Male Urinary Incontinence

Urinary incontinence is a problem with bladder and sphincter control. It is the uncontrolled leaking of urine. Millions of Americans, about 1 out of 2 of all women and 1 out of 4 men, suffer from urinary incontinence symptoms.

Incontinence can happen for many reasons:

• If your bladder squeezes at the wrong time, or if it squeezes too hard, urine may leak out.
• If the muscles around the urethra are damaged or weak, urine can leak out even if you don’t have a problem with your bladder squeezing at the wrong time.
• You can also have incontinence if your bladder doesn’t empty when it should. This leaves too much urine in the bladder. If the bladder gets too full, urine will leak out when you don’t want it to.
• If something is blocking your urethra, urine can build up in the bladder and cause leaking.

Urinary incontinence happens more often in older men than in young men, but it’s not just a normal part of aging.

Risk Factors

Many things have been associated with an increased risk of urinary incontinence in men. Incontinence may be the result of various health conditions or medical treatments, or it could be caused by family history or lifestyle. In some men, things from more than one of the lists below can combine to cause incontinence.

Physical conditions or lifestyle factors that may make urinary incontinence more likely include:

• Age-related changes, including decreased bladder capacity and physical frailty
• Smoking tobacco
• Injury to the bladder or urethra, such as from radiation therapy or prostate surgery
• Bladder infection or prostatitis
• Obesity
• Structural abnormalities of the urinary tract

Medicines and foods that may make urinary incontinence worse include:

• Caffeinated and carbonated drinks, such as coffee, tea, and soda pop
• Alcohol beverages
• Prescription medicines that increase urine production, such as diuretics, or relax the bladder, such as anticholinergics and antidepressants
• Other prescription medicines, such as sedatives, opioids, and calcium channel blockers
• Non-prescription medicines, such as diet, allergy, and cold medicines.

Several diseases or conditions may increase your risk of urinary incontinence, including:

• Neurological conditions such as Alzheimer’s disease, Parkinson’s disease, stroke, diabetes, spinal injury, and multiple sclerosis
• Bladder cancer
• Chronic bronchitis
• Interstitial cystitis
• Anxiety and depression

Symptoms

Urinary incontinence occurs when the muscle (sphincter) that holds your bladder’s outlet closed is not strong enough to hold back the urine. This may happen if the sphincter is too weak, if the bladder muscles contract too strongly, or if the bladder is overfull.

A man may have one or more types of incontinence, and each type may have a different cause.

Stress incontinence occurs when the muscle (sphincter) surrounding the urethra opens at an inappropriate time. This can happen when you laugh, sneeze, cough, lift something, or change posture. Stress incontinence can be caused by surgery to treat an enlarged prostate or prostate cancer, radiation therapy to treat prostate cancer or removal of the prostate.

Urge incontinence is caused by bladder contractions that are too strong to be stopped by the sphincter. Often the urge is a response to something that makes you anticipate urination, such as waiting to use a toilet, unlocking the door when returning home, or even turning on a faucet. The bladder contractions can be caused by many conditions, including:

• Urinary tract infection
• Bowel problems, such as constipation
• Prostatitis, a painful infection of the prostate gland
• Certain neurological conditions that affect nerve signals from the brain, such as Parkinson’s disease or stroke
• Kidney or bladder stones
• Blockage due to prostate cancer or benign prostatic hyperplasia (BPH)
• Overactive bladder (OAB) is a kind of urge incontinence. But not everyone with overactive bladder leaks urine

Overflow incontinence usually is caused by obstruction of the urethra from BPH or prostate cancer or when the bladder muscles contract weakly or don’t contract when they should. Other causes include:

• Narrowing of the urethra (stricture)
• Medicines, such as antihistamines and decongestants
• Nerve conditions, such as diabetes or multiple sclerosis

Functional incontinence is a rare form of incontinence caused by physical or mental limitations that restrict a man’s ability to reach the toilet in time.

Evaluation and Diagnosis

The first steps your doctor will take to learn the cause of your urinary incontinence are a medical history and a physical examination. The physical examination will include an examination of the penis, the prostate, and the nervous system. The history and examination, along with routine diagnostic tests such as a urinalysis, often provide enough information to determine the cause of the incontinence and enable your doctor to start treatment.

