Overview of Slings for Male Incontinence

Male stress urinary incontinence (SUI) is a condition where a man accidentally releases urine while doing activities that put pressure on the stomach. This can really affect the quality of life. Symptoms can range from minor urine leakage to complete loss of bladder control. The most common causes of male SUI are prostate surgery and nervous system diseases.

About 5 to 10% of men aged 65 and older experience a form of urine loss. After prostate surgery, up to 60% of men have some form of urine loss. The first way to treat male SUI includes lifestyle changes, exercises for the pelvic floor muscles, bladder training, and medication. Surgery like the insertion of a urethral sling is only considered when other treatments don’t work.

A male sling is a synthetic strip placed under the front part of the tube that carries urine from the bladder (the urethra). It helps keep the urethra closed and prevent urine leakage. The modern male sling, which is a simpler alternative to artificial urinary sphincters (AUS) that helps control the flow of urine from the bladder, was introduced in the 1990s. The way male SUI is managed is changing all the time, and there are many different types of adjustable and non-adjustable slings available now.

This activity looks at when a male sling should and shouldn’t be used, and what equipment, staff, and techniques are needed for this procedure. It also looks at how to identify, assess, and manage the most common complications after a male sling has been inserted. The aim is to show how a team of healthcare professionals can work together to improve results for men with SUI.

Anatomy and Physiology of Slings for Male Incontinence

Keeping control of male urine flow is a complicated process. It depends on the voluntary and automatic cooperation of various muscles and soft tissues in the lower urinary tract, or the system that carries urine out of your body. This cooperative group of parts is known as the urethral sphincter complex, which includes the internal and external urethral sphincters.

The internal urethral sphincter (IUS) is located at the neck of the bladder. It’s made up of smooth muscle fibers, which are extended from inner layer of the detrusor muscle, a big muscle that forms most of the bladder wall. The IUS wraps around the top part of the urethra and the neck of the bladder. During the process of the bladder filling up with urine, this sphincter remains contracted to ensure the urine stays in the bladder. This is due to nerves known as sympathetic nerves, which come from the lower part of your spine.

The external urethral sphincter (EUS) is made up of striated muscle fibers, basically a kind of muscle fiber with a striped appearance under the microscope. The EUS surrounds the membranous urethra, the part of the tube that carries urine out of the body that runs through the pelvic floor. This sphincter is anchored in the pelvis and helps to keep urine in during activities that cause a sudden increase in pressure in the abdomen, such as coughing or sneezing, thanks to its rapid contractions. These contractions are triggered by two sets of nerves; the pudendal nerve and the pelvic nerve plexus.

These two urinary sphincters work together to keep urine in your bladder. The EUS squeezes the membranous urethra to stop urine flow, and the IUS contracts at the neck of the bladder. When you urinate, these sphincters relax, allowing the urine to flow out.

Conditions like male stress urinary incontinence, the unintentional loss of urine, can occur due to damage to these sphincters which can happen following prostate surgery. The damage can affect any part of the urethral sphincter complex and disrupt your ability to hold in urine. This makes careful surgery crucial in preserving your ability to control your bladder.

Other factors, such as damage to the tissues that support the urethra, can weaken the ability to control urine after prostate surgery. Damages may cause the pressure in the urethra to decrease and also may shorten the effective length of the urethra, both of which lead to incontinence. Other causes of male stress urinary incontinence include nerve diseases, birth defects, injuries, or dysfunction in the bladder neck after surgery. In these cases, the bladder neck sphincter complex could be harmed, the nerves controlling the EUS may not function properly, or the urethral resistance to the flow of urine may be inadequate due to damages in the urethral sphincter complex.

Why do People Need Slings for Male Incontinence

In order to determine the best treatment for men experiencing urinary incontinence, medical professionals conduct a range of tests and evaluations. These include reviewing their complete medical history, conducting urinalysis, testing the amount of urine left in the bladder after peeing, and using urodynamics and cystoscopy to assess the urinary tract’s function and structure.

A male urethral sling, a supportive device placed around the urethra, may be suggested in cases where men experience light to moderate urine leakage, commonly less than 500 grams in 24 hours or using up to 2 pads a day. This treatment might also be suitable for those who haven’t seen improvement from other, less invasive treatments. However, for severe incontinence, a device known as an artificial sphincter could bring better results.

The sling could work for men who have undergone prostate surgery and still have some control over their sphincter, but have not found relief with other treatments. It’s possible for those who have had pelvic radiation treatment to benefit from this treatment as well. To assess this residual control, endoscopic tests such as awake cystoscopy or urodynamic studies are performed, as it’s crucial that patients can exert enough bladder pressure to counteract the resistance from the sling.

