Michael J. Amirian, MD
Patrick J. Shenot, MD, FACS
BASICS
DESCRIPTION
Defined by International Continence Society, urinary incontinence is the involuntary loss of urine that presents a social or hygienic problem
EPIDEMIOLOGY
Incidence
No published reports on incidence
Prevalence
• 3–11% overall prevalence rate of incontinence in male population
• NOBLE study
– Urge incontinence
2.6% American men of all ages
– After age 64, prevalence rose sharply
∼10% in men ≥75 (1)
– Reaches 31% in men ≥85 (2)
• Stress incontinence in men is rare
– Unless attributable to prostate surgery, neurologic disease, or trauma
• Incontinence after prostatectomy ranges from 1% after transurethral resection to 2–57% after radical prostatectomy
• Incontinence in male of all ages is ∼1/2 as prevalent as it is in women
RISK FACTORS
• Age
• Neurologic disease
• Prostate surgery
• Pelvic trauma
Genetics
N/A
PATHOPHYSIOLOGY
• Incontinence secondary to bladder abnormalities
– Detrusor overactivity results in urge urinary incontinence (UUI)
Associated with bladder outlet obstruction from benign prostatic hyperplasia (BPH)
• Incontinence secondary to outlet abnormalities
– Sphincteric damage
Secondary to pelvic surgery or radiation
– Sphincteric dysfunction
Secondary to neurologic disease
• Mixed incontinence is due to abnormalities of both bladder and the outlet
ASSOCIATED CONDITIONS
• Neurologic disease
– Parkinson disease, multiple sclerosis
• Pelvic radiation
• Pelvic trauma
• BPH
• Prostate surgery
GENERAL PREVENTION
None
DIAGNOSIS
HISTORY
• Voiding symptoms
– Duration and characteristics of incontinence
– Stress, urge, total
– Precipitants and associated symptoms
– Use of pads, briefs, diapers
– Fluid intake
– Alteration in bowel habits
– Previous treatments and effect on incontinence
• Diabetes mellitus
• Associated conditions
– Neurologic disease
• Medication use
– Diuretics
• Alcohol and drug use including caffeine
• Radical pelvic surgery or radiation
– Abdominoperineal resection
– Radical prostatectomy
PHYSICAL EXAM
• Abdominal exam
– Suprapubic mass
Suggests retention
– Suprapubic tenderness
Suggests UTI
– Surgical scars suggesting pelvic surgery
– Skin lesions associated with neurologic disease
Neurofibromatosis and café au lait spots
• External genitalia
• Prostate
• Spine/back
• Skelet al deformities
• Scars from previous spinal surgery
• Sacral abnormalities may be associated with neurologic bladder dysfunction
– Cutaneous signs of spinal dysraphism
Subcutaneous lipoma
Vascular malformation, tuft of hair, or skin dimple on lower back
– Cutaneous signs of sacral agenesis
Low, short gluteal cleft
Flattened buttocks
Coccyx not palpable
• Focal neurologic exam
– Motor function
Inspect muscle bulk for atrophy
Tibialis anterior (L4–S1): Dorsiflexion of foot
Gastrocnemius (L5–S2): Plantar flexion of foot
Toe extensors (L5–S2): Toe extension
• Sensory function
• Reflexes
– Anal reflex (S2–S5)
Gently stroke mucocutaneous junction of circumanal skin
If visible contraction (wink) absent, suggests peripheral nerve or sacral (conus medullaris) abnormality
– Bulbocavernosus reflex (BCR) (S2–S4)
Elicited by squeezing glans to cause reflex contraction of anal sphincter
Absence of BCR suggests sacral nerve damage
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Creatinine
– If significant retention suspected
• Urinalysis
– Glucosuria, infection
Imaging
None usually indicated
Diagnostic Procedures/Surgery
• Urodynamics
– Useful for confirming bladder outlet obstruction as a possible cause of detrusor overactivity
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Urge incontinence
– Loss of urine accompanied by urgency; often related to triggers such as sounds of running water, cold weather, passing a restroom
• Stress incontinence
– Urinary leakage associated with exertion, lifting, coughing, sneezing
• Mixed incontinence
– Urinary leakage associated with both stress and urge incontinence
• Low bladder compliance resulting in overflow incontinence
• Continuous urinary incontinence is the continuous loss of urine
• Post micturition dribble
– The involuntary loss of urine immediately after he has finished passing urine, usually after leaving the toilet
• Mobility or cognitive impairment post stroke
TREATMENT
GENERAL MEASURES
• Bladder diaries are invaluable
– Help patients understand patterns of incontinence
• Time voiding
– Avoids significant bladder distention
• For postradical prostatectomy incontinence see Section I: Incontinence, urinary, following radical prostatectomy
MEDICATION
First Line
• Urge incontinence
– Antimuscarinics: Inhibit the effect of acetylcholine at postjunctional muscarinic receptors on detrusor muscle cells
Tolterodine (2–4 mg/d)
Trospium XR (60 mg/d)
