Men's Health Q&A, Sponsored by Pfizer
April 21, 2006
Welcome to the National Association for Continence's 2nd live online question and answer session, sponsored by Pfizer, Inc. Dr. Steven Siegel will be answering a variety of questions about men's health related to incontinence. Dr. Siegel earned his medical degree from the University of Michigan in Ann Arbor in 1981, and completed his Urology residency at the Cleveland Clinic in Cleveland, Ohio in 1986. He later established and served as the Head of the Section of Female Urology and Urodynamics at that institution until 1993. Currently Dr. Siegel is the Director of the Twin Cities Continence Care Center of Metropolitan Urologic Specialists, PA, where he is a partner with 21 urologists. He is also the director of a fellowship program in female urology and voiding dysfunction. He has authored and coauthored many papers and book chapters on female incontinence and voiding dysfunction. Dr. Siegel played a key role in initial clinical research of neuromodulation of voiding dysfunction, and remains committed to educating colleagues about contemporary indications, techniques and outcomes. He is the immediate past president of the International Society of Pelvic Neuromodulation (ISPiN).
In order to avoid confusion and interruption, we have collected the questions ahead of time. You will see that NAFC will be asking the questions, which means that no one can interrupt the dialogue between NAFC and Dr. Siegel. Please refresh your browser if you cannot see the questions and answers. We hope that you learn from this session, and we will soon be asking to collect new questions for our 3rd session. Let's begin!
What causes an enlarged Prostate? Are genetics a factor?
Benign enlargement of the prostate (Benign Prostatic Hyperplasia or "BPH") is the most common tumor in men, and usually begins in younger men with microscopic nodules growing within the prostate gland. The prostate begins to enlarge through a process of cell multiplication when men are in their 40's, and increases with aging. According to one study, as many as 80% of men have at least some symptoms of BPH. The causes of this condition are not fully known. Most believe the interplay between testosterone and estrogen (all men make some) plays a role. The problem is more prominent in US and Europe compared to other parts of the world. Genetics may play a role, as some studies suggest that the problem is more common in Caucasians than Asians, for example. Also, a family history of BPH may increase a man's chance of developing the condition.
After prostate surgery, does the prostate continue to grow? Is it removed completely?
The answer depends on the type of surgery. In most treatments for BPH, only a portion of the gland is removed, or in some cases, the gland is heated internally (thermal therapy) without actually removing any tissue. In these instances, it is likely that over time, prostate tissue will re-grow, and there may be a need for further treatment in some men. When the entire prostate gland is removed (as in a "radical prostatectomy" for curative treatment of prostate cancer) there is no tissue left behind, and the chance for re-growth is much less.
Does the lack of a prostate cause erectile dysfunction?
You can have sex without a prostate! It is an organ of mystery to most men. It has an important role in sexual function in that it makes semen, which is a transport medium for sperm. The muscles within the prostate are important for expelling the semen during ejaculation. The testicles make testosterone, and that hormone is responsible for sex drive or libido. Even when the prostate gland is removed, hormonal production is not affected. There may be decreased or absent ejaculate as a consequence. The nerves that control erection travel next to the prostate, and sometimes they may be interfered with as a result of surgery. This is much more common as a side effect of treatment for prostate cancer than for BPH. Special care can be taken to preserve the nerves in many men with prostate cancer requiring surgical removal.
My doctor says I have an "inflamed" prostate. What does that mean and what caused it? Is there a treatment other than surgery?
Inflammation of the prostate is called "prostatitis". It can be caused by bacteria that infect the gland (bacterial prostatitis) and may require treatment with antibiotics. Most cases of prostatitis are not due to an infection (nonbacterial prostatitis), and won't respond to antibiotics. The causes of this condition are unknown, but usually conservative treatments such as diet, exercises, prostate massage, physical therapy, and certain medications such as alpha-blockers or muscle relaxants are indicated. Surgery is a rare form of treatment for prostatitis.
Is incontinence always a result of prostate surgery?
Well... the most common cause of incontinence in men is prostate surgery. However, most men who have prostate surgery are not incontinent afterward. About 1% of men who are treated surgically for BPH have incontinence. A much higher percentage of men who have surgery for prostate cancer have may have some degree of involuntary leakage afterward. Some studies report the condition in as much as 50% of men undergoing radical prostate removal. The rate of severe incontinence is less than 10% in most reported series.
Are bald men more likely to have high PSA (prostate specific antigen) levels? What does PSA measure?
The PSA measures the level of prostate-specific antigen in the patient's blood. Only prostate cells make this protein, which is important for the liquefaction of semen. It may be elevated in men with benign or cancerous enlargement of the prostate, or prostatitis. It is recommended as a screening test in order to detect early (and hopefully more curable) stages of prostate cancer, and as a marker in order to follow the progress of men known to have prostate cancer. I am not aware of any connection between baldness and PSA levels which should matter to patients.
