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The business of male urinary incontinence - (9/1/2018)

By Dr. Ron Gasbarro

Jim, 68, just had his prostate removed because his urologist found precancerous cells in his prostate. Jim said, “The worst thing now is not being able to control my bladder. Are diapers next?”

According to the American Cancer Society (ACS), prostate cancer is the most common cancer in American men, aside from skin cancer. The ACS’s 2018 estimates for prostate cancer in the United States are approximately 164,690 new cases of prostate cancer and about 29,430 deaths from prostate cancer, or about 1 death for every 5 or 6 cases. While prostate cancer is curable via chemotherapy, immunotherapy, hormonal therapy, diet changes, supplements, and targeted therapy, the sequelae of having no prostate may include either temporary or permanent urinary incontinence (UI).   

Incontinence stats 
Globally, up to 35% of the population over the age of 60 years is estimated to be incontinent [Hannestad, 2000]. In 2014, urinary leakage affected between 30% and 40% of people over 65 years of age living in their own homes or apartments in the US [Gorina, 2014] Twenty-four percent of older adults in the US have moderate or severe urinary incontinence that should be treated medically [Gorina, 2014]. Bladder control problems have been found to be associated with higher incidence of many other health problems such as obesity and diabetes. A difficulty with bladder control results in higher rates of depression and limited activity levels [Nygaard, 2003].

Why do men become incontinent? 

As mentioned, men with prostate cancer are prone to UI. Obesity is another factor that can cause UI in men. The prevalence of UI in the older population (aged 60 years old and above) is high due to chronic diseases such as Alzheimer’s disease, Parkinson’s disease, diabetes, and anxiety. Such chronic disease can weaken bladder nerves and muscles, which, in turn, can lead to UI. Urinary incontinence can cause mental trauma, thereby leading to physical inactivity and emotional stress. In addition, it increases the personal expenditure or average direct cost for an individual in the form of purchasing a huge number of continence pads.

According to Technavio, a NY-based market research firm, studies have shown that men are more likely to develop UI with age. In fact, 1 in 3 older American men has the problem of either unintentional or accidental passing of urine. An individual with the problem can either opt for therapeutic drug or undergo a surgery for the treatment of UI. However, the majority of the individuals select a medication, which is cheaper and more convenient than surgery.

Men tend to experience incontinence less often than women, and the structure of the male urinary tract accounts for this difference. It is common with prostate cancer treatments. Men can become incontinent from neurologic injury, congenital defects, strokes, multiple sclerosis, and physical problems associated with aging.

Age increases risk
While UI affects older men more often than younger men, the onset of incontinence can happen at any age. Estimates in the mid-2000s suggested that 17% of American men over age 60 – an estimated 3.4 million men – experienced UI, with this percentage increasing with age [Stothers, 2005]. The largest impact of UI in elderly men is in physician office visits, followed by outpatient services and surgeries. Resource use is greatest in the nursing home setting, where more than 50% of men have UI and require assistance with toileting [Thom, 1997].  

The management of UI with pads is mentioned in the earliest medical book known, the ancient Egyptian Ebers Papyrus (ca. 1500 BC) [Becker, 2005]. However, incontinence has historically been a taboo subject in Western culture. This situation changed some when the Kimberly-Clark Corporation aggressively marketed adult diapers in the 1980s with actor June Allyson as spokeswoman [O’Reilly, 2017]. Allyson was initially reticent to participate, but her mother, who had incontinence, convinced her that it was her duty in light of her successful career. The product proved successful and the marketing campaign has been credited for reducing the debilitating social stigma of incontinence.

