Incontinence and Prostate Cancer

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Incontinence and Prostate Cancer

• John C. Hairston, MD
• Associate Professor of Urology
• Integrated Pelvic Health Program
• Northwestern Feinberg School of Medicine

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What is urinary incontinence?
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
36165-174.
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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 11193-196.

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How does the process work?

• Bladder collects urine
• The sphincter - acircular 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

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Why am I incontinent?

• Prostate cancer treatment
• Radical Prostatectomy
• Radiation
• Cryotherapy
• Other pelvic surgery or trauma
• Spinal disease
• Neurologic disease

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Am I the only one with incontinence?
NO!
55 million men in the world suffer from loss of
urinary control AMS 2003 Annual
Report Campbells Urology 2002 8th Edition
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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

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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

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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

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Why treat incontinence?
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
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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

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Management options

• Pads/diapers
• Medication
• Devices

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Pads/diapers

• What do men know about pads?!?
• More absorbent and less irritating than other
  paper products
• Pads vs diapers
• Maxi vs. Mini pads

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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

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Devices Catheters

• External vs. Internal
• Advantages
• Works
• Disadvantages
• Attached to a bag
• Increased risk of infection

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Medication

• No FDA approved medication for stress
  incontinence in men (or women)
• Antidepressants
• You may be a candidate for anticholinergic
  medication
• Overactive bladder component

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Treatment options

• Behavioral modification
• Biofeedback
• Injectables
• Surgery

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Behavioral modification

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

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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

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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 1660-64.

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Surgical options for male stress incontinence

• Male Sling
• Artificial Urinary Sphincter

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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
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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.
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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

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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

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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

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AdVance Male Sling
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Virtue Male Sling
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Artificial Urinary Sphincter (AUS)over 100,000
implanted since 1972

• 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

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 1561975-1980.
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Animation of Artificial Urinary Sphincter
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AUS
Sling

• 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

• 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 ( lt 2)
• Reoperation rate (unknown?)

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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

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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/prostate
  -cancer
• For copies of this talk
• Sara Steinkamp
• s-steinkamp_at_northwestern.edu

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Thank You