urination, and a hesitant or weak stream of urine. Incomplete emptying of the bladder may worsen the frequency of urination. These symptoms can also occur even if the prostate is not enlarged.
Male Urinary System

As they age, men also have a greater tendency to experience an overactive bladder. Since the symptoms of urgency and frequency are similar to those caused by prostatic obstruction, it can be difficult for doctors to differentiate the diagnosis. It is possible for these conditions to be occurring at the same time. While men have the same probability as women of having symptoms of an overactive bladder, they typically have fewer accidents (not being able to reach the toilet before losing control of the bladder) than women. This is because pelvic muscle support is often weaker in women due to childbirth.

Overactive bladder symptoms can be caused by many other conditions like bladder or prostate infection, kidney stones, bladder cancer and nerve damage. Nerve damage caused by diseases such as diabetes, Parkinson’s disease, multiple sclerosis, or stroke can cause interruptions of the signals between the bladder and the brain. This can result in overactive bladder symptoms of urgency, frequency and incontinence. Another causal factor for leakage is obesity, which affects both genders, underscoring still another reason to maintain a healthy weight.

What to Expect at a Doctor’s Appointment

When first seeking treatment, expect your healthcare provider to be concerned about your complaint and to be attentive to the information you bring. Be prepared to give a complete history, have a complete physical examination, and give a urine specimen with testing afterwards to see if there is still urine in the bladder. This is done with a small sensor placed over the lower abdomen. A sample of blood may also be taken.

The doctor may begin treatment immediately or do some other tests. He/she may ask you to complete a diary about your bladder symptoms and undergo a pad test if you are incontinent to determine the severity of your leakage. Other tests including urodynamics and cystoscopy might be necessary. Urodynamics are done by passing a small tube via the urethra into the bladder to see how the bladder acts during filling and emptying. Cystoscopy uses a flexible scope to examine the inside of the bladder and the prostate. The reason and the potential for complications for all tests should be explained. You should know when and how you will get the results. Once the specialist has made a diagnosis of the bladder or bowel problem, expect to have the treatment choices explained, with the risks and benefits and estimated cost of each option.

Actively participating in your own care gives the best results. Treatment will be most successful when you help to choose the solution and are responsible for record-keeping, going to the toilet regularly, drinking the recommended amount and types of fluids, and performing pelvic floor muscle exercises. Report any side effects of medicines or treatments and discuss any concerns about treatment with your healthcare provider.

Diagnosis and Treatment Options
There are several types of urinary incontinence and problems with urination. An enlarged prostate and weakened bladder is associated with difficulty in emptying the bladder or retention.

Among the symptoms are:

  • Diminished or interrupted urine flow
  • Urgent and sudden need to urinate
  • Increased frequency of urination
  • Inability to empty the bladder completely when urinating
  • Difficulty in starting the urine flow, even when the bladder feels full.

Treatment options for retention in men caused by an enlarged prostate include:

  • Medications to reduce the severity of symptoms, improve the flow of urine and reduce the size of the prostate;
  • Minimally invasive treatment in a doctor’s office or surgery that does not require spending the night at a hospital (such as the use of microwave energy or low frequency radio waves), typically requiring a few days off work to recover; or
  • Surgery that is done in an operating room and might require an overnight hospital stay and additional time afterwards to recover.

A second category of problems is OAB, including urgency incontinence. Among the symptoms are:

  • Urgent and sudden urge to urinate
  • Increased frequency of urination
  • Getting up at night to urinate, or nocturia
  • Loss of urine when you can’t get to the
    toilet in time to prevent an accident

Treatment Options for OAB:

Note that some of the symptoms are the same in BPH and overactive bladder. Some men could have both conditions. It could be difficult to isolate the diagnoses and prescribe the correct treatment. The most common cause of these symptoms is prostatic obstruction, and the most effective treatment is surgery to relieve the obstruction, although increasingly less invasive procedures are available for removing excess tissue. Non-surgical treatment for OAB may include a combination of behavioral management (diet, bladder re-training, and pelvic floor muscle exercises) along with medication.

When medication is not satisfactory or effective, men may consider electrical stimulation of leg nerves, or in more severe cases, the implant of a device like a heart pacemaker. The device is called InterStim®. These treatments seek to establish more normal function of the bladder.

Treatment Options for Post- Prostatectomy Incontinence

Still another category of urine control problems follows prostate cancer surgery. When the prostate gland is removed, damage may occur to nerves, tissues, and the sphincter muscle that can impair the bladder's ability to store urine without leaking. When this occurs, there are various levels of intervention, depending on the severity and duration of the post-operative symptoms.

Pelvic muscle exercises, also called Kegel exercises or PMEs, are an important part of the behavioral treatment techniques that help increase bladder control and decrease bladder leakage. Research shows that men who do PMEs prior to surgery for prostate cancer are more likely to recover complete control over their bladder within six months. After surgery, pelvic muscle exercises help as well. Furthermore, they are important for maintaining sexual vitality and regaining erectile  function. PMEs, when performed correctly, help strengthen the muscles that support your bladder. These techniques require conscious effort and consistent participation. Through regular exercise, PMEs build strength and endurance to help improve, regain, or maintain bladder and bowel control. Biofeedback and electrical stimulation therapy could also be necessary for some men who need additional assistance with pelvic muscle rehabilitation.

