Urinary Incontinence

Urinary incontinence, or the involuntary leakage of urine is one of the most common problems treated in female urology. It is important for the clinician to realize that there are several different types of urinary incontinence, each with a different cause and potential treatment options. These include stress incontinence, urge incontinence, overflow incontinence, mixed incontinence (simultaneous stress and urge incontinence), total incontinence and functional incontinence.

Improper diagnosis of the type of urinary incontinence is probably the most common reason for treatment failure. A detailed history and physical examination is of paramount importance in the proper diagnosis and sub typing of urinary incontinence. In select cases, urodynamic testing or cystoscopy may be useful. A neurologic history and physical examination should be obtained in order to rule out neurogenic bladder.

Patients with “pure” stress urinary incontinence report activity-related urinary leakage which interferes with their quality of life. Any increase in abdominal pressure such as coughing, sneezing, laughing, exercising, jumping, running, or event sexual activity may precipitate urinary leakage. Stress incontinence may or may not co-exist with pelvic organ prolapse. In most cases urethral hypermobility is noted with rotational descent of the urethra upon straining. The need for treatment is largely dictated by the degree that it affects the quality of life of the patient . Pad usage and pad weight are sometimes used to gauge disease severity.

The current most popular surgical treatment to treat stress urinary incontinence is the sub-urethral sling. Transurethral bulking agent is another less successful and shorter duration treatment option. The suburethral sling can be performed using a synthetic mesh (mono-filament macroporous Type I mesh) or biologic allograft, autologous rectus fascia. Abdominal procedures such as Burch urethropexy are effective but remain more invasive than the transvaginal sling procedures. Currently, there is no approved medication for stress urinary incontinence. There is no evidence that estrogen therapy is effective in the management of stress urinary incontinence.

Patients with urge urinary incontinence report involuntary urinary leakage with bladder spasm and strong urges to void. Urge incontinence is one of the symptoms associated with overactive bladder. Overactive bladder is not necessarily related to aging or prior surgery. Most cases of overactive bladder and urge incontinence are idiopathic. Urge urinary incontinence is often associated with urinary urgency and frequency. However, a neurologic cause should always be ruled out especially in younger patients. The treatment algorithm of urge is very different from that of stress incontinence.

Behavioral therapy, fluid management, timed voiding, avoiding bladder irritants, pelvic floor exercises, Kegel exercises are useful in many cases. In more severe cases, anticholinergic medications can be used. Anticholinergics are plagued with adverse side effects such as dry mouth, constipation, cognitive side effects, and potential for urinary retention. The newest anticholinergic drugs have a better safety profile but yet remain far from being free from side effects. The newly developed beta-adrenergic agonists are promising. They are effective free from anticholinergic side effects but are associated with hypertension. The procedure is minimally invasive and can be performed in the office without general anaesthesia. A urinary retention rate of 6 % and poor bladder emptying are potential side effects of Botox. Urinary retention is rare in our personal practice and in well selected patients with a This option is FDA approved in the USA.

Another option is Implant of sacral nerve stimulator. It is possible to stimulate the third (S3) sacral nerve via an implantable neuro-stimulator. Medtronic (Interstim) manufactures the most popular device. The procedure is performed under local anaesthesia with the patient awake. A staged procedure (First -stage lead implant) and second stage (implantable pulse generator- IPG) implant is often required to obtain the best results. The device is expensive and the battery (IPG) half-life is 3-7 years. Patients who require infra-cranial MRIs can’t have the procedure performed. A few long term studies have documented the safety and efficacy of Intersim. Recently, posterior tibial nerve stimulation (PTNS) has been added to the armamentarium of urge incontinence treatment with very reasonable outcome data. Long term studies are needed. No implant is necessary for PTNS but multiple weekly office visits are required.

Dr. Angelo Gousse is a Urologist with offices in Aventura and Miramar serving all South Florida (Miami, Fort Lauderdale, West Palm Beach, Kendall, South Miami, Sunny Isles, Brickell, Boca Raton) and international clients. Dr. Gousse has been selected as an honored member of Trademark Top Doctors of America Honors Edition 2018.

Urinary Incontinence

Urinary Incontinence

Urinary incontinence is estimated to affect 12–17% of US males, with increasing prevalence associated with aging. Stress urinary incontinence (SUI) as a subtype has been defined by the International Continence Society as the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. Although any surgical or radiotherapeutic manipulation of the prostate may result in SUI, radical prostatectomy (RP), transurethral resection of the prostate (TURP), and radiation therapy are most commonly associated SUI .

