Urinary Incontinence in Men
Research indicates that as males develop they gain urinary control later than females. Therefore, as children, males may experience urinary incontinence (UI) or bladder leakage before they actually adapt to bladder regulation. An example is bedwetting (nocturnal enuresis) and this can occur until adolescence is reached.
The male urinary system is less complex than the female urinary tract and adult males generally do not experience UI disorders unless they have prostate irregularities. Other conditions, such as nerve damage in the urinary or prostate area, may lead to UI problems.
With ageing both males and females can experience urinary incontinence as bladder control weakens. Factors such as childbirth increase the likelihood of female UI since the urinary tract system is so close to the uterus. Prostate cancer may also impact bladder function in men and therefore screening is recommended.
Experiencing urinary incontinence increases stress when the body strains to release urine. Medical assessment can confirm a UI condition and medical treatments may be recommended. It is important to have screening for UI so that the right treatment is provided. Suffering with continued urinary incontinence will affect overall health and aspects of the urinary tract, including pelvic bones, muscles and nerves.
Urinary incontinence is categorised into four types:
- Temporary incontinence.
- Urge incontinence.
- Stress incontinence.
- Overflow incontinence.
Having a medical evaluation will help in the identification of incontinence conditions. Temporary incontinence is reversible and results from constipation, delirium or urinary tract infection. Nerve damage causes urge incontinence, while weak sphincter or pelvic muscles can result in stress incontinence. When the bladder does not empty properly during urination overflow incontinence may occur.
Causes of Male Urinary Incontinence
Learning to control urination develops through childhood and some males may experience developmental disorders or have learning difficulties that impact their ability to control urination. The male urinary tract system is encased by nerves, muscles and organs which work cohesively for urinary health. Nerves signal muscle action for urination and it is this process which young children learn into adulthood. The formation of the bladder and its positioning do affect bladder function. Where some developmental urinary conditions are self-correcting others may not be, such as with nerve signal disorders.
Urinary Incontinence from Nerve Disorders
Nerves in the body can be damaged as part of development, injury or disease. Similarly, nerves located within the bladder or urinary tract can be damaged and malfunction. Both children and adults may be affected by urinary incontinence due to nerve disorders. Typical conditions that result in nerve damage impacting male bladder function include:
- Conditions such as Parkinson's disease, stroke, multiple sclerosis and spinal cord injuries impact nerve signals that regulate bladder function. As a result the bladder may not function normally leading to incontinence.
- Genetic conditions such as myelomeningocele or spina bifida cause irregular formation of the backbone and spinal column, which may result in nerve damage and the inability to control urination.
- Nerve damage from long-term diabetes can impact bladder control and sexual health.
- Nerve damage and signal malfunction causing either underactive or overactive bladder function may trigger the need for frequent urination even though the bladder is not full, or leakage may occur when the bladder is at capacity but the signal to urinate is not received.
- Unknown causes may also underlie UI conditions.
Those who suffer with an overactive bladder, which is not uncommon, experience three main symptoms:
- Urinary frequency: the excessive need to urinate often during the night and day; some experience going on two or more occasions a night and others on eight or more occasions a day.
- Urinary urgency: abrupt and urgent need to pass urine without delay.
- Urge incontinence: leakage can occur if a urinal is not found in time when the need to pass urine is sudden and immediate.
Urinary Incontinence from Prostate Disorders
Located underneath the bladder and around the urethra, the prostate gland is walnut-shaped in men and plays a pivotal role in circulation, urination, orgasm and overall health.
Benign Prostatic Hypertrophy or Hyperplasia (BPH)
With ageing the male prostate enlarges and may pressurise and restrict the urethra and its function for passing urine. This condition is referred to as benign prostatic hypertrophy or hyperplasia (BPH). Urinary incontinence results in thickening, contraction and irritation of the bladder, even when the bladder is near to empty.
