Incontinence and Prostate Cancer
John C. Hairston, MD
Associate Professor of Urology
Integrated Pelvic Health Program
Northwestern Feinberg School of Medicine
What is urinary incontinence?
“The objective demonstration
of involuntary loss of urine consequent to
bladder and/or sphincter dysfunction.”
The International Continence Society
Ballanger P et al. Female Urinary Incontinence. Eur Urol 1999; 36:165-174.
Types of incontinence
• Stress Incontinence
– Leakage during physical activity that increases
intraabdominal pressure, i.e. lifting, exercising,
sneezing, and coughing
• Urge Incontinence
– Leakage associated with an overwhelming
need to urinate Gotta go, gotta go!
• Mixed Incontinence
– Combination of the above
–
–
Hunskaar et al. One hundred and fifty men with urinary incontinence. Scand J
Prim
Health Care 1993; 11:193-196.
How does the process work?
• Bladder collects urine
• The sphincter - a
circular muscle at
the level of the
prostate - controls
the flow of urine
• The sphincter muscle
wraps around the
urethra
• A healthy sphincter stays closed until
one relaxes it to urinate
Why am I incontinent?
• Prostate cancer treatment
– Radical Prostatectomy
– Radiation
– Cryotherapy
• Other pelvic surgery or trauma
• Spinal disease
• Neurologic disease
Am I the only one with incontinence?
NO!
55 million men in the world suffer from loss
of urinary control
AMS 2003 Annual Report
Campbell’s Urology 2002 8th Edition
Male Incontinence
• Rate of incontinence ranges between 2.5% up
to 69% after prostate cancer treatment
• Risk factors
• Degree of nerve sparing
• Postoperative bladder neck contracture
• Combination/Adjuvant treatment
• Presence of prior disease (stricture, etc)
• Salvage therapy
Male Incontinence
• Post-prostatectomy
- Often improves within 3-6 months
- 5-8% of men require treatment beyond
conservative measures
• Radiation
- Often a late complication
- Difficult to predict
- Probably improving with improved directed
therapies
Why treat incontinence?
Avoid negative feelings
embarrassment, discomfort, isolation,
anger and depression
Return to usual lifestyle
Regain dignity
Resume intimacy
Save money on protective garments
Improve quality of life
Why treat incontinence?
150 men reported the practical inconveniences
associated with incontinence:
52%
37%
17%
12%
11%
Extra laundry
Smell
Extra expense
Skin irritation
Disturbed sleep
Source: Hunskaar s, Sandvik H. one hundred and fifty men with urinary incontinence.
Scand J Prim Health Care 1993 v. 11 p.193-196
What to expect at an office visit
• History
– Spinal or neurologic disease
– History of BPH (Enlarged Prostate)
• Physical Exam
– Neurologic exam
• Urinalysis
• Postvoid Residual
• 24 hr pad testing *
• Urodynamics, Cystoscopy
Management options
• Pads/diapers
• Medication
• Devices
Pads/diapers
• What do men know about pads?!?
• More absorbent and less irritating than
other paper products
• Pads vs diapers
– “Maxi” vs. “Mini” pads
Devices: Clamps
– Cunningham clamp, C3-clamp
– Advantages
• Non-medical, non-surgical
• Easy to use
• Works well
– Disadvantages
• Bulky
• Pressure necrosis
• Generally not a turn on
Devices: Catheters
– External vs. Internal
– Advantages
• Works
– Disadvantages
• Attached to a bag
• Increased risk of
infection
Medication
• No FDA approved medication for stress
incontinence in men (or women)
• Antidepressants
• You may be a candidate for
anticholinergic medication
– Overactive bladder component
Treatment options
•
•
•
•
Behavioral modification
Biofeedback
Injectables
Surgery
Behavioral modification
•
•
•
•
Decrease fluid intake
Void frequently
Avoid caffeine, alcohol
Avoid activity that increases intraabdominal
pressure
Pelvic floor rehabilitation
• a.k.a. biofeedback
• Means of teaching Kegel
exercises
• Objective way to measuring
pelvic floor strength
• ? how much better than verbal
instruction
Bulking agents
• Collagen, carbon beads, autologous fat
• Success rates for collagen ~
17%-38% after prostatectomy
• Most recent International Consultation on
Incontinence regarded this treatment as showing
only modest benefit
• Poor surgical candidates with minor degrees of
leakage
Klingler HC et al. Incontinence after radical prostatectomy: surgical treatment options.
