Incontinence and Prostate Cancer

John C. Hairston, MDAssociate Professor of Urology

Integrated Pelvic Health ProgramNorthwestern Feinberg School of Medicine

“The objective demonstration of involuntary loss of urine consequent to bladder and/or sphincter dysfunction.”

The International Continence Society

Ballanger P et al. Female Urinary Incontinence. Eur Urol 1999; 36:165-174.

What is urinary incontinence?

Types of incontinence

• Stress Incontinence– Leakage during physical activity that increases

intraabdominal pressure, i.e. lifting, exercising, sneezing, and coughing

• Urge Incontinence– Leakage associated with an overwhelming

need to urinate Gotta go, gotta go!• Mixed Incontinence

– Combination of the above

– Hunskaar et al. One hundred and fifty men with urinary incontinence. Scand J Prim

– Health Care 1993; 11:193-196.

How does the process work?

• Bladder collects urine• The sphincter - a

circular muscle atthe level of the prostate - controls the flow of urine

• The sphincter muscle wraps around the urethra

• A healthy sphincter stays closed until one relaxes it to urinate

Why am I incontinent?

• Prostate cancer treatment– Radical Prostatectomy– Radiation– Cryotherapy

• Other pelvic surgery or trauma

• Spinal disease

• Neurologic disease

Am I the only one with incontinence?

55 million men in the world suffer from loss of urinary control

AMS 2003 Annual ReportCampbell’s Urology 2002 8th Edition

NO!NO!

Male Incontinence

• Rate of incontinence ranges between 2.5% up to 69% after prostate cancer treatment• Risk factors

• Degree of nerve sparing• Postoperative bladder neck contracture• Combination/Adjuvant treatment• Presence of prior disease (stricture, etc)• Salvage therapy

Male Incontinence

• Post-prostatectomy- Often improves within 3-6 months- 5-8% of men require treatment beyond

conservative measures• Radiation

- Often a late complication - Difficult to predict - Probably improving with improved directed therapies

Why treat incontinence?

Avoid negative feelings

embarrassment, discomfort, isolation, anger and depression

Return to usual lifestyle

Regain dignity

Resume intimacy

Save money on protective garments

Improve quality of life

150 men reported the practical inconveniences associated with incontinence:

52% Extra laundry

37% Smell

17% Extra expense

12% Skin irritation

11% Disturbed sleep

Source: Hunskaar s, Sandvik H. one hundred and fifty men with urinary incontinence. Scand J Prim Health Care 1993 v. 11 p.193-196

Why treat incontinence?

What to expect at an office visit

• History– Spinal or neurologic disease– History of BPH (Enlarged Prostate)

• Physical Exam– Neurologic exam

• Urinalysis• Postvoid Residual• 24 hr pad testing * • Urodynamics, Cystoscopy

Management options

• Pads/diapers• Medication• Devices

Pads/diapers

• What do men know about pads?!?• More absorbent and less irritating than

other paper products• Pads vs diapers

– “Maxi” vs. “Mini” pads

Devices: Clamps

– Cunningham clamp, C3-clamp

– Advantages• Non-medical, non-surgical• Easy to use• Works well

– Disadvantages• Bulky• Pressure necrosis• Generally not a turn on

Devices: Catheters

– External vs. Internal

– Advantages• Works

– Disadvantages• Attached to a bag• Increased risk of

infection

Medication

• No FDA approved medication for stress incontinence in men (or women)

• Antidepressants• You may be a candidate for anticholinergic

medication– Overactive bladder component

Treatment options

• Behavioral modification• Biofeedback• Injectables• Surgery

Behavioral modification

• Decrease fluid intake• Void frequently• Avoid caffeine, alcohol• Avoid activity that increases intraabdominal

pressure

Pelvic floor rehabilitation

• a.k.a. biofeedback• Means of teaching Kegel

exercises• Objective way to measuring

pelvic floor strength• ? how much better than verbal

instruction

Bulking agents

• Collagen, carbon beads, autologous fat• Success rates for collagen ~

17%-38% after prostatectomy• Most recent International Consultation on

Incontinence regarded this treatment as showing only modest benefit

• Poor surgical candidates with minor degrees of leakage

Klingler HC et al. Incontinence after radical prostatectomy: surgical treatment options. Curr Opin Urol 2006; 16:60-64.