Men suffering with benign prostatic hypertrophy and urinary incontinence are usually aged 40 or over, with the prevalence of the condition increasing with age. BPH is commonly present in men over the age of 70. The symptoms of BPH include difficulty urinating, an inability to urinate, dripping urination, the need to urinate frequently or urgently, and urge incontinence. Men may experience such symptoms not only from BPH, but from some other reason. It is important for men to have screening to determine the cause of symptoms and urinary incontinence.
Where prostate cancer is diagnosed treatments include:
- Radical Prostatectomy
- External Beam Radiation
Radical Prostatectomy is a surgical procedure to remove the prostate gland where cancer is present. Urinary incontinence may result from surgery through the abdomen and perineal (scrotum-to-anus section) to remove the prostate gland. Although nerve-sparing techniques are used to reduce such side-effects urinary incontinence and erectile malfunction may occur.
If removing the entire prostate is not necessary then external beam radiation via X-ray may be applied to the cancerous area of the prostate. Side-effects of external beam radiation include urinary incontinence or lack of bladder control, bladder wall inflammation, skin irritation, blood in urine, anal burning, reduced sexual function, diarrhoea, fatigue and loss of appetite.
Amongst other diagnostic methods medical professionals and prostate specialists use a scoring system when screening prostate conditions. An example is the American Urological Association (AUA) Symptom Scale or the International Prostate Symptom Score.
To score the symptoms patients have experienced over the last month or more the following questions will be asked:
- Within a two hour period how frequently have you urinated?
- How many times have you urinated from the point you fell asleep until waking or rising the next day?
- When finished urinating how frequently have you felt that your bladder is not fully empty?
- How frequently is your bladder stream low and not strong?
- How regularly have you experienced difficulty starting to urinate or felt the need to strain or push to urinate?
The score determined from these questions aids in identifying the most appropriate treatment, such as laser treatment, including the strength and duration of therapy.
Diagnostic Screening for Urinary Incontinence
Medical practitioners may use the following means to assess the presence of urinary incontinence in patients:
Review of Medical History
A patient's medical history provides medical practitioners with information about health conditions, illnesses, surgeries and medications in use. Health conditions may include a history of incontinence or urination problems. Prescribed and over-the-counter medications and diet may contribute to bladder irritation, including drinking excessive amounts of alcohol or coffee. Being open with healthcare providers about overall health, medication use, diet and lifestyle will help ensure an accurate diagnosis of the cause of urinary incontinence.
Keeping a Voiding Diary
The medical practitioner may suggest making records via a voiding diary to record the amount of fluid consumed and urination or leakage frequency. The diary enables the healthcare provider to assess the severity of the UI problem and whether or not to proceed with further diagnostic testing.
As part of the screening process the medical practitioner may check prostate health through physical examination or digital rectal examination. In doing so the doctor will wear gloves and place a finger within the anus to feel the prostate and determine if its size and location are normal. During physical examination the condition of the prostate may be assessed for nerve response and muscle reflex. Changes in sensations and numbness are monitored.
Electroencephalogram (EEG) and Electromyogram (EMG)
Where further diagnostic screening is necessary the healthcare provider may recommend an electroencephalogram (EEG) or electromyogram (EMG) test. The EEG monitors brain neural and signal activity through electrodes being placed on the outside of the head, while the EMG measures muscle response to nerve signals. Both tests allow assessment of bladder control to discover any underlying cause of urinary incontinence.
Abdominal and Transrectal Ultrasound or Sonography
Depending on the symptoms experienced by the patient the medical practitioner may recommend an abdominal or transrectal ultrasound test. The procedures for these ultrasounds differ as the abdominal ultrasound or sonography involves a technician sliding a transducer device over the outside of the abdomen to capture visual images of the kidneys and bladder on screen. While with transrectal ultrasound a wand is inserted within the rectum to capture images of the prostate gland. These tests allow the doctor to assess organ condition against symptom experience.
