Urinary incontinence in men

Internal Appliances in the treatment of UI

The use of internal appliances in the treatment of UI becomes more invasive than previous options. Barrie (2016) and Smart (2014) suggest internal appliances, such as various forms of catheterization (indwelling or suprapubic catheters and Intermittent Self-Catheterization (ISC)), should only be used as a last resort when conservative treatment measures have failed as they often cause complications. This is because indwelling catheters, in particular, can cause infection, blocking, bypassing and discomfort along with an increased risk of urosepsis and symptomatic UTIs. Suprapubic catheterization eliminated trauma and was more acceptable to those who were sexually active, but this was often not appropriate for those with cognitive impairment as there was a tendency to pull at the catheter. ISC was the most suitable option for those with incomplete bladder emptying (Barrie, 2015).

According to Hollander and Gonzalez (2012), men who suffered from UI that was nonobstructed but had high postvoid residuals included groups with detrusor underactivity and impaired contractility. The new P-3 adrenoreceptor agonists might also be effective in this population, although this has not been investigated (Hollander and Gonzalez, 2012). Although indwelling catheters are the last resort for managing UI, they are necessary for problems in bladder emptying, where intermittent catheterization is not an option, and allow urine drainage, thus managing overflow UI (Wilson, 2016).

Penile clamps and condom catheters are occasionally used but are not considered socially acceptable and can be a source of anxiety and discomfort (Moore & Lucas, 2010). Alternatively, Wilson (2014) showed external appliances such as urinary sheaths could be a viable option.

They offered a practical, cost-effective alternative to pads, pants, and the indwelling catheter. They were suitable for men with moderate-to-severe urinary incontinence, and those who experienced urgency and frequency and found it difficult to get to the toilet in time. Although latex sheaths are still available, the majority are made of latex-free (silicone) material. They come in oneor two-piece types and have variable penile circumference sizes and standard and short lengths, so individual measurement is essential (Wilson, 2015). Smart (2014) states that the urinary sheath, if used correctly, is a safe, discreet, convenient and comfortable method of managing male incontinence and compares favorably with pads and indwelling catheters.

Compared with pads, the urinary sheath was more hygienic, comfortable, cost-effective and more environmentally friendly. As the sheath directed urine away from the body, there was less likelihood of skin excoriation and infection, and there was less urine odor, as it is not exposed to air when the pad is full or has leaked onto clothing. Compared with indwelling catheters, the risk of urinary tract infection (UTI) is substantially reduced. A study involving 75 hospitalized men aged over 40 years old, without dementia, concluded that patients with an indwelling catheter were five times more likely to develop bacteriuria, symptomatic UTI or to die as those who used a urinary sheath (Smart 2014).

Smart (2014) stated that some men, although eager to use a sheath, were unable to do so because of allergy or retraction. An alternative to the utilization of a sheath is CliniMed's Bioderm; a product also appropriate for men experiencing frequent erections. Manufactured from hydrocolloid and latex free, it can remain in place for three days; one size fits all, and it connects to the urine drainage bag. Bioderm is appropriate for both circumcised and uncircumcised men, providing the foreskin will retract. Also available are body-worn urinals. Pubic pressure urinals are fitted when the patient has a retracted penis; the application of pubic pressure, exerted by a flange held firmly over the pubic area by groin and waist straps, extends the penile length. The appliance may have its own urine-collecting cone, or allow attachment of a non-adherent sheath. In her experience, some men wear an appliance only for going out and then do not have to remove an adhesive sheath on returning home (Smart, 2014).

Among the various conservative treatments that can be used to treat urinary incontinence, Functional Electrical Stimulation (FES) has been proposed as a promising alternative (Terzoni et al., 2015). This treatment is administered through anal probes or surface electrodes placed in the perineal area. Electrical impulses are produced by a dedicated machine, relayed by the probe or the electrodes, and transmitted to the muscles through afferent nerve fibers (Terzoni et al., 2015).

According to Hollander and Gonzalez (2010), electrical stimulation of the sacral nerve roots (S3-S4) is approved by the Food and Drug Administration (FDA) for urinary urge incontinence, urinary frequency syndrome, and incomplete and complete non-obstructive retention. Additionally, Terzoni et al. (2015) stated that when UI was present after radical prostatectomy, FES could be used to reduce urine leakage. When some patients had difficulty in performing PFE, and did not obtain clinically significant results, FES was helpful. There is a need to verify if FES can reduce urine leakage in patients who do not benefit from PFE as obtained mid-term data regarding the persistence of the results through was mixed (Terzoni et al., 2015).

