Treatment Options

Once the cause and the severity of the urinary incontinence has been assessed, you can then embark on treatment. In all cases of incontinence, it is important to make sure that you are voiding regularly, that is, every 3 hours, and avoiding alcohol and caffeinated fluids. Caffeine and alcohol cause the kidneys to make more urine and are bladder irritants. It may also be helpful to avoid acidic foods and foods with a lot of hot spices because these may also act as bladder irritants.

If a bladder neck contracture is present, treatment may consist of dilation or incision. There is a risk of stress incontinence after incision of a bladder neck contracture. If overflow incontinence occurs after interstitial seed therapy, your doctor may give you a medication called an alpha-blocker to relax the prostate, an anti-inflammatory drug, and prescribe clean intermittent catheterization until you are voiding on your own. Usually, voiding troubles of this nature after interstitial seed therapy resolve with time, so additional treatment is rarely needed. Your doctor will be quite reluctant to do anything more aggressive for the first 6 months after the placement of the seeds because of the high risk of urinary incontinence with a TURP.

Overactive bladder is treated with medications that relax the bladder muscle, the most common of which are called antimuscarinics, including:

• oxybutynin (Ditropan)

• Ditropan XL

• tolterodine (Detrol)

• Detrol LA

• solifenacin (Vesicare)

• trospium chloride (Sanctura)

• Sanctura XR

• darifenacin (Enablex)

• oxybutynin patch (Oxytrol)

• oxybutynin gel (Gelnique)

• fesoterodine (Toviaz)

More common side effects of these medications include dry mouth, facial flushing, constipation, and, in some patients, blurry vision. Dry mouth and constipation rates are decreased with the long-acting formulations.

A variety of treatment options exist for stress incontinence, including pelvic floor muscle exercises, a penile clamp, collagen injection, an artificial sphincter, and a male urethral sling.

Pelvic floor muscle exercises: Pelvic floor muscle exercises are intended to strengthen these muscles. To identify these muscles, simply try stopping your urine stream while you are urinating. The exercises involve repetitive contracting and relaxing of the pelvic muscles at least 20 times per day every day of the week. Pelvic floor stimulation and biofeedback allow you to identify these muscles better and to monitor the strength of the contractions.

Penile clamp: Several penile clamps are available, and all of them have the same principle, which is to compress the urethra to prevent urinary leakage (Figure 14). They should be worn for brief periods of time only and should not be left on all day. If they are left on for long periods of time, they may cause damage to the penile skin and the urethra. The clamp needs to be removed if you need to urinate. The penile clamp should not take the place of pelvic floor muscle exercises; rather, it should be used as a backup measure. For instance, if you are going out to dinner and want to make certain there is no leakage, then you should use the penile clamp.

Collagen injection: Collagen is a chemical that is found throughout your body. The collagen that is being used to treat urinary incontinence is derived from a cow. Because it comes from a source outside of your body,

Figure 14. Penile clamp.

you must have skin testing to make sure that you are not allergic to the collagen. The collagen is injected into the bladder neck and the proximal urethra to make the urethra come together (coapt) (Figure 15). The amount of collagen injected at each treatment varies from person to person. The collagen injection can be performed in the urologist's office under local anesthesia or in the operating room under spinal or general anesthesia. More commonly, the collagen is injected retrograde through a cystoscope that is placed through the penile urethra and positioned just before the injection site. A long, thin needle is then passed through the scope, advanced into the urethra at the appropriate location where the collagen

Figure 15. Location of collagen injection.

is injected. The collagen is injected at several sites in the urethra until the urologist is satisfied with the amount of urethral coaptation. Some urologists prefer to perform the procedure antegrade. A small needle is passed through the lower abdominal skin into the bladder. A small wire is then placed through the needle into the bladder, and the needle is removed. Small dilators are then placed over the wire to make an opening that is large enough for the cystoscope, which is then placed through the opening in the abdominal skin into the bladder. The bladder neck is identified and the collagen injected. Often, more than one treatment session is needed. Typically three to four injections, each 4 weeks apart, are necessary. It is also possible that repeat collagen injections will be necessary over the long term. Collagen injections provide a continence rate of about 26% in postprostatectomy incontinence and a reduction in the number of pads used per day in an additional 37% of men.

The advantages of collagen injection are that it is minimally invasive, it is repeatable, it is associated with a short recovery period, and if it fails, it does not prevent you from pursuing other forms of therapy. Disadvantages of collagen therapy are that only a small percentage of men become totally dry, a small number of men develop a urinary tract infection, and 11% of men have transient urinary retention requiring clean intermittent catheterization. Permanent retention has not been reported.

Lastly, some individuals will experience transient dysuria (discomfort with voiding) and urgency after the procedure. The best candidates for collagen are men who have higher Valsalva leak point pressures (60 cm H2O), who do not have overactive bladders, have not had prior radiation or cryotherapy, and who have not had a vigorous incision of a bladder neck contracture.

Artificial urinary sphincter: The artificial sphincter is a mechanical device that is comprised of a cuff that is placed around the urethra, a pump that is placed in the scrotum, and a reservoir that is positioned in the abdomen (Figures 16 and 17). All of these parts and the tubing that connects them are buried under the skin and are not visible. The cuff remains filled with sterile fluid and compresses the urethra. When you wish to urinate, the pump is pressed, which transfers fluid out of the cuff, allowing you to urinate. The cuff automatically refills to compress the urethra. Placement of the artificial sphincter requires general or spinal anesthesia and an overnight hospital stay. Initially after the surgery, the sphincter is

Figure 16. AMS Sphincter 800 urinary prosthesis.

Courtesy of American Medical Systems®, Inc. Minnetonka, Minnesota (AmericanMedicalSystems.com).

Figure 17. Location of artifical sphincter.

Courtesy of American Medical Systems®, Inc. Minnetonka, Minnesota (AmericanMedicalSystems.com).

deactivated so that it doesn't work. It will be activated 4 to 6 weeks after surgery, when the tissues have healed and the swelling and sensitivity have subsided. The artificial sphincter provides continence rates of 20 to 90%, including men who are either totally dry or who use one pad per day. The sphincter can be used after collagen has failed. Disadvantages of the sphincter include mechanical malfunction rates of 10 to 15%, erosion rates of 0 to 5%, and infection rates of 3%. The cuff may erode, or move, into the urethra or through the skin, and other parts of the sphincter may erode into the skin or other areas. If there is an erosion, the device must be removed. Similarly, if the sphincter becomes infected, it must be removed. It is very important that a urodynamic study be performed before the sphincter is placed to make sure that the bladder holds an adequate amount of urine at low pressures and to identify an overactive bladder, which would require additional treatment.

Male sling: The fascial sling has been used for several years in women with stress incontinence and has proved to be a successful and durable procedure. Because of its success in women, it has been used more recently in men who are incontinent after radical prostatectomy. The sling may be derived from the patient's own tissues, from a synthetic material, or from cadavers. The goal of the sling is to place tissue under the urethra to act as a buttress or a hammock. The tissue is anchored to either the abdominal wall or the pubic bone.

Success rates with the male sling vary, but about 50% will be dry with a single procedure and retightening of the sling in those who are incontinent after the initial surgery can improve the success rate. In a long-term study, 64% of patients were improved and required two or fewer pads per day after the sling and 36% required zero pads per day. This is a surgical procedure that usually involves an overnight stay in the hospital. Urinary retention may occur that requires CIC over the short term and loosening of the sling if persistent. Complications of surgery include the need for revision, erosion of the sling, and infection.