Incontinence and Prostate Cancer

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

2. What is urinary incontinence? “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.

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 - acircular muscle atthe 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? NO! 55 million men in the world suffer from loss of urinary control AMS 2003 Annual Report Campbell’s Urology 2002 8th Edition

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. Why treat incontinence? 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

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 rate1 1Onur 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 compressionon the urethra for urinary control • Procedure: • Spinal or general anesthesiacan be used • Small incision under the scrotum • Miniature titanium screws placedinto the pubic bone on each sideof the urethra • Sling positioned to exert gentlepressure on urethra • Sling secured to screws • Incision closed

25. AdVance™ Male Slinga 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 anesthesiacan be used • Three small incisions: 1 under the scrotum, 2 over groin creases • Specially designed surgical toolsare 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 • 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 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.

30. Animation of Artificial Urinary Sphincter

31. AUS Sling • 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 • 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?)

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-cancer • For copies of this talk • Sara Steinkamp • s-steinkamp@northwestern.edu

34. Thank You