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Incontinence and Prostate Cancer
John C. Hairston, MDAssociate Professor of Urology
Integrated Pelvic Health ProgramNorthwestern Feinberg School of Medicine
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“The objective demonstration of involuntary loss of urine consequent to bladder and/or sphincter dysfunction.”
The International Continence Society
Ballanger P et al. Female Urinary Incontinence. Eur Urol 1999; 36:165-174.
What is urinary incontinence?
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Types of incontinence
• Stress Incontinence– Leakage during physical activity that increases
intraabdominal pressure, i.e. lifting, exercising, sneezing, and coughing
• Urge Incontinence– Leakage associated with an overwhelming
need to urinate Gotta go, gotta go!• Mixed Incontinence
– Combination of the above
– Hunskaar et al. One hundred and fifty men with urinary incontinence. Scand J Prim
– Health Care 1993; 11:193-196.
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How does the process work?
• Bladder collects urine• The sphincter - a
circular muscle atthe level of the prostate - controls the flow of urine
• The sphincter muscle wraps around the urethra
• A healthy sphincter stays closed until one relaxes it to urinate
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Why am I incontinent?
• Prostate cancer treatment– Radical Prostatectomy– Radiation– Cryotherapy
• Other pelvic surgery or trauma
• Spinal disease
• Neurologic disease
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Am I the only one with incontinence?
55 million men in the world suffer from loss of urinary control
AMS 2003 Annual ReportCampbell’s Urology 2002 8th Edition
NO!NO!
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Male Incontinence
• Rate of incontinence ranges between 2.5% up to 69% after prostate cancer treatment• Risk factors
• Degree of nerve sparing• Postoperative bladder neck contracture• Combination/Adjuvant treatment• Presence of prior disease (stricture, etc)• Salvage therapy
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Male Incontinence
• Post-prostatectomy- Often improves within 3-6 months- 5-8% of men require treatment beyond
conservative measures• Radiation
- Often a late complication - Difficult to predict - Probably improving with improved directed therapies
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Why treat incontinence?
Avoid negative feelings
embarrassment, discomfort, isolation, anger and depression
Return to usual lifestyle
Regain dignity
Resume intimacy
Save money on protective garments
Improve quality of life
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150 men reported the practical inconveniences associated with incontinence:
52% Extra laundry
37% Smell
17% Extra expense
12% Skin irritation
11% Disturbed sleep
Source: Hunskaar s, Sandvik H. one hundred and fifty men with urinary incontinence. Scand J Prim Health Care 1993 v. 11 p.193-196
Why treat incontinence?
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What to expect at an office visit
• History– Spinal or neurologic disease– History of BPH (Enlarged Prostate)
• Physical Exam– Neurologic exam
• Urinalysis• Postvoid Residual• 24 hr pad testing * • Urodynamics, Cystoscopy
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Management options
• Pads/diapers• Medication• Devices
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Pads/diapers
• What do men know about pads?!?• More absorbent and less irritating than
other paper products• Pads vs diapers
– “Maxi” vs. “Mini” pads
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Devices: Clamps
– Cunningham clamp, C3-clamp
– Advantages• Non-medical, non-surgical• Easy to use• Works well
– Disadvantages• Bulky• Pressure necrosis• Generally not a turn on
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Devices: Catheters
– External vs. Internal
– Advantages• Works
– Disadvantages• Attached to a bag• Increased risk of
infection
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Medication
• No FDA approved medication for stress incontinence in men (or women)
• Antidepressants• You may be a candidate for anticholinergic
medication– Overactive bladder component
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Treatment options
• Behavioral modification• Biofeedback• Injectables• Surgery
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Behavioral modification
• Decrease fluid intake• Void frequently• Avoid caffeine, alcohol• Avoid activity that increases intraabdominal
pressure
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Pelvic floor rehabilitation
• a.k.a. biofeedback• Means of teaching Kegel
exercises• Objective way to measuring
pelvic floor strength• ? how much better than verbal
instruction
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Bulking agents
• Collagen, carbon beads, autologous fat• Success rates for collagen ~
17%-38% after prostatectomy• Most recent International Consultation on
Incontinence regarded this treatment as showing only modest benefit
• Poor surgical candidates with minor degrees of leakage
Klingler HC et al. Incontinence after radical prostatectomy: surgical treatment options. Curr Opin Urol 2006; 16:60-64.