Is it a signal of possible prostate/dihydrotestosterone (DHT) problems if my husband's hair is balding/thinning?
Male pattern baldness is a common condition, but I am not aware of an important link (other than maleness!) between these two conditions. Finasteride (marketed as Proscar and Propecia) is a medication used to treat both BPH and baldness, so men with both problems could potentially receive a double benefit. Some guys get all the luck!
Why does sitting for some time seem to increase the frequency and urgency of urination?
The muscles of the pelvic floor may be affected by sitting, and change of position (from sitting to standing) can trigger a bladder reflex in some patients. Learning the role of the pelvic floor muscles and exercising them by practicing controlled relaxation and contraction can reduce symptoms of urinary frequency and urgency. Since these are hidden muscles, it may be necessary to use techniques such as biofeedback to learn how to control them properly.
Can you please explain the notion of an "overflowing bladder"? Do only men have the problem of overflow?
An overflowing bladder is usually the result of a blockage or obstruction of the bladder outlet, which may be due to conditions such as BPH or a scar (stricture) of the urethra. These situations occur much more commonly in, but are not exclusive to men. The condition can also be caused by neurological changes such as lower spinal cord damage or peripheral nerve injury due to conditions such as diabetes. This cause is not specific to men. When the bladder doesn't empty, and can become so full that small amounts of urine escape with further filling, or due to certain movements or changes in abdominal pressure. This is called overflow incontinence. Demonstrating a large leftover or residual volume in the bladder after voiding can usually identify it. The treatment is to resolve the blockage when that is the cause. In other cases, intermittent self-catheterization may be needed to enable the bladder to empty completely.
What effect do medicines used for erectile dysfunction have on incontinence?
I am not aware of any.
Do depotestosterone injections have any effect on incontinence?
Men may take these injections to treat low testosterone states. I am not aware of any effect on incontinence from this type of treatment.
I have BPH. Does the size of my prostate gland matter? I thought BPH indicated an enlarged prostate, but my doctor says my gland is small?
Well... in the case of prostates, size does matter, but not in the way that you may think. A large gland may not cause any obstruction, and a small gland may cause a lot. Just like real estate, location matters most! When a small gland is obstructing, medications such as alpha-blockers may be most appropriate, and minimally invasive surgeries can be very effective. When large glands cause the problem, medications such as finasteride may be used to prevent the prostate from growing further, potentially reducing the risk of developing sudden retention requiring surgery. If surgery is required for a large gland, it may need to be more invasive than the options for small glands.
What is bladder outlet obstruction in men? What causes it? How is it treated?
The bladder outlet is located at the mouth of the bladder. In most men, the prostate is situated at the bladder outlet, though it may have been removed in some who have had treatment for prostate cancer. Enlargement of the prostate due to BPH or cancer may cause bladder outlet obstruction. So can conditions such as scarring or contractures following surgery. Treatment may center around reducing the muscle tone or size of the prostate with medications, heating the prostate, or actual surgical removal of all or a portion of the prostate gland depending on the cause of the blockage. A scar of the bladder outlet following surgery is a potential complication, and it may need to be treated with a surgical incision or dilations.
What can you tell me about urethral dilations?
Dilations are performed to stretch a narrowed or scarred segment of the urethra, which is the tube that drains the bladder from the bladder neck to the tip of the penis. The scarring can be the result of a previous procedure such as a catheter placement or telescopic instrumentation (cystoscopy) on the urethra. It can also be caused by trauma (such as a straddle injury) or infection. Once a scar forms in the urethra, it may cause a narrowing or "stricture" which can obstruct the flow of urine. Dilation may be required to open up the narrowed segment. Since it is due to a scar, the area of narrowing may recur, and need future dilations. In some cases, a surgical repair is needed to fix the problem definitively.
Please tell me more about the artificial urinary sphincter. Who is a candidate?
The artificial urinary sphincter (AUS) is a hydraulic device consisting of a cuff, a pump, and a reservoir. The device can be surgically implanted for the treatment urinary incontinence due to damage to the urinary sphincter, such as may occur following prostate surgery. Once in place, the device is completely internal, and not visible to the naked eye. The cuff is placed through an incision around the outside of the urethra, and is connected internally to a small pump which is located in the scrotum. Another tube connects the pump to a reservoir, which is usually placed in the lower abdomen. The AUS controls leakage by having the cuff squeeze around the urethra, thus limiting or preventing loss of urine due to increases in abdominal pressure (stress urinary incontinence), as might occur with a cough or bearing down, or just by walking upright. The patient must squeeze the pump in the scrotum to deflate the cuff in order to allow urination to occur. The cuff remains open for 2-3 minutes, and then closes automatically to maintain continence. The AUS has been used for over 25 years, and is considered to be the "gold standard" for the surgical management of stress urinary incontinence in men. For the right patient, an AUS can be a life changing therapy. Men who are candidates usually have more bothersome degrees of leakage requiring multiple pads throughout the day to keep dry. A urodynamic test is usually done to make sure the type of incontinence is suitable for management with the AUS. They must not have scarring of the urethra or bladder neck, or the scars must remain open and stable after treatment. A cystoscopy is usually done to document this. A certain mental capacity and degree of manual dexterity is needed in order to operate the AUS successfully. The surgical implant of the device is usually done under general or spinal anesthesia, and may be accomplished on an outpatient basis or require an overnight hospital stay. The device is not usually activated at the time of implant, allowing swelling of the urethra to resolve before tissue compression by the cuff is allowed.
