Scott Webb (Host): Male stress urinary incontinence is a common condition for men who have suffered a pelvic injury or who have survived prostate cancer, and though it's not life threatening, it can affect the quality of life for those who are living with it. And joining me today to discuss male stress urinary incontinence and how we can help folks is Dr. Jaspreet Singh. He's the co-director of Men's Health and Urology Services at Montefiore St. Luke's Cornwall.

 This is Doc Talk presented by Montefiore St. Luke's Cornwall, I'm Scott Webb.

Dr. Singh, it's so nice to have you back on today. Today, we're going to talk about male stress urinary incontinence, and that's a mouthful, but we're going to talk about what that is and who suffers and what you can do to help. So let's start there. What are the causes of male stress urinary incontinence?

Jaspreet Singh, DO: Yeah, Scott, before we get into the causes, let's define what incontinence is. So, simply put, incontinence is the involuntary loss of control of urine, and there's various reasons for that and categories of incontinence, and we're, we'll primarily discuss stress incontinence, but to be complete, the other more common urinary incontinence is what we call urge incontinence, where one may have the desire to find a bathroom quickly, urgently, and then on the way to the bathroom have a loss of urine. Stress incontinence, particularly in men, there needs to be a particular reason, a trauma to the pelvis, or most commonly what we are seeing are men who have undergone removal of their prostate for prostate cancer, and less frequently men who undergo certain procedures for prostate enlargement who have a complication and are finding that they're losing control of the urine.

Host: Yeah, I see what you mean. And as you say, uh, we could, do a separate podcast on the other type of incontinence, but today, male stress urinary incontinence, so it seems obvious, but with an expert here, might as well ask, what are the signs and symptoms?

Jaspreet Singh, DO: Right. So, stress incontinence, unlike the urge incontinence, is primarily caused by some sort of activity that increases abdominal pressure. So although stress Scott, we may say stress like physical or a mental stress that incontinence causes, but what is happening is that the bladder, think about it as a balloon, has a neck, or an opening where you blow up the balloon.

And in this case, you have the male urethra, which is the tube that drains the bladder. And there's a muscle that's at the opening of the bladder that is primarily in charge of keeping the urine within the bladder. It's the same way that you pinch off the opening of a balloon so that air does not escape the balloon.

And, with prostate removal, because of how close that muscle is, what we call the urinary sphincter, and how close that is to the prostate, that sometimes can get damaged, and so what happens is because that muscle is damaged, perhaps it's weakened, and less frequently just the loss of control of that muscle leads to urine not being able to be stored effectively within the bladder, so any sort of pressure, coughing, laughing, as simple as even getting out of a chair and standing up, creates pressure on the bladder, muscle is not tight enough, and what happens is then there's escape of urine, and, what men experience is an embarrassing leakage of urine, perhaps in certain situations that you're not necessarily ready for.

Perhaps hanging out with grandchildren or maybe presenting to a company, a meeting or something like that. So it can be quite embarrassing.

Host: Yeah, I am sure. And, you know, as a guy in his mid fifties, I'm sort of following along here thinking, yes, I can think about embarrassing situations where it really wouldn't be convenient. So I've just started to think about, you know, so who's at the highest risk, right? So it's men who've suffered some sort of trauma or prostate removal or related to their prostate. Is there anybody else? And if it's just limited to those folks, what do you do to help them?

Jaspreet Singh, DO: Right. So, those are the most common situations, you know, infrequently we may have patients that have had radiation therapy for prostate cancer and this was more kind of a historical completeness sake where seed implants were placed for prostate cancer treatment. Now, we don't typically, that's not a very common way we're treating prostate cancer this day and age, but perhaps seeds were put in close to where the sphincter is and can cause laxity or weakness of the sphincter muscles.

So, some patients who have had radiation therapy. We talk about traumas, specifically we talk about pelvic fractures, motorcycle accidents, you know, things like that where the pelvis itself is fractured causes a sheer trauma to the sphincter and can't recover. But all in all, that typically is the most common scenarios that we see patients. And then very infrequently, men who have spinal cord injuries who now have some sort of neurologic deficit where the sphincter is not working.

Host: Yeah. So let's talk about then, uh, what either, guys can do to help themselves or you can do to help them. Is there any behavior, lifestyle, things they can change and maybe don't ride motorcycles? I don't know. I don't want to judge. But in general, is there anything we can do? Is there any sort of like physical therapy or anything like that? And then what do you do when you come in? What do you do to help?

Jaspreet Singh, DO: Yeah, so there's a whole slew of options that we have now. Before we even intervene as clinicians, often patients will cut down their fluid intake as a way of avoiding making a lot of urine, which, as you can understand, is not the healthiest approach to managing urinary incontinence. You can't dehydrate yourself.

 But initially, men will then manage with some sort of pads or Depends, to help capture the leakage of the urine. That in itself can be cumbersome where you have to be able to keep up with the incontinence. And then also you may not be able to travel with a supply of sanitary pads, or you may have to change your, the way your trips are planned around this, managing the incontinence. There are also condom catheters. Men will purchase a condom catheter apparatus that's placed over the penis so that the urine will then drain into a tube, which then is captured into a external bag, often is attached to the leg, and trying to avoid the pads and the Depends issue.

 Also men will can try to manage with an external clamp, something we call a Cunningham clamp, and just to kind of put a picture, to what I'm talking about, it's, essentially like a clothespin that goes over the penis to compress the urethra from the outside to prevent leakage. So these are kind of initial strategies.

Although, of course, you're talking to me as a urologist and as a surgeon, these are just kind of, I would consider like a band aid to the actual problem. And there are surgical ways we can address urinary incontinence, which we'll get to in a second. As far as, initially after a prostate is removed, I often counsel patients on performing Kegel exercises.

