What are the treatment options for male stress urinary incontinence (SUI)?
Both conservative and surgical treatment options are available for men with stress urinary incontinence (SUI).
The most common cause of male stress urinary (SUI) is now radical prostatectomy surgery for the treatment of prostate cancer. It is estimated that up to 60% of men will suffer from stress urinary incontinence in the early postoperative period after radical prostatectomy surgery. This is mild in most cases and decreases with the passage of time but around 4% of men can suffer significant ongoing leakage. The rates of stress urinary incontinence (SUI) reduce significantly in the first 3 months after surgery. By a year after radical prostatectomy surgery, around 14% of men experience male stress urinary incontinence (SUI).
All men can benefit from conservative treatment options for stress urinary incontinence. Surgical treatments are considered in men with bothersome stress urinary incontinence (SUI) that persists more than a year after the time of radical prostatectomy or earlier in men who have very severe symptoms.
Conservative treatment options for Men with SUI
Men with stress urinary incontinence can benefit from non-surgical treatment options including:
- Pelvic floor muscle physiotherapy
- Correcting problems that cause chronic constipation and coughing
- Cutting out smoking
- Continence devices and aids
- Advice regarding the appropriate choice of continence aids can be provided through specialist Urology Nurses and specialist Continence Advisors.
- Options may include the use of pads and condom drainage (an external collecting device for urine).
Surgical treatment options for Men with SUI
Before considering surgery, a full assessment of stress incontinence should be made to determine an individual’s suitability for surgery and make a recommendation regarding type of surgery. Such assessment may include:
- Assessment of stress urinary incontinence (SUI)
- Assessment of urinary incontinence
- Urodynamic testing
Many surgical treatment options exist for men with bothersome stress urinary incontinence including:
- Injectable agents for stress urinary incontinence
- Sling surgery with suburethral slings specifically designed for male stress urinary incontinence
- Artificial urinary sphincter (AUS)
Overall the artificial urinary sphincter (AUS) is regarded as the “gold standard” treatment for severe male stress urinary incontinence (SUI) occurring after radical prostatectomy surgery. Slings, injectable agents and other devices are better suited to men experiencing mild to moderate stress incontinence.
What is an Artificial Urinary Sphincter (AUS) for men with stress urinary incontinence (SUI)?
An artificial urinary sphincter (AUS) is a surgically inserted device used to treat stress urinary incontinence due to severe problems with the function of the urethral sphincter (on/ off valve that prevents urine leakage from the bladder).
Surgery to insert an artificial urinary sphincter (AUS) involves insertion of an artificial valve to control the passage of urine from the bladder.
The artificial urinary sphincter consists of 3 parts:
- A circular cuff that is placed around the urethra (water pipe) or around the bladder neck to compress the urethra and prevent urine leakage
- A scrotal pump that connects to the cuff.
- This part of the device is located under the skin in the scrotum and is the mechanism used to activate/ deactivate (or turn on / off) the artificial sphincter
- A balloon reservoir- a small fluid filled balloon implanted in the abdomen that stores the fluid that circulates through the artificial urinary sphincter.
The artificial urinary sphincter (AUS) tries to reproduce the function of the normal urethral sphincter by opening and closing the urethra at the control of the patient. The device is operated by the patient. In the resting state, the AUS occludes the urethra and prevents stress urinary incontinence (SUI). When the AUS is “turned off” (also known as deactivation) by the patient at the time of urination, the cuff deflates and releases pressure on the urethra which allows the patient to empty the bladder. The AUS is deactivated by the patient using pressure applied by the fingers on the scrotal pump that is located under the skin of the scrotum. The AUS cuff reinflates automatically a few minutes after urination leading to pressure on the urethra and blockage of urine outflow.
In order to be able to use the AUS device, a patient requires good manual dexterity and must be able to be taught how to deactivate the AUS. Patients with poor memory and poor hand function (e.g. due to arthritis or injury) are not appropriate candidates for surgery with an artificial urinary sphincter (AUS). A full assessment of suitability for the AUS surgery and the patient’s ability to be able to use the AUS device is made before surgery is planned.
The AUS device is not turned on (also known as activation) immediately after the procedure and therefore the surgery does not result in immediate relief of stress urinary incontinence (SUI). The device is activated or turned on in the doctor’s rooms about 6 weeks after surgery by pressing a button on the pump located within the scrotum to inflate the cuff. The patient is also give further training in sphincter activation/ deactivation at this stage.
The AUS device is effective in treating all degrees of stress urinary incontinence (SUI) and is generally used in patients suffering from severe SUI that is less effectively treated by other surgical options such as injectable agents and the male sling.
What are the potential side effects of Artificial Urinary Sphincter (AUS) surgery for Stress Incontinence?
All surgery for stress urinary incontinence has potential side effects.
Specific risks associated with artificial urinary sphincter (AUS) surgery include:
- Failure to improve or rarely worsening of stress urinary incontinence
- Development of new overactive bladder (OAB) symptoms or worsening of pre-existing OAB symptoms such as frequency, urgency and nocturia
- Damage to nearby structures on insertion of the AUS such as the urethra
- Urinary tract infection
- Wound infection
- Infection of the device requiring removal in the long-term
- Mechanical failure of the device in the long-term
- Later failure of the device due to loosening of the cuff around the urethra (known as urethral atrophy)
- Small risk of problems related to the use of synthetic material e.g. erosion of the device through the urethra
- Complication rates are higher in the presence of previous radiotherapy treatment and neurological problems.
What are the outcomes of Artificial Urinary Sphincter (AUS) surgery for Stress Incontinence?
The success rates in improving or curing stress urinary incontinence in appropriately selected patients range from 55 to 90% with low complication rates. About 10% of patients can still have significant stress incontinence with an artificial urinary sphincter (AUS).
The effectiveness of artificial urinary sphincter (AUS) surgery can decline with time. The expected lifespan of an artificial urinary sphincter (AUS) is about 10 years with revision (repeat) surgery required most commonly for mechanical failure or cuff loosening (due to urethral atrophy or pressure effects of the cuff).
Long term data on the AUS device for stress urinary incontinence shows a retreatment rate of about 25%.