Urinary incontinence, defined by the International Continence Society as “a condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrable,” is largely seen in our society as a woman’s problem.
And the statistics support that perception. Urinary incontinence is more common in women than men by a 2-1 ratio. However, 18 percent of men are affected by incontinence sometime in their lifetime and should be not ignored.
For this group, their social lives, confidence, activities and even independence can be completely taken away if the condition is not acknowledged and addressed.
Who makes up this 18 percent of the male population? Predisposing factors for male incontinence are an enlarged prostate gland, radical prostatectomy, nerve damage (usually as a result of diabetes or radiation therapy), pelvic surgery, obesity, chronic constipation and poor muscle coordination.
The approximate annual cost of the condition in the United States has been estimated at $11.2 billion in the community and $5.2 billion in nursing homes. It is estimated that $2 million is spent solely on paper products to hide the problem.
Unfortunately, only one out of every 10 men who suffers from incontinence will seek treatment. The consequences of this silence are many and can dramatically affect everyday life from the most basic activities to sexual relationships and physical fitness. For example, it is estimated that of the men who suffer from incontinence, 19 percent discontinue heavy physical activities, 46 percent change their lifestyle/social life, and 50 percent identify incontinence as a major problem.
Men must be educated that incontinence is a side effect to many health-related issues but is something that can be treated successfully. As health care professionals, we need to communicate not only to men, but also to physicians and caregivers, that incontinence is not something that men or women have to accept in their lives.
Types of Male Incontinence
There are three forms of incontinence in men, each with its own symptoms. These include stress incontinence, urge incontinence and neurogenic bladder or overflow incontinence.
Stress incontinence is the most common form. It is characterized by bladder leakage as a result of an increase in abdominal pressure such as a cough, sneeze or laugh. This occurs because an individual’s urethral pressure falls below their bladder pressure resulting in a failure to stop small amounts of urine loss. Those with stress incontinence are usually dry at night.
Urge incontinence is characterized by urine leakage with a strong sudden urge to urinate. An individual’s bladder pressure overcomes their urethral pressure resulting in a “failure to store”–sometimes called the “key in the lock” syndrome. With urge incontinence, it is typical to urinate frequently with low amounts of volume voided and also to wake up frequently at night. Urge incontinence is most common in the elderly and its primary cause is an enlarged prostate.
Overflow incontinence is also a common result of men with enlarged prostates. It refers to a bladder that has been “overstretched” or overworked over the course of many years and has gone untreated. As a result of the sustained, repeated stretch or overwork, when it is time to empty the bladder, it becomes very difficult to do so because the bladder has lost its contraction force to empty as it once had. Another name used to refer to this condition is “floppy bladder.”
Each of these types of incontinence can be linked to prostate cancer, which is the most common male cancer other than skin cancer in the United States. A frequently recommended treatment for the localized disease is radical prostatectomy, which carries long-term morbidity that includes the development of impotence, incontinence or both. Early reports show that 10.3 percent of men have total incontinence after this procedure. More recent studies estimate that up to 57 percent of all patients have some degree of incontinence. Many individuals will regain spontaneous urinary control within one hour of surgery, but some will continue to experience bladder leakage. Even with surgical treatment for the enlarged prostate, up to 25 percent will continue to have incontinence.
The Biology of Continence
The muscles involved with continence are both striated and smooth. Striated muscles are innervated by the voluntary system. They include the obturator internus and the pelvic diaphragm (levator ani). Together these two muscles have in common the arcuate tendon (insertion).
Additional striated muscles include the urethral diaphragm (perineum), the external sphincter and the hip adductor muscles. The smooth muscles are innervated by the autonomic nervous system and include the detrusor (bladder) and the urethra.
Continence is maintained by optimal bladder and bowel position, appropriate intra-abdominal pressure forces, effective muscle action and reflex responses. As the pelvic diaphragm lifts and the obturator internus tightens, it elevates the bladder, urethra and bowel and maintains optimum bladder-urethra angle and rectal angle for continence. It also facilitates the sphincteric action and co-adaptation of the urethra for continence.
