Urinary Incontinence is Curable after Prostate Cancer Treatment
What is Urinary Incontinence.
Urinary incontinence is estimated to affect 12–17% of US males, with increasing prevalence associated with aging. Stress urinary incontinence (SUI) as a subtype has been defined by the International Continence Society as the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. Although any surgical or radiotherapeutic manipulation of the prostate may result in SUI, radical prostatectomy (RP), transurethral resection of the prostate (TURP), and radiation therapy are most commonly associated SUI .
The true prevalence of SUI following radical prostatectomy remains unknown with estimates varying from 2 to 43%. Regardless of the etiology of severe male SUI it remains a very debilitating condition which greatly affects quality of life. It is estimated that 56% of patients will suffer from urinary incontinence in the peri-operative period following catheter removal after a prostate is removed for cancer (post prostatectomy). This decreases to 21% at three months, and up to 14% at one year. While the initial management of post-prostatectomy incontinence consists of emotional support and reassurance, it is expected that, in most cases, steady improvement will be noted. In severe cases, ongoing skin irritation due to urine bathing the skin and difficulty with pads may necessitate the use of condom catheters, penile clamps and even indwelling Foley urinary catheters to improve control.
The good news is there is hope for patients who often are suffering in silence.
Surgical therapy should be considered in men with post-prostatectomy stress urinary incontinence (SUI) that persists beyond the first postoperative year, or even earlier in men with severe symptoms. Other patients with severe urinary incontinence or with neurogenic bladder can also benefit from the treatment.
The surgical device aims to prevent involuntary urinary leakage during storage by increasing bladder outlet resistance while allowing unimpeded flow during voluntary urination. The “Gold Standard” surgical treatment, to date, is the artificial urinary sphincter.
How the Device Works?
The artificial urinary sphincter (AUS) is a surgically implantable device used to restore urinary control in men. Most commonly, the device is implanted in men who have sphincter or valve muscle damage following prostate surgery. The entire device is implanted inside the body in a brief outpatient surgical procedure lasting approximately one hour. With appropriate evaluation for the proper selection of candidates for the AUS, the long-term results in experienced hands are excellent. One the leading artificial urinary sphincter implanters and authority in the country, Dr Angelo Gousse has performed more than 700 AUS implants, making him the number one implanter in Florida.
Components and Function
The AUS consists of three components: the cuff, which goes around the urethra, the pump, which goes inside the scrotum, and the balloon, which holds the fluid for the device (see figure). The balloon is available in different pressure ranges and is filled with a fluid that is very safe even if it leaks. The device works hydraulically, with the cuff around the urethra staying closed at all times. When the person wants to urinate, the pump is squeezed and the cuff opens. Automatically, in 3-5 minutes, the cuff closes again. The refilling of the cuff is controlled by a resistor mechanism inside the pump.
Indications for Use
The most common indication for implanting the AUS is sphincter damage following prostate surgery (especially radical prostatectomy for prostate cancer). It is essential that the exact cause of urine leakage be defined by special bladder and sphincter function tests, called urodynamics, before any surgery is performed. In order for the AUS to be successful, the bladder must be able to store a normal amount of urine at low pressure and to empty normally. This ability of the bladder to function normally is examined during the urodynamic testing.
Technique of Implantation In the Male
Insertion of the AUS is performed in a hospital operating room under either a general or a spinal anesthetic. Two small incisions are made: one in the groin area and the other between the scrotum and the rectum. The proper size cuff is placed around the urethra and the tubing from the cuff is passed up to the groin area. The small pressure-regulating balloon, which is about the size of a golf ball, is placed beneath the abdominal muscles and the pump that controls the device is tunneled down into the scrotum, just beneath the skin. All connections between the three components are made in the groin area and the incisions are closed. At the conclusion of the operation, the cuff is locked open for 4-6 weeks until healing is complete.
It is an outpatient procedure and there is minimal postoperative pain. Most men return to work 2-3 weeks after surgery. About 4-6 weeks after surgery, the AUS is activated in the office by squeezing a button (no surgery is required) to allow urinary control to be restored.