Your doctor may ask you to keep a voiding log, which is a record of the amount of liquids you drink and how much and how often you urinate.

Tests that may be done to determine the type and cause of your urinary incontinence include:

• Urinalysis and urine culture, which may be done to learn whether a urinary tract infection (UTI) or prostatitis is present or whether there is blood or sugar in your urine.
• Cough test to check for urine leakage while coughing.
• Urodynamic studies focus on the bladder’s ability to store urine and empty steadily and completely, and on your sphincter control mechanism. It can also show whether the bladder is having abnormal contractions that cause leakage. The testing involves measuring pressure in the bladder as it is filled with fluid through a small catheter. This test can help identify limited bladder capacity, bladder overactivity or under activity, weak sphincter muscles, or urinary obstruction. If the test is performed with EMG surface pads, it can also detect abnormal nerve signals and uncontrolled bladder contractions.
• Your doctor may conduct a cystoscopic examination (a test that allows your doctor to see inside the urinary tract) to rule out other causes of incontinence.

Further tests may be required if the first treatment for incontinence has failed. Other tests may also be needed if you have had previous prostate surgery, radiation therapy, or frequent urinary tract infections, or if a catheter cannot be easily placed into your bladder.

Treatment

No single treatment works for everyone. Your treatment will depend on the type and severity of your problem, your lifestyle, and your preferences, starting with the simpler treatment options. Many men regain urinary control by changing a few habits and doing exercises to strengthen the muscles that hold urine in the bladder. If these behavioral treatments do not work, you may choose to try medicines or a continence device—either an artificial sphincter or a catheter. For some men, surgery is the best choice.

Behavioral Treatments

For some men, avoiding incontinence is as simple as limiting fluids at certain times of the day or planning regular trips to the bathroom—a therapy called timed voiding or bladder training. As you gain control, you can extend the time between trips. Bladder training also includes Kegel exercises to strengthen the pelvic muscles, which help hold urine in the bladder. Extensive studies have not yet conclusively shown that Kegel exercises are effective in reducing incontinence in men, but many clinicians find them to be an important element in therapy for men.

Medicines

Medicines can affect bladder control in different ways. Some medicines help prevent incontinence by blocking abnormal nerve signals that make the bladder contract at the wrong time, while others slow the production of urine. Still, others relax the bladder or shrink the prostate. Before prescribing a medicine to treat incontinence, your doctor may consider changing a prescription you already take. For example, diuretics are often prescribed to treat high blood pressure because they reduce fluid in the body by increasing urine production. Some men may find that switching from a diuretic to another kind of blood pressure medicine takes care of their incontinence.

If changing medicines is not an option, your doctor may choose from the following types of drugs for incontinence:

• Alpha-blockers: Terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), and alfzosin (Uroxatral) are used to treat problems caused by prostate enlargement and bladder outlet obstruction. They act by relaxing the smooth muscle of the prostate and bladder neck, allowing normal urine flow and preventing abnormal bladder contractions that can lead to urge incontinence.
• 5-alpha reductase inhibitors: Finasteride (Proscar) and dutasteride (Avodart) work by inhibiting the production of the male hormone DHT, which is thought to be responsible for prostate enlargement. These 5-alpha reductase inhibitors may help to relieve voiding problems by shrinking an enlarged prostate.
• Imipramine: Marketed as Tofranil, this drug belongs to a class of drugs called tricyclic antidepressants. It relaxes muscles and blocks nerve signals that might cause bladder spasms.
• Antispasmodics: Propantheline (Pro-Banthine), tolterodine (Detrol LA), oxybutynin (Ditropan XL), darifenacin (Enablex), trospium chloride (Sanctura), and solifenacin succinate (Vesicare) belong to a class of drugs that work by relaxing the bladder muscle and relieving spasms. Their most common side effect is dry mouth, although large doses may cause blurred vision, constipation, a fast heartbeat, headache, and flushing.