There are several possible causes for incontinence following prostatectomy, which include nerve damage/trauma, involvement/disruption of the bladder neck and its thick circular layer of muscle called the sphincter vasicae, and/or disruption of the involvement of the urethra, which passes through the prostate.
Other possible causes for incontinence could be adhesions that can develop post-surgery or the disruption of ligamentous support of the bladder, altering the optimal bladder position.
A feasible alternative treatment for incontinence following prostate surgery is biofeedback. In 1948, Dr. Kegel advocated the use of active exercise of the pelvic floor muscles to enhance urethral resistance, thus improving urinary control. Biofeedback helps individuals locate these muscles and more effectively use exercise to control the problem.
The long-term goals of biofeedback include: a) complete continence; b) normalization of voiding intervals toward every three to four hours, and c) a significant improvement in continence with a reduction in pads worn. The benefits of using biofeedback are many. The procedure is non-invasive, inexpensive, versatile, low risk and encourages independence. It also provides objective data for measurement.
The intervention of biofeedback serves as an adjunct to teaching one how to isolate a contraction of the pelvic diaphragm, which is known as specificity of contraction. It also helps coordinate the pelvic diaphragm contraction with the lower abdominal and/or the additional accessory muscles of obdurate internus and hip adductors. Biofeedback can be carried out with external perineum sensors or with the internal rectal sensor.
Biofeedback creates an image of the target muscle’s activity with the external or internal primary sensor. The activity of the accessory muscle(s) is also available by using an accessory (second) channel with the accessory sensor. In the case of incontinence, the primary sensor is used to train/strengthen the levator ani muscles by showing the patient the immediate activity being generated by the exercise performed. Thus, the individual can practice the exercise technique with immediate feedback and adjust accordingly to maximize the effects of the exercise. The accessory sensor is helpful in identifying inappropriate muscle activity of the abdominal, gluteus or other muscles as well as the appropriate co-contraction.
When the pelvic diaphragm muscles are very weak (2/5 or less) it is often necessary to enlist the assistance of hip adductors/obturator internus and gluteals. The use of accessory muscles is known as coordination of contraction versus isolated pelvic floor contraction known as specificity. Also important in continence and pelvic floor rehab is appropriate lower abdominal contraction, which is referred to as abdominal bracing. It is a goal of the individual to learn the correct lower abdominal contraction versus bearing down when exercising the pelvic floor and with function.
Treatment protocols vary provider to provider but a typical progression involves an initial evaluation, weekly treatment sessions for four weeks, and then a decrease of frequency to one visit every two weeks throughout a six- to eight-visit duration plan. Within the first four weeks of pelvic floor rehabilitation, the changes reported by an individual are attributed to improved motor recruitment–the individual is identifying and using the desired muscles appropriately.
After six weeks of consistent strength training, the muscles will hypertrophy and the improved continence experienced by the individual is truly due to improved strength of the pelvic floor and accessory muscles. To attain optimal strength of the target muscles, the individual is expected to complete a minimum 30 repetitions of exercise. Any additional is a bonus on the way to continence.
In the case of urge incontinence, one not only wants to rehabilitate the pelvic floor diaphragm muscles for the benefits of strength and support of internal organs, but also to educate the individual how to contract the pelvic floor diaphragm to use for deferment of the bladder urge. This occurs via facilitation of Bradley’s Loop #3, a reflex loops of the autonomic nervous system.
The use of biofeedback and pelvic floor diaphragm rehabilitation for continence can provide an individual with a noninvasive method of attaining continence, often without the need for medication. It is inexpensive and encourages self-reliance, however, it does demand compliance.
By Tammy Rolfingsmeier, PT From www.advanceweb.com
Tammy Rolfingsmeier is a physical therapist for SSM Rehab in St. Louis. SSM Rehab is a comprehensive inpatient and outpatient rehabilitation provider and the only not-for-profit acute rehabilitation hospital in the St. Louis metropolitan area. Visit www.ssmrehab.com