Surgical treatment of stress urinary incontinence (SUI) is useful when men have incontinence to such a degree that they are bothered by the leakage. This may be different for each man, as levels of activity and the degree of inconvenience felt with the use of pads or adult diapers varies. Determining the amount of incontinence (mild, moderate, severe) can be based on number of pads used per day and how soaked the pads are when changed. A physician specializing in bladder health will ask patients questions about pad use during a patient’s visit to the office. When a man is more active (playing golf, exercising, lifting or working), it tends to lead to more stress urinary incontinence. Men who find themselves limiting their activity due to fear of getting wet pants or who are troubled with their pad use should speak with a surgeon to discuss surgical treatment for stress urinary incontinence. There are options to keep them active! In fact, there are several devices that can be placed during a straightforward operation to help men dealing with incontinence.  The male sling and artificial urinary sphincter are well established treatments to provide men with long-term urinary control.

Surgical procedures to treat male incontinence: artificial sphincter, male sling and bulking agents

There are multiple options for stress urinary incontinence surgery. Men should be very clear and open with their doctor about when and how their incontinence occurs.  By helping their physician understand the amount and bother of the incontinence, men can help ensure that they receive the treatment most likely to provide the best patient satisfaction.

Men should be very clear and open with their doctor about when and how their incontinence occurs.

One incontinence treatment option procedure is injection of bulking agents. Bulking agents can be injected into the urethra, the tube that carries urine from the bladder out of the body. This helps provide more resistance and minimizes leakage, but this is not often a successful incontinence treatment for men with severe SUI. In fact, 42-49% of men saw no improvement after their injection sessions.⁴³ Incontinence surgery options for men that have high success rates are the male sling and artificial sphincter.

The male sling is the simpler and quicker of the two stress incontinence surgeries. The best patients for a male sling have mild to moderate SUI.²³ The male sling is a mesh material that is placed through an incision in front of the anus. The male sling re-positions the urethra. This leads to more support of the muscle used to hold urine. This is a basic procedure typically with only mild discomfort for the patient. The male sling provides an excellent SUI treatment option for men who leak urine. There are no mechanical parts with the sling. Placement of a male sling is also a great procedure for men who have climacturia (release of urine at the time of orgasm).

An artificial urinary sphincter is the incontinence surgical treatment proven to work best for patients with a history of radiation therapy, moderate to severe incontinence or for patients with mixed incontinence. Mixed incontinence includes a sudden urge to go to the bathroom prior to leaking urine. The artificial urinary sphincter is the gold standard, meaning it is a proven treatment;²⁵ all other treatments are compared to it. The artificial urinary sphincter is a device that has multiple components. It typically is placed through two incisions. It treats even the worst incontinence. The artificial urinary sphincter has a cuff that surrounds the urethra to keep it closed and prevent urine from passing through it. When a man wishes to void, a pump is pressed in the scrotum (no, it is not painful.) This opens the cuff, allowing urine to flow through. The cuff then fills on its own to close the urine channel again, to prevent leakage of urine.

Some men are not good candidates for incontinence surgery

There are few conditions that will exclude a patient from incontinence surgical treatments.  An artificial urinary sphincter requires the patient to be able to squeeze a bulb in the scrotum.  Patients with dexterity issues may not be able to benefit from this incontinence treatment option.  Men unfit for surgery may not be candidates for these treatments either. Men taking blood thinners may be required to stop these medications prior to surgery.

Why surgical procedures for incontinence are often the recommended course of treatment

Stress urinary incontinence is a very bothersome condition for many men. This condition may develop following surgery on the prostate and come on suddenly. Physical therapy for incontinence is the most common initial treatment to address loss of bladder control but will still fail in many men. Surgery for SUI often provides men the control and quality of life they desire. As physicians, we want our patients to stay active and enjoy life. The procedures placing the artificial urinary sphincter and male sling aim to return men to normal continence and confidence.

Patient satisfaction is generally high following the artificial urinary sphincter and male sling surgeries for incontinence.^{27, 32} There are many factors that influence patient satisfaction. First of these is determining what is success. Some men are happy to reduce their incontinence by half, while other men wish to be completely dry again. Typically in my practice, the aim is to return men to one to two pads per day, which is considered socially continent. As a physician that regularly performs incontinence procedures, it is important for me to clarify the patient’s expectation before considering or recommending surgery. Other factors that affect patient satisfaction include use of radiation, presence of urge incontinence, ease of use of the device and the need for further procedures. Prior to surgery, a patient’s physician should be able to provide him with appropriate expectations for success. Overall, satisfaction is generally high. As men experience a significant improvement in their SUI, it is extremely beneficial to their quality of life.

Patient satisfaction is generally high following the artificial urinary sphincter and male sling surgeries for incontinence.^{27, 32}

Prior to incontinence surgery, patients should learn about the SUI procedures and ask their doctor questions

Men should know that the procedures used to treat SUI have been available for many years, that they are very successful and can be life altering in a positive way. However, it is also important that a patient realizes that after the procedure, he may not have complete bladder control with no leakage. Through working with my patients, it has been my observation that the male sling and artificial sphincter can be overcome if the bladder is allowed to be filled fully. Put another way, a man may need to continue to plan bathroom breaks and wear a pad for “security” because leaks are still possible or even could be expected if he waits too long to void his bladder.

Men should know that the procedures used to treat SUI have been available for many years, that they are very successful and can be life altering in a positive way.

Men are often embarrassed to discuss their incontinence, but there are successful treatments available. Urologists specializing in male continence restoration are accustomed to treating patients who drip or leak upon movement; we are comfortable talking about the details.

Here is a list of questions to ask your doctor about stress incontinence procedures and devices:

1. 1. Will I be completely dry? If not, how improved will I be?
   2. Is there an alternative option that is not surgery?
   3. How will radiation therapy affect my outcomes?
   4. Will I need to stay overnight in the hospital?
   5. Will I have a foley catheter after surgery?
   6. What is the risk of infection of the device?
   7. What happens if an infection occurs?
   8. How long will I have discomfort or pain after surgery?
   9. Do I need to limit my activity after surgery, and for how long?
   10. Will the procedure affect my erections or sexual function?
   11. Does the artificial sphincter or male sling ever fail?
   12. If it does fail or does not work, do we have other options?
   13. How many of these procedures do you do a year?

This physician is a Boston Scientific consultant but was not compensated for the creation of this article. Patients are strongly encouraged to talk with their own physician; clinical results can vary.