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Surgical options for male stress incontinence
• Male Sling • Artificial Urinary Sphincter
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Male Incontinence Severity Level Guidelines
Onur R, Rajpurkar A, Singla A. New perineal bone-anchored male sling; Lessons learned. Urology Jul 2004 v. 64 (1) p.58-61
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InVance™ Male Sling
• Effective treatment for mild to moderate incontinence
• Minimally invasive, 45± minute outpatient procedure
• Continence is immediately restored
• Nothing to operate
• Device is completely hidden inside the body
• 88% satisfaction rate1
1Onur R, et al. Efficacy of a new bone-anchored perineal male sling in intrinsic sphincter deficiency. International Incontinence Society. Oct. 5-9, 2003. 33rd annual meeting, Florence, Italy. Abstract 399.
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InVance™ Male Sling
Sling creates gentle compressionon the urethra for urinary control
• Procedure:
– Spinal or general anesthesiacan be used
– Small incision under the scrotum
– Miniature titanium screws placedinto the pubic bone on each sideof the urethra
– Sling positioned to exert gentlepressure on urethra
– Sling secured to screws
– Incision closed
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AdVance™ Male Slinga new, innovative treatment option
• Innovative treatment for mild to moderate incontinence
• Minimally invasive, fast outpatient procedure
• Continence is immediately restored
• Nothing to operate
• Device is completely hidden inside the body
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AdVance™ Male Sling
Sling restores urethra to its proper anatomical position for optimal sphincter function, restoring urinary control
• Procedure:
– Spinal or general anesthesiacan be used
– Three small incisions: 1 under the scrotum, 2 over groin creases
– Specially designed surgical toolsare used to position the sling
– Sling is gently tensioned– Incision closed
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AdVance™ Male Sling
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Virtue™ Male Sling
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Artificial Urinary Sphincter (AUS)over 100,000 implanted since 1972
Litwiller SE, et al. Post-prostatectomy incontinence and the artificial urinary sphincter; a long-term study of patient satisfaction and criteria for success. J of Urol 1996; 156:1975-1980.
• The Gold Standard for treatment of moderate to severe incontinence
• 60± minute outpatient procedure
• 92% of patients would have the device placed again
• 96% of patients would recommend it to a friend
• Device is placed completely in the body, providing simple, discreet control
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Animation of Artificial Urinary Sphincter
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Sling
• Appropriate for treatment of mild to moderate incontinence
• 70-85% success rates
• 45-60± minute outpatient procedure
• Transient scrotal/penile and perineal pain
• Passive
• Favorable 2 year data (durability?)
• Complications
• Infection and Erosion ( < 2%)
• Reoperation rate (unknown?)
• The Gold Standard for treatment of moderate to severe incontinence (85-95% success)
• 60± minute outpatient procedure
• Catheter for 23 hours
• Transient scrotal/penile and perineal pain
• “Active”
• Over 30 year track record of durability
• Complications
• Infection and Erosion (5-10%)
• Approx 15% require revision surgery over a 10-15 year period
AUS
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What should you do next?
See your Urologist! • Come prepared with questions • Discuss your treatment options• Your lifestyle and medical condition are
important factors• Ask if you can speak to one or more of
his/her satisfied patients
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Summary
• Incontinence is a common problem
• Most cases resolve within 6-12 months
• Some treatments are more effective than others
• Surgical treatment options offer proven, long-term solutions
• Talk to your Urologist – talk to your partner• Podcast at NMH.com
– http://www.nmh.org/nm/ihealth-mens-health– http://www.patientpower.info/health-topic/prostat
e-cancer
• For copies of this talk– Sara Steinkamp– [email protected]
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Thank You