Pelvic muscle exercises and pelvic rehabilitation
The muscles of the pelvic floor are located in the base of the pelvis between the pubic bone and tailbone. These muscles have three main functions: (1) they help support the abdominal and pelvic contents, (2) they help control bladder and bowel function, and (3) they are involved in sexual response. Like other muscles of the body, if they get weak they are no longer efficient at doing their job.

Identification of the pelvic floor
It can be difficult to isolate the pelvic floor muscles. They are the ones used to hold back gas or stop a urine stream. It is important to isolate the contraction of these muscles and avoid tightening the buttocks or abdomen.

Quick contractions and slow contractions
PMEs can be performed anywhere, anytime, and in a variety of positions (sitting, standing, lying down, etc.) There are two types of exercises used to strengthen the pelvic floor. The first  exercise is called a quick contraction, and it works the muscles that quickly shut off the flow of urine to prevent leakage. The muscles are quickly tightened, lifted up, and then released. The second exercise works on the holding ability of the muscles and is referred to as a slow contraction. The muscles are slowly tightened, lifted up, and held up to the goal of 10 seconds.

Exercise schedule
To improve muscle function, PMEs must be done regularly. It is advisable to start with three sets of 10 quick and 10 slow contractions, twice a day. Ultimately, the number of repetitions and sets can progress to three sets of 15 quick and 15 slow contractions, three times a day.

Biofeedback helps detect and record pelvic floor muscle activity by placing small sensors close to the muscles of the pelvic floor. For men, internal sensors are placed inside the anus or external sensors, similar to small adhesive bandages, can be placed on the skin surface just outside the anal opening. The information collected during biofeedback can be used to: (1) ensure that a man is correctly contracting his pelvic floor, and (2) plan a personal exercise program to increase the strength and holding power of the muscles that control urination.

Electrical stimulation of the pelvic floor, or pelvic floor stimulation, involves the controlled delivery of small amounts of stimulation to the nerves and muscles of the pelvic floor and bladder. This stimulation helps the muscles contract, thereby strengthening the pelvic floor and support of the bladder. The stimulation is generated through a tampon-like sensor that is placed in the rectum or by surface electrodes around the anus. Electrical stimulation is not painful. Some people describe a tightening of the pelvic floor muscles. Others feel nothing or a light tapping or mild tingling sensation. Over time, it is believed that electrical stimulation helps relax the bladder muscle, so it also can be helpful for men with overactive bladder or urgency incontinence. Biofeedback and electrical stimulation are available from a physical therapist or nurse specialist. Ask your urologist for a referral.

More information about performing PMEs
If you want more information about performing PMEs, you can order NAFC’s pelvic muscle exercise kit for men with an instructional recording on audio cassette tape and printed manual. Call 1-800- BLADDER or visit the online store to order.

Treatment Options for Post- Prostatectomy Incontinence (cont.)

Over the past decade, several different biocompatible materials have received FDA approval to serve as bulking agents aimed at improving closure of the urethra to avoid more invasive procedures. Injection therapy has not been very successful in men with sphincter weakness; only 8-20% of men report successful outcomes following injection of biocompatible materials.

For men with moderate leakage who have not responded to behavioral therapy, a sling be placed to help restore continence. Mesh is surgically implanted to support the urethra by means of an incision between the scrotum and the rectum. The results indicate an improvement in up to 80% of men, and half of these men completely stop leaking afterwards. Like all surgery, slings are associated with  potential complications, and your doctor can discuss these with you. Previous radiation therapy may reduce the odds of success with a sling.

In men with more severe, another option would be surgically implanting an artificial urinary sphincter. This is a mechanical ring that helps close the exit from the bladder. Studies show satisfaction in up to 90% of all men with this device.

Seek Help
Generally, start with your primary care provider (PCP) in seeking help with your problems with bladder or bowel control. If a PCP does not have a special interest in diagnosing and treating incontinence, or symptoms persist, ask to be referred to a urologist. A urologist is a surgeon who specializes National Association For Continence in the urinary conditions of men and women. Many urologists have advanced training in the surgical correction and medical treatments for incontinence. They can also help arrange non-surgical treatments such as pelvic muscle exercises, bladder training, biofeedback, and electrical stimulation. Some nurse practitioners and nurse specialists, physical therapists, and occupational therapists have training that qualifies them to offer non-surgical treatments for incontinence. This is true in the case of electrical stimulation and biofeedback therapy as a means of behavioral treatment.

Pads and Appliances
If you prefer not to undergo specific treatment or if you are not completely cured after treatment:

  • In managing with absorbent products, other collection devices that may be worn, or an external condom catheter, make sure you have the appropriate size and fit. NAFC has information about a number of choices in products. Visit the "Find A Product" section for more information.
  • Change the product at least once a day for good hygiene and protection against fungus and skin irritations.

We hope that this information will encourage you to seek treatment, allow you to talk to your healthcare provider about your symptoms, and get an accurate diagnosis. Remember, asking questions and choosing among options puts you in a better position to safeguard your health. Use our Find An Expert database for help in finding an expert.