Diagnosis and Treatment Options for Stress Urinary Incontinence in Men

Interviewer: Stress urinary incontinence, it's the most common type of incontinence in men, and it impacts about 10% of men at some point in their lives. The good news is there are a lot of treatments available that can help keep men dry.

Dr. Benjamin McCormick is a surgical urologist at University of Utah Health. Dr. McCormick, let's go through the process of assessing a patient's situation and then provide them with the information that they need to decide what treatment options would be best for their urinary incontinence.

Identifying Stress Urinary Incontinence in Men

Dr. McCormick: Yeah, sure. So I think the most important thing is sussing out what type of incontinence the patient has. So there are several different varieties. What we focus on is stress urinary incontinence, and that's the, you know, cough, sneeze, swinging a golf club, sitting up from a recliner leakage. And that's the things that we can help with from a surgical standpoint.

Another type of urinary incontinence is overactivity incontinence. And so that's, you know, when you have the urge to pee and you've really got to go, you can't make it in time and you leak. And then overflow incontinence, which is related to, you know, a host of problems, but often kind of neurologic problems with the bladder or outlet.

And so the devices that we use to fix urinary incontinence don't help types of incontinence other than stress incontinence. And so trying to have a conversation with a patient, kind of gleaning some details from their story, a good example would be, you know, men with pure stress incontinence often don't leak at night because they're lying down and the urine just kind of gathers in the bladder. Whereas patients who have overactivity incontinence will often leak a lot at night. And so, you know, getting an idea of the type of incontinence is important, what medications they're on, their prior surgical urologic history. So that's the first step.

Urodynamics Testing for Diagnosing Incontinence

Interviewer: Are there other ways that you can be sure that you have diagnosed the nature of the dysfunction correctly?

Dr. McCormick: Yeah, so there's a test called urodynamics. Basically, it's a test wherein, you know, a small catheter is placed in the bladder, a very small catheter in the rectum, and it measures pressures while filling. And so during this test, the bladder is filled through the catheter. It also has a pressure-sensitive tip. And so fill the bladder and the sensors can detect when the bladder squeezes, you know, and it measures the volume. So basically, it's a pretty, you know, invasive test that can really suss out what exactly is going on. It's not perfect, and it's not super comfortable, but in patients in whom they're a question of the type of incontinence, it can be really useful.

Treatment Options for Incontinence

Interviewer: So once you have a good idea of what type of urinary dysfunction is going on and that it is truly stress incontinence, then what do you do after that in a consult to help men decide or give them the information they need to decide what type of treatment they want to pursue?

Dr. McCormick: One of the things we'll do is try to gauge how severe their incontinence is. There are a number of ways of doing this. One is by the number of pads or diapers they use per day. If men are only using one or two pads a day, that's a very different patient than those who are using 10 diapers a day. And they can both be extremely bothersome. But different treatments, I think, are in order.

Cystoscopy

We'll also often do a cystoscopy, which is just putting a small flexible camera in the urethra and making sure the urethra is open. After prostate cancer surgery some scars can occur, which can complicate device placement. And so we just want to make sure that the urethra is open, that the bladder looks good. You know, if we place a device in someone whose bladder is the size of a plumb, they're not going to be super happy, you know, peeing every 15 minutes. And so those are some things to consider.

Interviewer: Are urologists pretty good at nailing down the nature of the dysfunction?

Dr. McCormick: Yeah, sometimes. We're fooled from time to time, and patients can come back and they're not happy because they're still leaking or they have worse urgency symptoms. And so, you know, we have treatments for those patients too. But, you know, sometimes we're fooled. It can be really tricky. I think urination is extremely complicated. It's kind of a wonder that any of us can do it at all really.

Interviewer: Something that we just take for granted, huh?

Dr. McCormick: Yes.

Interviewer: It's a lot more complicated than we ever imagined.

Dr. McCormick: Yep. Until it goes wrong.

Considering Patient's Personal Treatment Goals

Interviewer: Yeah. Right. Exactly. Yeah. And the last thing you want to kind of take into account is the personal goals of the patient. So if a patient is in your office, what types of things should they be talking to you about to communicate what those personal goals are? What does that conversation look like?

Dr. McCormick: Sure. I think that they should communicate the types of things they want to do or hope to do and be dry or relatively dry. You know, I think that I would never counsel anybody that they will be completely dry after the surgery. And if they're using a security pad a day because when they're on their mountain bike, they leak a little bit, you know, I think that it can be tough to make those guys happy. And so I think having a real honest discussion with your surgeon about what can you realistically expect is pretty important for everyone's happiness.

Interviewer: And for some, it just might be truly that the level is so low that surgical procedures might not be the best call because you're just going to go through a surgery to maybe not get the satisfaction that you hoped. I mean, could you...

Dr. McCormick: Yeah, I mean, that's definitely true. There are some patients who have, you know, just a very small amount of incontinence that's, you know, very bothersome to them. But, you know, it's hard to make someone completely dry when they're 99% dry. And there are complications that come with these procedures, so it would have to be a very special case for me to agree to move forward in that scenario.

After Consult: Patient's Decision-Making Process

Interviewer: After a man comes into your office and you talk through the three different things, you figure out the nature of the dysfunction, the level of incontinence, and then the personal goals of the patient, where do you kind of leave that conversation at that point? Like, they have to go home and make a decision, right? So, like, what do you send them off with? What advice do you have for them?

Dr. McCormick: Yeah, well, I think that I kind of based off of those, you know, their goals, their type and severity of incontinence, I will present them with the options, all the options and kind of the ones that I think would work for them. And then, you know, it's ultimately up to the patient. Certainly don't want to talk anybody into surgery. And, you know, there are some patients who say, "Okay, like I'll do it tomorrow." And there are others who really need to think about it because, you know, surgery is surgery and complications can happen.

It's also, you know, it's not... especially with sphincters, there are some shackles that come with it in some respects. I mean, I think that you need to wear a medical alert bracelet so you don't have a catheter placed through an activated sphincter. You know, you need to be comfortable with the device likely needing to be replaced within 10 years and the complications that come with device placement. And so, you know, it's often what I'll say is, you know, "Hey, I'll submit a surgery request, and we'll give you a call, and if you're ready to go forward, then great. If not, then happy to see you back. Happy to call you on the phone. Really whatever you need."

Incontinence is Common

Interviewer: Before you recommend surgery to anybody, do you usually recommend that they go see a pelvic floor physical therapist first?

Dr. McCormick: Almost always. I mean, there are some patients who are so incontinent that no amount of pelvic floor physical therapy is going to help or get them to where they want to be, in which case I'd say, you know, we should just probably move forward. I personally think that everyone should see a pelvic floor physical therapist. I think they're great, and they do a lot of good work. You know, men carry a lot of stress in their pelvis and, you know, that can be a cause of discomfort or even some leakage that can be addressed by these folks. And so really shout out to them for the work they do.

You know, I think that what a lot of patients don't know about incontinence is that it's a really common problem. Upwards of 10% of patients who have prostate cancer surgery especially experience some degree of urinary incontinence. And, you know, no matter the degree of incontinence you have, you know, there are things we can do about it. And not all those things involve surgery, which is great. But for patients who need surgery or would benefit from surgery, it can be a really life-changing procedure. And so, you know, happy to see anyone and talk to them about it. You know, I think there can be real changes made.