Urinary Incontinence
What is Sphincteric incontinence?
Sphincteric incontinence is the involuntary loss of urine due to malfunction of the urinary sphincter. It’s like a leaky faucet.
What causes incontinence in men?
If you are a man and you have sphincteric incontinence, the chances are that you’ve had a prostate operation such as a radical prostatectomy (e.g. Robot assisted laparoscopic prostatectomy) or that you have a neurologic disorder like spina bifida. In men, sphincteric incontinence is uncommon; in women, it’s very common. Incontinence may also complicate surgery for benign prostatic conditions. It may also occur after radical cancer surgery of the rectum and in certain neurologic conditions. Neurologic causes include spina bifida (myelodysplasia), injuries to the lower spine and ruptured (herniated) intervertebral discs. There are also a few very rare degenerative neurologic diseases, collectively known as multi system atrophy, that can cause sphincteric incontinence and, finally, there may be an injury to the blood supply of the spinal cord after surgery on the aorta which results in a condition know as anterior cord syndrome.
What is the Urinary Sphincter?
The urinary sphincter is a specialized structure which lies in the wall of the urethra whose function in both sexes is to maintain urinary control. In men, though, the sphincter serves an additional function; it is also a genital sphincter. That means that during sex, when ejaculation occurs and sperm are ejected into the urethra, the sphincter closes. This prevents sperm from going backwards into the bladder and insures that the sperm go out the tip of the penis.
How does the (Urinary) Sphincter work?
Normally, the urinary sphincter is kept closed in large part due to contraction of the smooth (involuntary) & striated (voluntary) muscle inside and around the urethral wall. During urination these muscles relax and open, allowing urine to pass through. Of course, if the muscles have become damaged or weakened, they do not stay tightly closed and incontinence can occur. The sphincter is actually composed of a number of different elements, not just muscle. Other components of the urethral wall including collagen & elastin provide the architectural framework for the sphincter, like the frame of a house. In addition, the inner lining of the urethra (mucosa) secretes a mucus layer that acts like an additional seal, similar to a rubber gasket on a garden hose. In women, this whole arrangement is rather simple. In men, because of the presence of the prostate, the anatomy and function of the urethra is much more complicated.
What are the Internal and External Sphincters?
The junction between the urethra and the bladder is called the bladder neck or internal sphincter. Its wall is composed mostly of smooth muscle, which is arranged in both a circular and longitudinal pattern around the urethra. The smooth muscle of the urethra is called the internal sphincter. It begins at the bladder neck and is intermingled with the tissue of the prostate. Further, the prostate adds considerable bulk to the sphincter. Consequently, the internal sphincter in men has considerably more strength than in women.
The ejaculatory ducts pass through the prostate and empty into the urethra. Ejaculation, which occurs during sex, is the forceful expulsion of sperm mixed with prostatic secretions, through the ejaculatory ducts, into the urethra, and then out the tip of the penis. There is striated muscle in the wall of the urethra, located mostly just past the prostate and there is striated muscle outside the urethra called the periurethral striated muscle. Together, these constitute the external urethral sphincter, which is much less important than the internal sphincter. If the internal sphincter has been badly damaged, incontinence occurs even if the external sphincter works normally. The main function of the external sphincter is to allow you to suddenly interrupt the stream if you are in the middle of urinating or to hold back once you get a strong urge. If your internal sphincter has been damaged and you have severe incontinence, the chances are that you are still able to momentarily prevent incontinence by contracting your external sphincter. However, since it is a voluntary (striated) muscle, it fatigues easily (after only 10 – 15 seconds or so) and once that happens the urinary loss continues.
What is the difference in male and female sphincters?
In women, because the sphincter is naturally much weaker than in men, incontinence is much more common. It occurs, in part, as a consequence of repeated stretching and damage to the nerves and muscles of the sphincter which occur during pregnancy and childbirth and in part as a result of the effects of gravity, which tend to make the vaginal muscles sag and weaken. Incontinence is so common in women that many consider it a normal part of aging. In men, sphincteric incontinence is rare. It is never a consequence of aging or sphincter muscular weakness; rather, it occurs almost exclusively when the sphincter is damaged by prostatic surgery or radiation treatment for cancer of the prostate.
Evaluation and treatment of male incontinence
After almost all prostate surgeries, a urethral catheter is left in place for a few days to a few weeks depending upon the type and nature of surgery. In the first few weeks after removal of the catheter many patients develop temporary urinary frequency, urgency and urge incontinence. Although the symptoms usually subside spontaneously within a few months, even at this early stage, it is important that your doctor exclude two treatable conditions urinary tract infection and urinary retention.
Infection is diagnosed by urinalysis and urine culture. If you do have an infection, it should be treated with culture specific antibiotics (antibiotics which have been shown to be effective against the particular bacteria that are causing your infection). Urinary retention means that you either cannot urinate at all, or even though you urinate a bit, you are not emptying your bladder and are leaving a large amount of urine behind.
You may not have any symptoms of urinary retention other than frequency of urination and incontinence, but your doctor should be able to diagnose it easily by palpating (feeling) a distended bladder in your lower abdomen. He can confirm the diagnosis by checking with an ultrasound or by passing a catheter through the urethra into the bladder and measuring the amount of residual urine after you void.
If you do have urinary retention, it should be treated with an indwelling catheter until the surgery has healed (usually a few weeks). If you still can’t urinate well after that, it will be necessary to do some more tests to determine whether the cause is a urethral blockage or a weak bladder. In order to make this distinction, two further tests are necessary, cystoscopy (looking into the bladder) and urodynamic evaluation.
Conclusion
Sphincteric incontinence in men is uncommon. It is almost always the result of surgery or radiation for prostate cancer, but can also occur after surgery for non-cancerous prostate conditions and in certain neurologic conditions like spina bifida. Most of the time, when incontinence occurs after prostate surgery, it subsides within a matter of weeks or months, but occasionally takes a year or more. Treatment is difficult during this stage, but effective methods are available to manage the incontinence until it subsides. For persistent incontinence there are a few treatment options including the Male Slings, and the artificial urinary sphincter (sphincter prosthesis).
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