Urinary incontinence in men

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Catholic University in Ruzomberok, Faculty of Health, Slovakia

Urinary incontinence in men

Babecka Jozef

Introduction

Urinary incontinence has a significant psychosocial impact in men, reducing their quality of life. It has been less thoroughly investigated than incontinence in women; nevertheless, a detailed history and physical examination to classify the type of incontinence are key to guiding management. Urinary incontinence is defined by the International Continence Society as `the complaint of any involuntary loss of urine'.

Several types of urinary incontinence have been defined in the adult male, the most common being urgency urinary incontinence, stress urinary incontinence and mixed urinary incontinence (see Table). In clinical practice, it is often the case that a patient presents with features of more than one type of incontinence, along with a variety of underlying disease processes. Nevertheless, it is useful to make such classifications as each type of incontinence has different aetiologies, clinical manifestations and treatments.

Table.

Types of urinary incontinence (Source: Mangir, N., 2020)

Impact of urinary incontinence

Urinary incontinence has a significant impact on the patient, family members and healthcare system. In men it has been less thoroughly investigated than incontinence in women, due to the assumption that male incontinence is less of a problem socioeconomically and epidemiologically. However, urinary incontinence has a significant psychosocial impact in men, reducing their quality of life with abstinence from daily activities and higher rates of depression.

Every year around 100 million adult men are affected by incontinence worldwide. The prevalence of urinary incontinence in men increases with age, although prevalence rates are nearly half those of women in the same age group. However, men are also more reluctant to seek help for their incontinence problem compared with women. For example, in a population-based study conducted in the EU, 22% of men in the community who experience an episode of incontinence per week sought care, compared with 45% of women (Babecka 2021).

Urgency urinary incontinence is the most common cause of urinary incontinence in men. Patients typically experience a `sudden and compelling desire to pass urine that is difficult to defer', which may result in urine leakage. Urgency urinary incontinence in men is typically associated with bladder overactivity (overactive bladder syndrome) and/or obstruction to urine flow as a result of benign prostatic enlargement (bladder outlet obstruction).

The specific mechanisms underlying urgency urinary incontinence are not completely understood. However, the pathophysiology involves involuntary bladder contractions (detrusor overactivity), which can be measured during urodynamic studies (Wilson, 2016). Detrusor overactivity could be due to a defect in afferent sensory signalling from the urinary tract, a defective central processing of these signals, and/or it can be a primary problem of the detrusor muscle. Other factors such as age, previous pelvic surgery and comorbidities such as diabetes and hypertension may also play a role in development of detrusor overactivity. However, only age has been shown to be an independent risk factor for bladder overactivity. Epidemiological studies demonstrate that symptoms of bladder overactivity increase with age, independent of other factors in both men and women.

Bladder outlet obstruction is shown to cause bladder overactivity. Research has demonstrated several mechanisms by which bladder outlet obstruction can cause detrusor activity. These include detrusor smooth muscle hypertrophy, hypertrophy of afferent and efferent nerves, and denervation hypersensitivity. Accordingly, clinical experience shows that prostate surgery for benign prostatic enlargement to relieve the outflow obstruction (namely, transurethral resection of the prostate), improves bladder overactivity symptoms in 70-80% of patients.

On the other hand, stress urinary incontinence in men almost invariably develops due to previous prostate surgery (post-prostatectomy incontinence). The most common cause of persistent stress urinary incontinence in men is radical prostatectomy, with incontinence rates between 10 and 25%. Other causes of stress incontinence in men could be severe pelvic trauma and neurological diseases that damage the external sphincter mechanism (Gulasova, Babecka, 2020).

Our understanding of how urinary incontinence develops after surgery for prostate cancer (radical prostatectomy) is still evolving. Although postprostatectomy incontinence has been broadly explained to occur as a result of damage to the external urethral sphincter mechanism during surgery, slightly different mechanisms are probably responsible for failure of sphincteric functions after surgery for benign disease and malignant disease.

Stress urinary incontinence after surgery for benign prostatic disease can be a result of direct damage to the external sphincter mechanism (the striated muscle), or the prostate surgery stimulates a pre-existing incompetence of the distal urethral sphincter after ablation of the proximal sphincter mechanism. Factors predisposing to distal sphincteric damage involve pelvic trauma, denervation from pelvic surgery, intervertebral disc disease and radical radiotherapy. The other factor is injury sustained during surgery, such as neural injury or sphincteric denervation.

Different mechanisms play a role in the development of urinary incontinence after surgery for prostate cancer. Recent advancements in robotic surgeries have probably improved our understanding of the pathophysiology of post-prostatectomy incontinence. Research has shown that perioperative factors such as membranous urethral length, reconstruction of periurethral support structures, preservation of bladder neck and the neurovascular bundles also play a key role in development of urinary incontinence after radical prostatectomy.8 Patient-related factors such as age, body mass index (BMI), prostate size and presence of other functional bladder problems before surgery have also been thought to play a role. The external sphincter mechanism is often not damaged following radical prostatectomy (Gulasova, Babecka, 2020).

The article meeting the criteria for inclusion in this appraisal were evaluated and entered into the Synthesis Matrix. The study findings that answered the research question were assessed and grouped into therapies. A critical appraisal of the literature sought to determine best practices in the treatment of male UI. An evidence table served as a guide to answer the study question “What are the most current and best evidencebased practice treatments for males with Urinary Incontinence?” The elements within the table included evidence type, sample size, study findings that helped answer the research question, limitations, and evidence rating. The sources included Medline (PubMed), Cumulative Index to Nursing and Allied Heath Literature (CINHAL), PsycINFO, Cochrane Library, ProQuest, DynaMed, Google Scholar, Arctic Health Publications Database, and Nursing Commons.

Urgency urinary incontinence. The first-line treatment of urgency urinary incontinence involves bladder retraining and behavioural therapy. If these measures fail, anticholinergic therapy can be used. In cases where medical therapy fails, the treatment options include intradetrusor botulinum toxin injections or neuromodulation.

Stress urinary incontinence. First-line treatment for men with stress urinary incontinence is conservative. This involves behavioural therapy and pelvic floor muscle training/ pelvic physiotherapy. Behavioural interventions are mostly supportive measures in this setting that mainly involve weight loss for patients with a high BMI. Surgical treatment can be considered if conservative measures fail. Generally, any surgical intervention is postponed for 6-12 months after surgery. Surgical treatment options include peri-urethral bulking agents, urethral slings and artificial urinary sphincters. Artificial sphincter is the gold standard treatment option for post-prostatectomy incontinence, with continence rates after surgery being more than 80%.

Mixed urinary incontinence has components of both urgency and stress incontinence. Management first requires the clinician to determine the most bothersome complaint of the patient. It often involves a combination approach by a specialist, as the treatment of one may make the other worse. Continuous urinary incontinence. It may suggest the development of a fistula between the urethra beyond the distal sphincteric mechanism, or a grossly deficient sphincteric mechanism leading to no restriction of flow. Management of this condition involves surgery or continence devices.

Behavioral Therapies in the treatment of UI

Much of the literature substantiates the use of Behavioral Therapy as first-line treatment of UI in males (Babecka, 2020). These treatments have been found to be the least invasive and have few side effects (Vansac, 2019).

Behavioral interventions for UI in men with prostate diseases were examined in ten studies. The continence rates in the control groups increased to more than 62% across all trials after the intervention (Markland et al., 2010).

A treatment plan starts with lifestyle modifications;