MALE STRESS URINARY INCONTINENCE/MALE SLING 

• Overview
• Evaluation
• Treatment
• Male Sling
• What to Expect After the Procedure
• Is it Right for You? 
• Insurance 
• Risk Information

OVERVIEW

Men can have incontinence for a variety of reasons.  After ignoring a blocking prostate for years, men can finally start leaking- it won't be the first symptom of their enlargement, but they may eventually leak. Men can also  leak from a variety of  neurologic causes- including stroke, diabetes, multiple sclerosis.  This section does not  deal with any of those. This  section focuses only on  the leakage  that  occurs with coughing , laughing, lifting, and staining ( stress urinary incontinence or SUI) in men after they've had  either their prostate removed for prostate cancer ( robotic , laparoscopic or  open radical prostatectomy), or , rarely, trimmed for obstruction ( TURP, PVP, Microwave).
 
With increased screening,  there has been a dramatic rise in the number of potentially curable prostate cancer cases found.  At the same time, less invasive robotic radical prostatectomy has made the recovery after prostate cancer removal surgery much  more patient friendly.  As a result of these two trends , more prostate cancer cases are being found at curable stages and more of them are being treated with radical prostatectomy.  Because of these two trends, the number of men suffering from stress incontinence is increasing. The percentage of patients undergoing surgical prostate removal who have incontinence can vary from 2- 20%, depending  on how the studies define and report incontinence.  I tend to agree with the smaller number. No matter what the number is, for the patient who has loss of bladder control after prostate surgery, the problem is devastating! 
 
Fortunately, there is good news. There has always been a cure for male stress incontinence. The artificial urinary sphincter was developed years ago and is a great solution for debilitating incontinence.  Sphincters work! They are especially appreciated for their ability to dry severe incontinence. Many men, understandably, are less than enthusiastic about the prospect  of having  another procedure to fix the leakage that followed their first surgery- especially if they don't leak "all that much".  Men with lesser degrees of incontinence, weary of surgery, have often opted to  live with their leakage rather than fix it.  To many of them, using a sphincter to cure mild incontinence seemed like using an atom bomb on remove an anthill.  Fortunately, the  male urethral sling, an effective, 45 minute non-invasive procedure,  gives men with mild to moderate incontinence a more appropriate option. 
 
EVALUATUON:

To see if you are a candidate for the male sling, your  bladder must first be studied. Men who leak after prostate cancer surgery  generally have a non-working sphincter. But there are other causes of leakage in men, and  often men have a combination of causes.  The evaluation of a man who leaks  determines if his leakage is solely due to one cause, or multiple causes. The other causes of male leakage could be scar tissue blocking the bladder neck  or  damage to the nerves of the bladder. Both are rare but could happen after  prostate removal surgery .  All of these  conditions could be present, and all could contribute to your incontinence. Your incontinence CAN be fixed, but the key to fixing it is knowing all the factors causing it.  For this reason, the evaluation of male leakage  includes doing a cystoscopy to rule out scar and doing urodynamics to rule out nerve damage causing an under- or over-active bladder. (Both tests are painlessly done in the office and involve either simply looking at the bladder with a flexible scope or measuring the bladder's pressure responses to being filled through a skinny catheter).  Ideally you would like  your cystoscopy to show no scar tissue and your urodynamic evaluation to show that everything else functions normally.  Results such as these suggest all you need is a male sling to fix your leakage. ie  Testing is important to successful treatment.
Incontinence Questionnaire:
 
There are a number of signs of incontinence, depending on the type. You may be experiencing involuntary loss of urine during physical activity; a compelling need to urinate with inability to stop leakage long enough to reach a toilet; or continued leakage because the bladder is full beyond capacity.

In addition to the testing mentioned above, answers to the following questions will help indicate  the cause(s) of your problem.

1. Do you leak urine unexpectedly?

2. Is the urine leakage:

- Mild (a few drops)
- Moderate (wet underwear)
- Severe (wet outerwear)

3. Does the urine loss occur during coughing, sneezing, laughing, bending or lifting?

4. Does the urine loss occur when you change from a sitting or lying position to a standing position?

5. Do you leak urine continuously?

6. Is urine loss a problem to you?

7. Has this urine loss caused you to change your lifestyle?

8. If you have changed your lifestyle, how?

• I limit the fluids I drink 
• I stay at home 
• I limit my choice of clothing to dark colors

Your answers to these questions will be discussed in our first meeting.

TREATMENT

People with incontinence can manage accidental urination by using a number of different options.

