> Table of Contents > Incontinence, Urinary Adult Male
Incontinence, Urinary Adult Male
Amar Talati, DO
David O. Parrish, MS, MD, FAAFP
image BASICS
DESCRIPTION
  • Urinary incontinence (UI) refers to the involuntary loss of urine that presents a medical, financial, social, or hygienic problem; the five main types of incontinence include stress, urge, mixed, overflow (urinary retention), and functional UI (1).
  • Stress incontinence: involuntary urine leaks secondary to increased intra-abdominal pressure being greater than the sphincter can control; may be precipitated by sneezing, laughing, coughing, exertion
  • Urge incontinence: Involuntary leakage of urine associated with urgency is believed to be secondary to uncontrolled contraction of the urinary bladder. It is also called detrusor overactivity.
  • Mixed incontinence: involuntary leakage of urine with urgency and with stress, such as sneezing, laughing, coughing, exertion
  • Overflow incontinence: Also known as urinary retention; this occurs with bladder overdistention due to impaired detrusor contraction or bladder outlet obstruction (due to benign prostatic hyperplasia [BPH], bladder stones, bladder tumors, pelvic tumors, urethral strictures or spasms).
  • Functional UI: urine leakage variable, often due to environmental or physical barriers to toileting (i.e., reduced mobility).
  • Other causes transient UI often due to infection, medication side effects, or psychological disorder, in addition to postmicturition dribbling associated with BPH
  • Polyuria is defined by excessive amounts of urine (≥2.5 to 3 L) over 24 hours
  • Nocturnal polyuria is where >33% of total daily urine output occurs during sleeping hours.
EPIDEMIOLOGY
  • Stress incontinence in men is rare, unless it is attributable to prostate surgery, neurologic disease, or trauma.
  • Detrusor overactivity may be spontaneous or provoked, but involuntary, and may be neurogenic in cause or idiopathic.
  • Reported rates of incontinence range from 1% after transurethral resection to 2-66% after radical prostatectomy, and 1-15% following transvesical prostatectomy, although rates decline with time (1).
Prevalence
  • 12.4% prevalence of UI in community dwelling adult men in the United States as based on the National Health and Nutrition Examination Survey (NHANES) as of 2008.
  • 4.5% reported moderate to severe UI, of which 48.6% experienced urge, 23.5% experienced other UI, 15.4% experienced mixed, and 12.5% experienced stress incontinence as per the NHANES report in 2010.
  • UI is common in nursing home patients, with a prevalence of about 70% in the Southeastern United States from 1999 to 2002.
  • Major depression, hypertension, and benign prostatic hypertrophy associated with UI.
  • Incontinence in men of all ages is approximately half as prevalent as it is in women; however, after 80 years of age, both sexes are affected equally (1).
ETIOLOGY AND PATHOPHYSIOLOGY
  • Incontinence secondary to bladder abnormalities
    • Detrusor overactivity results in urge incontinence.
    • Detrusor overactivity commonly is associated with bladder outlet obstruction from benign prostatic hyperplasia (BPH).
  • Incontinence secondary to outlet abnormalities
    • Sphincteric damage secondary to pelvic surgery or radiation
    • Sphincteric dysfunction secondary to neurologic disease
    • Commonly associated with BPH due to compression of the urethra, affecting urinary flow
  • Mixed incontinence is caused by abnormalities of both the bladder and the outlet overflow or by enlarged prostate/bladder neck contracture from prostate surgery.
  • Stress incontinence is caused by weakened urethral sphincter and/or pelvic floor weakness.
RISK FACTORS
  • Age
  • Hypertension
  • Neurologic disease
  • Prostate surgery
  • Pelvic trauma
  • History of urinary tract infections
  • Major depression
  • Diabetes
GENERAL PREVENTION
Proper management of conditions, such as symptomatic bladder outlet obstruction caused by BPH early in the course may prevent continence problems later in life; no evidence for screening in men unless patient is experiencing symptoms using The 3 Incontinence Questions tool to evaluate the type of UI (2)[C].
COMMONLY ASSOCIATED CONDITIONS
  • Neurologic disease (cerebrovascular accident, parkinsonism, multiple sclerosis, myelodysplasia, spinal cord injury)
  • Pelvic radiation
  • Pelvic trauma
  • BPH
  • Prostate surgery
image DIAGNOSIS
PHYSICAL EXAM
  • Abdominal examination
    • Suprapubic mass suggests retention.
    • Suprapubic tenderness suggests UTI.
    • Surgical scars suggesting pelvic surgery.