My doctor told me I have stress incontinence. I thought this type of incontinence only occurs in women. Please explain.
Stress incontinence means leakage of urine when pressure is increased in the abdomen (stress maneuver), as may occur with a cough, sneeze, lift, or bend. "Urge incontinence" is another type of leakage that is caused by a sudden increase in bladder pressure in the absence of straining. Patients can have more than one form of incontinence at the same time. The treatments for stress and urge incontinence are usually different, so it is important to understand which it is in order to provide the right solution. A history and physical exam can be helpful in distinguishing the type of leakage, but a test of bladder function such as a urodynamic study may be needed to know with certainty. Both stress and urge incontinence are more common in women, but many men suffer from these problems, too. Women tend to develop stress incontinence after childbearing, with aging, menopause, or after hysterectomy. Men typically develop stress incontinence as a complication of prostate surgery.
I am experiencing incontinence after my prostatectomy. Will pelvic floor muscle exercises help me regain continence?
The pelvic floor muscles are accessory muscles of urinary control, and exercising them may increase the rate of recovery of urinary control after prostate surgery. Some doctors advocate beginning the exercises before surgery for this reason. Work with a therapist using biofeedback may be helpful in order to learn to do them properly. In general, patients with mild degrees of leakage are more likely to resolve the problem with exercises as compared to those with a severe degree of leakage. Maximal improvement is usually seen after doing the exercises regularly for 3 to 6 months, though continued exercises may be needed to maintain control. The exercises may be combined with medications for further benefit.
Please tell me more about injectables to help with my continence.
Injectables or bulking agents are materials that can be injected through a telescope into the tissues near the bladder neck in order to build up passive resistance to leakage at the bladder outlet. The material most often used for this in men is collagen, which is processed cowhide. A skin test must be done a month before to make sure there is no allergic reaction to the foreign protein. Though once thought to be a promising, minimally invasive alternative for stress incontinence in men, this form of treatment has largely fallen out of favor with urologists. It usually requires many separate injection procedures over 6 months to a year, and then the benefits tend to be incomplete and temporary. The collagen may not be able to bulk the tissue adequately, which is scarred from prior surgery. It also tends to leak out or break down over time due to its protein makeup. Some patients may be more suitable candidates for this than others, and some urologists may have better results with this technique. In general, I tend to discourage my male patients from this form treatment.
My wife had the sling procedure to help with her incontinence. I have heard there is a sling procedure for men. Is it similar to my wife's procedure, and should I expect a successful treatment like hers?
It's true that minimally invasive sling procedures have revolutionized the management of stress incontinence in women. While the name is similar, the techniques, materials, and outcomes are different for females. There is such a thing as a "Male Sling" which involves the surgical placement of a 4 by 7cm band of material (usually silicone mesh) up against the underside of the urethra. It is inserted through and incision in the perineum (between the scrotum and anus) and held in place by 2-3 sets of bone screws, which are drilled into the pubic bone and attached to the mesh material with sutures. The mesh is pulled tight against the urethra, providing a compressive force that resists stress incontinence, yet allows the voluntary passage of urine. Unlike the AUS, the male sling is not a dynamic device, and does not require manipulation by the patient in order to void. It is immediately effective, and does not need to be activated 4 to 6 weeks after surgery, as does the AUS. Patients with severe degrees of incontinence may be better candidates for the AUS. Unlike the AUS, which has been around for decades, the male sling is relatively new, and urologists do not have the same track record with it to compare. Still, it is an emerging and increasingly attractive form of treatment for many men with stress incontinence.
Thanks for watching our 2nd live question and answer session. We hope that you learned and may benefit from Dr. Siegel's expertise. This session will be archived on our website so that you may always refer to it. We give many thanks to our sponsor, Pfizer, Inc., makers of DETROL LA for overactive bladder (OAB). Thanks again to Dr. Siegel for his time and participation. Please take time to post on our Bladder Forum with feedback about this session so that we may consider your input for our 3rd session.
