The approach to the investigation and treatment of urinary incontinence in men is similar to that of women. Many men experience urinary incontinence at some point in their lives. The incidence increases with age, and in some cases involving the prostate in particular. Incontinence in men is a subset of “lower urinary tract symptoms” (LUTS), which usually includes post-void dripping, obstruction and overflow, nocturia, and urgency.
The probability of an important underlying cause of incontinence is higher in men and it is always necessary to investigate the cause. Incontinence in men is often associated with prostate abnormalities or a neurological condition. The most common cause of urinary incontinence in men is benign prostatic hyperplasia, which causes urinary incontinence, frequency, and other LUTS because the prostate pushes against the bladder. Prostatectomy and radiation therapy of the prostate also contribute significantly to male incontinence (84% of men who undergo radical prostatectomy develop incontinence).
Neurological causes of incontinence include age-related changes that lead to bladder overactivity, diabetes and other systemic conditions that reduce nerve function, and neurological disorders such as stroke. More rarely, incontinence may result from malignancy or kidney or bladder conditions such as vesical stones (bladder stones). The predominant types of incontinence in men are similar to those seen in women, namely stress, urgency and overflow incontinence, and bladder overactivity.
Diagnosis and Diagnosis of Urinary Incontinence in Men
First of all, symptoms for urinary incontinence in men should be evaluated and the patient should be referred if necessary. As with women, patient history should be used to assess the likelihood of an underlying cause, the severity of the incontinence, and the impact of the incontinence on the patient’s daily life. The disease history should also include questions about previous prostate conditions or surgery.
Determining the type of incontinence present in men is similar to women and should be based on when and why leaking occurs, for example, if leaking occurs during exercise, stress incontinence is likely. General examination should focus on non-genitourinary causes or conditions that may contribute to incontinence, eg obesity, stroke.
The external genitalia should be examined for phimosis (the foreskin cannot be fully retracted over the glans), balanitis (inflammation of the glans), hypospadias (a birth defect that causes an abnormal ventral or inferior placement of the urethral opening); penis, hernias, signs of infection or other abnormalities, etc. as
A digital rectal examination is then recommended. Assess the size and consistency of the prostate and examine for nodules, tenderness, and any masses. The patient’s pelvic floor musculature should also be evaluated at this point using a representative measure of the patient’s anal tone. To do this, with the patient lying on their back, insert a finger one to two centimeters into the rectum (finger pad toward the coccyx) and assess the resting tone of the sphincter before asking the patient to stretch the muscles. This contraction should be held for five seconds. Assess the relative strength and endurance of muscle contraction. As for women, a rating scale such as the Oxford rating scale can be used for this.
Urine dipstick analysis should be performed in all men with urinary incontinence to assess the possibility of a treatable underlying cause, such as infection. If any of the following are present, serum creatinine levels should be checked as kidney dysfunction or abnormalities may be a contributing factor.
• Chronic urinary retention: This is recommended with excessive flow incontinence (eg bedwetting) or an enlarged bladder detected on abdominal palpation or percussion.
• Whether there is a recurrent urinary tract infection
• When urinary tract stones form
The patient should be asked to complete a bladder diary. Additional urodynamic tests such as flow testing (uroflowmetry) may be requested in the second step.
Treatment of Urinary Incontinence in Men
The management of urinary incontinence in men differs slightly from women because the probability of a significant underlying pathology is relatively high, especially if there is no history of prostate surgery or radiation. Management is based on the primary type of incontinence.
When managing stress incontinence in men, when stress urinary incontinence is caused by prostatectomy, patients should be referred to a Continence Nurse, Continence Physiotherapist, or urology clinic for supervised pelvic floor muscle exercises. Pelvic floor muscle exercises are very similar for both men and women. At least three months of exercise should be done before considering more invasive treatment options. If stress urinary incontinence is not due to prostatectomy, the patient should be referred to a Urologist for evaluation to look for the cause. This is due to the potential for an important underlying cause to be present, such as prostate cancer or structural abnormalities.
Referral to a Urologist should still be considered in men with incontinence following prostatectomy, particularly if behavioral treatments are ineffective. Surgical interventions are available for men with stress incontinence. These are usually limited to male slings and artificial urinary sphincters. For men with mild to moderate stress incontinence, male sling surgery has a 40-60% recovery rate and a 10-40% more significant improvement. The procedure is minimally invasive and the artificial urinary sphincter is also highly effective, achieving complete continence in 60 – 90% of men. However, this is a more invasive procedure and may be associated with greater side effects such as urethral atrophy and mechanical failure of the device.
Management of Urgent Incontinence and Overactive Bladder in Men
First, all treatable causes of urgent incontinence should be excluded or managed, such as benign prostatic hyperplasia, neurological conditions, existing UTI or STI, vesical stones, or prostate or bladder cancer. This may involve multiple consultations and temporary continence products may be recommended while the cause of the incontinence is being investigated. Benign prostatic hyperplasia can be treated with alpha-blockers such as doxazosin or terazosin. Finasteride (Special Authority) may also be considered if alpha blockers are not tolerated. NB Alpha blockers can potentially contribute to stress incontinence.
When no preventable underlying cause has been identified, referral to a Physiotherapist or Nurse Specialist for incontinence is recommended for bladder training. Bladder training is similar for both men and women. If symptoms persist despite bladder training, or where bladder training is not possible, a trial of oxybutynin should be considered. If pharmacological treatment is ineffective, referral to a Urologist is recommended. Surgical and medical options for the treatment of emergency incontinence in men include botulinum injections into the bladder wall, sacral nerve stimulation, and augmentation cystoplasty.
Writer: Ozlem Guvenc Agaoglu