For situations where urinary incontinence is mainly an issue while sleeping, a male external vacuum catheter may be suggested. These catheters can be used overnight and require a suction device for connection.

Another treatment option is dual-balloon adjustable continence device therapy (DBACT). This method uses silicon balloons, placed around the urethra via a minor surgical procedure, to compress the urinary sphincter and prevent leakage. Adjustments can be made to the amount of compression by changing the balloon volume through a small port in the scrotum. This can be carried out in a clinic or office under local anesthesia. This method is suggested for men who have had moderate to severe urinary incontinence for at least a year following prostate surgery.

An artificial urinary sphincter (AUS) is typically chosen for patients with significant and troublesome incontinence or a history of pelvic radiation treatment that have not seen improvements with less invasive treatments. Even though AUS placement is the most invasive treatment for male incontinence, it might be the optimal choice for persistent and severe incontinence.

When choosing a method to treat male urinary incontinence, various factors are taken into consideration like the severity and type of incontinence, previous surgical procedures or radiotherapy, existing health issues and the patient’s expectations. Also, the patient’s lifestyle, the surgeon’s experience, and the overall objective of the intervention play a crucial role in the decision-making process.

When a Person Should Avoid Slings for Male Incontinence

There are a few situations where a doctor may decide that procedures to correct male stress urinary incontinence (SUI), wetting yourself when you cough, sneeze or exercise, are not suitable. These include:

* If there are problems with the bladder that could affect kidney function. This includes issues such as a lack of flexibility (compliance) in the bladder or backflow of urine into the kidneys at low bladder pressures.
* Damaged bladder neck or urethra caused by factors such as a need for surgical closure of the bladder neck or a change in the route of urine passage (urinary diversion).
* Blockages in the urinary tract that haven’t been resolved. These could be stubborn, recurring, or untreated blockages in the urethra.
* Unresolved urinary tract infections.

In certain cases, performing sling procedures for male SUI might not be totally ruled out, but they’re generally avoided. These cases include:

* A patient having previously undergone treatment for cancer in the pelvic area or erosion of the urethra.
* Patients who are likely to require further procedures including surveillance cystoscopy for urothelial carcinoma, a type of bladder cancer.
* Severe SUI that is unlikely to be fully resolved by a sling procedure alone.
* A patient with a history of having an artificial urinary sphincter fitted may still have a sling procedure in the future.
* Patients who have a reduced life expectancy due to severe illnesses such as widespread cancer.

Equipment used for Slings for Male Incontinence

To perform a procedure called a male sling for men experiencing stress urinary incontinence, the doctor usually needs the following tools and supplies:

* A compact surgical tray, which is used to organize and hold all the required instruments.
* Adson forceps, a tool used to hold or move tissues during the procedure.
* Adson-Beckman and Richardson retractors, tools that are used to separate and hold back the skin or other tissues to improve visibility during surgery.
* Retractors named after Richardson, used like the Adson-Beckman ones.
* Different types of scissors including Metzenbaum, Mayo, and suture types, used for cutting tissues and sutures.
* A needle driver, a tool used to hold the suturing needles during stitching.
* Surgical irrigation with antibiotics or antiseptics, used to clean the area during the procedure.
* Special threads (3-0 and 4-0 braided and 4-0 monofilament) that can be absorbed by the body, used for suturing.
* Skin tissue adhesive, a kind of glue applied to skin to hold wound edges together.
* Electrocautery, a device that uses an electric current to cut, dissection, coagulate, and achieve hemostasis (stop bleeding).
* Perineal self-retractor, a tool used to keep an area of the body open or move tissues during the procedure.
* A 16F indwelling catheter, a thin tube inserted into the body to drain urine from bladder.
* A special device known as a male urethral sling, used to support the urethra (the tube through which urine leaves the body).

Who is needed to perform Slings for Male Incontinence?

In order to carry out a procedure to treat male Stress Urinary Incontinence (SUI), a condition where a man may leak urine when he coughs, sneezes, or is physically active, certain medical professionals are required. These include:

The main doctor, known as the primary surgeon, who leads the procedure. This surgeon is assisted by a second person, known as the surgical first assistant.

Then there are anesthesiologists – these are the people who ensure you stay pain-free and might even sleep during the procedure.

A surgical technician or an operating room nurse is also part of the team. They assist the surgeons by handing them the surgical instruments they need during the procedure.

The circulating nurse is another important member of the team. They make sure that the operating room remains safe and sterile during the procedure.

Last but not least, a representative from the company that makes the sling device used in this procedure is usually present. They offer technical advice and help solve any issues that might come up during the procedure.