An Excellent Track Record
More than 100,000 men worldwide have received the AMS 800 Urinary Control System. For almost 35 years, physicians worldwide have been implanting the AMS 800 as an effective treatment for stress urinary incontinence in men. The AMS 800 has been proven to be effective in the treatment of male incontinence following prostate surgery, and is considered the gold standard by most urologists. When using this device, most men are dry, with only minor leaks or dribbles of urine, usually with strenuous exercise or exertion. Most men use one pad or less per day to manage these minor leaks. As with any medical procedure, the AMS 800 is not 100% effective in all patients. Some men may require additional protection.
The AMS 800 offers the following benefits in helping to restore your quality of life:
Recently, the male synthetic sling called Advance has become available. Although long-term outcome data is currently being accumulated, the procedure appears to be most effective for mild to moderate male urinary incontinence. Urethral Bulking agents (Collagen and Durasphere, Teflon, Coaptite) for male incontinence have fallen by the way-side for lack of efficacy.
What the Future Holds?
Dr Angelo Gousse is the lead surgeon as part of a research team at the University of Miami developing a novel artificial urinary sphincter based on blue tooth technology. The key features of the device include implant simplicity using less implantable components, no fluid in the device, and improved versatility for real-time pressure adjustments using a hand-held remote control device.
Don’t let your bladder control your life.
Don’t let your bladder run your life. Control your bladder. If you're one of the 33 thousand women who experience bladder control problems, don't let embarrassment keep you from getting the help you deserve. Involuntary leakage of urine, having to urinate frequently and experiencing other symptoms of urinary incontinence affect your quality of life and are not necessarily a natural part of aging.
Many health care providers do not routinely ask about urinary function during a clinic visit. It's up to you to take control and make the first step in treating your problem. If you have bladder control problems, tell your doctor about them and ask for help.
Why to seek help?
Bladder control problems require medical attention for several reasons.
When to seek help
A few rare and isolated incidents of urinary leakage don't necessarily require medical attention. However, if the problem continues or affects your quality of life, consider getting these symptoms evaluated.
You may opt to see a bladder control specialist if you are experiencing any of these problems.
In most circumstances, symptoms can be improved.
Choose your Bladder Control Specialist Carefully
Many clinicians can treat bladder control problems without referring you to a specialist. However not all health care providers have the necessary training to properly guide you or offer state of the art treatments. In spite of better understanding and treatment of urinary incontinence, some providers consider it an inevitable consequence of childbearing, menopause or normal aging — a belief that makes them unlikely to consider you for evaluation or treatment.
If you feel that you are not getting the evaluation or treatments you deserve consider visiting Dr Angelo E Gousse.
What is Urinary Incontinence?
Urinary incontinence or the involuntary leakage of urine is one of the most common problems treated in female urology. It is important for the clinician to realize that there are several different types of urinary incontinence, each with a different cause and potential treatment options. These include stress incontinence, urge incontinence, and overflow incontinence, mixed incontinence (simultaneous stress and urge incontinence), total incontinence and functional incontinence.
What are the Various Types of Urinary Incontinence?
Improper diagnosis of the type of urinary incontinence is probably the most common reason for treatment failure. A detailed history and physical examination is of paramount importance in the proper diagnosis and sub typing of urinary incontinence. In select cases, Urodynamic testing or cystoscopy may be useful. A neurologic history and physical examination should be obtained in order to rule out neurogenic bladder.
Patients with “pure” stress urinary incontinence report activity–related urinary leakage which interferes with their quality of life. The disorder is unrelated to psychologic stress. Any increase in abdominal pressure such as coughing, sneezing, laughing, exercising, jumping, running, or event sexual activity may precipitate urinary leakage. Stress incontinence may or may not co-exist with pelvic organ prolapse. In most cases urethral hypermobility is noted with rotational descent of the urethra upon straining. The need for treatment is largely dictated by the degree that it affects the quality of life of the patient. Pad usage and pad weight are sometimes used to gauge disease severity
What are the treatment options for Stress Urinary Incontinence?
