Artificial urinary sphincter
This involves having an operation to fit a small device inside you penis to stop urine leaking out. The artificial urinary sphincter is made up of:
• A cuff filled with fluid
• A balloon
• Tubing
• A pump
During the operation the cuff is placed around your urethra and the balloon is placed in front of your bladder. The tubing runs from the balloon and cuff, to the pump. The pump is inserted into your scrotum (sack containing the testicles) and when you need to pass urine you can squeeze the pump in your scrotum several times. This moves the water out of the cuff and into the balloon. When the cuff is empty it will stop pressing your urethra closed, so you can pass urine. After several minutes, the fluid will automatically flow back into the cuff. Once the cuff is full of fluid it will squeeze your urethra closed again
You will normally only have an artificial urinary sphincter fitted if you are leaking a lot of urine regularly, at least a year after treatment for prostate cancer. After the operation around seven out of ten men (seventy per cent) may leak less urine for up to three years but some men will continue to have urinary problems.
One disadvantage of this treatment is that there can sometimes be complications, such as infections or parts of the device breaking. These complications may mean that you will need to have another operation to correct any problems. One study showed that around one in ten men (around ten per cent) had the artificial urinary sphincter taken out because of complications.
Internal slings
If you leak a moderate amount of urine (you need to use two to three pads a day) another option is having an operation to insert an internal sling. An internal sling is a small piece of synthetic material that presses on your urethra to keep it closed and stop urine leaking out. You will normally have the sling inserted under a general anaesthetic.
There are different types of synthetic sling available but all work in a similar way. The aim is that the sling is tight enough to stop urine leaking out, but not so tight that it blocks the flow of urine.
The success of this operation varies but around three to seven out of ten men
(30 to 70 per cent) will have no leaking
urine and will not need to wear pads. Slings may not work as well for men who have severe incontinence or who have previously had radiotherapy.
Like all operations the sling procedure has some risks. Around two to six out of a hundred men (two to six per cent) may need to have the sling removed because it is rubbing on their urethra. Most men experience some pain after the operation. The pain may last for around three to four months. If you are considering having an internal sling you should discuss the possible risks and side effects with your specialist team.
A re-adjustable sling is also available in some treatment centres. After the operation you will either stay in hospital overnight or be brought back into the hospital after 24 hours as an outpatient. This is so that the specialist can adjust the sling to meet your specific needs while you are awake. They will ask you to perform the movements that cause you to leak urine. For example coughing or walking. Your specialist can also readjust the sling in the future if you begin to leak urine again.
Research into the success of this procedure has shown promising results for men who leak a mild to moderate amount of urine but this procedure is not available everywhere.
Bulking agents
This involves injecting a gel such as silicone into the tissue around your urethra or bladder neck. This will make the tissue thicker and keep the opening of the urethra and bladder closed to prevent leaks. This can normally be done under a local anesthetic and takes around 15 minutes. One study showed that using bulking agents can be useful for men who only leak a small amount of urine. If your urinary problems are more severe then other treatments might work better. If you have had a radical prostatectomy then you may not be able to have an injection of bulking agents into your bladder neck, as it may be scarred.
What if I dribble after I finish
passing urine?
Losing a few drops of urine after you have finished passing urine is common in men of all ages, but is more likely to happen if the pelvic floor muscles are weak. Many men find that even after waiting and shaking the penis, a very small amount of urine will leak out afterwards. This may happen if the urethra has not emptied completely and a small pool of urine gets left behind.
After you have finished passing urine try tightening your pelvic floor muscles once for several seconds or tightening and releasing them a few times. This will push the urine out of the urethra and help to stop the dribbling.
Alternatively, after you have finished passing urine, wait a few seconds and then use your fingertips to press gently behind the scrotum. Move your fingers forward toward the base of the penis under the scrotum and keep pressing gently. This should push the urine further along the urethra. You can then shake the last few drops out in the normal way.
What if I pass urine frequently and
with little warning?
Some men find that they need to pass urine more often and that they have a sudden urge to go to the toilet that is difficult to ignore. Sometimes they may leak before they get there. This may mean that your bladder wants to squeeze out urine, even if it not full and you are not ready.
There are a number of things you can do to reduce or relieve your symptoms:
• Avoid drinks that might irritate the bladder such as fizzy drinks, caffeine and alcohol.
• Keep drinking enough liquid (two litres or three to four pints per day). Do not reduce your fluid intake as this can make symptoms worse.
• Pelvic floor muscle exercises may help
(see page 4).
• Bladder retraining (see below).
If you need to urinate frequently and notice that your urine is cloudy, smells or stings, you may have a urine infection and should
go and see your GP.
Bladder retraining
Your bladder should normally be able to hold between half a pint and a whole pint (250-500ml) before you need to go to the toilet. Most people first feel that they need to pass urine when the bladder is about half full. They are then usually able to hold on until the bladder is fuller and there is a convenient place to go.
