Male urinary incontinence is a problem that effects millions of American men, particularly as they reach the later years of their lives. Many men live with it silently. They believe there is little that can be done . This situation has affected more and more men as it is realized that many of the problems that effect the urinary system in men can be cured. With cureof the problem, involuntary loss of urine may occur.

We need, first, to examine the issue of continence and what it is dependent upon.

In order to be continent, one has to be mobile, have a reasonably normal ability to think that one wants to be dry, be motivated to take action, have a certain degree of manual dexterity and have a bladder that is near normal or can be made that way with medical or surgical treatment.

In men, the lower urinary tract passes through the prostate. The prostate, pound for pound, is one of the most troublesome organs in human kind. We’ve learned a great deal about it in recent decades. Prostate cancer in 2000 and beyond has great potential for cure.

The problem is the treatments for this disease may compromise the sphincter or shut-off mechanism which involves the area, not only of the bladder neck which is above the prostate but the pelvic floor just beyond the prostate and also muscle groups contained within the prostate.

In order to understand the physiology of the lower urinary tract, we need to think about the bladder’s two basic functions : storage and emptying.

The bladder is unique in that its muscles have characteristics unlike any other organ in the body. The muscle bundles of the bladder can slide, one over another, allowing the bladder to increase in capacity without increasing the pressure within. For instance, unlike a balloon … as the volume of a balloon is increased, the pressure within it is increased. This unique characteristic of the bladder is called compliance. The best example of a compliant substance is "silly putty". As you stretch out a wad, it doesn’t recoil, it just assumes its new shape. Silly putty is a very compliant substance. On the other hand, a rubber band is highly elastic. Once stressed, it recoils and is clearly unlike the highly compliant substance such as silly putty. When the bladder is in its storage phase it has high compliance, when it is emptying it is very much like the elastic characteristic of a rubber band or a balloon that is contracting and emptying.

Urodynamics is a study that we use in urology that allows us to understand the characteristics of compliance and elasticity of the bladder. This is known as a cystometrogram. One aspect of the study involves filling the bladder and measuring the pressure that is generated in doing so. In effect, we are measuring the compliance capabilities of the bladder. This test is done by placing a small catheter in the bladder, another small catheter in the rectum and electropads on the bottom or perineum. The bladder is filled with saline, and the patient…after the bladder is full….is asked to void. This activity is all recorded. This series of curves produces a signature. If it is abnormal, we can, many times, tell what makes the bladder function abnormally. The central nervous system has a very close relationship to the bladder, and there are many reflexes that evolve and help the bladder functions. In summary, we can say the bladder has two basic functions : storing and emptying. Urodynamic testing, then, can tell us if these functions are normal or abnormal.

Closer study of the bladder has made us aware of the chemical agents secreted by the nerves that enter the bladder and, in many ways, govern how the bladder functions. Medications that are similar to these chemicals have been manufactured, and these can be used to treat an abnormal bladder.

Ditropan XL

Detrol

The subject of the "overactive bladder" has come from research done by pharmaceutical companies to understand the chemistry of the bladder and how it can be modified.

Bladder malfunction is very frequent in our society. These companies have recognized that there is a great need and, therefore, a very good business in supplying medicines that can make abnormal bladder function normal. The two leading medications are Ditropan and Detrol. These substances have a very significant ability to modify bladder function and if abnormal, this medication can make it approach normal. The problem in using these medications is, at times, they can cause side effects such as dry mouth, constipation or blurred vision. These medicines are now produced in a slow-release form. In the case of Ditropan it is known as Ditropan XL. The slow-release form of Detrol is known as Detrol LA. The net result is that otherwise unpleasant side effects of these valuable medications can be modified in such a way that the medications can be used in a very efficient manner to bring the abnormal bladder back toward a normal function with minimal side effects.

The bladder, however, does not function alone. It interacts with a support system known as the pelvic floor. Pelvic floor and bladder are connected to the central nervous system in such a way that when the pelvic floor contracts, the bladder relaxes. When the bladder contracts, the pelvic floor relaxes.