The current most popular surgical treatment to treat stress urinary incontinence is the sub-urethral sling. Transurethral bulking agent is another less successful and shorter duration treatment option.
The suburethral sling can be performed using a synthetic mesh (mono-filament macroporous Type I mesh) or biologic allograft, autologous rectus fascia. Abdominal procedures such as Burch urethropexy are effective but remain more invasive than the transvaginal sling procedures.
Currently, there is no approved medication for stress urinary incontinence. There is no evidence that estrogen therapy is effective in the management of stress urinary incontinence.
What are the treatment options for Urge Incontinence?
Patients with urge urinary incontinence report involuntary urinary leakage with bladder spasm and strong urges to void. Urge incontinence is one of the symptoms associated with overactive bladder. Overactive bladder is not necessarily related to aging or prior surgery. Most cases of overactive bladder and urge incontinence are idiopathic. Urge urinary incontinence is often associated with urinary urgency and frequency. However, a neurologic cause should always be ruled out especially in younger patients. The treatment algorithm of urge is very different from that of stress incontinence.
Behavioural therapy, fluid management, timed voiding, avoiding bladder irritants, pelvic floor exercises; Kegel exercises are useful in many cases. In more severe cases, anticholinergic medications can be used. Anticholinergics are plagued with adverse side effects such as dry mouth, constipation, cognitive side effects, and potential for urinary retention. The newest anticholinergic drugs have a better safety profile but yet remain far from being free from side effects. The newly developed beta-adrenergic agonists are promising. They are effective free from anticholinergic side effects but are associated with hypertension.
What are your options when the pills do not work for urge incontinence?
What is Bladder Botox?
In cases refractory to oral medications, intradetrusor injection of Onabotulinum toxin A (Botox) offers new hope to affected patients. Pic III The procedure is minimally invasive and can be performed in the office without general anaesthesia. A urinary retention rate of 6 % and poor bladder emptying are potential side effects of Botox. Urinary retention is rare in our personal practice and in well selected patients with a post void residual of less than 100 ml pre-Botox- procedure. Botox should be re-injected every 3-6 months to remain effective. Few patients with urge incontinence require Botox re-injection yearly. The usual dosage is 100 Units of Botox in patient with idiopathic urge incontinence refractory or intolerant to medications. This option is FDA approved in the USA.
What is Interstim Sacral Nerve Stimulation?
Another option is implant of a sacral nerve stimulator (looks like a pacemaker). It is possible to stimulate the third (S3) sacral nerve via an implantable neuro-stimulator. Medtronic (Interstim) manufactures the most popular device. The procedure is performed under local anaesthesia with the patient awake. A staged procedure (First –stage lead implant) and second stage (implantable pulse generator- IPG) implant is often required to obtain the best results. The device is expensive and the battery (IPG) half-life is 3-7 years. Patients who require infra-cranial MRIs can’t have the procedure performed. A few long term studies have documented the safety and efficacy of Interstim. Recently, posterior tibial nerve stimulation (PTNS) has been added to the armamentarium of urge incontinence treatment with very reasonable outcome data. Long term studies are needed. No implant is necessary for PTNS but multiple weekly office visits are required.
What is Mixed Urinary Incontinence?
Patients with mixed urinary incontinence have a combination of stress and urge incontinence. Often, the most dominant symptom is treated first. Some clinicians treat both symptoms simultaneously. Mixed incontinence can be stress predominant, urge predominant, or balanced. Many (up to 50%) mixed incontinence patients with stress predominance become dry of both subtypes of incontinence after sub-urethral sling (synthetic, allograft, autologous rectus fascia).
What is Overflow Incontinence?