Types
Urge incontinence: Involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate. 
Stress incontinence: Also known as effort incontinence, is due essentially to insufficient strength of the pelvic floor muscles to prevent the passage of urine, especially during activities that increase intra-abdominal pressure, such as coughing, sneezing, or bearing down.
Overflow incontinence: Sometimes people find that they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after they have passed urine. It is as if their bladders were constantly overflowing, hence the general name overflow incontinence.
Mixed incontinence: Common the elderly population and can sometimes be complicated by urinary retention.
Functional incontinence: Occurs when a person recognizes the need to urinate but cannot make it to the bathroom. The loss of urine may be large. There are several causes of functional incontinence including confusion, dementia, poor eyesight, mobility, or dexterity, unwillingness to toilet because of depression or anxiety or inebriation due to alcohol. Functional incontinence can also occur in certain circumstances where no biological or medical problem is present. For example, a person may recognize the need to urinate but may be in a situation where there is no toilet nearby.
Double incontinence: There is also a related condition for defecation known as fecal incontinence. Due to the involvement of the same muscle group (levator ani) in bladder and bowel continence, patients with urinary incontinence are more likely to have fecal incontinence in addition [Shamliyan, 2007] This is sometimes termed "double incontinence".
Post-void dribbling: The phenomenon where urine remaining in the urethra after voiding the bladder slowly leaks out after urination.
Climacturia: Urinary incontinence during orgasm. It can be a result of radical prostatectomy.

Medications
A number of medications exist to treat incontinence including fesoterodine (Toviaz®), tolterodine (Detrol®), mirabegron (Mybetriq®), and oxybutynin (Ditropan®, Oxytrol®). While a number appear to have a modest benefit, the risk of side effects is a concern [Shamliyan, 2012]. For every 10 people treated, only one will become able to control their urine and all medications are of similar benefit [Shamliyan, 2012]. Medications are not recommended for those with stress incontinence and are only recommended in those who have urge incontinence who do not improve with bladder training [Quaseem, 2014].

Devices
Men who continue to experience UI need to find a management solution that matches their individual situation. 
Collecting systems: Consists of a sheath worn over the penis funneling the urine into a urine bag worn on the leg. These products come in a variety of materials and sizes for individual fit. Studies show that urisheaths and urine bags are preferred over absorbent products – in particular when it comes to ‘limitations to daily activities’ [Chartier-Kastler, 2011]. Solutions exist for all levels of incontinence. Advantages with collecting systems are that they are discreet, the skin stays dry all the time, and they are convenient to use both day and night. Disadvantages are that it is necessary to get measured to ensure proper fit and you need a health care professional to write a prescription for them.
Absorbent products: Include shields, undergarments, protective underwear, briefs, adult diapers, and underpants; these are the best-known product types to manage incontinence. They are generally easy to obtain in pharmacies and supermarkets or online. The advantages of using these are that they barely need any fitting or introduction by a health care specialist. The disadvantages of absorbent products are that they can be bulky, leak, have odors and can cause skin breakdown.
Fixer-occluder devices: These are strapped around the penis, softly pressing the urethra and stopping the flow of urine. This management solution is only suitable for light or moderate incontinence.
Indwelling catheters: Also known as Foleys, these are often used in hospital settings or if the user is not able to handle any of the above solutions himself. The indwelling catheter is typically connected to a urine bag that can be worn on the leg or hang on the side of the bed. Indwelling catheters need to be changed on a regular basis by a healthcare professional. The advantage of indwelling catheters is that the urine is funneled away from the body keeping the skin dry. The disadvantage is that it is very common to get urinary tract infections (UTIs) when using indwelling catheters [Cravens, 2000]. UTIs in males are more complicated than UTIs in females
Intermittent catheters: Single-use catheters that are inserted into the bladder to empty it. Once the bladder is empty, they are removed and discarded. Intermittent catheters are primarily used for retention (inability to empty the bladder) but for some people can be used to reduce or avoid incontinence.

Exercises

Biofeedback uses measuring devices to help the patient become aware of his or her body's functioning. By using electronic devices or diaries to track when the bladder and urethral muscles contract, the patient can gain control over these muscles. Biofeedback can be used with pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence.
Time-voiding while urinating and bladder training are techniques that use biofeedback. In time-voiding, the patient fills in a chart of voiding and leaking. From the patterns that appear in the chart, the patient can plan to empty the bladder before he would otherwise leak. Biofeedback and muscle conditioning, known as bladder training, can alter the bladder's schedule for storing and emptying urine. These techniques are effective for urge and overflow incontinence.
Pelvic floor muscle training (PFMT) exercises are a series of exercises designed to strengthen the muscles of the pelvic floor. A PFMT exercise is like imaging that the patient has to urinate and then holding it. One relaxes and tightens the muscles that control urine flow. Locating the correct muscles to tighten is essential. Preoperative PFMT in men undergoing radical prostatectomy was not effective in reducing urinary incontinence [Wang, 2014].