Absorbent Products

Pads may  help patients deal with bladder control problems. It takes considerable time and effort  to deal with moderate to severe incontinence thru the use of pads. Patients who do successfully treat their leakage with pads generally have come to accept that leakage and do not progress  further in regaining the ability to stay dry.
 
Collection Devices

A collection device may be internal , such as a catheter, or external, such as a condom catheter. Another external device is a Cunningham clamp which  ,when placed on the penis, compresses the pee channel so no urine leaks out. Internal catheters can lead to infection and external devices ( both condom catheters and penile clamps) can lead to skin breakdown. Both categories of devices have their place, but for active patients or patients hoping to regain a more active life style, neither is satisfactory.
 
Biofeedback

The theory of biofeedback  to help a man regain continence assumes that he is unaware of whether he is or isn't contracting the remaining sphincter muscles correctly.  My experience with this suggests that the man's problem lies not in unawareness  but  in the muscles being too weak to hold the urine back. Biofeedback doesn't change the weakness of the muscles, it just makes the patient more aware of it. ie.: Unfortunately, it isn't an effective solution for this problem.
 
Surgical Options

Surgical procedures are available to treat male urinary stress incontinence.
• Injections of bulk-producing agents, such as collagen, into the urinary sphincter. (These don't work.)
• Implanting a "male sling," a device designed to support the muscles around the urethra.
• Implanting an artificial urinary sphincter, which mimics the function of a normal, healthy urinary sphincter. Currently AMS offers the only artificial urinary sphincter available - an effective solution for moderate to severe stress urinary incontinence following prostate surgery.

MALE SLING

The  male sling  safe and effective procedure for men suffering from mild stress urinary incontinence. The procedure is a minimally invasive outpatient surgery that can restore bladder control immediately.

While moderate to severe cases of incontinence in men have been treated surgically with artificial sphincters for years, the majority of incontinent men — those only mildly to moderately incontinent — now have the option of choosing the lesser invasive male sling..

The sling is made of synthetic mesh  and is placed inside the body through small incisions. It supports the urethra, restoring normal bladder control. Most patients are continent immediately following the procedure and can resume normal, non-strenuous activities shortly thereafter.

The procedure offers many benefits to men suffering from mild stress urinary incontinence:

• Short surgery ( usually 30-40 minutes),  either as an outpatient or overnight stay
• May be performed under spinal or general anesthesia
• Recovery is often rapid — results may vary
• Often no catheter necessary upon discharge
• No device activation required
• Immediate improvement
• Restored dignity and quality of life 

What to Expect After the Procedure

You will have a catheter draining your bladder  during the sling placement and it will be removed the following morning.
Most patients are dry immediately following the procedure.

You will receive a  prescription for oral antibiotics for a period of time following the procedure. Normal ( non -strenuous) activities can be resumed after a few days, although patients should avoid heavy lifting, strenuous exercise — including biking — and intercourse for a minimum of six weeks. You will get a printed  post-op instruction sheet. Be sure to read and follow it completely. You will usually be seen in follow up in the office  about 7 to 10 days after the  procedure.
 
ResultsThe male sling is a safe, innovative and effective treatment solution for mild stress urinary incontinence in men.
Over 1,500 men have been treated using this approach. Long term published data show success rates of 90-96%.

Is it Right for You? 

The male sling  is a minimally invasive surgical treatment option for mild to moderate stress urinary incontinence in men, which often results from a radical prostatectomy or TURP.
 
Good candidates for the sling are men with:

• Mild to moderate SUI
• 1-5 ppd, < 200 g 1 hour pad weight
• Residual sphincter function
 
The  male sling is not for people with:

• Recurrent urinary infections
• Blood coagulation disorders
• Compromised immune systems or any other condition that would compromise healing
• Renal insufficiency
• Upper urinary tract  obstruction

Further contraindications for sling surgery are the same as contraindications  for artificial sphincter placement, and include:

1)  an overactive bladder( which may be the result of a stroke or other  nerve damage)
2)  a shrunken low- volume bladder ( which may occur after radiation to the pelvic area)
3)  an underactive bladder ( hypotonic due to diabetes and other causes)
4)  lack of coordinated  relaxation of the  sphincter during a bladder contraction( that again may be due to nerve damage from stroke or MS or other  diseases that affect the nerves' ability to send messages). 
 
Insurance 

Medicare and most insurance carriers cover the cost of the male sling. 
 
Risk Information 

In general, the risks are minimal, but, like with any surgical procedure, some inherent risks are present. Although rare, the most severe risks include infection and erosion,  or scarring. As with any procedure,surgical, physical, psychological, or mechanical complications may occur that could necessitate revision or removal of the sling.