Patients with overflow incontinence have impaired bladder emptying associated with an elevated post void residual. Impaired bladder emptying can be associated with bladder outlet obstruction (urethral stricture, severe pelvic organ prolapse, urethral diverticula). Other causes include detrusor muscle underactivity ( acontractile ) or neurologic disorders. Patients with overflow incontinence are best treated by intermittent self-catheterization or relieving the bladder outlet obstruction.
What is Functional Incontinence ?
Patients with functional incontinence are unable to reach the rest room because of functional difficulties associated with body mobility. Elderly patients with cognitive impairment and or orthopaedic problems are most commonly affected by functional incontinence. Nursing care and physical therapy are the most effective treatment options.
If you have questions about Bladder control or pelvic organ prolapse, contact Angelo E Gousse MD, urologist and board certified in Female Pelvic Medicine and Reconstruction, (305)-606-7028, Dr Gousse, Voluntary Professor of Urology at the University of Miami Miller School of Medicine, is associated with Memorial Hospital System, Aventura Hospital, University of Miami Hospital and Clinics, Jackson Memorial Hospital. Web site www.bladder-helath.net
Sexual Dysfunction is more prevalent in Women than Men
It is estimated that approximately 40 million American women are affected by Female Sexual Dysfunction ( FSD). Some investigators have found that sexual dysfunction is more prevalent in women (43%) than in men (31%), and increases as women age. Unlike men FSD can occur in young women in their 20's. Some recent studies have noted that married women have a lower risk of sexual dysfunction than unmarried women. Racial differences have also been noted. Hispanic women consistently report lower rates of sexual problems, whereas African American women have higher rates of decreased sexual desire and pleasure than do white women. Sexual pain (dyspareunia), however, is more likely to occur in white women.
Although the exact cause of Female Sexual Dysfunction remains unknown, both physiologic and psychological components are believed to play a part. In order to better understand FSD it is imperative to be familiar with normal female sexual function. Many changes occur in the female external and internal genitalia during sexual arousal. Increased blood flow promote what is called " vasocongestion of the genitalia". Secretions from uterine and vaginal glands lubricate the vaginal canal. Vaginal smooth muscle relaxation allows for lengthening and dilation of the vagina. As the clitoris is stimulated, its length and diameter increase and engorgement with blood occurs. In addition, the labia minora becomes also engorged because of increased blood flow. Vaginal temperature increases during arousal.
FSD is psychologically complex. While the female sexual response cycle was first characterized by Masters and Johnson in 1966 and included four phases: excitement, plateau, orgasm, and resolution, in 1974, Kaplan modified this theory and characterized it as a three-phase model that included desire, arousal, and orgasm.
Other investigators have proposed that the female sexual response is driven by the desire to enhance intimacy. Currently, it is believed that various biologic and psychological factors can negatively affect this cycle, thereby leading to FSD. Hormonal changes, such has a drop in estrogen, seen in post-menopausal women, can also greatly affect sexual desire and vaginal lubrication. Nerve and small vessel disorders seen in conditions such as diabetes, high cholesterol, cigarette smoking can also affect sexual function. Women with hypertension, vascular problems are at very high risk because of diminished blood flow going to the genitalia.
Female sexual dysfunction can be divided into 5 major subtypes: 1- Disorder of libido ( sexual desire ) 2- Arousal dysfunction 3- Vaginal lubrication disorders 4- Disorders related to orgasm 5- Vaginismus and Dyspareunia ( painful intercourse ). Many women with FSD are affected by all or some of the subtypes.
For many reasons, treatment options are more difficult and less established in women than in men. There is no "magic" female sexual dysfunction pill. Although there is extensive research in the field, the exact cause of FSD remains unclear. Furthermore, dual psychologic and physiologic causes are often present . While the oral tablets such as Viagra, Cialis, Levitra which fall in the category of phosphodiasterase-inhibitors (PDE-5) have been useful in male erectile dysfunction, they have little value in FSD. Hormonal manipulation, while often helpful in FSD, must be weighed very carefully against possible side effects such as weight gain or cardiovascular risks. Vacuum erection devices of the clitoris, while available in women, have not been widely used for clitoral engorgement and arousal disorders. Women with lubrication disorders can be treated with estrogen vaginal cream or lubricants. This often alleviates dyspareunia (painful intercourse) when present. Psychological counseling and sexual therapy have remained at the forefront of FSD related to sexual intimacy or psychologic disorders. Often, a multispecialty approach is most effective. Women suffering from FSD who desire treatment are best treated with clinicians specialized in the area.