Preparing for Slings for Male Incontinence

Before a man has surgery to insert a sling, a doctor needs to do a special test called a cystoscopy. This is to make sure the patient is a good candidate for the surgery. They also recommend doing a cough stress test or a urodynamic evaluation while standing. These tests measure the strength of the bladder and the ability to hold urine when there is pressure like when coughing.

The bladder muscle, also known as the detrusor muscle, needs to be strong enough to force urine to flow out, even when the sling offsets some of the flow. This is important because it’s how the body ensures that the bladder is completely emptied.

Before the surgery, the doctor needs to do a test of the patient’s urine (urinalysis) to make sure there is no urinary tract infection. Not having an infection is very important when preparing for surgery.

How is Slings for Male Incontinence performed

A male urethral sling procedure is a surgical treatment for urinary incontinence, or trouble controlling urine, in men. This procedure is performed with the patient lying on their back with their legs raised and spread apart. Doctors administer antibiotics beforehand to prevent infection and shave the area to prepare for surgery. After this, the medical team cleans the area using skin cleansers to kill any remaining germs.

There are two main methods to place the sling – through an opening in the groin area (transobturator approach) or from behind the pubic bone (retropubic approach). The best method depends on the circumstances and the specific device being used.

If performing a transobturator approach, a small cut is made in the perineum area (the space between the anus and the scrotum) to get access to the urethra and the surrounding muscles. The skin on each side of the groin is also cut to insert a device (trocar). Once these cuts are made, the sling device is guided through these tracts and then adjusted to give the urethra proper support. The muscles are then sutured and the skin is sealed with stitches.

For the retropubic approach, an additional cut is made in the lower belly area. Here, the sling device gets threaded through the belly cut and those in the groin. Using a small camera, surgeons ensure there’s no damage to the bladder or urethra. Once everything is in place, the incisions are closed.

It’s important to note that the specific techniques may change depending on the device being used. Some may require different sling paths or more cuts.

After the procedure, patients may be allowed to go home on the same day or stay for overnight observation. Doctors will check if patients can urinate on their own the next day. If not, a small, flexible tube known as a catheter may be inserted into the bladder. If after a week patients still cannot urinate properly, they may have to self-insert the catheter on a regular basis until they can. In some cases, if the problem persists for longer than 3 months, the sling might have to be loosened.

Patients will also need pain relief medication, mild laxatives, and antibiotics to prevent infections. To ensure that the sling remains in place, patients would need to avoid heavy lifting and strenuous activity for 6 weeks. These activities include, amongst others, squatting, bending, climbing, cycling, jogging, and sexual activity. Bathing and swimming are also discouraged for 2 weeks following the procedure.

Possible Complications of Slings for Male Incontinence

After a procedure to place a male sling for urinary incontinence, some men may experience issues like pain in the lower pelvis (the area between the abdomen and the thighs), difficulty urinating, sudden and uncontrollable urges to urinate, and infections. About 45% of men might feel some sort of pain after surgery, but this usually goes away on its own. Depending on the type of sling used, anywhere from 3% to 46% of men could have trouble urinating after the surgery. However, the chances of getting an infection are quite low, between 1% and 3%.

Compared to another type of device called an artificial urinary sphincter, male slings have a much lower rate of needing to be operated on again, about 1%. The sling wearing away or eroding happens in less than 1% of cases, but this is mostly seen in men who have had radiation therapy to the pelvis. These men also have a higher risk of getting infections, not having their symptoms fully go away, and requiring the sling to be removed.

The sling slipping out of place is very rare, happening in less than 1% of men, and this is usually due to physical activities that increase pressure in the abdomen. Slings that have slipped or failed might need to be adjusted or replaced, or a different method could be tried.

Complications arising during the surgery to place the male sling are very rare. These can include bleeding from a blood vessel in the groin, injury to the urethra (the tube that carries urine out of the body), or damage to the bladder from the insertion of the surgical tool. Any bleeding is typically minor and stops on its own. The risk of the urethra or bladder getting injured is also very low, and doctors can lower these risks with good surgical practices like making sure the bladder is empty before starting the procedure.

What Else Should I Know About Slings for Male Incontinence?

The success rate for male sling surgeries, a procedure used to treat urinary leakage in men, varies widely from 36% to 90%. “Success” is usually defined by needing 0 to 1 pad a day or experiencing more than a 50% reduction in leakage. But do be aware that these definitions might differ in various research studies. The severity of the urinary leakage also affects the surgery’s success: mild instances see 80%-90% success, moderate levels between 32%-83%, and severe cases up to 70%.

Despite some remaining leakage, approximately 75% of patients properly chosen for this surgery experience either complete recovery or significant improvement in their condition. Patient satisfaction is often high, with many reporting an improved quality of life. However, the effectiveness of male slings lessens over time, and after five years, another procedure may be required, such as a revision, replacement, or the insertion of a DBACT device or an artificial urinary sphincter (AUS).

