Incontinence is a condition that can be treated in various ways. But what are the types of the condition and what can be done?
Developments in prostatectomy technology and continence-preserving surgery have led to significant improvements in saving critical structures in the prostate that may not have been possible in the past. Skilled urologist Mr Philip Charlesworth provides a guide to urinary incontinence and state-of-the-art ways to treat it.
In a man, urine is retained and thus stored in the bladder by the contraction of the urinary sphincter. This sits below the prostate, is supported by numerous structures above and below it, and works in conjunction with the pelvic floor muscles. Small nerves that pass close to the prostate, control its function.
The bladder itself is a muscular ball that slowly fills as urine passes to it from the kidneys. In this filling - or storage - phase, the bladder muscle is usually relaxed and the urinary sphincter is contracted. Pressure-sensing nerves in the bladder send signals to the brain that it is getting full and it’s time to go to the toilet. Urine will flow out when a man relaxes his urinary sphincter and contracts his bladder when at the urinal/toilet.
What are the causes of incontinence?
Leakage or incontinence of urine is usually caused by three mechanismsꓽ
Overflow incontinence is where the bladder lacks the pressure-sensing aspect, or the musculature power to empty. It becomes overfull and as the pressure rises, it goes above the ability of the urinary sphincter's power to keep it inside and it leaks out. It most common for this to occur when you are sleeping at night.
If this is left untreated, it can lead to kidney failure because of the high pressure being transmitted to the kidneys so it’s important to seek medical advice if this is the case.
Treatment usually involves ways to decrease the pressure in the bladder (which can be catheters), with a view as to whether prostate surgery would be enough to relieve the extent of pressure that’s needed for the emptying of the bladder.
Urge incontinence is where the bladder muscle twitches, or spasms during the filling/storage phase, when it should be relaxed. Leaking or incontinence of urine can occur because the sudden contraction of the bladder muscle can cause an increase in pressure and force the urine through the closed sphincter. These sudden spasms may be secondary to a blockage from the prostate gland which is essential to bladder function, other drugs such as caffeine or a combination of all three.
Treatment of urge incontinence depends on the cause so a diagnosis needs to be made by a urologist. They can then advise which optionꓼ lifestyle modification, medications, intravesical Botox or surgery, is the most appropriate.
Stress incontinence is where there, most often during surgery to the prostate, there is impairment to the nerve supply, muscle or supporting structures of the urinary sphincter.
Surgical removal of the prostate (radical prostatectomy) is a common treatment for localised prostate cancer. In removing the whole prostate gland (with the cancer contained within), damage can occur to the nerve supply to the sphincter, to the muscles of the sphincter/pelvic floor and the sustaining ligaments and structures around the sphincter.
Treatment for this will involve intensive specialist pelvic floor physiotherapy, including the Emsella chair. Surgical intervention, such as bladder neck bulking agents, urethral slings, balloon occlusion devices and ultimately, artificial urinary sphincters, can be considered if progress is insufficient. Enabled by advancements in robotic surgical systems, there have been many advances in prostate cancer surgery over years.
What is the retzius sparing robotic prostatectomy technique?
Continence-preserving surgery has been a passion of mine for many years and I have been one of the pioneers of the Retzius sparing robotic prostatectomy technique. The technique approaches the prostate and urinary sphincter from below, which leads to preservation of critical supporting structures above, along with the nerves and pelvic floor muscles. This has allowed urinary incontinence post-radical prostatectomy to become largely a thing of the past for my patients.
Mr Charlesworth provides a leading urology service in Reading, London and Windsor. If you have concerns about any related condition, you can get in touch with him via his Top Doctors profile here.