Urinary incontinence in men

Bladder dysfunction, also referred to as voiding dysfunction, is a general term to describe abnormalities in either the filling and/or emptying of the bladder

Urinary incontinence in men can be caused by functional abnormalities of the bladder or urethra, particularly in men with prostate disease.

DEFINITIONS

●Urgency incontinence is involuntary leakage accompanied by urgency. Urgency is the complaint of a sudden and compelling desire to pass urine that is difficult to defer.

●Stress incontinence is involuntary leakage with exertion, sneezing, and/or coughing. Leakage may be provoked by minimal or no activity when there is severe urethral sphincter damage.

●Postvoid dribbling is a term used to describe dribbling of urine retained in the urethra after the bladder has emptied.

●”Overactive bladder” is a symptom syndrome consisting of urgency, frequency, and nocturia, with or without urinary incontinence.

Risk factors — Risk factors for urgency incontinence in men include:

●Advanced age

●Prostate disease, particularly with a history of prostate surgery or radiation therapy

●History of urinary tract infections

●Physical limitations, including impairments in activities of daily living

●Neurologic disease, particularly stroke, spinal cord injury, and impaired cognition

●Constipation

●Depression

●Diabetes

●Sleep apnea

DIAGNOSTIC EVALUATION

History — The key components of the history include:

●Onset and temporal course of incontinence

●Severity

●Associated symptoms

●Precipitants

●Bowel function

●Sexual function

●History of prostate disease

●Comorbidities

Physical examination — The key components of the physical examination are similar for men and women, with a particular focus on the cardiovascular, abdominal, and neurologic examinations.

Laboratory testing — A urinalysis should be performed in all patients, with urine culture if infection is suspected. Urine cytology is indicated only if there is hematuria or risk factors for bladder cancer (eg, extensive smoking history, previous bladder tumor).

Measurement of renal function should be obtained if recent results are unavailable.

Prostate-specific antigen (PSA) testing should be considered in men who present with urinary incontinence..)

to correlate them with objective measures of bladder and urethral function.

MANAGEMENT

Nonpharmacologic therapy — 

  • lifestyle advice (particularly weight loss and dietary changes),
  • bladder training, biofeedback, and pelvic floor muscle exercises.
  • Although evidence demonstrating efficacy is lacking in men, it is reasonable to try nonpharmacologic therapies given their safety, low cost, and proven efficacy in women

Pharmacologic therapy — 

The pharmacologic management of urinary incontinence includes alpha blockers, antimuscarinic drugs, beta-adrenergic agonists, and serotonin norepinephrine reuptake inhibitors.

Urgency incontinence — 

Antimuscarinic drugs and beta-adrenergic agonists are the main pharmacologic agents available for urgency incontinence, and
alpha blockers are used for men with urgency incontinence associated with benign prostatic hyperplasia (BPH).

Antimuscarinic drugs (oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, trospium) and beta-adrenergic agonists (mirabegron) are a mainstay of pharmacologic therapy for urgency incontinence.

  • reduce involuntary bladder contractions by blocking the muscarinic cholinergic receptors located on the detrusor muscle cell wall (antimuscarinics) or
  • by enhancing the inhibitory adrenergic signals to the detrusor muscle (beta-agonists).
  • For the antimuscarinic medications, adverse effects may limit drug tolerability and dose escalation; these include inhibition of salivary secretion (dry mouth), inhibition of gut motility (constipation), blurred vision, tachycardia, drowsiness, and impaired cognitive function.
  • All antimuscarinics are contraindicated in gastric retention, untreated narrow angle closure glaucoma, and supraventricular tachycardia.
  • Evidence suggests that cumulative exposure to potent antimuscarinics is associated with increased rates of dementia and Alzheimer disease.
  • All antimuscarinics exert peripheral anticholinergic effects (eg, dry mouth, constipation, tachycardia, palpitations).
  • All antimuscarinics may have additive side effects with other medications that have strong anticholinergic effects (eg, first-generation H1 antihistamines, muscle relaxants, tricyclic antidepressants, antipsychotics, inhaled anticholinergic bronchodilators)
  • Beta-adrenergic receptor agonists Mirabegron,

 first-in-its-class drug approved for the treatment of OAB with symptoms of UUI, urgency, and urinary frequency. This drug is associated with improved bladder compliance, increased bladder capacity, reduced urinary frequency, and reduced incontinence

  • Adverse effects of beta-adrenergic agonists are less common and include hypertension, nasopharyngitis, and urinary tract infection.
  • Mirabegron is not currently licensed for use in children

Choosing medication — Despite the lack of evidence to guide urgency incontinence therapy in men who do not respond to lifestyle interventions or pelvic floor muscle exercise, we suggest initial pharmacologic treatment with an alpha blocker. Alpha blockers are generally better tolerated than antimuscarinic drugs.

If symptoms persist after appropriate titration of an alpha blocker, we suggest the addition of an antimuscarinic drug or beta-adrenergic agonist

Stress incontinence — In men with stress incontinence who do not respond to lifestyle interventions or pelvic floor muscle exercise, we suggest the addition of duloxetine.

Duloxetine, a serotonin-norepinephrine reuptake inhibitor, is approved for this indication in many European countries.

Propiverine is an oral anti-muscarinic approved in Asia and recently in Canada and is awaiting FDA approval for the US
Transdermal formulations of oxybutynin and tolterodine were introduced in 2007 to avoid/minimize systemic AEs associated with oral treatments.

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