    • Skin lesions associated with neurologic disease (e.g., neurofibromatosis and café au lait spots)
  • External genitalia
  • Prostate
  • Spine/back
  • Skeletal deformities
  • Scars from previous spinal surgery
  • Sacral abnormalities may be associated with neurogenic bladder dysfunction
    • Cutaneous signs of spinal dysraphism
      • SC lipoma
      • Vascular malformation, tuft of hair, or skin dimple on lower back
    • Cutaneous signs of sacral agenesis
      • Low, short gluteal cleft
      • Flattened buttocks
      • Coccyx is not palpable.
  • Focal neurologic exam
    • Motor function
      • Inspect muscle bulk for atrophy.
      • Tibialis anterior (L4-S1): dorsiflexion of foot
      • Gastrocnemius (L5-S2): plantarflexion of foot
      • Toe extensors (L5-S2): toe extension
  • Sensory function
  • Reflexes
    • Anal reflex (S2-S5)
      • Gently stroke mucocutaneous junction of circumanal skin.
      • Absent visible contraction (wink) suggests peripheral nerve/sacral (conus medullaris) abnormality.
    • Bulbocavernosus reflex (BCR) (S2-S4)
      • Elicited by squeezing glans to cause reflex contraction of anal sphincter
      • Absence of BCR suggests sacral nerve damage.
DIFFERENTIAL DIAGNOSIS
  • Urge incontinence
  • Stress incontinence
  • Mixed incontinence
  • Overflow incontinence
  • Functional UI
  • Transient UI
DIAGNOSTIC TESTS & INTERPRETATION
  • Urinalysis and urine culture to check for glucosuria, pyuria, proteinuria, and/or blood
  • Voiding diary, The 3 Incontinence Questions
  • Pad test if quantity of leakage or objective outcome measure is desired.
  • Do not routinely perform urodynamics before conservative treatment for UI (EAU Grade B).
  • P.553

  • Postvoid residual (PVR) volume if difficulty voiding or other lower urinary tract symptoms using ultrasound (US) to measure postvoid residual: PVR persistently ≥100 mL indicates voiding dysfunction.
  • Uroflowmetry
  • PSA only if diagnosis of prostate cancer will influence treatment or if levels can help decision-making for patients at risk for BPH.
  • Renal function if renal impairment or hydronephrosis is suspected, or if considering surgical treatment for lower urinary tract symptoms
  • Voiding cystogram in select cases
Diagnostic Procedures/Other
  • Urodynamics is useful for confirming bladder outlet obstruction as a possible cause of detrusor overactivity and may reduce surgical treatment of symptoms and persistence of objective obstruction following surgery compared to immediate transurethral resection of prostate in men with voiding dysfunction (level 2 [mid-level] evidence)
  • Prostate US and biopsy if indicated by physical exam or PSA
  • Urethrocystoscopy to exclude suspected bladder or urethral pathology or before invasive therapies if findings might influence treatment
  • Imaging of upper and lower urinary tract is not routinely indicated as part of UI assessment.
  • Consider US (preferred) or MRI of lower urinary tract if indicated.
    • US is rarely required to diagnose or rule out BPH in patients with UI as digital rectal exam can diagnose and guide treatment in most patients.
    • Consider US of prostate if it assists with choice of drug therapy for lower urinary tract symptoms.
    • Consider US of prostate to assess for intravesical prostatic protrusion (IPP) if considering surgical treatment.
    • Consider US of upper urinary tract in patients with large postvoid residual, hematuria, or history of urolithiasis.
image TREATMENT
  • Best managed by combining lifestyle modification and medication; rule out transient causes of UI.
  • Lifestyle changes: Manage diabetes, weight loss (especially if overweight), limit fluids (especially at night), toilet on a scheduled basis, eliminate certain foods that may make symptoms worse (e.g., caffeine, acidic foods, alcohol), reduce use of medications that may cause UI or nocturnal diuresis.
  • Treat reversible causes if symptomatic (i.e., UTI), if not symptomatic in elderly, do not treat.
  • Before and after radical prostatectomy, it is best to offer pelvic floor muscle training to improve recovery and reduce long-term UI (level 2 evidence).
GENERAL MEASURES
  • Bladder diaries are invaluable in helping patients understand patterns of incontinence.
  • Time voiding to avoid significant bladder distention.
  • Techniques of relaxed voiding and double voiding
  • Urethral milking to prevent postmicturition dribble
  • Distraction and behavioral techniques to take mind off the bladder and toilet
  • Treat for constipation if applicable.
MEDICATION
First Line
  • Urge incontinence: Antimuscarinic agents are first line, caution in those with bladder outlet obstruction and PVR >250 to 300 mL. In men with urgency associated with BPH, consider &agr;-blockers (i.e., tamsulosin, alfuzosin, silodosin) as monotherapy or in combination with antimuscarinic for residual overactive bladder (3).