The true prevalence of SUI following radical prostatectomy remains unknown with estimates varying from 2 to 43%. Regardless of the etiology of severe male SUI it remains a very debilitating condition which greatly affects quality of life. It is estimated that 56% of patients will suffer from urinary incontinence in the peri-operative period following catheter removal after a prostate is removed for cancer (post prostatectomy). This decreases to 21% at three months, and up to 14% at one year. While the initial management of post-prostatectomy incontinence consists of emotional support and reassurance, it is expected that, in most cases, steady improvement will be noted. In severe cases, ongoing skin irritation due to urine bathing the skin and difficulty with pads may necessitate the use of condom catheters, penile clamps and even indwelling Foley urinary catheters to improve control.

The good news is there is hope for patients who often are suffering in silence.

Surgical therapy should be considered in men with post-prostatectomy stress urinary incontinence (SUI) that persists beyond the first postoperative year, or even earlier in men with severe symptoms. Other patients with severe urinary incontinence or with neurogenic bladder can also benefit from the treatment.

The surgical device aims to prevent involuntary urinary leakage during storage by increasing bladder outlet resistance while allowing unimpeded flow during voluntary urination. The “Gold Standard” surgical treatment, to date, is the artificial urinary sphincter.

The artificial urinary sphincter (AUS) is a surgically implantable device used to restore urinary control in men. Most commonly, the device is implanted in men who have sphincter or valve muscle damage following prostate surgery. The entire device is implanted inside the body in a brief outpatient surgical procedure lasting approximately one hour. With appropriate evaluation for the proper selection of candidates for the AUS, the long-term results in experienced hands are excellent. One the leading artificial urinary sphincter implanters and authority in the country, Dr Angelo Gousse has performed more than 700 AUS implants, making him the number one implanter in Florida.

The AUS consists of three components: the cuff, which goes around the urethra, the pump, which goes inside the scrotum, and the balloon, which holds the fluid for the device (see figure). The balloon is available in different pressure ranges and is filled with a fluid that is very safe even if it leaks. The device works hydraulically, with the cuff around the urethra staying closed at all times. When the person wants to urinate, the pump is squeezed and the cuff opens. Automatically, in 3-5 minutes, the cuff closes again. The refilling of the cuff is controlled by a resistor mechanism inside the pump.

The most common indication for implanting the AUS is sphincter damage following prostate surgery (especially radical prostatectomy for prostate cancer). It is essential that the exact cause of urine leakage be defined by special bladder and sphincter function tests, called urodynamics, before any surgery is performed. In order for the AUS to be successful, the bladder must be able to store a normal amount of urine at low pressure and to empty normally. This ability of the bladder to function normally is examined during the urodynamic testing.

Insertion of the AUS is performed in a hospital operating room under either a general or a spinal anesthetic. Two small incisions are made: one in the groin area and the other between the scrotum and the rectum. The proper size cuff is placed around the urethra and the tubing from the cuff is passed up to the groin area. The small pressure-regulating balloon, which is about the size of a golf ball, is placed beneath the abdominal muscles and the pump that controls the device is tunneled down into the scrotum, just beneath the skin. All connections between the three components are made in the groin area and the incisions are closed. At the conclusion of the operation, the cuff is locked open for 4-6 weeks until healing is complete.

It is an outpatient procedure and there is minimal postoperative pain. Most men return to work 2-3 weeks after surgery. About 4-6 weeks after surgery, the AUS is activated in the office by squeezing a button (no surgery is required) to allow urinary control to be restored.

More than 100,000 men worldwide have received the AMS 800 Urinary Control System. For almost 35 years, physicians worldwide have been implanting the AMS 800 as an effective treatment for stress urinary incontinence in men. The AMS 800 has been proven to be effective in the treatment of male incontinence following prostate surgery, and is considered the gold standard by most urologists. When using this device, most men are dry, with only minor leaks or dribbles of urine, usually with strenuous exercise or exertion. Most men use one pad or less per day to manage these minor leaks. As with any medical procedure, the AMS 800 is not 100% effective in all patients. Some men may require additional protection.

The AMS 800 offers the following benefits in helping to restore your quality of life:

  • Time-Tested: For almost 35 years, the AMS 800 has been the gold standard for treating incontinence caused by intrinsic sphincter deficiency (ISD) following prostate surgery.
  • Effective: The AMS 800 is capable of offering most men with sphincteric damage the opportunity to achieve continence over time.
  • Long Lasting: Published clinical data shows long-term results.
  • Recently, the male synthetic sling called Advance has become available. Although long-term outcome data is currently being accumulated, the procedure appears to be most effective for mild to moderate male urinary incontinence. Urethral Bulking agents (Collagen and Durasphere, Teflon, Coaptite) for male incontinence have fallen by the way-side for lack of efficacy.

Dr Angelo Gousse is the lead surgeon as part of a research team at the University of Miami developing a novel artificial urinary sphincter based on blue tooth technology. The key features of the device include implant simplicity using less implantable components, no fluid in the device, and improved versatility for real-time pressure adjustments using a hand-held remote control device.