1. Incontinence and Prostate Cancer John C. Hairston, MD Associate Professor of Urology Integrated Pelvic Health Program Northwestern Feinberg School of Medicine

2. “The objective demonstration of involuntary loss of urine consequent to bladder and/or sphincter dysfunction.” The International Continence Society Ballanger P et al. Female Urinary Incontinence. Eur Urol 1999; 36:165-174. What is urinary incontinence?

3. Types of incontinence Stress Incontinence –Leakage during physical activity that increases intraabdominal pressure, i.e. lifting, exercising, sneezing, and coughing Urge Incontinence –Leakage associated with an overwhelming need to urinate Gotta go, gotta go! Mixed Incontinence –Combination of the above –Hunskaar et al. One hundred and fifty men with urinary incontinence. Scand J Prim –Health Care 1993; 11:193-196.

4. How does the process work? Bladder collects urine The sphincter - a circular muscle at the level of the prostate - controls the flow of urine The sphincter muscle wraps around the urethra A healthy sphincter stays closed until one relaxes it to urinate

5. Why am I incontinent? Prostate cancer treatment –Radical Prostatectomy –Radiation –Cryotherapy Other pelvic surgery or trauma Spinal disease Neurologic disease

6. Am I the only one with incontinence? 55 million men in the world suffer from loss of urinary control AMS 2003 Annual Report Campbell’s Urology 2002 8 th Edition NO!

7. Male Incontinence Rate of incontinence ranges between 2.5% up to 69% after prostate cancer treatment Risk factors Degree of nerve sparing Postoperative bladder neck contracture Combination/Adjuvant treatment Presence of prior disease (stricture, etc) Salvage therapy

8. Male Incontinence Post-prostatectomy - Often improves within 3-6 months - 5-8% of men require treatment beyond conservative measures Radiation - Often a late complication - Difficult to predict - Probably improving with improved directed therapies

9. Why treat incontinence? Avoid negative feelings embarrassment, discomfort, isolation, anger and depression Return to usual lifestyle Regain dignity Resume intimacy Save money on protective garments Improve quality of life

10. 150 men reported the practical inconveniences associated with incontinence: 52% Extra laundry 37% Smell 17% Extra expense 12% Skin irritation 11% Disturbed sleep Source: Hunskaar s, Sandvik H. one hundred and fifty men with urinary incontinence. Scand J Prim Health Care 1993 v. 11 p.193-196 Why treat incontinence?

11. What to expect at an office visit History –Spinal or neurologic disease –History of BPH (Enlarged Prostate) Physical Exam –Neurologic exam Urinalysis Postvoid Residual 24 hr pad testing * Urodynamics, Cystoscopy

12. Management options Pads/diapers Medication Devices

13. Pads/diapers What do men know about pads?!? More absorbent and less irritating than other paper products Pads vs diapers –“Maxi” vs. “Mini” pads

14. Devices: Clamps –Cunningham clamp, C3-clamp –Advantages Non-medical, non-surgical Easy to use Works well –Disadvantages Bulky Pressure necrosis Generally not a turn on

15. Devices: Catheters –External vs. Internal –Advantages Works –Disadvantages Attached to a bag Increased risk of infection

16. Medication No FDA approved medication for stress incontinence in men (or women) Antidepressants You may be a candidate for anticholinergic medication –Overactive bladder component

17. Treatment options Behavioral modification Biofeedback Injectables Surgery

18. Behavioral modification Decrease fluid intake Void frequently Avoid caffeine, alcohol Avoid activity that increases intraabdominal pressure

19. Pelvic floor rehabilitation a.k.a. biofeedback Means of teaching Kegel exercises Objective way to measuring pelvic floor strength ? how much better than verbal instruction

20. Bulking agents Collagen, carbon beads, autologous fat Success rates for collagen ~ 17%-38% after prostatectomy Most recent International Consultation on Incontinence regarded this treatment as showing only modest benefit Poor surgical candidates with minor degrees of leakage Klingler HC et al. Incontinence after radical prostatectomy: surgical treatment options. Curr Opin Urol 2006; 16:60-64.

21. Surgical options for male stress incontinence Male Sling Artificial Urinary Sphincter

22. Male Incontinence Severity Level Guidelines Onur R, Rajpurkar A, Singla A. New perineal bone-anchored male sling; Lessons learned. Urology Jul 2004 v. 64 (1) p.58-61

23. InVance™ Male Sling Effective treatment for mild to moderate incontinence Minimally invasive, 45± minute outpatient procedure Continence is immediately restored Nothing to operate Device is completely hidden inside the body 88% satisfaction rate 1 1 Onur R, et al. Efficacy of a new bone-anchored perineal male sling in intrinsic sphincter deficiency. International Incontinence Society. Oct. 5-9, 2003. 33rd annual meeting, Florence, Italy. Abstract 399.

24. InVance™ Male Sling Sling creates gentle compression on the urethra for urinary control Procedure: –Spinal or general anesthesia can be used –Small incision under the scrotum –Miniature titanium screws placed into the pubic bone on each side of the urethra –Sling positioned to exert gentle pressure on urethra –Sling secured to screws –Incision closed

25. AdVance™ Male Sling a new, innovative treatment option Innovative treatment for mild to moderate incontinence Minimally invasive, fast outpatient procedure Continence is immediately restored Nothing to operate Device is completely hidden inside the body

26. AdVance™ Male Sling Sling restores urethra to its proper anatomical position for optimal sphincter function, restoring urinary control Procedure: –Spinal or general anesthesia can be used –Three small incisions: 1 under the scrotum, 2 over groin creases –Specially designed surgical tools are used to position the sling –Sling is gently tensioned –Incision closed

27. AdVance™ Male Sling

28. Virtue™ Male Sling

29. Artificial Urinary Sphincter (AUS) over 100,000 implanted since 1972 Litwiller SE, et al. Post-prostatectomy incontinence and the artificial urinary sphincter; a long- term study of patient satisfaction and criteria for success. J of Urol 1996; 156:1975-1980. The Gold Standard for treatment of moderate to severe incontinence 60± minute outpatient procedure 92% of patients would have the device placed again 96% of patients would recommend it to a friend Device is placed completely in the body, providing simple, discreet control

30. Animation of Artificial Urinary Sphincter

31. Sling Appropriate for treatment of mild to moderate incontinence 70-85% success rates 45-60± minute outpatient procedure Transient scrotal/penile and perineal pain Passive Favorable 2 year data (durability?) Complications Infection and Erosion ( < 2%) Reoperation rate (unknown?) The Gold Standard for treatment of moderate to severe incontinence (85-95% success) 60± minute outpatient procedure Catheter for 23 hours Transient scrotal/penile and perineal pain “Active” Over 30 year track record of durability Complications Infection and Erosion (5-10%) Approx 15% require revision surgery over a 10-15 year period AUS

32. What should you do next? See your Urologist! Come prepared with questions Discuss your treatment options Your lifestyle and medical condition are important factors Ask if you can speak to one or more of his/her satisfied patients

33. Summary Incontinence is a common problem Most cases resolve within 6-12 months Some treatments are more effective than others Surgical treatment options offer proven, long-term solutions Talk to your Urologist – talk to your partner Podcast at NMH.com –http://www.nmh.org/nm/ihealth-mens-health –http://www.patientpower.info/health- topic/prostate-cancerhttp://www.patientpower.info/health- topic/prostate-cancer For copies of this talk –Sara Steinkamp –s-steinkamp@northwestern.edu

34. Thank You