What are Kegel exercises?
Exercising the muscles of the pelvis such as with Kegel exercises are the first-line treatment for people with stress incontinence [Quaseem, 2014]. An effort to increase the time between urination, known as bladder training, is recommended in those with urge incontinence. Both may be used in those with mixed incontinence.

Kegel exercises are performed by contracting and relaxing the pubococcygeal muscle and other muscles of the pelvic diaphragm. Perform these exercises when sitting, standing in the supermarket checkout line. Do them immediately after surgery and continue until you regain continence.
Suggested Kegel regimen:
Contract the pelvic floor muscles
Hold the contraction for 3 seconds, then relax
Repeat 10 times
Do this 3 times per day
Data exist to support this recommended regimen. A meta-analysis of randomized controlled trials concluded that pelvic floor muscle training with biofeedback early in the postoperative period immediately following the removal of the catheter can promote an earlier return to continence [Hunter, 2007].

Ron Gasbarro, PharmD, is a registered pharmacist, medical writer, and principal at Rx-Press.com. Read more at www.rx-press.com  

References 

Becker H-D, ed. Urinary and fecal incontinence: an interdisciplinary approach. Berlin: Springer; 2005:232. 

Chartier-Kastler E, Ballanger P, et al. Randomized, crossover study evaluating patient preference and the impact on quality of life of urisheaths vs absorbent products in incontinent men. BJU Int. 2011;108: 241–7. 

Cravens DD, Zweig S. Urinary catheter management. Amer Fam Phys. 2000;61: 369–76. 

Gorina Y, Schappert S, Bercovitz A, et al. Prevalence of incontinence among older Americans. National Center for Health Statistics. Vital Health Stat. 3:2014.

Hannestad YS, Rortveit G, Sandvik H, Hunskaar S. A community-based epidemiological survey of female urinary incontinence: The Norwegian EPINCONT Study. J Clin Epidemiol 2000;53:1150–7.

Hunter KF, Moore KN, Glazener CM. Pelvic floor muscle training to improve urinary incontinence after radical prostatectomy: a systematic review of effectiveness. BJU Int. 2007;100:119.

Nygaard I, Turvey C, Burns TL, Crischilles E, Wallace R. Urinary incontinence and depression in middle-aged United States women. Obstet Gynecol. 2003;101:149–56. 

O'Reilly T. Now Splinter Free: How Marketing Broke Taboos. CBC Radio One. Pirate Radio; June 8, 2017. Available at: http://www.cbc.ca/radio/undertheinfluence/now-splinter-free-how-marketing-broke-taboos-1.4149558. Accessed September 5, 2018.

Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD, Shekelle P; for the Clinical Guidelines Committee of the American College of, Physicians. Nonsurgical management of urinary incontinence in women: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161:429–40.

Shamliyan T, Wyman J, Bliss DZ, Kane RL, Wilt TJ. Prevention of urinary and fecal incontinence in adults. Evid Rep Technol Assess (Full Rep). 2007;161:1-379.

Shamliyan T, Wyman JF, Ramakrishnan R, Sainfort F, Kane RL. Systematic review: Benefits and harms of pharmacologic treatment for urinary incontinence in women". Ann Intern Med. 2012;156:861–74,

Stothers L, Thom D, Calhoun E. Urologic diseases in America project: Urinary incontinence in males - Demographics and economic burden. J Urol. 2005;173:1302-8.

Thom DH, Haan MN, Van Den Eeden SK. Medically recognized urinary incontinence and risks of hospitalization, nursing home admission, and mortality. Age Ageing. 1997;26:367–74. 

Wang W; Huang Q, Liu F; Mao, QQ. Effectiveness of preoperative pelvic floor muscle training for urinary incontinence after radical prostatectomy: a meta-analysis. BMC Urol. 2014;14:99.


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