  • Review efficacy and side effects <30 days after treatment.
    • Oxybutynin (Ditropan XL) 5 to 15 mg PO every day
    • Tolterodine (Detrol LA) 2 to 4 mg PO every day
    • Darifenacin (Enablex) 7.5 to 15 mg PO every day
    • Solifenacin (VESIcare) 5 to 10 mg PO every day
    • Trospium chloride (Sanctura XR) 60 mg PO every day
    • Transdermal oxybutynin (Gelnique) 10% apply daily (EAU Grade B)—no dry mouth
    • Fesoterodine (Toviaz) 4 to 8 mg PO every day
  • Stress incontinence
    • No generally accepted drug therapy
    • Mixed stress and urge incontinence, ER formulations are preferred due to reduced side effects.
Second Line
  • Urge incontinence
  • Tricyclic antidepressants
    • Imipramine 10 to 25 mg PO BID/TID
  • Desmopressin (DDAVP) for occasional short-term relief of UI
    • 25 to 50 &mgr;g PO or intranasal at bedtime
  • Intradetrusor botulinum toxin injections 100 U intravesical injections (not FDA-approved)
  • Mirabegron (Myrbetriq): new &bgr;3 agonist (FDA-approved) 25 to 50 mg PO daily. Caution: HTN
  • Duloxetine for temporary improvements of incontinence with dose titration (mixed stress/urge)
Geriatric Considerations
  • Anticholinergics and tricyclics may result in significant cognitive impairment in elderly patients.
  • DDAVP should be avoided in patients with known/potential cardiac disease.
ADDITIONAL THERAPIES
  • Pelvic floor rehabilitation (Kegel exercises) may significantly reduce both stress and urge incontinence in male patients and should be considered a part of initial management for stress UI.
  • Timed voiding is a useful therapy for patients with urge incontinence.
  • Overflow incontinence is usually caused by poor bladder contractility with urinary retention.
    • Indwelling catheter
    • Intermittent catheterization
    • Evaluate for outlet obstruction.
SURGERY/OTHER PROCEDURES
  • Urge incontinence
    • Sacral nerve stimulation with behavioral therapy
    • Augmentation cystoplasty and urinary diversion
    • Botulinum toxin injection via cystoscopy
  • Stress incontinence (4)[B]
    • Urethral bulking agents: modest success rates with low cure rates
    • Male sling procedures: promising short-term and intermediate results but no long-term studies
    • Artificial urinary sphincter implant has excellent long-term continence rates and is considered gold standard (5).
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Acupuncture in selected cases
  • Physical therapy in selected cases
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Must monitor residual volume after voiding in patients taking anticholinergic medications; monitor side effects.
PROGNOSIS
Continence can be improved in almost all patients.
REFERENCES
1. Khandelwal C, Kistler C. Diagnosis of urinary incontinence. Am Fam Physician. 2013;87(8):543-550.
2. Gravas S, Bachmann A, Descazeaud A, et al. EAU guidelines on the management of non-neurogenic male lower urinary tract symptoms (LUTS), including benign prostatic obstruction (BPO). Arnhem: The Netherlands; European Association of Urology; 2014.
3. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol. 2012;188(6 Suppl):2455-2463.
4. Lucas MG, Bedretdinova D, Bosch JL, et al. EAU Guidelines on urinary incontinence. Arnhem: The Netherlands; European Association of Urology; 2014.
5. Herschorn S, Bruschini H, Comiter C, et al. Surgical treatment of stress incontinence in men. Neurourol Urodyn. 2010;29(1):179-190.
Additional Reading
&NA;
  • Bauer RM, Bastian PJ, Gozzi C, et al. Postprostatectomy incontinence: all about diagnosis and management. Eur Urol. 2009;55(2):322-333.
  • Markland AD, Goode PS, Redden DT, et al. Prevalence of urinary incontinence in men: results from the national health and nutrition examination survey. J Urol. 2010;184(3):1022-1027.
Codes
&NA;
ICD10
  • R32 Unspecified urinary incontinence
  • N39.3 Stress incontinence (female) (male)
  • N39.41 Urge incontinence
Clinical Pearls
&NA;
  • Think “outside” the lower urinary tract: Comorbid medical illness and impairments are independently associated with UI; treat contributing comorbidities and rule out secondary causes.
  • Always check PVR to rule out overflow incontinence.
  • Have patient complete the International Prostate Symptom Score and do uroflow, PSA if indicated.
  • Urodynamics if conservative management fails
  • Pelvic floor rehabilitation handouts may have a significant effect for male patients than physical therapy-mediated pelvic floor rehabilitation.