Neuromodulation Therapy for Urge Incontinence

Neuromodulation involves the placement of a lead wire to stimulate the nerves that control the bladder. For this treatment, a small electrode is placed near the nerves that control your bladder. It sends electrical pulses to the bladder to stop the spasms which cause leaks. There are two types:

Percutaneous tibial nerve stimulation (PTNS) — This therapy stimulates the tibial nerve. For this type of neuromodulation, you will not have to have surgery. PTNS is performed during an office visit that takes about 30 minutes. Your health care provider places a needle electrode near your ankle. It sends electrical pulses to the tibial nerve which runs along your knee to the sacral nerves. The electrical pulses help block the nerve signals that aren’t working correctly. Often, patients receive 12 weekly treatments, depending on how well they are doing.

Sacral neuromodulation (SNS) — This therapy works by stimulating the sacral nerve (near the base of the spine). This nerve carries signals between the spinal cord and the bladder. In urge incontinence, these nerve signals don’t work the right way. SNS uses a “bladder pacemaker” to interrupt these signals, which can improve urge incontinence.

During the placement of a “bladder pacemaker,” a surgeon makes a small cut and places a thin wire close to the sacral nerves. The device is then tested to see how well it works for you. In a second procedure, the surgeon connects the wire to a small battery-operated device placed under the skin. This device delivers electrical impulses to the bladder to stop the signals that can cause urge incontinence.

Surgical Treatment for Stress Incontinence

Bulking agent injections — A variety of bulking agents, such as collagen and carbon spheres, are available for injection near the urinary sphincter. Bulking agent is injected into the tissues around the bladder neck and urethra to make the tissues thicker and close the bladder opening to reduce stress incontinence.

Often, the injections are done under local anesthesia in your healthcare provider’s office. The injections can be repeated if needed. This method may not be as effective as other surgeries, but the recovery time is short. Bulking agents are a temporary treatment for stress incontinence.

Male sling — Similar to female mid-urethral slings, the male sling is a narrow strap made of synthetic mesh that is placed under the urethra. It acts as a hammock to lift and support the urethra and sphincter muscles. Most commonly, slings for men are made of surgical mesh. The surgical incision to place the sling is between the scrotum and rectum.

The male sling is most often used in men with mild to moderate stress incontinence. It is less effective in men who have had radiation therapy to the prostate or urethra, or men with severe incontinence.

Artificial urinary sphincter (AUS) — The most effective treatment for male stress urinary incontinence is to implant an artificial urinary sphincter device. This device has three parts:

• A fluid-filled cuff (the artificial sphincter), surgically placed around your urethra.
• A fluid-filled, pressure-regulating balloon inserted into your belly.
• A pump you control inserted into your scrotum.

The artificial urinary sphincter cuff is filled with fluid which keeps the urethra closed and prevents leaks. When you press on the pump, the fluid in the cuff is transferred to the balloon reservoir. This opens your urethra and you can urinate. Once urination is complete, the balloon reservoir automatically refills the urethral cuff in 1-3 minutes.

Artificial sphincter surgery can cure or greatly improve urinary control in more than 7 out of 10 men with stress incontinence. Results may vary in men who have had radiation treatment. They also vary in men with other bladder conditions or who have scar tissue in the urethra.

Other Treatment Choices

Catheterization may be used to treat severe incontinence that cannot be managed with medicines or surgery. Catheters don’t cure incontinence but rather allow you or a caregiver to manage incontinence.

• Intermittent self-catheterization is done with a thin, flexible, hollow tube (catheter) that is inserted through the urethra into the bladder, allowing the urine to drain out.
• Indwelling catheterization uses a catheter that remains in place continuously. For more information, see the topic Care for an Indwelling Urinary Catheter.
• Condom or Texas catheter uses a special condom that can be attached to a tube for short-term use. The condom, placed over the penis, keeps the tube in place. The tube allows the urine to drain out.
• Behavioral therapies, including biofeedback and pelvic muscle exercises, are used to treat urge and stress incontinence.
• Continence products such as absorbent pads or diapers, incontinence clamps, or pressure cuffs may be used to manage any form of incontinence. Some of these products absorb leaked urine and some put pressure on the urethra to help prevent urine from leaking.