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Urinary Incontinence In Men

Humza Khizer

Overview

A common health condition, urinary incontinence refers to an uncontrollable leaking of urine. 
Urinary incontinence in men not only affects their physical health but also affects their mental, emotional, social, and economic wellbeing.

According to the collected data, it is estimated that around 3.4 million men in the United States have urinary incontinence<a href="#accordion">[2]</a>.

Even though urinary incontinence (UI) affects twice as many women as men, the probability that it will develop in men as well increases with age<a href="#accordion">[3]</a>. This is because the muscles responsible to provide support to the bladder lose their strength and cause urinary incontinence. 
&nbsp;

Furthermore, UI is caused by multiple health conditions as well and can indicate cancer, kidney stones, infection, or enlarged prostate.

According to a study, in Pakistan, it was seen that 2.4% of the male participants had an overactive bladder<a href="#accordion">[9]</a>. 
&nbsp;

Moreover, according to a study carried out among community-dwelling men, the prevalence of one episode of urinary incontinence increased with age &ndash; from 5% among 19-44-year-olds to 11.2% among 45-64-year-olds to 21% in men older than 65 years. It has also been reported that the prevalence is higher in men who live in nursing homes<a href="#accordion">[10]</a>.

UI has proven to cause hindrance in an individual&rsquo;s day-to-day routine which, in turn, can lead to accidents. That&rsquo;s why it is crucial to reach out to the doctor at the earliest because they may be able to look out for the root cause that can be life-threatening, too<a href="#accordion">[3]</a>. 
&nbsp;

There are multiple types of UI: 
&nbsp;

<ol>
	<li>
	<h5>Urgency Incontinence</h5>
	</li>
</ol>

The urgency incontinence variant of the disease is often referred to as an &ldquo;overactive bladder&rdquo; or OAB. The characteristic feature of this type is a sudden, strong, and urgent need to pee<a href="#accordion">[4]</a>.

One condition is that the brain instructs the bladder to empty itself, regardless of the amount of urine present in it, whereas another condition would be that the muscles of the bladder start contracting and the individual inevitably leaks urine even though they don&rsquo;t have a full bladder. 
&nbsp;

<ol start="2">
	<li>
	<h5>Stress Incontinence</h5>
	</li>
</ol>

Stress incontinence refers to a condition when the urine leaks as soon as the person feels some sort of pressure on their bladder. Day-to-day conditions that may cause this leaking to include coughing, sneezing, laughing out loud, walking, lifting heavy objects, and exercising<a href="#accordion">[4]</a>. 
&nbsp;

<ol start="3">
	<li>
	<h5>Overflow Incontinence</h5>
	</li>
</ol>

Overflow incontinence is the most common type that occurs in men. The pathology behind this is that the bladder empties inefficiently. This leads to an overfilled bladder that causes leakage<a href="#accordion">[4]</a>. 
&nbsp;

<ol start="4">
	<li>
	<h5>Functional Incontinence</h5>
	</li>
</ol>

Functional incontinence refers to a condition when the person has a pre-existing medical condition that makes it difficult for them to move. As a result, they&rsquo;re unable to reach the toilet in time to avoid leakage<a href="#accordion">[4]</a>. 
&nbsp;

<ol start="5">
	<li>
	<h5>Mixed Incontinence</h5>
	</li>
</ol>

If more than one type of incontinence exists simultaneously, it means the individual has mixed incontinence. For example, stress incontinence can occur at the same time as urgency incontinence<a href="#accordion">[4]</a>. 
&nbsp;

Signs and Symptoms

The signs and symptoms of urinary incontinence include:

<ul>
	<li>An uncontrollable and urgent need to urinate, especially when hearing the sound of running water or when feeling cold</li>
	<li>Being unable to hold in urine after a sudden, strong urge to urinate</li>
	<li>Unintentional leakage, especially during everyday activities like sneezing, changing position, or lifting something heavy</li>
	<li>Leakage without any urge or warning</li>
	<li>Passing urine while sleeping (nocturia)</li>
	<li>Waking up more than once during the night to pass urine</li>
	<li>Bedwetting</li>
	<li>Leaking during sexual activity, especially during orgasm</li>
	<li>Urinating frequently, i.e., more than 8 times a day</li>
	<li>Having difficulty starting urine flow, often straining</li>
	<li>Discomfort while urinating</li>
	<li>Feeling as if the bladder is full despite passing urine</li>
	<li>Slow stream of urine</li>
	<li>Pressure in the lower abdomen</li>
	<li>Total (severe and continuous) or transient (temporary) incontinence</li>
	<li>Dribbling or constant dripping from the urethra 
	&nbsp;</li>
</ul>