Surgical options for male stress incontinence

• Male Sling • Artificial Urinary Sphincter

Male Incontinence Severity Level Guidelines

Onur R, Rajpurkar A, Singla A. New perineal bone-anchored male sling; Lessons learned. Urology Jul 2004 v. 64 (1) p.58-61

InVance™ Male Sling

• Effective treatment for mild to moderate incontinence

• Minimally invasive, 45± minute outpatient procedure

• Continence is immediately restored

• Nothing to operate

• Device is completely hidden inside the body

• 88% satisfaction rate1

1Onur R, et al. Efficacy of a new bone-anchored perineal male sling in intrinsic sphincter deficiency. International Incontinence Society. Oct. 5-9, 2003. 33rd annual meeting, Florence, Italy. Abstract 399.

InVance™ Male Sling

Sling creates gentle compressionon the urethra for urinary control

• Procedure:

– Spinal or general anesthesiacan be used

– Small incision under the scrotum

– Miniature titanium screws placedinto the pubic bone on each sideof the urethra

– Sling positioned to exert gentlepressure on urethra

– Sling secured to screws

– Incision closed

AdVance™ Male Slinga new, innovative treatment option

• Innovative treatment for mild to moderate incontinence

• Minimally invasive, fast outpatient procedure

• Continence is immediately restored

• Nothing to operate

• Device is completely hidden inside the body

AdVance™ Male Sling

Sling restores urethra to its proper anatomical position for optimal sphincter function, restoring urinary control

• Procedure:

– Spinal or general anesthesiacan be used

– Three small incisions: 1 under the scrotum, 2 over groin creases

– Specially designed surgical toolsare used to position the sling

– Sling is gently tensioned– Incision closed

AdVance™ Male Sling

Virtue™ Male Sling

Artificial Urinary Sphincter (AUS)over 100,000 implanted since 1972

Litwiller SE, et al. Post-prostatectomy incontinence and the artificial urinary sphincter; a long-term study of patient satisfaction and criteria for success. J of Urol 1996; 156:1975-1980.

• The Gold Standard for treatment of moderate to severe incontinence

• 60± minute outpatient procedure

• 92% of patients would have the device placed again

• 96% of patients would recommend it to a friend

• Device is placed completely in the body, providing simple, discreet control

Animation of Artificial Urinary Sphincter

Sling

• Appropriate for treatment of mild to moderate incontinence

• 70-85% success rates

• 45-60± minute outpatient procedure

• Transient scrotal/penile and perineal pain

• Passive

• Favorable 2 year data (durability?)

• Complications

• Infection and Erosion ( < 2%)

• Reoperation rate (unknown?)

• The Gold Standard for treatment of moderate to severe incontinence (85-95% success)

• 60± minute outpatient procedure

• Catheter for 23 hours

• Transient scrotal/penile and perineal pain

• “Active”

• Over 30 year track record of durability

• Complications

• Infection and Erosion (5-10%)

• Approx 15% require revision surgery over a 10-15 year period

AUS

What should you do next?

See your Urologist! • Come prepared with questions • Discuss your treatment options• Your lifestyle and medical condition are

important factors• Ask if you can speak to one or more of

his/her satisfied patients

Summary

• Incontinence is a common problem

• Most cases resolve within 6-12 months

• Some treatments are more effective than others

• Surgical treatment options offer proven, long-term solutions

• Talk to your Urologist – talk to your partner• Podcast at NMH.com

– http://www.nmh.org/nm/ihealth-mens-health– http://www.patientpower.info/health-topic/prostat

e-cancer

• For copies of this talk– Sara Steinkamp– s-steinkamp@northwestern.edu

Thank You