Darifenacin (7.5–15 mg/d)
Solifenacin (5–10 mg/d)
Oxybutynin (IR 7.5–20 mg/d, XL 5–30 mg/d, patch twice weekly)
Fesoterodine (4–8 mg/d)
– β3-adrenergic agonist agent: Promotes detrusor muscle relaxation
Mirabegron (25–50 mg/d)
• Stress incontinence
– No generally accepted drug therapy
– Tricyclics sometimes used
Imipramine 10–25 mg PO BID-TID
Second Line
• Urge incontinence
– Tricyclic antidepressants
Imipramine 10–25 mg PO BID-TID
– DDAVP for nocturnal symptoms
0.1–0.5 mg PO or intranasal QHS (off label)
Avoided in patients with cardiac disease and older patients
Risk of significant hyponatremia
– Intradetrusor botulinum toxin injections
SURGERY/OTHER PROCEDURES
• Urge incontinence
– Sacral neuromodulation
– Augmentation cystoplasty
• Stress incontinence
– Urethral bulking agent
– Male sling procedure
Promising short-term results
No long-term studies (3)[B]
– Artificial urinary sphincter
Excellent long-term continence rates (4)[A]
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Pelvic floor exercise (Kegels)
– Significantly improve SUI/UUI
• Biofeedback
• Timed voiding in UUI
• Overflow incontinence due to poor bladder contractility with urinary retention
– Indwelling catheter
– Intermittent catheterization
– Evaluate for outlet obstruction
Complementary & Alternative Therapies
• Penile clamps, condom catheters, and pads are occasionally used
• They should be reserved for minor degrees of incontinence or in patients who have multiple other comorbidities in whom surgery may be thought inappropriate (5)
• Penile compression clamps
– Applied externally to the penis to exert nonsurgical compression of the urethra, thereby preventing leakage of urine
– 3 types of commercially available penile incontinence clamps (C3, U-Tex Male Adjustable Tension Band and Cunningham clamp) have been studied in a small trial (6)
– No device completely eliminated leakage when applied at a comfortable pressure
– Complications of penile clamps can include edema, pain, urethral erosion, and obstruction
– Penile clamps should not be used for more than 4 hrs at a time
• Absorbent products (pouches, absorbant pants, small pads) were evaluated in a multi-center, multi-crossover study (7)
– The conclusion was that no one product suits every patient although small pads came closest
– Washable absorbant pants for men with light incontinence have economic advantages
ONGOING CARE
PROGNOSIS
Continence can be improved in almost all patients
COMPLICATIONS
• Candidiasis
• Dermatitis
• Skin breakdown
FOLLOW-UP
Patient Monitoring
Monitor post-void residual in patients on anticholinergic medications
Patient Resources
Urology Care Foundation. Surgical Management of Urinary Incontinence http://www.urologyhealth.org/urology/index.cfm?article=33, Accessed April 2013.
REFERENCES
1. Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the US. World J Urol. 2003;20:327–336.
2. Anger JT, Saigal CS, Stothers L, et al. Urologic Diseases of America Project. The prevalence of urinary incontinence among community dwelling men: Results from the National Health and Nutrition Exam survey. J Urol.2006;176(5):2103–2108.
3. Comiter CV. The male sling for stress urinary incontinence: A prospective study. J Urol. 2002;167:597–601.
4. Elliott DS, Barrett DM. Mayo Clinic long-term analysis of the functional durability of the AMS 800 artificial urinary sphincter: A review of 323 cases. J Urol. 1998;159:1206–1208.
5. Moore, KC, Lucas, MG. Management of male urinary incontinence. Indian J Urol. 2010;26(2):236–244.
6. Moore KN, Schieman S, Ackerman T, et al. Assessing comfort, safety, and patient satisfaction with three commonly used penile compression devices. Urology. 2004;63:150–154.
7. Fader M, Macaulay M, Pettersson L, et al. A multi-centre evaluation of absorbent products for men with light urinary incontinence. Neurourol Urodyn. 2006;25:689–695.
ADDITIONAL READING
Burden H, Warren K, Abrams P, et al. Diagnosis of male incontinence. Curr Opin Urol. 2013;23(6):509–514.
See Also (Topic, Algorithm, Media)
• Bladder Areflexia (Detrusor Areflexia)
• Cunningham Clamp
• Incontinence Clamps
• Incontinence, Urinary, Adult Male Image 
• Incontinence, Urinary, Following Radical Prostatectomy
• Incontinence, Urinary, with Orgasm (Climcaturia)
• Lower Urinary Tract Symptoms (LUTS)
CODES
ICD9
• 788.30 Urinary incontinence, unspecified
• 788.31 Urge incontinence
• 788.32 Stress incontinence, male
ICD10
• N39.3 Stress incontinence (female) (male)
• N39.41 Urge incontinence
• R32 Unspecified urinary incontinence
CLINICAL/SURGICAL PEARLS
• Prevalence of incontinence in males is 50% that of women.
• Continence can be improved in almost all patients.
• An Artificial urinary sphincter has excellent long-term continence rates.