NOTE: In some cases, incontinence is a medical emergency. Seek medical help if you or a loved one presents with loss of consciousness, confusion, tingling or weakness in any part of the body, loss of bowel control, and trouble speaking or walking<a href="#accordion">[3]</a>. 
&nbsp;

Causes

Symptoms can range from mild to severe, especially if UI is due to an underlying health issue<a href="#accordion">[3]</a>:

<ul>
	<li>Chronic cough</li>
	<li><a href="https://merisehat.pk/disease/constipation">Constipation </a>or hard stool present in the rectum</li>
	<li><a href="https://merisehat.pk/disease/obesity">Obesity</a></li>
	<li>Urinary tract infection</li>
	<li>Certain medicines, including blood pressure drugs, sedatives, muscle relaxants, and some heart medications</li>
	<li>Added stress on the sphincter muscle</li>
	<li>A hindrance, such as a kidney or a bladder stone, in the urinary tract</li>
	<li>Narrow urethra due to an injury, infection, or swelling</li>
	<li>Weakened bladder muscles</li>
	<li>Hypertrophic (enlarged) prostate</li>
	<li><a href="https://merisehat.pk/disease/benign-prostatic-hyperplasia">Benign prostatic hyperplasia (BPH)</a></li>
	<li>Inflammation of the prostate (prostatitis)</li>
	<li>Inflammation of the bladder (interstitial cystitis)</li>
	<li>Prostate or bladder cancer</li>
	<li>Cognitive issues like Alzheimer&rsquo;s</li>
	<li>Neurological issues like stroke</li>
	<li>Muscular issues like arthritis</li>
	<li>Excessive alcohol or caffeine consumption</li>
	<li>Smoking</li>
	<li>Surgery on any part of the urinary tract or genitals</li>
	<li>Prostate surgery</li>
	<li>A recent bowel (intestinal) surgery</li>
	<li>A lower back surgery 
	&nbsp;</li>
</ul>

There are no such screening tests available for urinary incontinence in men. 
&nbsp;

Diagnosis

Diagnosis may include one or more of the following investigations<a href="#accordion">[5]</a>: 
&nbsp;

<h5>Patient History</h5>

A thorough history is essential to the evaluation of urinary incontinence. The clinical presentation of urinary incontinence, based on frequency, severity, and amount of debilitation is different for everyone.

It&rsquo;s understandable if the patient appears reluctant to initiate discussions about incontinence. Therefore, doctors can ask forced questions of patients, especially those older than 65 years. It is best to avoid nonspecific terms such as urge or nocturia, as they may have different meanings for different patients.

These questions will pertain to the patient&rsquo;s family history, medical history, the drugs they&rsquo;re taking, the kind of symptoms they&rsquo;re experiencing, how long they&rsquo;ve been experiencing it, and how UI has affected their quality of life. 
&nbsp;

<h5>Bladder Diary</h5>

Patients are also asked to maintain a bladder diary for at least 3 days. This means taking note of how often they go to the bathroom and other day-to-day symptoms. It helps keep a track of:

<ul>
	<li>What, when, and how much fluid does the patient drink</li>
	<li>When and how much the patient urinates</li>
	<li>When and how much urine leaks</li>
	<li>When and how often the patient experiences the &ldquo;urge&rdquo; to go 
	&nbsp;</li>
</ul>

The bladder diary informs the doctor about the patient&rsquo;s habits, their urinary symptoms, and the extent to which UI affects their life &ndash; all of which are important for the doctor to assess the cause of the bladder control problem and provide proper treatment. 
&nbsp;

<h5>1.&nbsp; Physical Examination</h5>

A complete physical examination can help the healthcare provider to order further investigations in a relevant direction. The doctor will also ask the patient to cough, laugh, sneeze, or exercise while their bladder is full to check if they leak urine (stress test).

They will also administer a rectal examination to check if the prostate is larger than it should be or if there is hardened or impacted stool present in the rectum. 
&nbsp;

<h5>2. Diagnostic Tests 
&nbsp;</h5>

<ul>
	<li>A Sample Of Urine is taken to check for blood, protein, sugar, or sign of infections. A urine culture and urinalysis can also show if a man has prostatitis.</li>
	<li>A Blood Sample is collected to assess for problems with the prostate or kidney, or even if there&rsquo;s a chemical imbalance.</li>
	<li>An Ultrasound Of The Bladder or a catheter can help the doctor assess how much urine is left in the bladder after the patient has urinated into a container that measures urine output. A large post-void residual means the patient is having difficulty emptying their bladder.</li>
	<li>A Pelvic Ultrasound checks for abnormalities in the urinary tract or genitals.</li>
	<li>A Cystourethrogram is an X-ray of the bladder as well as the urethra while the patient is urinating</li>
	<li>An EMG or electromyogram is used to record the electrical activity of muscles. 
	&nbsp;</li>
</ul>

<h5>3. Cystoscopy</h5>

An endoscope (a thin tube with a camera attached to it) is inserted into the urethra and bladder to identify any abnormal changes in the structure that can be causing incontinence. It&rsquo;s a series of tests that measures bladder pressure at multiple levels of fullness. 
&nbsp;

<h5>4. Urodynamic Study</h5>

It&rsquo;s a stress test for the bladder. A catheter is placed inside the urethra and another catheter is placed in the rectum. Then, electrodes are attached to the pelvis. The patient&rsquo;s bladder is filled with warm saline water to assess how well it functions. When the patient urinates, the strength of the stream and bladder function are measured again. It shows if the bladder can store urine normally, if it&rsquo;s oversensitive, or if it&rsquo;s working too hard to empty. 
&nbsp;

Treatment

The recommended course of action largely depends on what is causing UI. Medication, surgery, or further interventions can be used to treat an underlying medical condition<a href="#accordion">[3]</a>: 
&nbsp;

<ul>
	<li>Pelvic Floor Muscle Exercises: Kegel exercises strengthen the pelvic floor muscles, thereby, tightening and relaxing the muscles that control urine flow. This is especially useful if the patient complains of dribbling after urination. 
	&nbsp;</li>
	<li>Absorbent Undergarments: Smaller leaks may be contained by using absorbent undergarments, such as reusable or even disposable underwear. Absorbent padding can also be worn over the penis, held in place by close-fitting underwear, to deal with dribbles. 
	&nbsp;</li>
	<li>Catheter Placement: The doctor can recommend an internal or external catheter to help manage overflow incontinence or, in some cases, functional incontinence if it is persistent and negatively affecting the patient&rsquo;s quality of life. The catheter is removed once the urine empties. 
	 
	There are several different types of urinary catheters, which are inserted and used in different ways, including intermittent, indwelling, and suprapubic catheters. An indwelling catheter (also known as a Foley catheter) is a preferred alternative, but it may result in urinary tract infections. The condom catheter increases the risk of UTIs and skin irritation with prolonged use, hence, it&rsquo;s not encouraged for long-term use. 
	&nbsp;</li>
	<li>Reducing Hurdles To The Bathroom: Consider keeping a straight and well-lit pathway to the toilet, especially at night, for nighttime or urge incontinence. This will help get there as quickly as possible, avoiding leakages. For functional incontinence, installing a bedside commode or elevated toilet seat can be considered. 
	&nbsp;</li>
	<li>Lifestyle Changes: Since caffeine increases the amount of urine produced by the body, it&rsquo;s best to reduce its consumption. This is in addition to changing the overall amount of fluid intake in a day &ndash; drinking too little or drinking too much will aggravate symptoms, especially in case of stress incontinence. So, follow the doctor&rsquo;s advice on this. 
	 
	Moreover, it&rsquo;s important to stay a healthy weight and not become overweight or obese to avoid placing unnecessary pressure on the bladder. Regular exercising and healthy eating help! Avoid spicy and acidic foods and carbonated drinks because they irritate the bladder as well. 
	 