Many of my female patients understand perhaps after giving childbirth, they're counseled on squeezing that muscle that is in the pelvis. As you're urinating, you can stop the flow of the urine, relax, stop. So that muscle is what we're exercising. That's the pelvic diaphragm that is being exercised through Kegel exercises.

And I often will tell patients that you can't do too many of them, where it would, you know, every few hours try to get in 10 reps, three sets, something like that. There's slow squeezes, long squeezes. So we work with patients on understanding how Kegels work. But again, many of us don't know our anatomy and I'll have patients come in saying that they're doing Kegel exercises, but they're doing nothing but clenching their butt cheeks and not getting to the muscle in the pelvis. And so, we have a pelvic floor therapist. There's a thing called biofeedback that we employ our patients, encourage them to see a nurse who then in real time can counsel patients Hey, that is the muscle you should be working on. Something called biofeedback. So, there are early exercises to help recover urinary incontinence after prostate removal, not only sooner, but at a higher rate.

And, the data shows that Kegel exercises are best done within six months of prostate removal. If you go past the six months, definitely after 12 months, the likelihood of recovery with Kegel exercises declines quite, significantly.

Host: Okay. All right. So then let's talk about the surgical options. As you said, you know, you're a urologist and a surgeon. So when we get to that point and we've tried everything else and surgery is indicated, take us through that.

Jaspreet Singh, DO: Yeah, so there are two main ways we treat male urinary incontinence, or male stress urinary incontinence. And, primarily the treatment option is based on how severe the incontinence is. We classify into mild to moderate, and then moderate to heavy. And we categorize that by the amount of pads that somebody needs. And also how heavy the pads are. And so we kind of have a rough idea. So, for example, Scott, a patient who's had a prostate removed now is a year after and is talking about the lack of recovery of urinary incontinence, or perhaps initially was heavy. And then now saying, Doc, when I'm out playing golf or when I'm more active throughout the day, I need one to two pads, throughout the day, and they could be as light as a liner or, you know, something that will, like a pad that captures the urine.

 And most often, Doc, these aren't heavy. I don't have to wring them out, so that's what we'd consider kind of mild, and, maybe if the pads were a little heavier and too moderate, as opposed to men who are needing, two, three Depends, if not more, are heavy when they change it or even supplementing the Depends, putting an extra pad in between to prevent the leakage.

So we consider that heavy. For men who have mild to moderate incontinence, the surgical approach that we pursue is something called a male urethral sling. And there's a lot of data on this, there's a lot of data even in our female patients with urinary incontinence, stress urinary incontinence.

 But specifically to men, what we're doing is we are repositioning that urethra that used to be in the pelvis when the prostate was there. When the prostate is removed, the actual urethra, the bladder and the urethral connection kind of drop outside of the pelvis. So it's a sling that pulls it back and then allows a compression on the urethra.

So it amplifies the closure of the sphincter that's weak. It's a procedure that takes about half an hour to 45 minutes. It's a same day procedure. Physical recovery is something that takes about two to three weeks. And, as far as expectations go, we are looking at, you know, greater than 50 percent improvement from baseline in men, about 80 to 85 percent at five year, after the procedure.

And so, you know, data's pretty good. It helps to improve the urinary incontinence. Our goal, obviously, is to get men completely dry. And so, I think in my hands, most of my men that undergo this procedure are reporting not needing a pad or perhaps just a safety pad in case there's a drop or two, in the majority of my patients.

 Alternatively is a procedure called the artificial urinary sphincter, which we consider as the gold standard to managing stress urinary incontinence. This is a device that's placed on the urethra. So again, we are implanting a device that helps to close the urethra. It's inside the body, nothing that's on the outside, and the sensation to urinate is the same.

The signal to go to the bathroom is the same, the bladder fills up, but this artificial urinary sphincter is a device that's keeping the urethra closed. There's a small pump, a scrotal pump, a bulb that's placed in the scrotum that the patient then has to press, allows the sphincter to open up as a natural sphincter would open up and relax and open up.

And then the patient can empty the bladder and the nice thing about the artificial urinary sphincter is that it closes by itself. So there isn't any other thing that you have to press. As far as the success rates go, they are much better than even the urethral sling.

And so the artificial urinary sphincter, you know, it's, is considered a gold standard because it, it helps to treat, all types of incontinence, whether it's mild, moderate, or heavy. But typically, because it is more involved, you're actually implanting a device, tends to be a longer recovery and are reserved for men who are heavy leakers, moderate to heavy.

Host: Sure. Yeah, this is all really interesting. And, you know, you mentioned earlier, as we kind of finish up here, it is with the pads and everything can be cumbersome and inconvenient and at times with leakage, embarrassing. Final thoughts and takeaways, Doctor, for guys who are suffering, who haven't been into the office to see you and your best recommendations.

Jaspreet Singh, DO: Yeah, you know, urinary incontinence is obviously not a life or death situation, unlike prostate cancer. But it is a very high on the quality of life of men who are prostate cancer survivors. So men who are, living with these issues, don't have to live this way. There are treatment options to kind of regain some of that quality of life.

And although it's a very sensitive and perhaps embarrassing conversation to have with your doctor, it really should be done, should be driven by the patient and, time to take charge and recovering some of the side effects of prostate cancer treatment.

Host: Yeah. Take charge for sure. Well, I know we're going to speak again soon. Thank you for your time and you stay well.

Jaspreet Singh, DO: Thanks you too, Scott.

Host: And visit MontefioreSLC.org for more information about urology services. And if you found this podcast to be helpful, please be sure to share it on your social channels and be sure to check out all the other Doc Talk episodes. This has been Doc Talk, the podcast from Montefiore St. Luke's Cornwall Hospital. I'm Scott Webb. Stay well.