The surgical treatment options for SUI include a male urethral sling and an artificial urinary sphincter. These procedures should be done by a urologist with specialized training for these procedures.
Work Up
If you have SUI, please discuss your symptoms with your urologist. You will need to tell them when and how much you leak and how many pads you use and how wet they are when you change them. You may be asked to keep a diary of urinating (peeing) habits, including how much fluid you take in. After finding out how much you are leaking, your doctor will need to do a cystoscopy. This means a very small camera will be inserted through your urethra into your bladder to look at your urethra, urethral sphincter, and bladder. With all this information, your urologist will decide which surgical option is best for you. Your urologist may also prescribe pelvic floor physical therapy to help make your surgical outcome better.
Male Urethral Sling
A male urethral sling is a piece of mesh that is placed over the urethra to support to the urethra which prevents SUI. These are often used for patients with mild to moderate SUI. Slings are not the best option for patients that have had radiation treatment because of changes to the tissues from this treatment.
There are two types of slings available—the two-arm sling and the quadratic (four-arm) sling. Choosing which sling to use is based on which one your urologist prefers and the amount of leaking you have. The two-arm sling is smaller and elevates or lifts the urethra to stop the leaking. The quadratic sling is larger so it can lift and squeeze the urethra. One difference between slings and artificial urinary sphincters (described below) is that you don’t have to use your hands to make the sling work. Another difference is that the patient will see an improvement in continence (ability to hold urine) soon after surgery.
Artificial Urinary Sphincter (AUS)
An AUS is a device made of three parts—a cuff, pump, and balloon. The cuff that is wrapped around the urethra mimics, or acts like, your natural urethral sphincter. The pump is placed in the scrotum next to the testicle during surgery. At rest, the sphincter is closed. It squeezes the urethra closed to stop urine from leaking. When you feel like you need to urinate, you squeeze the small pump and it opens the sphincter to allow urine to pass through the urethra. After 90 seconds, the sphincter closes on its own. This prevents any further leaking or passing of urine until the pump is squeezed again.
AUS is considered the gold standard for the treatment of SUI. It is typically used on patients with moderate to severe SUI. This is also the treatment of choice for patients that have had radiation therapy for prostate cancer. Unlike the sling, the AUS will not be “activated” or turned on to prevent SUI right after the surgery. This is because the urethra needs time to heal before applying pressure on it with the AUS. You will visit your urologist's office about six weeks after surgery to activate it.
Conclusions
The ability to control when you urinate or pee is something many people may take for granted. Unfortunately, many prostate cancer survivors are dealing with incontinence due to the treatment they have received. For patients with leakage that is too severe for non-surgical options, a sling or an AUS can allow the patient to control their continence again. These surgical options can be used along with non-surgical options to improve urine control. Pelvic floor physical therapy is a non-surgical option that is often used with surgical options. If you are interested in having one of these procedures, it is important to find a urologist who is an expert in placing a sling and/or AUS.
The non-surgical treatment options for SUI are pelvic floor physical therapy, incontinence clamps, and tension penile loops.
Pelvic Floor Physical Therapy (PFPT)
PFPT is a branch of physical therapy that focuses on the muscles in the pelvis. This is an excellent first-line option for all patients with SUI. If they have very mild symptoms, this will be the only option. However, patients that have very severe SUI will need surgical treatment.
For patients planning for a prostatectomy (surgery), PFPT can be started before the operation. This helps men control their pelvic floor better to get ready for post-operative SUI. Physical therapists with postgraduate training focused on the pelvic floor provide this therapy.
Every therapist has their own practice style, but some of the cornerstones of this treatment include:
- pelvic floor muscle training (think Kegels on steroids)
- behavioral changes (changing how much liquid you drink and your urinating schedule)
- manual therapy (direct treatment to the pelvic floor)
- biofeedback (monitor to show you what you are doing)
- functional training (including muscle squeezing during daily activities)
PFPT has also been shown to help with urge urinary incontinence, constipation, fecal incontinence, and pelvic pain.
External Devices
These are devices that are placed around the penis to compress the urethra. There are different types depending on the activity they are needed for.
Incontinence Clamp
Incontinence clamps are simple tools used daily to stop urine leakage. A clamp is placed around the outside of the penis shaft to stop urine from leaking. There are different brands on the market, which are very similar, so it is important to choose the one that works best and is the most comfortable for you. Incontinence clamps come in different sizes, so it is essential to pick the correct size to get adequate compression without preventing blood flow to your penis. If using one of these devices, you must follow the instructions to prevent injury, specifically only wearing the clamp when awake and removing it every few hours to urinate. You should also rotate the location you place the clamp on your penis from the base to the midshaft and move it every few hours.
Tension Penile Loop
Another unique subtype of SUI is climacturia. This occurs when you have leakage of urine when you reach climax or orgasm. Many men think that it is ejaculate or semen. However, after the prostate is removed, the patient is unable to ejaculate. The ejaculate volume can also be diminished from radiation therapy. Men can still achieve orgasm without ejaculating. For men experiencing this, a tension penile loop is a non-surgical option. These loops are made of silicone and are very similar to constrictive rings used for erectile dysfunction. They are placed at the base of the penis and cinched down to compress the urethra while not causing problems with blood flow. It is important that you remove the loop as soon as you are done having intercourse.
Precautions for External Compression
When using any external device, you should alert your doctor if you have numbness, pain, swelling, discoloration, or skin irritation of your penis.
Conclusions
The ability to control continence is something that many people may take for granted. Unfortunately, many prostate cancer survivors are dealing with incontinence as a result of the treatment they have received. However, there are many treatment options depending on how bad your incontinence is.
If these non-surgical options are not enough to control your incontinence, then there are surgical options. To explore these options, it is important to find a urologist who is an expert in these procedures. Please refer to the article about surgical options for stress urinary incontinence for more details.
If you are having surgery or radiation for the treatment of prostate cancer, it is important to understand that there will be side effects. One side effect is stress urinary incontinence (SUI). This means that you will leak urine when you cough, sneeze, laugh, strain, lift things, or move around. SUI happens because these activities increase pressure in the abdomen, which pushes on the bladder.
Urine (pee) comes out of the body through an opening called the urethra. Before cancer treatment, the urinary sphincter — which is a muscle around the urethra — can squeeze to stop urine leaking. It can squeeze the urethra shut even with added pressure on the abdomen.
After treatment, the nerves that control the sphincter may be damaged and the sphincter may be weakened. Depending on how bad the leaking is, there are many treatment options for this problem.