Urinary Incontinence The Problem

Incontinence is a problem because the male urethra, which carries urine from the bladder to outside the body, runs directly through the prostate. Thus, when the prostate is being destroyed by surgery, radiation, or cryotherapy, the urethra is inevitably affected.

As detailed in Appendix A, urine flow in males is controlled by two sphincters—an internal one immediately above the prostate, where the urethra exits the bladder, and an external one just below the prostate. During surgery for prostate cancer, the internal sphincter is destroyed, because it is anatomically contiguous to the prostate; to preserve the internal sphincter risks leaving behind some cancer cells. That effectively leaves one working sphincter to do a job previously done by two. The average daily urine flow is approximately one-half gallon, so the task is demanding. Further, radiation and cryotherapy treatment may damage either or both sphincters.

The magnitude of urinary incontinence as a problem in any particular man depends on several factors. Most important is the function and strength of the external sphincter, the development of

An Incontinent House

One man noted that, while he was having problems with urinary incontinence, the plumbing in his house also developed problems. ''The dishwasher leaked and stained the ceiling of the room below, the kitchen drain started dripping, a toilet seal had to be replaced, and the sink in the master bath joined the dripping chorus.'' He concluded, ''My house is incontinent!"

—Aubrey Pilgrim,

A Revolutionary Approach to Prostate Cancer which varies in different men. Like all muscles, it weakens with age. Urologists with lesser skills may inadvertently damage the external sphincter; the incontinence in such cases is caused by incompetence.

The two principal types of urinary incontinence are stress incontinence and urge incontinence. Stress incontinence occurs when pressure inside the abdomen increases, as during coughing, sneezing, blowing the nose, laughing, singing, passing gas, or exercising. The increased abdominal pressure causes the bladder to contract and thereby exert more pressure on the external sphincter, which, if it is weak, lets urine pass through. A full lower bowel will also cause this type of incontinence, since the bowel presses on the bladder.

Urge incontinence occurs when the man cannot hold his urine long enough to get to the bathroom. This may result from irritation or spasms of the bladder. It occurs frequently in men with benign prostatic hypertrophy and following radiation treatment for prostate cancer. Although most books discuss stress incontinence and urge incontinence as if they were distinctly separate entities, in real life many men have combinations of both types.

Assessing the severity of urinary incontinence is difficult because men vary widely in their reaction to it. Intermittent dribbling, necessitating the wearing of a thin pad, may be of no consequence for one man but a constant calamity for another. For this reason, Mark Litwin

''This looks too complicated for me—I suggest you call a urologist.''

and his colleagues at UCLA Medical Center developed a brief questionnaire that covers both the magnitude of the problem and the extent to which it bothers the man (see Table 6). The questionnaire is now widely used because the correlation between the magnitude of the problem and how much it bothers men turns out to be quite low; that is, men with a small problem may be very bothered by it, and men with a big problem may not be.

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