Bladder retraining aims to help you hold back or ignore the strong feelings of wanting to go to the toilet when the bladder is not full. This helps you to regain control over your bladder by reducing the number of times you need to pass urine and helping you hold on for longer. If you leak urine because you cannot get to the toilet in time, bladder retraining can also help reduce or stop this.
The following steps may help you:
1 Keep a record of how often you go to the toilet and how much urine you pass eachtime. You should keep this record for at least three days. You should also note how much warning you get before any urine leaks out.
2 You can use this information to start your own bladder retraining plan. For example, if you can hold on for two minutes before urine leaks out then you need to train your bladder at this starting point. So when you get the first feelings that you need to pass urine, try holding on for two minutes. It is important not to start holding on from when the feelings have become too urgent as this could lead to you wetting yourself.
3 Practice holding on every time you need to pass urine, this will help get your bladder into a new routine.
4 When you get the urge to pass urine try doing a long slow contraction of your pelvic floor muscles. Sitting on a hard surface may help as this gives support to these muscles. You could also try distracting yourself with a book or the television. When it is time to go to the toilet try and walk slowly. Rushing may make your pelvic floor muscles sag and urine may be more likely to leak out.
5 When you are able to hold on for two minutes each time you need the toilet, for three days in a row, try increasing this time by one minute.
6 Continue increasing the ‘hold’ time until you can hold on for 15 minutes. This can take some time, so try not to rush things.
Bladder retraining is not about holding on for as long as you can. Not all men will be able to hold on for as long as 15 minutes. Bladder retraining should be able to help you find a time scale that works for you and means you are not going to the toilet quite so often.
It can take time to retrain your bladder. Keep
a record whilst you are doing this so that you can see your progress. Some people find it easier to do bladder retraining with the help
and support of a continence advisor or specialist physiotherapist.
Other treatments
In some cases drug treatment may be effective. There are drugs available called anti-cholinergics which can reduce frequency, urgency and leaks. They can take up to a few weeks to work. These tablets can cause side effects including a dry mouth, headaches, constipation and dizziness. If the drug you are prescribed causes side effects you can discuss alternatives with your specialist team.
In rare cases, some men might need surgery. This involves adding a piece of bowel to the bladder to increase its size and make it more stable. Another relatively new treatment involves injecting botox into the wall of the bladder to stop it contracting before it is full.
What if I get up to pass urine many times at night?
If you are bothered by having to get up to go to the toilet a lot at night, try cutting down on any drinks in the last two hours before you go to bed, particularly any alcohol, coffee or tea. Bladder retraining may help, but you will need to train your bladder in the daytime before you work on any problems with urinating at night. Read page 6 for information on bladder retraining. If you have swollen legs, you may find that you pass more urine at night. This is because the body reabsorbs the fluid held in your legs when you lie down. Try putting your legs up whenever you can during the day. If this does not work, consult your specialist team. They may suggest a diuretic pill, to stimulate urine production during the day.
What if I have problems emptying
my bladder?
You may not be able to empty your bladder because your urethra is very narrow. Prostate cancer, treatments for prostate cancer or other prostate problems such as benign prostatic hyperplasia (BPH) can cause narrowing of the urethra.
If you have a sudden and painful inability to pass urine (acute retention) you will need treatment straight away, usually at a hospital. You should contact your specialist team as soon as possible. They may need to drain your bladder using a tube (catheter). The catheter is either passed through your penis into the bladder or through your abdomen into your bladder (suprapubic catheter).
Some men may be able to pass some urine but leave increasingly large amounts of urine behind in the bladder (chronic retention). The first signs for some men include leaking urine, wetting the bed, an expanding waistline or increased urine infections.You may find that your bladder still feels full after passing urine or notice that your stream is weak.
You should let your specialist team know if you are having any of the problems described above. Chronic retention is usually painless but it means that you are not passing all of the urine that is in your bladder. Your bladder slowly stretches as it tries to cope with the pressure of the urine which can weaken the bladder muscle. The urine left in your bladder may cause an infection or bladder stones. Without treatment, the build up of urine can overwork the kidneys and cause them to fail.
If your bladder is not emptying because of a narrowing of the urethra, your doctor may prescribe tablets called alpha-blockers which can help to relax the muscles around the prostate or the neck of the bladder. Sometimes a small operation can help. This works by either stretching the narrow area or by removing some excess prostate tissue, depending on the cause of the problem.
If you do not want an operation or your doctor does not recommend tablets or an operation, you may be shown how to self-catheterise. This involves passing a fine, hollow tube (catheter) up through the penis into the bladder to drain the urine. Your specialist nurse will show you how to do this and advise how often it is necessary to do it.
