August 2, 2017

Addressing Male Urinary Incontinence

A conversation with men's health expert Ronald Morton, MD, FACS

One in four men over the age of 65 has urinary incontinence, according to the Centers for Disease Control and Prevention. In this interview, men's health expert Ronald Morton, MD, FACS, describes how urinary incontinence is diagnosed and treated. He also provides detailed information about the key medical devices that are available to treat this condition.

Many men who are subjected to surgery for prostate cancer and who then suffer from incontinence don't recognize, or aren't made aware, that there are treatments for it. And they suffer in silence.

Approximate listening time: 14 minutes

About the Interview

Although urinary incontinence is not as common in men as it is in women, it is more prevalent than many people think. According to the Centers for Disease Control and Prevention, one in four men over the age of 65 suffers from it.

The underlying causes are often similar in both genders: aging and weakening of the pelvic floor muscles. However, pelvic trauma or prostate disease or surgery can also contribute to the problem in men.

Urinary incontinence creates significant quality-of-life issues, so finding effective treatments is very important.

In this interview with urologist Ronald A. Morton, Jr., MD, FACS, Natural Medicine Journal’s publisher Karolyn A. Gazella discusses the prevailing treatment options for male urinary incontinence. For some men, pelvic floor exercises alone can provide relief. For others, diet and weight modification are necessary. Others may opt for more advanced interventions, including surgery.

Surgical options range minimally invasive to extensive. On the simpler end of the spectrum is the basic urinary sling. In this quick procedure, a sling is inserted to replicate the support lost in previous interventions or trauma. On the other end of the spectrum is an artificial urinary sphincter, which regulates urine flow through a pump.

Of course, surgical interventions are not without risks and side effects. Morton addresses those and discusses how to determine whether a patient is a good candidate for surgery.

Listen to this interview to learn more about the current treatment options for male urinary incontinence, as well as Morton’s predictions for the future of incontinence treatment.

Scroll down for the full transcript.

About the Expert

Ronald A. Morton, JR, MD, FACS, is the vice president of clinical sciences for the Urology and Pelvic Health division of Boston Scientific, a position that he has held since August 2015. Before joining Boston Scientific, via acquisition, Morton worked for Endo International plc as chief surgical officer, American Medical Systems. Previously, he worked for GTx, a biotech company in Memphis, TN, as chief medical officer. Prior to joining GTx, Morton was chief of urology at Robert Wood Johnson Medical School and director of urologic oncology for the Cancer Institute of New Jersey. He also held an endowed chair position as director of the General Clinical Research Center. Morton holds a BA in natural sciences from The Johns Hopkins University and received his medical doctorate from The Johns Hopkins University School of Medicine. He has board certification as a diplomat, American Board of Urology.


Karolyn: Hello, I'm Karolyn Gazella, the publisher of the Natural Medicine Journal. Today our topic is male urinary incontinence and my expert guest is Dr. Ronald Morton. Dr. Morton, thank you for joining me.

Dr. Morton: Hi, Karolyn, and thank you for having me today.

Karolyn: Well great. Well, let's just start with the basics. How is urinary incontinence diagnosed in men?

Dr. Morton: Karolyn, urinary incontinence is not as common in men as it is in women, although it does happen more commonly than people think. The main causes are as it is with women, aging and weakening of the pelvic floor muscles. But more importantly, and the reason for many of the interventions that we have for urinary incontinence in men is it can be due to trauma to the male pelvis and/or surgery for diseases of the prostate. When I say disease of the prostate I mean both benign conditions like BPH, which many men suffer from and are aware of, and then also prostate cancer, which is a very common cause for surgery on the male pelvis.

Karolyn: And then what's considered the gold standard of treatment for this particular men's health condition?

Dr. Morton: There are many ways to treat male incontinence, as there are many ways to treat female incontinence. The usual approach that will be taken by a urologist is to go from the least invasive to more invasive solutions until the patient is happy. I think that one thing that always has to be kept in mind is that this is really a quality of life issue for most men, especially since urinary incontinence in males is generally a disease of men who are older. The median age of diagnosis of prostate cancer is about 63 years of age or so. Since operations on the prostate are the common cause for this, they're generally older men and it's a quality of life issue.

What one male will find satisfactory control of the urinary incontinence might be totally unsatisfactory to another. So the general approach would be to start with exercises, commonly called Kegel exercises. The same exercises that we suggest that women do who have a mild degree of urinary incontinence and see if that won't help. If Kegel exercises won't help and it's not something that can be helped with diet and weight modification, then we go into more invasive treatments for male urinary incontinence.

The first level of invasion is a procedure that only takes a few minutes, really, less than a half an hour called a male urinary sling. It's much like the slings that are used in women. It  supports the male urethra and holds it up, providing support that has been lost due to the previous surgical intervention or pelvic trauma in hopes that that will correct the incontinence.

Fore more severe degrees of incontinence we often times need to move towards what is really considered, as you say in your question, the gold standard for severe incontinence, which is the artificial urinary sphincter [AUS]. In that procedure, a cuff is placed around the urethra and this cuff is connected to a pressure-regulating balloon, which controls pressure in the cuff, keeping the urethra closed and preventing leakage of urine and also a pump, which is placed in the scrotum. When it's time to urinate, the male can just activate the device. The fluid leaves the cuff and goes into the pressure-regulating balloon, opening the urethra. The male can then urinate and then after a period of lock-out time, the cuff will refill, returning him to a state of continence.

