Amanda Wilde (Host): Next urologist, Dr. Ajaydeep Sidhu shares his expertise on the signs and treatment options available for male stress incontinence. This is WakeMed Voices, brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. I'm Amanda Wilde. Dr. Sidhu, welcome and thank you so much for being here.

Dr. Ajaydeep Sidhu: Absolutely. Thank you so much for having me.

Host: What is stress incontinence for men versus other kinds of incontinence, and what are the signs someone may be suffering from it?

Dr. Ajaydeep Sidhu: So, we think of urinary incontinence as the involuntary loss of urine. When we talk about stress urinary incontinence and how we differentiate that from other forms of incontinence, this is essentially the involuntary loss of urine that happens with what we call stress maneuvers. That can be a cough, a sneeze, doing a jumping jack, exercising, standing up from a seated position, anything that could result in an increase in your abdominal pressure resulting in that loss of urine.

Host: And what are the signs of stress incontinence in men?

Dr. Ajaydeep Sidhu: So usually, we would see men who complain of involuntary loss of urine, so leakage of urine, wearing pads to contain that loss of urine or male diapers or other absorbent materials, that sort of thing. They may have a history of surgeries or procedures or treatments that may have put them at a higher risk for developing those symptoms. And those may be some of the things that sort of clue us into what exactly is going on.

Host: Yeah. I was just going to ask if there are men who are at greater risk for having this condition, and you just mentioned surgeries, are there any other risk factors we should know about?

Dr. Ajaydeep Sidhu: Absolutely. The largest component of patients who suffer from this problem tend to be people who've had treatments for prostate cancer. So, radical prostatectomy to remove the prostate, sometimes radiation treatments to treat prostate cancer, sometimes a combination of both. There are also procedures that are out there to treat men who have enlarged prostates or something known as BPH. And some of those treatments may carry a small risk of leakage of urine. Those are the primary factors that we see. In addition, men who've had pelvic trauma, after say some massive accident or something like that, that resulted in trauma to that region could also suffer from this problem.

Host: Well, no one loves the idea of dealing with leakage, so let's talk about options for treatment. It's my understanding there are several options, both surgical and non-surgical. And you do a whole range, don't you?

Dr. Ajaydeep Sidhu: Absolutely. You know, we always start with conservative measures first. So, things like pelvic floor, physical therapy. Some of the listeners may have heard of Kegel exercises. We teach our patients how to do those. We have fantastic physical therapists who can help us hone in those skills and work on strengthening those pelvic floor muscles for some men. We also use absorbent materials like pads, things like that. They're also external urinary collection devices. So, think of these as like external catheters that can collect urine when you're out and about. And those are some of the more conservative options that don't involve surgical treatments.

Host: And what are the success rate of those kinds of interventions?

Dr. Ajaydeep Sidhu: So certainly, if the leakage is more mild, we found a lot more success with physical therapy and things like that. It also depends on where the continuum you are in your journey, say, from a prior surgery in terms of that leakage. So for example, after a radical prostatectomy, it's very common for a large group of men to experience stress urinary incontinence. And that can sometimes persist for several months and tends to improve slowly over time. When we get to about, you know, say a year after treatment, that's where most people will be more likely to be dry.

Host: And for those who are not, and those earlier interventions aren't doing the job, then there's a surgical. Is there more than one surgical option for treatment?

Dr. Ajaydeep Sidhu: There are. There are a handful of surgical options. There are some less invasive treatment options that do exist that are surgical. They're off-label use of something called bulking agents. These are materials that we essentially inject around the urethra to help occlude it or help occlude the sphincter a little bit more. They tend to not have as strong of a success rate. But in really, really mild cases, that may be something that a patient, you know, elects to undergo. In terms of the main surgical treatment options, the two most commonly used options are something called the sling, or the male urethral sling, or the artificial urinary sphincter.

Host: And can you talk a little more about what those do?

Dr. Ajaydeep Sidhu: Absolutely. So, the way a sling works is it's a thin piece of mesh that we place underneath the urethra to essentially increase the resistance of the urethra, basically bulking up your sphincter muscles to allow more support, which basically allows you to increase the resistance when you cough or sneeze, or do any of those stress maneuvers so that you're less likely to leak. It's a great option for men who have more mild urinary incontinence, maybe somebody who's only leaking a couple pads a day, that sort of thing.

They also have to have some sphincter function still. So, sometimes patients who've had these surgeries or had radiation may not have robust urinary sphincter function, in which case we need to use something that may be a little bit more durable for them. And that's where the artificial urinary sphincter comes in. So, what an artificial urinary sphincter is, it's also an internal device, that has three components that basically act like a blood pressure cuff going around the urethra so that when the blood pressure cuff is inflated, the urethra is closed so that you don't leak. And when you need to go use the restroom, you'll depress a pump that's placed within your scrotum, and that'll open up that cuff so you can empty your urine.

