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A recently published pilot study of men with a particular type of urinary incontinence examined the factors that lead to choosing a surgical treatment.
Despite advances in minimally invasive surgical techniques, up to 30% of men treated for prostate cancer with surgery will have trouble with incontinence after their surgery. Our recently published mixed-methods pilot study found that men who undergo treatment for this incontinence cite several factors, including the recommendation of their urologist, in deciding which option to pursue.
Many men have persistent stress urinary incontinence (SUI) after prostate surgery, and studies show that several treatments are safe and effective. Yet only 3-6% of men with SUI receive surgery to correct the condition.
Our study used clinical information and personalized patient interviews to help understand why men living with SUI seek help. Objective clinical assessment of SUI, online participant surveys, and patient interviews help us understand how patients live day-to-day with these challenges so that we can better help. Our research was published in the journal Translational Andrology and Urology.
The results paint a picture of nuanced decision-making, with a mix of factors contributing to what procedure men ultimately decide to undergo.
What is stress urinary incontinence?
Urinary incontinence occurs when the body cannot control urine. This can happen for several reasons, including:
- Urge incontinence: Not holding urine long enough to reach the toilet.
- Overflow incontinence: When the bladder doesn’t empty as it should and leaks urine afterward.
- Stress incontinence: Weakened muscles and tissues allow urine to leak during positions or maneuvers that pressure the bladder, such as laughing, coughing, sneezing, lifting, or exercising.
While 24-45% of women will experience SUI, only about 3-17% of men develop symptoms. Women can develop SUI due to obesity, vaginal childbirth, menopause, or other causes. Men with SUI have had some or all of their prostate at least partially removed, often during cancer treatment.
That’s because people born with male anatomy have two sphincters that control the release of urine. Prostate surgery can damage one or both control valves, allowing urine to leak out under stress. Leaking urine is often managed with sanitary pads.
Urinary incontinence’s hygienic and social challenges can significantly impact patients’ quality of life. Men with SUI have higher rates of depression and are more likely to limit their participation in activities, including hobbies, volunteering, career advancement, and more.
Studies have shown that only about 20% of men with SUI symptoms seek treatment. Those that do wait an average of two years before seeking medical help. The good news is that safe, effective treatments can help men regain control over their urinary function.
Surgical treatment options for SUI.
Our study examined two primary treatment options for men seeking SUI to understand how they decide between these methods: male sling and artificial urinary sphincter.
One minimally invasive surgical option to treat stress urinary incontinence involves the placement of a sling. This soft mesh repositions the urethra to support the muscles surrounding the tube through which urine leaves the body.
This undetectable device is placed entirely inside the body to help keep the urethra closed, particularly during maneuvers like coughing and sneezing.
This outpatient procedure takes about 60-90 minutes to perform. Studies have shown that up to 80% of men need one sanitary pad or less per day following the procedure. As many as 65% of men report they are pad-free.
Artificial Urinary Sphincter.
An artificial urinary sphincter (AUS) is an implanted device that helps control urine flow from the bladder. It includes a fluid-filled cuff around the urethra, a pump in the scrotum, and a balloon in the abdomen.
When the pump is squeezed, the fluid will temporarily flow out of the cuff, opening the urethra for urine to pass through. Less than a minute after urination, the fluid flows from the balloon to the cuff and closes the urethra.
The AUS is implanted with minimally invasive surgery, usually with a few tiny incisions. Most patients do not stay overnight in the hospital following surgery. Studies show this treatment to be very effective, with a 91.8% success rate and Almost 84% of patients reporting dryness.
While the ability to stay dry was an essential factor in men deciding which surgery to pursue, it was not the only consideration.
Research: Exploring factors in decision making.
During our pilot study, we spoke with 11 men who underwent treatment for SUI to help understand why they chose which procedure. Of these, three opted for the sling procedure, while another eight opted for AUS. On average, these patients decreased their usage of sanitary pads from 3.2 per day before surgery to less than one after. They experienced no major surgical complications.
Through surveys and qualitative interviews, we were able to identify factors in decision-making for patients. The essential elements were a patient’s activities, the influence of their urologist, and embarrassment related to incontinence. In interviews, patients corroborated these findings. They noted that the ability to resume regular and pleasurable activities like walking and traveling significantly influenced their decision.
For some men, sex and relationships played a significant role in their decision. Others who may not be sexually active said that sex had little to no impact on deciding treatment for SUI. Some patients indicated that urine leakage during sexual intercourse played a substantial role in their decision to seek treatment.
When reflecting on their choice between the sling and AUS surgery, participants were asked to examine which of the five considerations influenced the type of procedure they chose. All participants placed a high value on dryness. Participants who chose the AUS procedure valued dryness the most and cited a desire to avoid future surgery, as did patients who chose the sling.
Some AUS patients expressed concern that the sling might be less effective, while those who chose the sling did not want to have to activate a mechanical device like the AUS pump to urinate. All patients who were offered a sling device chose that option.
Among the themes that emerged in our research was the importance of the source of SUI and treatment information. For many patients, hearing this information from their physician was a critical source of hope that their SUI might be resolved. Some patients felt entirely dependent upon their urologist’s recommendations, and many expressed relief upon learning treatment options.
The findings of this pilot study address the need for further research. They also offer urologists essential guidance as they help their patients consider treatment options. First, broadly counseling patients on all available treatment options may reveal their priorities other than dryness, such as avoiding mechanical device activation.
The study also demonstrates that urologists’ opinions or recommendations about treatment plans significantly impact patient choice. These patients trusted their urologist’s opinion over their primary doctor, family members, and friends.
Urologists play a significant role in helping patients make important decisions about their treatment options and should be aware of their influence over patient choices. This highlights the critical nature of shared decision-making when discussing urinary incontinence treatment options. Making decisions with patients provides the most thorough, ethical, and patient-centered care and leads to better outcomes.
For patients experiencing SUI, knowing there are effective, safe options to help control urine is essential. Some patients meet with a urologist and determine their symptoms do not require surgery. For others, these procedures can be “quality of life-saving,” helping them regain their independence, rejoin their social lives, and heal from the mental health effects of SUI.