There are factors that can lead to the failure of the sling surgery, including intense urinary leakage, past radiation therapy, and previous surgeries. Keep in mind, current data doesn’t suggest adjustable slings are superior to nonadjustable ones. Before the surgery, patients should understand that the sling’s effectiveness may decrease over time and it’s possible they won’t achieve total relief from leakage.

An AUS is often considered the best solution for serious urinary leakage in men due to its superior effectiveness and flexibility. Although it carries higher complication rates and is more complex, the long-term results show up to 50% of patients achieve complete relief for up to 5 years following the placement of an AUS. However, using an AUS requires manual dexterity from patients and can increase the risk of erosion and infection. Around 20%-30% of patients will require an AUS device revision or removal. Still, it’s often the recommended choice for severe cases.

Both options should be discussed thoroughly with your doctor, including the benefits, risks, and outcomes of each device available to treat urinary leakage. Your specific situation and preferences should guide the decision. Generally, slings are recommended as the first surgical treatment for mild-to-moderate urinary leakage, with other treatments guided by the individual patient’s circumstances.

Frequently asked questions

1. What are the different types of slings available for male incontinence and which one would be most suitable for my condition? 2. What are the potential risks and complications associated with the sling procedure? 3. How long is the recovery period after the sling procedure and what can I expect during this time? 4. Are there any lifestyle modifications or exercises that I should follow to optimize the effectiveness of the sling? 5. What are the chances of the sling needing to be adjusted or replaced in the future?

Slings for Male Incontinence can help individuals who are experiencing male stress urinary incontinence, which is the unintentional loss of urine. These slings can provide support to the urethral sphincter complex, which includes the internal and external urethral sphincters, and help individuals regain control over their bladder. Slings can be especially beneficial for those who have undergone prostate surgery or have experienced damage to the sphincters or supporting tissues.

You may need slings for male incontinence if you have certain conditions or situations that make other procedures or treatments unsuitable or ineffective. These can include problems with the bladder that could affect kidney function, damaged bladder neck or urethra, unresolved blockages in the urinary tract, or unresolved urinary tract infections. In some cases, sling procedures may not be ruled out completely but are generally avoided, such as in patients who have previously undergone treatment for cancer in the pelvic area, severe SUI that is unlikely to be fully resolved by a sling procedure alone, or patients with a reduced life expectancy due to severe illnesses.

A doctor may decide that a sling procedure to correct male stress urinary incontinence (SUI) is not suitable if there are problems with the bladder that could affect kidney function, if there are damaged bladder neck or urethra, if there are blockages in the urinary tract that haven't been resolved, or if there are unresolved urinary tract infections. Additionally, in certain cases, sling procedures might be avoided if the patient has previously undergone treatment for cancer in the pelvic area or erosion of the urethra, if they are likely to require further procedures for bladder cancer, if they have severe SUI that is unlikely to be fully resolved by a sling procedure alone, if they have a history of an artificial urinary sphincter, or if they have a reduced life expectancy due to severe illnesses.

The recovery time for slings for male incontinence can vary, but typically patients may be allowed to go home on the same day or stay for overnight observation. Patients will need pain relief medication, mild laxatives, and antibiotics to prevent infections. To ensure that the sling remains in place, patients would need to avoid heavy lifting and strenuous activity for 6 weeks.

To prepare for Slings for Male Incontinence, the patient should undergo a special test called a cystoscopy to determine if they are a good candidate for the surgery. They should also have a urinalysis to ensure there is no urinary tract infection. Before the surgery, the patient may need to take antibiotics to prevent infection, and the area will be shaved and cleaned using skin cleansers.

Complications of slings for male incontinence include pain in the lower pelvis, difficulty urinating, sudden and uncontrollable urges to urinate, and infections. About 45% of men may experience some pain after surgery, but it usually resolves on its own. Depending on the type of sling used, 3% to 46% of men may have trouble urinating after surgery. The chances of getting an infection are low, between 1% and 3%. Other complications include sling erosion, which occurs in less than 1% of cases and is more common in men who have had radiation therapy. The sling slipping out of place is rare, happening in less than 1% of men, and may require adjustment or replacement. Complications during surgery, such as bleeding, urethral injury, or bladder damage, are very rare.

Symptoms that may require slings for male incontinence include light to moderate urine leakage (less than 500 grams in 24 hours or using up to 2 pads a day), lack of improvement from other treatments, and residual control over the sphincter after prostate surgery or pelvic radiation treatment.

There is no information provided in the given text about the safety of slings for male incontinence in pregnancy. It is recommended to consult with a healthcare professional for specific advice regarding this matter.

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