To test sphincter muscle control and the bladder's ability to hold urine urodynamic testing is used. The bladder is filled with fluid via a small catheter and bladder pressure is monitored for abnormal contractions, over-activity and under-activity. Sphincter muscle weakness and urinary obstruction may also be identified during urodynamic testing. When combined with EMG tests both the urodynamic and EMG results can indicate if there is abnormal nerve activity or weak bladder control resulting in leakage.
Urinary Incontinence Treatment
The examination and diagnostic screening results will determine the type of treatment recommended by a medical practitioner. The severity of the condition and patient preference will also play a role in the treatment selected. Treatment options vary but in some cases UI may be corrected without invasive care.
Treatment options for UI include:
- Behavioural therapy to improve bladder control
- Muscle-strengthening techniques to improve bladder control and function, such as Kegel exercises
- Bladder control medication
- Bladder control devices, such as catheter or artificial sphincter
- Bladder surgery – urinary diversion
Behavioural Therapy for UI
Where UI is not severe regulating fluid intake or reducing fluid consumption to particular times of the day may help in training the bladder for improved bladder control. The idea is to try and increase the time period between urinations.
Kegel Exercises for Improved Muscle Control
Kegel exercises may be used for pelvic muscle-strengthening. Improving the strength of pelvic muscles helps to improve urine storage and reduces leakage from weak bladder control. Studies are inconclusive in indicating that Kegel exercises reduce incontinence in men who regularly practice pelvic muscle-strengthening. However, clinicians feel that such therapy is an important part of male bladder training.
In some cases, clinicians recommend combining Kegel exercises with biofeedback, particularly where men have difficulty in knowing if they are performing Kegel exercises correctly. Biofeedback can include electrical stimulation with sensors to provide visual and audio feedback on muscle function. During the exercises a pen-sized probe is inserted in the rectum to record muscle activity, which may be visualised on a monitor or heard through a speaker. The visuals or sounds and electrical pulses help individuals doing the exercises to identify if they are correctly exercising the right muscles.
Kegel exercises work by squeezing muscles normally used in an attempt to stop passing gas and are done whilst lying down. The sensation should be a feeling of "pulling". These muscles are the ones used for pelvic exercises and are the only muscles used for Kegel exercises. It is important to breathe freely not hold in the breath nor tighten the stomach, buttock or leg muscles. Only the pelvic muscles should be squeezed otherwise the bladder may be improperly pressured.
The pelvic muscles should be pulled or squeezed for 3 counts, then relaxed for 3 counts whilst lying down. The exercises should be done for 3 sets of 10 repeats and not overdone. As the pelvic muscles strengthen the exercises can be done sitting, standing or lying down. Sitting or standing while exercising adds more gravity and therefore more weight. Do these exercises for five minutes, three times per day. Patients have reported experiencing improvement in bladder control within a 6 week period.
Medications to Prevent Incontinence
There are various types of medications used to regulate bladder control and each work differently. While some work to block or regulate nerve signals to prevent incontinence, others reduce urine production or work for improved bladder relaxation and control. Certain medications act to shrink the prostate so that the urethra is not unduly squeezed or pressured.
The severity of UI is assessed and so are medications in use, such as diuretics. Diuretics are used to regulate blood pressure, particularly if blood pressure is high, and may raise urine production causing UI; altering prescribed medications may improve bladder function. Specific medication types used to treat incontinence include:
Antispasmodics: work to relieve bladder spasms through relaxing the muscles of the bladder; includes Ditropan XL or Oxybutynin, Pro-Banthine or Propantheline, and Detrol LA or Tolterodine. Potential side-effects of antispasmodics include constipation, dry Propantheline mouth, racing pulse or heart rate, headaches, blurred vision and flushing. Side-effects may manifest differently in each person.