Stother (2010) suggested that using combinations of strategies in men following prostatectomy has yielded inconsistent results. In some cases, where researchers studied PFE alone and in combination with electrical stimulation versus no treatment following prostatectomy they found no difference in UI among groups. In a randomized controlled trial of electrical stimulation followed by biofeedback and PFM exercises versus no treatment in 30 men with detrusor hyperreflexia associated with multiple sclerosis, there was a significant improvement in subjective symptoms in the male group only, providing another option in specialized circumstances (Stother, 2010).

This project provides an overview of male UI treatment strategies and their effectiveness: To treat a male with UI in the outpatient setting, a comprehensive history and physical exam is the first step. The exam should include a 72-hour bladder diary, completion of the International Prostate Symptom Score (I-PSS), and a Post Void Residual (PVR) test. This information will provide the basis for recommendations for future treatment options. Diagnostic work up includes a comprehensive urinalysis and basic metabolic panel (BMP), and a prostate specific antigen (PSA) test will be added if the patient is over 50 or demonstrates overflow incontinence or has an abnormal prostate exam. The results of these tests will determine the UI type and the treatment options.

If the patient has a PVR over 200 mL, overflow incontinence is diagnosed. However, a PVR greater than 200 to 300 mL does not in itself require treatment in the absence of symptoms or recurrent infection. Management typically involves an indwelling urinary catheter or clean intermittent catheterization in addition to medication management. A referral to urology is the best course of action for overflow incontinence (Hollier, 2016).

A patient may also present with complications such as recurrent or total incontinence or they admit to UI mixed with pain, hematuria, recurrent infection, prostate irradiation or radical pelvic surgery. In this situation, they must be referred to a Urologist. Any other abnormality should also be referred.

The results of the patient history will determine if the UI is stress, urge, or mixed. A diagnosis of stress, urge or mixed incontinence will lead to a discussion of treatment options with the patient specific to the etiology. Urological experts suggest lifestyle changes as the first option as they have shown great promise in male UI treatment. These changes include weight loss, dietary changes, biofeedback, bladder training and PFE. Other options may be considered, but less desirable are containment products or medications such as antimuscarinics, or a-andrenergic antagonists.

Failure of any of these treatment options requires a more specialized treatment approach.

Once again, referring to the patient's history, if patients present with post-prostatectomy incontinence or with urgency/ frequency, then the NP may consider referral to a Urologist for urodynamics and imaging of the urinary tract to further refine the source of the issue. Urethrocytoscopy is an option if indicated (Lobchuk, et al., 2014).

If the results of these tests show stress incontinence due to sphincteric incompetence, then an appliance such as an artificial urinary sphincter or male sling is indicated. If urgency incontinence is diagnosed due to detrusor over-activity, then there are several options. First, with no other reported symptoms, electrical stimulation is first line (Mathur, 2016). Secondly, if the detrusor over-activity coexists with bladder outlet obstruction, then a-blockers, antimuscarinics, or referral to a urologist for surgery correction of the bladder outlet obstruction is indicated. And finally, if the detrusor overactivity coexists with underactive detrusor during voiding, then intermittent catheterization or antimuscarinics are called for. Signs of mixed incontinence should lead to treating the major component first (Utomo, 2015).

These treatment options are within the scope of practice for the nurse practitioner in primary care. Trying first line options allows the patients to consider or implement treatment options before seeing a specialist. Often family practitioners are asked for low-cost options during the patient discussion; the nurse practitioner can provide viable options (Allapattu, et al., 2016).

The recommendations, based on the strength of evidence, showed behavioral modification as the most widely used and most successful therapy. Prescribing medication was shown to be a viable (although less common) alternative treatment option. Containment devices, internal and external appliances were recommended at a similar rate, but were shown to be used even less often. Finally, the use of electrical stimulation and combined therapies were shown to be the least proven (Babecka, et al., 2021).

Conclusions

Urinary incontinence in men can be debilitating for the individual. The psychosocial impact of the condition can vary and should be assessed before a tailored treatment is planned. Classification of urinary incontinence can help better identify the underlying causes and guide clinical management, although quite often patients present with complex symptoms that do not typically fit into any type of definition. The initial assessment of urinary incontinence in men should take into account the red flag signs. Readers are strongly advised to review recent guidelines on male lower urinary tract symptom.

References

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Annotation

The study analyzes the treatment of male urinary incontinence.

Methods. 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.

Results. 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. 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.