Host: And how successful have you found the artificial sphincter solution?

Dr. Ajaydeep Sidhu: It's definitely a great solution for men who have more moderate to severe incontinence. We've been using it for several decades, and it's been modified a few times for sure. But it has really seen the test of time in a lot of ways, and it's really considered the gold standard for men with stress urinary incontinence. It is a little bit more of an invasive procedure, slightly longer than putting in a sling only. But these still have fantastic success rates. If you look at both of these devices together in the carefully selected patient, you're looking at 90 plus success rate.

Host: Wow, that's a really high number. How long does the procedure take?

Dr. Ajaydeep Sidhu: A sling takes about 90 minutes to two hours, and a artificial sphincter takes about two and a half to three hours.

Host: And then, what is the recovery process like after these procedures? Are there risks and complications associated with these treatments?

Dr. Ajaydeep Sidhu: So, both of them are considered outpatient procedures. You can come in or go home the same day. Sometimes you stay overnight. With the sling, you should notice your continence immediately after the surgery. Whereas with the artificial sphincter, we do leave that cuff in the open position for about six weeks after surgery while men heal. Both surgeries take about six weeks to heal from completely. So, we really want to avoid anything strenuous during that period of time. It's not unlike any other surgery that's out there, and we tell you to take it easy for about six weeks.

You know, in terms of the risks with the sling, there's a small risk of infection, small risk of bleeding or anesthesia with any operation we offer. There is a very, very small risk of mesh infection. But fortunately, the mesh we use is very safe and we've been using it for a really long time, and it has really strong data behind it to support its use. With the artificial urinary sphincter, it has some unique risks associated with, because it is a device. And so, there's the risk that the device could break down over time, the device could injure the urethra, the device could get infected and need to be removed. Now, fortunately, these risks tend to be really, really low, and they are more likely in certain groups of people than others. So, most men tend not to fall into the high risk groups.

Host: Right. And when someone is actually considering this, they'll see an expert like you and figure out where they fall on that spectrum.

Dr. Ajaydeep Sidhu: Absolutely. I tell patients I'm here to help kind of guide your decision and work you through that process. You know, a lot these guys, you know, they had surgery for prostate cancer. They may have had radiation for prostate cancer. They may have had hormones and other treatments out there. And so, the last thing they want to do is think about another operation or another procedure. However, I will tell you these are some of the happiest patients that I get to work with because it truly is life-changing for a lot of them. To go from being able to go out to dinner wearing a diaper to being able to go out to dinner wearing no pads or feel comfortable boarding an airplane, it's truly life-changing for these men.

Host: So actually, anyone suffering from leakage or stress incontinence or any incontinence should really visit a doctor, a urologist like yourself, to figure out what options may be available, because it can really drastically improve your quality of life.

Dr. Ajaydeep Sidhu: I think this is an important thing for a lot of men as they go through this process. And absolutely, you know, we want to help them as much as we can.

Host: You mentioned the followup care that's typically recommended for patients after these surgeries. Is there further followup care as the years move on? Do you follow those patients?

Dr. Ajaydeep Sidhu: I like to keep an eye on people and know how they're doing. You know, our symptoms can change over time. And we focused on stress urinary incontinence during this talk, but other types of leakage or urinary symptoms can certainly be revealed, especially when a man goes from being floridly incontinent to now all of a sudden being continent again. Well, they may find that they have more urgency with the bladder being full again, having gone years without having a full bladder before. And so, it's helpful to identify these things and help patients through that process if new things come up.

Host: Plus, which like a lot of areas of medicine, this is always an evolving field, so we don't know what technology might be available in the next few years that might change what your recommendations may be.

Dr. Ajaydeep Sidhu: Absolutely right. I would say this stuff is definitely cutting edge work that we're doing and it's always changing. And technology is changing and the resources available for our patients are changing. And so, there are treatment options that evolve over time and techniques that evolve over time, especially if somebody is in the group of men that initially does well and then has some residual problems or leakage as the years go on. It's great to know that there are newer things out that work great to help patients.

Host: And it's great to know there are urologists such as yourself who are well-schooled on the latest techniques. Thank you, Dr. Sidhu, for this really insightful conversation on male stress incontinence.

Dr. Ajaydeep Sidhu: Thank you so much for having me, Amanda.

Host: Dr. Ajaydeep Sidhu is a WakeMed urologist. To learn more about WakeMed Urology services and locations, please visit wakemed.org. If you found this podcast helpful, please share it on your social channels. You can check out our entire podcast library for other topics of interest to you. This is WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina.