Male Urinary Incontinence: An Overview
Guest: Lynette Franklin – Urology Services, MUSC
Host: Dr. Linda Austin – Psychiatry, MUSC
Dr. Linda Austin: This is Dr. Linda Austin. I’m talking, today, with Lynette Franklin. We’re going to be talking, now, about male incontinence. Lynette is an advanced practice nurse in the Department of Urology and works with a lot of patients, male and female, with this problem. Lynette, tell us what some typical causes of male incontinence might be.
Lynette Franklin: Well, first of all, the way a man voids is such that the bladder is like a balloon; it fills up, and the message is sent to the brain to find a socially appropriate place to empty it. The bladder squeezes, the pelvic floor relaxes, and the urine comes out. Right below the bladder, in men, is the prostate gland. As men age, the gland can grow and cause an obstruction to the urethra, such that he can’t completely empty his bladder. He has a slow stream, and has to go frequently because he’s not able to empty his bladder completely; the prostate acts like a cork.
Another problem is that the prostate may be cancerous. If the prostate gland develops cancer, one of the options a man might choose is to have the prostate removed. In doing so, sometimes the mechanism for continence is also removed. And it’s much more difficult for men to hold their urine after surgery. So, after surgery, they may have a dribbling effect, and an inability to control their urine. Men with a spinal cord injury or a disease process that affects their brain or spinal cord; such as Parkinson’s disease, multiple sclerosis, or paraplegia/quadriplegia, are unable to empty their bladder effectively.
Dr. Linda Austin: When a man comes to the urology clinic complaining of incontinence, what are the things you do to evaluate that? Clearly, you take a very good history; and a detailed history, I’m sure. But, beyond that, are there diagnostic tests that you perform?
Lynette Franklin: Typically, we would also check to make sure that the patient doesn’t have a urinary tract infection. Urinary tract infections are one of the number one causes of transient or new-onset incontinence. The bacteria cause the bladder to be irritated, and it will squeeze frequently. Also, once the history has been taken, one of the tests that might be done is a Uroflow PVR. We ask the patient to void over an electric toilet. This measures the amount of urine he can release from his bladder, how quickly he does it, and how long it takes. We’ll scan his bladder to see how much is left; if anything, in his bladder. That gives us a good indication as to whether he’s emptying properly.
The second thing that may be done is a cystoscopy. The physician will use a camera to look through the urethra, into the bladder. This is to see if there’s anything structurally wrong. He’ll be able to evaluate how large the prostate is, if there are any stones in the bladder, or if there’s any damage to the lining of the bladder.
Dr. Linda Austin: Now, you said that the doctor will use a camera. I’m sure that terrifies many people listening to this. Just what type of camera is this?
Lynette Franklin: It’s called a cystoscope. It looks like a camera on the end of a long piece of spaghetti. So, the part that’s inserted into the patient looks like a long thin piece of spaghetti, almost. It’s fiber-optic, so it’s very small. The patient is prepped before, and lidocaine, or numbing gel, is applied inside the penis. So, it does hurt, but it’s not painful; it’s more like pressure. And, a lot of times, if a patient relaxes and tries to pee during the test, he won’t be able, but his pelvic floor will be relaxed, making him less uncomfortable than a lot of people would think.
The final test, on the other hand, is as uncomfortable as a lot of people would think. It’s a pressure flow urodynamics test, or a cystometrogram. This is to determine how well the bladder’s muscles and nerves work. The bladder sits in the pelvic floor. So, a lot of people end up not using their bladder muscle, and instead use their abdominal muscles to void. They may have been doing this their whole life without realizing it. So, the way this test works is such that the pressure in the bladder and pelvis is measured to see if you’re using your bladder muscles, or your pelvic muscles, to void.
For this test, a very small catheter; about the size of a piece of linguini, is placed in the penis, into the bladder, and this is connected to a computer. There’s also a very small catheter that’s place in the rectum. Both of these [catheters] are connected to the computer. The bladder is filled up, and the patient is asked to tell us three things: when they feel anything at all going into the bladder; it might be wet, cold, or pressure, when they have a desire to void; like if you were watching TV, you’d say that you’d better get up at the next commercial, because you have to pee, and, finally, when they have to void so bad as when you’re driving down a highway, you’d pull over immediately.
This is not a torture test; although some people think it is. What we’re doing is trying to reproduce the symptoms that you’re having at home: Is it a muscle problem? Is it a blockage? Or, is it an emptying problem? Then, the patient is asked to void. At this time, the amount of fluid coming out of the bladder is measured as to how fast it comes out, and how much you’re able to void.
This test can also have a video component, and that’s called video-urodynamics. In this test, at the same time that we’re filling you up, an x-ray machine is taking pictures of your bladder. This allows us to see whether the fluid is staying in your bladder, or if it goes back up your ureters; into your kidneys, and, when you’re voiding, how it comes out your urethra. The urethra is a tube that exits from the bladder to the outside world.
Dr. Linda Austin: Now, Lynette, when you’re describing all of this, it is in the most matter-of-fact way. And I’m sure you perform these procedures many times a day. But I can imagine, for a man who is considering having this evaluation, it all sounds kind of scary, and embarrassing. They’re not used to having that part of their body instrumented, or even looked at. It may be painful; maybe uncomfortable. How do you help people with those sorts of concerns? How do you make it more comfortable for the patient?
Lynette Franklin: First of all, when you come to the Bladder and Pelvic Health Program, we recognize that this is embarrassing, and you’ve probably never been through this before; which is why you’ve come to us. My goal is to treat everybody with the utmost respect, and answer your questions throughout the procedure, and to keep communication open. It’s really important that if a patient has a question to go ahead and ask us. I don’t want anyone to leave feeling violated in any sense.
During the exam, you’re put in a chair that has a comfortable pad. The room is kept at a comfortable temperature. We assist patients with deep breathing, and different exercises, during the procedure to help them relax, and handle them in a very professional manner.
Dr. Linda Austin: Caring?
Lynette Franklin: Yes.
Dr. Linda Austin: So, it’s, really, with an attitude of compassion and caring, and a lot of sensitivity.
Lynette Franklin: Right.
Dr. Linda Austin: It’s not an everyday procedure.
Lynette Franklin: Yes. It’s not an everyday procedure. And, actually, a lot of patients have said to me that it’s not as bad as they imagined.
Dr. Linda Austin: Lynette, thank you so much for talking with us today.
Lynette Franklin: Thank you.
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