Karolyn: So let's talk about these two, the sling and the sphincter. What determines whether or not a patient is severe enough for the sphincter versus the sling? What's the difference between those two patients, the one that gets the sling and the one that gets the sphincter?

Dr. Morton: Good question because again, it has a lot to do with personal preference. But there are some general guidelines that one can go by. When we measure incontinence and it can be a difficult thing to put a number on, but most men who have incontinence will use urinary pads in their shorts in order to trap urine leaking. A good gauge of to what degree a male leaks is how many times they have to change that pad. Now, some men will as soon as there's a small amount of urine because of the discomfort it will cause will change that pad right away. Some men tend to allow the pad to get very, very soaked before they'll change it. Everyone behaves a little bit differently.

A way to get a handle on exactly how much leakage a man has it to do what we call the pad weight test. So we'll give them all the pads that they might need for a day and a bag that can prevent evaporation and they just collect the pads that they use for the day, put it in this bag, and everything is pre weighed, and then we weigh it to see what the volume of urine leakage is.

A rule of thumb, if they're leaking around five pads or 300cc of urine a day, that's severe and is more likely to be treated with the artificial urinary sphincter. Degrees of urinary leakage that are less than that can be and generally might be recommended that they be treated with the sling procedure.

Karolyn: Now are there are any contraindications associated with each of these options, the sling or the sphincter? So in other words, are there men who would not be a good candidate for either of these options?

Dr. Morton: Well, they have to be able to undergo a surgical procedure, and while the sling procedure is relatively short, it does require at least a regional anesthetic. The artificial urinary sphincter procedure is a little bit longer and requires a general anesthetic so they have to be fit for the surgery. The sling is generally not recommended for men if they have been treated for prostate cancer with radiation. The outcomes there haven't been as good as they have been with the artificial urinary sphincter so in that setting we generally would recommend a sphincter as opposed to a sling, even if they were otherwise a good candidate for a sling.

Karolyn: What about side effects? Are there any side effects associated with either of these devices?

Dr. Morton: I'll take that question separately for each of the two devices. The side effects associated with the sling are that if you don't choose the patient in the best way, two things can happen. One, the patient can not have their incontinence adequately treated. A second issue is if you put a sling in a patient whose major problem is not one of the urethra but is a bladder issue, and that can be sorted out ahead of time with uro dynamics, but if you did you may render that patient obstructed or in urinary retention. The problem doesn't have to do with external sphincter deficiency for that patient.

For the artificial urinary sphincter what we're doing is we're placing this cuff around the urethra. It does over time potentially compromise some of the blood supply to the urethra in that area and you can get what's known as atrophy of the urethra in the area of the cuff. When you get atrophy in the area of the cuff there can be a return to urinary incontinence. Of course for both of these procedures, since you're putting a foreign body in, there's a risk of infection, although infectious problems with these devices have been relatively low.

Karolyn: Okay, that makes a lot of sense. Now, I'm just curious because you have a certain expertise in this area as chief surgical officer of American Medical Systems. What general advice do you give to physicians who are treating men with urinary incontinence?

Dr. Morton: One, most of the advice that I have is for physicians who have men with incontinence but aren't necessarily the experts in treating them. There's a couple of things. One of the things that our research has shown us is that many men who are subjected to surgery for prostate cancer, for example, and who then suffer from incontinence don't recognize, or aren't made aware that there are treatments for it and they suffer in silence we like to say. So, if we can get anything out to the many physicians listening to this podcast it would be don't let this happen to any of your patients. Make sure they understand that if they do get incontinence after, for example, radical prostatectomy, there are options and there are potential solutions for this.

The second message is I spend a lot of time working with the engineers and we're constantly looking at ways to come up with a better mouse trap if you will. What can we do to avoid the complications we spoke of earlier? What can we do to help physicians identify the proper patients so we don't use a sling in a patient who should've had an AUS, or an AUS in a patient who should've had a sling? And what can we do to make the functioning of the AUS a little bit easier so that in this elderly population of men they are always candidates for the device?

Karolyn: Yeah, that makes a lot of sense and I'm glad that you brought that up about suffering in silence and information. Obviously, a well-informed patient is the best patient to have. So letting that patient know his options is absolutely critical.

So one final question for you Dr. Morton. What is on the horizon when it comes to devices for this particular issue with men? Do you see existing devices just being improved? Do you see new devices? Are we kind of where we should be? Look into your crystal ball and tell me what the future holds for this.

Dr. Morton: I don't know if I'm the best person to predict the future, but I think that our efforts are to make sure that A, these are the right solutions. We are constantly looking at, are there other options? Are there other ways to manage urinary incontinence? Could we come up with a less invasive way to place the sling or a less invasive device would replicate the great performance of a sling?

On the urinary sphincter side of things it's a mechanical device, so can we simplify that mechanism so that it's easier for the patient to implement? Remember there's a patient interface with the AUS. Most devices that we implant, like when a cardiologist implants a pacemaker, there's no patient interface. The patient doesn't have to decide whether or not their pacemakers work. It's in and it just works. For our device, at least for the artificial urinary sphincter, there's that patient interface. So if we can improve that patient interface with the device and make it as reliable as possible, that's what we're looking to do in order to improve the overall performance of the device and have men have a greater satisfaction with their quality of life.

Karolyn: Yeah, that makes a lot of sense. Well, this has been very informative. Once again, thank you, Dr. Morton, for joining me today.

Dr. Morton: Karolyn, thank you for having me.

Karolyn: Have a great day.

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