Patients can learn to exercise the muscles of the pelvic floor in such a way as to gain control over the reflexes that involve storage/emptying of the bladder. There are also sophisticated instruments that we can use to learn to control these reflexes and the activity of the pelvic floor. These are referred to as the instruments of bio-feedback.

Bio-feedback Instrumentation

This can be accomplished by putting a small probe into the rectum, using the input from this probe to a computer that can demonstrate when the patient contracts or relaxes pelvic floor muscles. This knowledge, gained by the patient using this equipment, may allow him/her to quiet the bladder, keep it from contracting inappropriately, such times as when bladder emptying is not desirable. By using the technology of bio-feedback a knowledgeable therapist can train patients to use pelvic floor muscles and their associated reflexes to great advantage in improving urinary control.

Contigen

Contigen is a substance that has been developed over the past decade for use in urology. This substance can be implanted into the area of the sphincter. This can be done as an outpatient procedure in the physician office. Collagen is a biologic product that comes in a paste form and can be injected into body tissue and accepted by those tissues. In urology we have learned there are circumstances where the sphincter or shut-off valve mechanism does not seal as efficiently as is required in a person who has normal continence. We can change this by using collagen, applying it through a scope and a very delicate needle and injecting the collagen in the region of the sphincter. The result is the enhanced ability of the walls of the urethra to come together. This is called coaptation and can enhance the shut-off valve of the urethra (the sphincter) to work more efficiently. I have seen, on numerous occasions, patients who have had urinary incontinence because of sphincter damage…the bladder was otherwise normal, and after a few injections of collagen/Contigen they became dry. I’ve even seen the patient come to the office wet and after the 20 – minute office procedure where collagen was used, walk out dry.

Artifical Urinary Sphincter (AUS)

The artificial urinary sphincter is probably the most significant development for the management of male urinary incontinence that has occurred in this century. Dr. Brantly Scott, a brilliant urologist whom I have had the good fortunate to work with, developed this concept.

The artificial sphincter consists of a device made of silastic which is accepted by the body and is totally implanted. It consists of a pressure reservoir that is implanted in the abdomen. A pump that is placed in the scrotum and a cuff that is surgically inserted around the urethra in the area of the normal sphincter. When this device is implanted the patient is only aware of a small "kernel" in the scrotum that can be manipulated in such a way as to cause increased resistance around the urethra by increasing pressure in the implanted cuff. This enhances the patient ability to retain their urine and stay dry. The device has a long history. It was developed in the late 1960s and went through a number of modifications until the mid-1980s. The device is a successful product. It is unique and for many patients a near miracle in that it has allowed these people, who otherwise are committed to wearing diapers, isolated from society, to essentially become close to normal and, once again, a functioning citizen.

The artificial sphincter is totally implanted. It has three phases to its function cycle.

A cuff that is placed around the urethra when full exerts gentle pressure that increases resistance to passage of urine through the urethra.

When the cuff is empty, the resistance in the urethra is reduced, and the patient can void in the normal manner.

This shift of fluid from the cuff to the reservoir brought about by the patient manipulating a pump in the scrotum, and this is the "magical" function of the artificial sphincter. In summary, when the patient has the urge to urinate he manipulates the pump in the scrotum, empties the cuff and voids in the normal fashion. The reservoir which has an elastic characteristic that will cause fluid to be pushed out of the reservoir back into the cuff over a period of about 180 seconds……re-establishing pressure in the cuff and increasing resistance in the urethra resulting in continence.

Summary

The message in this discussion is not so much about technology but about patients. Those of you who have the problem of urinary incontinence can be helped. The first action must be your own in recognizing you need to seek help and find the right health-care provider. There are health professionals who understand these technologies, are sympathetic to your problem and can do the testing and bring about the benefits of the wide variety of technologies available to dramatically improve your condition and your life. If your health-care provider does not seem to understand this need or have interest or time to deal with it, obtain a second opinion. Contact a urologist and if that urologist does not seem to have the answer, seek yet another. I encourage you to take this action. There are literally millions of people (in the closet) whose lives can be decidedly better, can become dry, confident and, once again, socially acceptable, productive members of our society.

If you would like further information please contact us at Riverside Urology, Inc. at our e-mail : urology@2rui.com or telephone us at (614) 442-3000.