	Work with a doctor to gain confidence to pursue hobbies, like exercising, hiking, and gardening, which all appear daunting with UI. Similarly, sexual activity can also be troublesome; remember communicating with your partner is key. 
	&nbsp;</li>
	<li>Electrical Stimulations:This is only recommended if the person is unable to contract their pelvic floor muscles. A small probe is inserted into the anus and an electrical current is run through it to strengthen the pelvic floor muscles during exercise. Usually, gentle electrical stimulation can be relieving for urge and stress incontinence. However, multiple treatments are required. 
	&nbsp;</li>
	<li>Condition Management:Treating the underlying disease that is causing urine incontinence, such as constipation or a UTI, may also help with urinary incontinence. 
	&nbsp;</li>
</ul>

Depending on the cause of bladder incontinence, the doctor may prescribe medication. These include:

<ul>
	<li>Alpha-Blockers (e.g., tamsulosin, silodosin, alfuzosin, and doxazosin) for urge or overflow incontinence.&nbsp;</li>
	<li>Anticholinergics (e.g., solifenacin, oxybutynin, fesoterodine, trospium chloride, tolterodine, and darifenacin) are effective for urge incontinence and overactive bladder.</li>
	<li>Mirabegron can treat urge incontinence. 
	&nbsp;</li>
</ul>

NOTE: Depending on the medication, some of the potential side effects include nausea, hypertension, fatigue, constipation, and dry mouth. Do NOT stop medication without a doctor&rsquo;s consultation. 
&nbsp;

<ul>
	<li>Bladder Training:This is to help the patient train their bladder to stick to a schedule to reduce leaking. That is, the person urinates every 2-4 hours instead of waiting for the need to go to the bathroom. 
	 
	The doctor also makes use of the patient&rsquo;s bladder diary to schedule trips to the bathroom, called timed voiding. The patient will be asked to maintain the record for the doctor to review and adjust with time. 
	For instance, if the patient seems to be improving at holding their pee, the doctor may gradually increase the time between regular bathroom trips until the person will be able to hold off and urinate once every 2.5-3.5 hours. 
	 
	Also, the doctor can advise patients, particularly those with benign prostatic hyperplasia, to practice double voiding, i.e., urinating as much as possible at one go, relaxing for a few moments, and then urinating again. 
	 
	Behavior therapy is also useful to suppress or control the sudden, strong urge to urinate. This means the person will not have to hurry to a bathroom and still risk a leak. Urgency suppression involves distracting the mind from the urge to urinate.</li>
</ul>

&nbsp;

<ul>
	<li>Interventional Therapies</li>
</ul>

These include:

<ul>
	<li>Botox injections into the bladder muscle if a person with urge incontinence or overactive bladder did not benefit from any other treatment.</li>
	<li>Bulking material injections into tissues around the urethra is generally not as effective as surgery and requires multiple treatments; is recommended for stress incontinence.</li>
	<li>Nerve stimulators can be implanted under the buttock skin with wires connected to the lower back to stimulate sacral nerves, which are involved in bladder control. Again, it&rsquo;s recommended only when other therapies didn&rsquo;t work for urge incontinence or an overactive bladder. 
	&nbsp;</li>
	<li>Alternative Medicine:While the research is limited, some studies that acupuncture and yoga might benefit individuals with urinary incontinence. 
	&nbsp;</li>
	<li>Surgery:Surgery for urinary incontinence is recommended only when no other treatment works. This includes procedures like sling procedures, artificial urinary sphincter, and bladder neck suspension. 
	 
	In rare cases, augmentation cystoplasty is suggested to treat urge incontinence only if the person is willing to use a catheter. 
	&nbsp;</li>
</ul>

Urinary incontinence and treatment for urinary incontinence may result in the following complications<a href="#accordion">[3]</a>: 
&nbsp;

<ul>
	<li>Urinary Tract Infections (UTI): UTIs can develop due to wet underwear pressing against the skin as they encourage bacterial growth.</li>
	<li>Kidney Damage: Kidney disorders or failure can occur if the urine flow is obstructed.</li>
	<li>Skin Problems: Rashes, sores, and skin infections can develop from constantly wet skin.</li>
	<li>Deteriorating Mental Health: Feelings of <a href="https://merisehat.pk/disease/anxiety">anxiety</a>, <a href="https://merisehat.pk/disease/depression">depression</a>, or isolation can develop due to incontinence, especially as it affects work, social, and even personal relationships. 
	&nbsp;</li>
</ul>

Men are more likely to develop UI if they have one or more of these risk factors: 
&nbsp;

Age: As they age, men are more likely to develop UI. Holding urine becomes more challenging. This loss of bladder control can be a symptom of an age-related illness. 
&nbsp;

Lifestyle: Lack of physical activity increases the risk of weight gain, which can aggravate urinary incontinence symptoms. Smoking increases the risk of urinary incontinence as well. 
&nbsp;