Curr Opin Urol 2006; 16:60-64.
Surgical options for male stress
incontinence
• Male Sling
• Artificial Urinary Sphincter
Male Incontinence Severity Level
Guidelines
Onur R, Rajpurkar A, Singla A. New perineal bone-anchored male sling; Lessons learned.
Urology Jul 2004 v. 64 (1) p.58-61
InVance™ Male Sling
• Effective treatment for mild to
moderate incontinence
• Minimally invasive, 45± minute
outpatient procedure
• Continence is immediately
restored
• Nothing to operate
• Device is completely hidden
inside the body
• 88% satisfaction rate1
1Onur
R, et al. Efficacy of a new bone-anchored perineal male sling in intrinsic sphincter deficiency.
International Incontinence Society. Oct. 5-9, 2003. 33rd annual meeting, Florence, Italy. Abstract 399.
InVance™ Male Sling
Sling creates gentle compression
on the urethra for urinary control
• Procedure:
– Spinal or general anesthesia
can be used
– Small incision under the scrotum
– Miniature titanium screws placed
into the pubic bone on each side
of the urethra
– Sling positioned to exert gentle
pressure on urethra
– Sling secured to screws
– Incision closed
AdVance™ Male Sling
a new, innovative treatment option
• Innovative treatment for mild to
moderate incontinence
• Minimally invasive, fast
outpatient procedure
• Continence is immediately
restored
• Nothing to operate
• Device is completely hidden
inside the body
AdVance™ Male Sling
Sling restores urethra to its proper anatomical position
for optimal sphincter function, restoring urinary control
• Procedure:
– Spinal or general anesthesia
can be used
– Three small incisions: 1 under the
scrotum, 2 over groin creases
– Specially designed surgical tools
are used to position the sling
– Sling is gently tensioned
– Incision closed
AdVance™ Male Sling
Virtue™ Male Sling
Artificial Urinary Sphincter (AUS)
over 100,000 implanted since 1972
• The Gold Standard for treatment
of moderate to severe
incontinence
• 60± minute outpatient procedure
• 92% of patients would have the
device placed again
• 96% of patients would
recommend it to a friend
• Device is placed completely in
the body, providing simple,
discreet control
Litwiller SE, et al. Post-prostatectomy incontinence and the artificial urinary sphincter; a longterm study of patient satisfaction and criteria for success. J of Urol 1996; 156:1975-1980.
Animation of Artificial Urinary Sphincter
AUS
Sling
• Appropriate for treatment of mild to
moderate incontinence
• 70-85% success rates
• 45-60± minute outpatient procedure
• Transient scrotal/penile and perineal pain
• Passive
• Favorable 2 year data (durability?)
• Complications
• The Gold Standard for treatment
of moderate to severe
incontinence (85-95% success)
• 60± minute outpatient procedure
• Catheter for 23 hours
• Transient scrotal/penile and perineal
pain
• “Active”
• Over 30 year track record of
durability
• Complications
• Infection and Erosion ( < 2%)
• Infection and Erosion (5-10%)
• Reoperation rate (unknown?)
• Approx 15% require revision
surgery over a 10-15 year
period
What should you do next?
See your Urologist!
• Come prepared with questions
• Discuss your treatment options
• Your lifestyle and medical condition are
important factors
• Ask if you can speak to one or more of
his/her satisfied patients
Summary
• Incontinence is a common problem
• Most cases resolve within 6-12 months
• Some treatments are more effective than others
• Surgical treatment options offer proven,
long-term solutions
• Talk to your Urologist – talk to your partner
• Podcast at NMH.com
– http://www.nmh.org/nm/ihealth-mens-health
– http://www.patientpower.info/healthtopic/prostate-cancer
• For copies of this talk
–
–
Sara Steinkamp
s-steinkamp@northwestern.edu
Thank You