Tricyclic Antidepressants: are used to block bladder spasms caused by nerve signals to improve bladder muscle relaxation and includes Imipramine or Tofranil. Imipramine may be used as a treatment for children who experience bed-wetting.
5-Alpha Reductase Inhibitors: inhibits male hormone DHT production that may cause prostate enlargement and includes Avodart or Dutasteride, Proscar or Finasteride. A Medical Therapy of Prostate Symptoms (MTOPS) clinical trial sponsored by The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) identified how such 5-alpha reductase inhibitors substantially reduced the risk of BPH development.
Alpha-Blockers: work to relax prostate and bladder muscles for healthy urine function and treat bladder obstructions, irregular bladder contractions, urge incontinence and prostate enlargement. They include Cardura or Doxazosin, Hytrin or Terazosin, Uroxatral or Alfuzosin, and Flomax or Tamsulosin.
Bladder Control Devices
Where UI is severe medical practitioners may recommend the use of a bladder control device, such as a catheter, artificial sphincter or male sling. Urethral injections may be an option for urethra closure with collagen.
Catheters: comprise a narrow tube that is inserted through the urethra for bladder drainage. Two types include clean intermittent catheterisation and condom catheters.
Clean intermittent catheterisation may be self-managed or done through a healthcare provider. The bladder is frequently drained of urine to prevent overflow incontinence from happening. Those with nerve damage UI or an enlarged prostate may be recommended this treatment. Sterility is vital with catheter use to prevent kidney stones and infection developing.
An alternate catheter treatment is with condom catheters that slide over the penis for urine drainage. However, sterility is also important in preventing infection and skin irritation from developing.
Artificial Sphincter: comprises a urethra cuff, abdominal balloon reservoir and scrotum-placed pump; all implanted within the body to function as a replacement sphincter, where nerve damage or weak sphincter muscle action prevents the body's own sphincter from functioning normally. General or spinal anaesthesia is provided for surgical implanting of the artificial sphincter.
The artificial sphincter regulates normal urine flow and prevents leakage from abnormal sphincter function. However, it may not eliminate incontinence problems that result from bladder contractions or a lack of bladder control. The device works as the liquid-filled cuff snugly fits the urethra preventing leakage.
As the urge to urinate builds the patient presses the pump which acts to deflate the cuff. As the cuff deflates the liquid fills the balloon reservoir, resulting in urine release via the urethra. Once the bladder empties and within about five minutes, the cuff inflates with liquid sealing the urethra again to prevent leakage.
Male Sling: a surgical procedure involving the creation of a urethra support through encasing the urethra with a material strip with ends that connects to the pelvic bone. The male sling acts to prevent urine leakage by applying constant pressure to the urethra until the conscious urge and need to urinate arises.
Urethral Injections: although not a device urethral injections may be used to insert collagen or a fatty bulking agent within the urethra-bladder opening under local anaesthetic or sedation. To be effective in preventing urine leakage these injections need to be repeated. Medical practitioners take care to ensure that patients are not allergic to the agents used.
Bladder Surgery – Urinary Diversion
Certain severe cases of urinary incontinence may involve an entire loss of bladder functionality due to nerve damage. When this occurs medical recommendation may be to remove the bladder and create a urinary diversion. The urinary diversion involves removal of part of the small intestine so that a reservoir can be created to which the ureter is diverted. The urine then drains through a surgically-made stoma and in the lower abdomen and catheter for excretion into a medical bag.
Support for UI Sufferers
Urinary incontinence, whether male or female, is a recognised medical condition that requires proper healthcare and treatment. Individuals may experience a lack of confidence and embarrassment due to their UI condition, while some sufferers may restrict their social lives and experience isolation and reduced quality of life.
Having support is important before, during and after treatment. There are UI and prostate cancer support groups for men to join to help in coping with the condition and to share experiences. Prostate and UI treatment may be ongoing or need constant maintenance. Organised groups give men support through this process so that embarrassment and isolation are reduced.