History Of Certain Conditions: UI can be temporary or permanent either as a consequence of prostate cancer or an enlarged prostate or as a treatment for these disorders. Infections, such as bladder infection and kidney infection, cancer like prostate or bladder cancer, and diabetes increases the risk of UI, too. Moreover, UI can also be caused by a mental condition that doesn&rsquo;t let the individual go to the bathroom or communicate to other people for assistance when needed. 
&nbsp;

Neurological Issues: Multiple sclerosis, Parkinson&#39;s disease, dementia, and Alzheimer&#39;s disease are a few conditions that can affect how efficiently the brain communicates with the bladder and urinary system. 
&nbsp;

Birth Defects: The risk of developing UI is great if the urinary tract didn&#39;t develop properly during childhood. 
&nbsp;

Trauma: Physical damage to the pelvic floor muscles from childbirth can also cause urinary incontinence. Damage to these muscles can be caused by surgery as well. 
&nbsp;

Medicines: Some medicines that disrupt or increase the amount of urine or the process of storing urine include diuretics, sedatives, and some antidepressants. 
&nbsp;

Family History: UI can be due to genetics as well. So if other people in the family have UI, it increases the risk for an individual, too. 
&nbsp;

Some precautions can help lower the risk of getting UI. Try to:

<ul>
	<li>Maintain a healthy weight</li>
	<li>Exercise regularly</li>
	<li>Eat a healthy diet</li>
	<li>Limit intake of caffeine</li>
	<li>Quit smoking and drinking alcohol</li>
	<li>Avoid lifting</li>
	<li>Get appropriate medication for the urinary tract or bladder infections</li>
	<li>Treat constipation promptly 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li>A common health condition, urinary incontinence (UI) refers to an uncontrollable leaking of urine.</li>
	<li>According to the collected data, it is estimated that around 3.4 million men in the United States have urinary incontinence.</li>
	<li>UI has proven to cause hindrance in an individual&rsquo;s day-to-day routine which, in turn, can lead to accidents.</li>
	<li>According to a study, in Pakistan, it was seen that 2.4% of the male participants had an overactive bladder.</li>
	<li>The urgency incontinence variant of the disease is often referred to as an &ldquo;overactive bladder&rdquo; or OAB, characterized by a sudden, strong, and urgent need to pee.</li>
	<li>Stress incontinence refers to a condition when the urine leaks as soon as the person feels some sort of pressure on their bladder.</li>
	<li>Overflow incontinence is the most common type that occurs in men. The pathology behind this is that the bladder empties inefficiently.</li>
	<li>Functional incontinence refers to a condition when the person has a pre-existing medical condition that makes it difficult for them to move.</li>
	<li>If more than one type of incontinence exists simultaneously, it means the individual has mixed incontinence.</li>
	<li>The usual causes of UI include chronic cough, constipation, obesity, UTI, and certain medications.</li>
	<li>There are no such screening tests available for urinary incontinence in men.</li>
	<li>The recommended course of action largely depends on what is causing UI. Medication, surgery, or further interventions can be used to treat an underlying medical condition.</li>
	<li>Some precautions can help lower the risk of getting UI. Try to maintain a healthy weight, exercise regularly, eat a healthy diet, limit caffeine consumption, and quit smoking. 
	&nbsp;</li>
</ul>

[1] Cheng MC, Liu SP, Chuang YC, Hsu KCP, Chow PM. Prevalence and impacts of male urinary incontinence on quality of life, mental health, work limitation, and health care seeking in China, Taiwan, and South Korea (LUTS Asia): Results from a cross-sectional, population-based study. Investig Clin Urol. 2022;63(1):71-82. doi:10.4111/icu.20210259

[2] Incontinence in men: Treatment and management (no date) WebMD. WebMD.

[3] Ellis, M.E. (2022) Causes of urinary incontinence, treatments, and more, Healthline. Healthline Media.

[4] What is urinary incontinence in men? what are the types? (no date) WebMD. WebMD

[5] Higuera, V. (2019) Feel like you're running to the bathroom too much? it could be an overactive bladder., Healthline. Healthline Media

[6] Reconstructive urology clinical care (no date) Reconstructive Urology Clinical Care | Expertise | Urology | IU School of Medicine.

[7] Chiu L-W, Chen W-C, Hsieh P-F, Chen Y-H, Huang C-P. Efficacy and Complications of the Re-Adjustable Male Sling System for Stress Urinary Incontinence after Radical Prostatectomy. Journal of Clinical Medicine. 2022; 11(22):6764.

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