05 August 2022
Urinary incontinence significantly compromises heath-related quality of life and when conservative measures fail can be improved by surgical treatment. This includes the male sling (bulbar urethral sling), and the artificial urinary sphincter (AUS). These procedures prevent involuntary urinary loss by increasing resistance to flow at the bladder exit (bladder neck).
How do we usually remain dry?
Urinary continence in the male depends on a compliant and contractile bladder body, functional urethra, the bladder neck (surrounded by a muscular sphincter – internal sphincter), prostate and most importantly an external sphincter (below the prostate and surrounding the urethra).
[See previous blog on anatomy of the prostate: BLOG: Why is the tap still on? - PCFA Online Community]
Why does incontinence develop?
The main reason is due to failure to store urine as a result of inadequate resistance of the bladder outlet sphincter. After a radical prostatectomy intrinsic sphincter deficiency (ISD) occurs as a result of incompetence of the external sphincter.
Associated bladder dysfunction such as reduced compliance or overactivity of the muscle in the bladder wall, may complicate or confound the diagnosis and management of incontinence requires careful evaluation.
So what is the next step?
The initial evaluation will include detailed questioning by your doctor, a physical examination, a urine test and blood tests. At some point there will be a camera check with a flexible tube passed up the urethra (cystoscopy). A urination test to measure flow (UroFlow) may be performed and some may be required to do a urodynamics test to evaluate for potential bladder neck contracture (blockage) and assess bladder storage function.
What will your urologist ask you in a consultation?
This will include the type, degree, and severity of incontinence; previous surgical procedures; and any symptoms of neurologic disease. Differentiation between stress and urge incontinence is important and can be aided by a voiding diary (where you record your intake and urine output) and an incontinence pad test, simple inexpensive assessments of that are recommended before proceeding with invasive testing. The voiding diary reliably assesses the number of incontinent episodes and may uncover significant urgency and urge incontinence (the immediate need or desire to urinate which may or may not be associated with leakage of urine). Another more objective measure is the 24-hour pad weight test, which measures the magnitude of the incontinence and may be helpful in directing appropriate therapy.
What does the physical examination involve?
A complete examination of the abdomen, back, genitalia, perineum, rectum, and occasionally the neurologic system. The skin is looked at for signs of infection from ongoing leaking urine which may require treatment before any surgery is considered.
Which laboratory tests are important?
Urine is analysed for infection as any infections must be treated prior to surgical correction. Kidney function is assessed with a blood test and a PSA test ensures there is no cancer recurrence.
It is essential to do this procedure as any blockage in the urethra (urine pipe between the bladder and end of penis) will complicate the success of the sling procedure. It also determines whether a sling is more appropriate than an artificial urinary sphincter.
A urinary catheter is placed in the urethra and a small tube in the rectum. In this way bladder capacity and function can be adequately assessed. If the bladder doesn’t function properly and generate enough pressure to overcome the resistance created by a sling the procedure will be unsuccessful.
Who qualifies for the male sling?
All people with irreversible intrinsic sphincter deficiency and mild incontinence (defined as a 24-hour pad weight of less than 150 grams) and bothersome involuntary leakage of urine.
After prostatectomy, all men should undergo a course of pelvic floor muscle exercise. Because progressive improvement in continence occurs after surgery, many urologists recommend a 6–12 month observation period. In those with severe or gravitational incontinence who show no improvement beyond 6 months and particularly if cystoscopy shows a significant external sphincter defect an earlier sling procedure may be prudent.
The decision is made jointly with the patient and the following factors are considered:
- the severity of incontinence and degree of bother
- patient characteristics, including prior surgical procedures, bladder function, and cystoscopic findings
- efficacy of the various implants
- long-term risk of complications and reoperation
The procedure will not be done under the following conditions:
- Bladder disorders which could lead to kidney failure
- Poor quality of internal tissues surrounding the bladder neck or urethra to accommodate a sling (after certain types of radiation)
- Active prostate cancer disease
- Bladder cancer in addition to prostate cancer
- Evidence of urethral erosion
Blockages of the urethra (strictures or bladder neck contractures) if present may have to be treated first before a sling is considered. If they can’t be fixed then a sling may not be possible.
How does it work?
The transobturator sling augments sphincteric function by repositioning and lengthening the membranous urethra. The significant tensioning required during sling placement suggests that compression of the urethra may play a role in the function of the transobturator sling as well.
The surgery is done under general anaesthesia and takes a couple of hours to complete (nothing like the original prostate removal). There may be a small scar in the perineum. One usually stays overnight with a urinary catheter that gets removed the next day before discharge home. Most patients make a fairly quick recovery with rapid return to normal function.
The most commonly reported complications of male slings include pain in the perineum, inability to urinate, infection, and in rare cases erosion of the sling into the urethra. The benefit of a sling over an artificial sphincter is that they impart outlet resistance without occlusion of the urethra with a cuff, potentially reducing the risk of erosion and mechanical failure of a pump.
How effective is it?
A transobturator sling introduced by Boston Scientific (AdVance) has been shown to be effective in short-term follow up of well-characterized case series. In these highly selected populations, approximately 85% of patients are cured or significantly improved, with results persisting at 12 months. Seventy seven percent of patients reported to be satisfied at 5 years using the Patient Global Improvement Indices score. There appears to be less success and satisfaction in those with previous pelvic radiotherapy and incontinence surgery or urethral stricture surgery.
Post prostatectomy stress urinary incontinence does not have to negatively impact ones quality of life because where conservative measure fails there are always surgical options available.
1. Montorsi F et al. How to prevent and manage post-prostatectomy incontinence: A review. World J Mens Health 2021; 39(4): 581-597
2. McCammon et al. Long term success durability of transobturator male sling. Urology 2019; 133:222-228.
View webinar recording by Australian Functional Urologist Professor Vincent Tse speaking about the various treatment options available for post-prostatectomy incontinence: Urination troubles after surgery - prostate cancer - YouTube
Register for the next webinar on urinary incontinence (24/09/22) with Sydney Based Urologist Amanda Chung and functional urologist, Professor Kurt McCammon from Virginia, USA. Register here.
For more information on the male sling (bulbar urethral sling), and the artificial urinary sphincter (AUS) visit Men’s Health Treatments.
About the Author
MBBCh, FC Urol (SA), MMed (Urol), Dip.Couns (AIPC)
Kalli is an internationally renowned Urological Surgeon, specialising in oncology and robotic surgery. He trained and worked in South Africa, before relocating to Australia where he has worked at Macquarie University Hospital and Westmead Hospital. His passion for what he does extends beyond the operating room, through public health advocacy, education and community awareness of men’s health, cancer and sexuality.
Kalli has been involved with the Prostate Cancer Foundation of Australia for many years, advocating for improved cancer care and facilitating community prostate cancer support groups.