Urinary incontinence, or UI, is a distressing and serious health problem. Its psychosocial and economic burden leads to significant quality of life issues. UI is more prevalent than hypertension, depression and diabetes, yet it is underreported. Fewer than half of all patients are willing to report their symptoms to their physicians. The urological surgeons at The University of Kansas Health System are skilled in the diagnosis and treatment of these conditions.
According to the International Continence Society, the three most common types of UI are:
- Stress urinary incontinence, or SUI: involuntary leakage on effort, exertion, sneezing or coughing.
- Urge urinary incontinence, or UUI: involuntary leakage accompanied by, or immediately preceded by, urgency.
- Mixed urinary incontinence, or MUI: involuntary leakage associated with urgency and exertion, effort, sneezing or coughing.
Signs and symptoms
Most men who experience urinary leakage will have symptoms based on their type of incontinence. In order to maintain proper control, a complex series of interactions must take place in the body, including closing of the urinary sphincter muscle, proper bladder filling, and, finally, intact sensation and motor function.
- Stress urinary incontinence: results in a weakness of the urinary sphincter and typically involves leakage during activities such as coughing, laughing, sneezing, exercise and position changes. Patients will describe squirts of urine that occur with activity. In severe cases, the leakage may be constant.
- Urge urinary incontinence: characterized by the inability of the bladder to hold urine, which results in uncontrolled urination associated with, or preceded by, a feeling of urgency.
- Mixed urinary incontinence: a combination of both urge and stress incontinence.
The cause for underlying incontinence must be properly determined prior to initiating therapy.
- Stress urinary incontinence: most often due to side effects of surgical treatment for benign prostatic hypertrophy, prostate or bladder cancer. Injury to the urinary sphincteric mechanism (rhabdosphincter), thought to be the main mechanism, results in the inaility to hold urine due to a weakened muscle.
- Urge urinary incontinence: due to an overactive bladder muscle, or OAB. The underlying pathophysiology of OAB can relate to alterations in any of the reflex cycles in normal urination or structural changes in the smooth muscle, nerves or lining of the bladder. Treatment of OAB is based on diagnosis after excluding other pathologies, i.e., urinary tract infection, bladder stones and diabetes.
Patient evaluation starts with a thorough history and physical. The majority of patients can be diagnosed based on their symptoms. Additional tests may be required to help plan treatment, including urodynamic studies, which measure pressure within the urinary system, bladder and sphincter function, presence of overactive bladder and bladder capacity. Other additional tests can include insertion of a camera into the bladder, called cystoscopy.
Our treatment plan for male incontinence is customized to fit each individual patient.
- Stress urinary incontinence: following prostate surgery, bladder surgery or radiation, men are encouraged to attempt active conservative management (fluid restriction, medication management and pelvic floor exercises, also known as "Kegels"). If these conservative measures fail, Josh Broghammer, MD, provides surgical intervention for treating persistently bothersome male stress incontinence. The main surgical techniques are:
- Bulking agents: Endoscopic management includes injections of agents under the lining of the urethra to narrow the inside lumen to help aid in holding urine. These can be performed as outpatient procedures, require no incisions, but have limited success.
- Male sling: using either the InVance™ or AdVance™ systems, male slings provide increased control for those with light stress urinary incontinence, generally less than three pads per day. These minimally-invasive techniques can be performed with a simple overnight stay in the hospital.
- Artificial urinary sphincter, or AUS: the artificial sphincter is the gold standard of intervention for male stress incontinence. It is a proven and effective treatment for mild to severe incontinence. A ring called a cuff is wrapped around the urethra to provide extra pressure to hold in urine. There is an implantable pump placed within the scrotum, under the skin, which is pumped to allow the patient to urinate.
Incontinence can limit your activities and keep you homebound in costly, messy pads, dealing with frustration, embarassment, and constant fear of leaking and odor. The reality is, you don't have to live with bladder control problems anymore.
Our practice specializes in real solutions from minimally invasive surgical procedures like the male sling for mild to moderate incontinence, to the gold standard AUS implant that can resolve even severe incontinence.
Mild to moderate incontinence
- AdVance™ Male Sling System
- Small sling made of synthetic mesh placed inside the body through small incisions
- Supports the urethra, restoring normal bladder control
- Most patients are continent immediately following the procedure
- Can resume normal, non-strenuous activities shortly thereafter
- InVance™ Male Sling System
- Also involves placing a mesh sling completely inside the body
- Places pressure on the urethra to reduce the possibility of urine leakage
- Most patients are continent immediately following the procedure
- Can resume normal, non-strenuous activities shortly thereafter
Moderate to severe incontinence
- AMS 800™ Urinary Control System
- Artificial urinary sphincter placed completely inside the body
- Provides simple, discreet urinary control
- Mimics a healthy sphincter, keeping the urethra closed until you want to urinate
- Connected system of:
- Pump implanted in the scrotum
- Inflatable cuff around the urethra
- Balloon reservoir implanted in the abdomem
- How it works:
- Controls urination by squeezing and releasing the pump
- Moves fluid out of the cuff and back into the reservoir
- Urine can flow out of the bladder
- Fluid returns from reservoir to cuff, squeezing urethra closed again
Make an appointment to learn more
If you suffer from incontinence, don't wait another day. Make an appointment to talk about your options for a permanent solution that can help you restore your quality of life – and live life dry!
As with any surgical procedure, inherent risks are present. Although rare, some of the most severe risks may include infection and erosion and surgical, physical, psychological or merchanical complications. If these occur, they may necessitate revision or removal of the device. For additional product and risk information, contact us today.
The way the procedure is done, the patient is brought to the operating room.
They are actually awake. Although, we do give sedation and local anesthetics, so they're very comfortable while we're doing the procedure.
What we do is we look for the specific landmarks.
So, we look for the tailbone, and then we identify the bones by feeling through the skin.
Once we've located the area where we believe the appropriate nerve root is, we actually take a small electrical conduction needle and place it through the skin that's been anesthetized and down into the opening in the bone, and that then sits down right alongside the nerve.
Once that's in place, we test it electrically and we take some X-ray pictures to make sure that we're in the right position.
Once we're sure that we're in the correct placement, we exchange this needle for an electrode that has four small contact points on it.
That actually again goes through the bone and sits down right alongside the nerve.
So, the nerve would be coming out kind of down in this area and that's what's going to give the electrical impulses to the nerve.
The patient wears this for one to two weeks.
It's connected to a little external wire that comes out of the skin, and the patient hooks it up to a small generator.
It looks sort of like a pager, and they keep a diary for us about their symptoms.
When they come back in one to two weeks, if it looks like they've had a good response and an improvement in their symptoms, then what we do is connect this lead to a small internal generator.
So, it's basically like a pacemaker battery, and that is put just under the skin kind of in the lower part of the back kind of above the hip.
It's very thin, and so for most patients they really don't even feel it unless they're pressing on it.
Then, this has a small set of computer chips in it that allows the patient to program the device and adjust it based on their symptoms.
This particular patient that had his surgery today was a patient who had undergone a radical prostatectomy for prostate cancer.
His prostate cancer was cured, but he was left with one of the unfortunate side effects that happen in a low percentage of people, and that is urinary incontinence.
He presented today to get an artificial urinary sphincter in place.
The prostate actually lies right next to what we call the genitourinary sphincter, which is the muscle that you use to control your urine.
So, sometimes after a prostatectomy or a prostate removal you can actually have an injury to that muscle, where patients stat to lose control.
That can be variable, from just a little bit of leakage to really quite dramatic leakage with someone using anywhere from eight to 10 pads a day.
The incontinence that occurs is usually called stress incontinence.
This occurs when people are doing heavy activity.
They're playing golf.
They're doing kind of the things in their day-to-day living.
Simply getting out of a chair can cause a leakage, so it can be quite debilitating.
It's difficult to go out to dinner if you're worried about having wet pants, changing multiple pads per day.
Car trips are often difficult or leaving the house for long periods of time. It can really change someone's life.
Basically, what we do is we make a small incision in the perineum, which is the space in between the legs, to locate the urethra or the tube that you pee through.
So, what we're looking at here is we've split the fat layer over top of the urethra, and we're just now getting into the muscle that surrounds the urethra. Last loop.
So, what we've essentially done here to start the case is we've made an incision through the perineum and dissected down through the subcutaneous fat.
We've spread open the bulbospongiosus muscle, which is the muscle used for ejaculatory function, to expose the urethra, which is this blue midline structure, which we also have the blue tape wrapped around.
This is the area where our artificial sphincter is gonna go and where we specifically size it and custom fit it to the patient's needs in terms of their degree of incontinence.
So, this is the cuff that we're going to place here in the patient.
This will provide the pressure support to help hold the urethra closed. Here you can see the cuff being put into place. We're just going to deploy this.
This is what the device looks like. You can see here the inflatable cuff is around.
There's tubing that we're gonna pass into the abdomen, so the patient can activate the device, but this is essentially gonna provide coaptation of the urethra in order for him to help maintain his continence.
What we're going to do now is just pack the wound with an antibiotic soaked sponge and then proceed to the abdominal portion of the operation. All right.
What we've basically done here is we've made a series of sharp incisions down to the muscle layer of the abdominal wall. We're then entering the extraperitoneal space, which is the space outside the sac that holds the intestines and the bladder.
We're just adjacent to the bladder.
We'll be putting the reservoir, which holds the fluid, in order to make the device function.
Again, same with the other incision.
We copiously irrigate this in order to prevent an infection.
What we have here is his device comes from ... this black and clear tubing comes from the reservoir.
This yellow tubing comes from the cuff.
We have a retractor or ring forceps in the scrotum right now, which is marking where we're gonna put our pump to.
So, we'll place this device, and then we'll make the connections. Here you can see the device has been implanted into the scrotum.
The pump has been subcutaneously tunneled down into the scrotum.
This is what the patient will manipulate in order to use the restroom. All right.
Now, what you can see here is we've made the connections and trimmed the tubing down, so it's an appropriate length.
We're going to release these connections and bury the tubing.
We'll pull the pump down into its appropriate spot within the scrotum, which you can see here, and the tubing disappears.
We'll then begin to close our incisions.
What we did today is we placed a small cuff around that urethra and then hooked it up to a device that goes into the scrotum, which we refer to as the pump.
So, when the patient needs to urinate, he simply squeezes that pump, releases the cuff around the urethra.
He's able to urinate. The device then resets, and he can go about his normal daily affairs, hopefully dry.
This is an example of the device. Here we have a reservoir, which goes into the patient's abdomen.
This stores the fluid to help make the device function.
What I've illustrated here with this red catheter is the urethra or the peeing tube, if you will.
We have a cuff or a balloon which goes around that.
By this device squeezing, this is what's gonna help provide the patient continence.
When the patient needs to urinate, this pump has been tunneled into his scrotum, in which case he just simply squeezes the base of this.
This will then release the cuff around his urethra.
He'll be able to urinate.
Then the device automatically resets without having to do any manipulation.