Blood in the Urine can Indicate Serious Medical Conditions
What is Hematuria ?
Hematuria is defined as the abnormal presence of red blood cells (RBCs) or gross blood in the urine. If only the clinician can see the red blood cells under the microscope while the urine appears grossly clear it is called microscopic hematuria. If the patient can notice a change in color of the urine with the naked eye - either red , dark red, or dark, or notices blood clots, it is called gross hematuria. It is important to note that both gross and microscopic hematuria can indicate serious medical conditions.
In other words, . although both microscopic and gross hematuria can signal a serious medical condition, unexplained gross hematuia is often more concerning to the patient and the clinician.
Several conditions can cause hematuria, most of them are not serious. For example, vigorous exercise or even sexual intercourse may cause hematuria that goes away in 24 hours. Many people have microscopic hematuria without any other related problems. Often, despite a thorough evaluation, no specific cause can be found for the presence of red blood cells in the urine. But because hematuria may be the result of a cancer, a tumor, or other serious medical problem, a doctor should be consulted.
How to Evaluate Blood in the Urine ?
To find the cause of hematuria, or to rule out certain causes, the doctor may order a series of tests, including urinalysis, blood tests, kidney imaging studies, and cystoscopic examination. A cystoscope can be used to look, examine, and take pictures of the inside of the urinary bladder. A cystoscope is a tiny lighted lens with a camera at the end of a thin tube, which is inserted through the urethra. A cystoscope may provide a better view of a tumor or bladder stone than can be seen in an urinary tract imaging study. A cystoscopy is the only reliable test to evaluate the urinary bladder in cases of hematuria. According to the established guidelines of the Ameican Urologic Association (AUA), no other test can be substituted for a cystoscopy when evaluating blood in the urine .Therefore, a cystoscopy performed by a urologist is imperative to complete the hematuria evaluation.
Urinalysis is the examination of urine for various cells and chemicals. In addition to finding red blood cells, the doctor may find white blood cells that signal a urinary tract infection or casts, which are groups of cells molded together in the shape of the kidneys' tiny filtering tubes,that signal kidney disease. Excessive protein in the urine also signals kidney disease. Blood tests may reveal kidney disease if the blood contains high levels of wastes ( Urea Nitrogen ) that the kidneys are supposed to remove. Blood tests may also provide a general idea od the kidney function ( creatinine, estimated glomerular filtration rate eGFR , etc ). In general, impaired kidney function diseases are best evaluated and treated by nephrologists ,instead of a urologist.
Kidney imaging studies include renal ultrasound, computerized tomography (CT) scan, or intravenous pyelogram (IVP). An IVP or CT Urogram is an x ray of the urinary tract obtained with intravenous contrast material ( Iodine ) . While renal simple cysts are frequently noted on kidney imaging studies, they typically do not cause hematuria and do not require any treatment. However complex kidney cysts should be further investigated for the possibility of kidney cancer. Kidney imaging studies with Iodine are best to detect kidney cancers and other serious urinary tract pathology. Imaging studies may reveal findings which can explain the hematuria such as a kidney or bladder cancer, a benign tumor of the urinary tract , a kidney or bladder stone, an enlarged prostate, or other blockage to the normal flow of urine.
It is important to note that cigarette smoking significantly increases the chance of developing bladder and urothelial cancers. This is another reason to avoid cigarette smoking.
Treatment for hematuria depends on the cause. After a very thorough evaluation, if no serious condition is causing the hematuria, no treatment is necessary and the patient can be reassured. If the hematuria is persisting after an initial evaluation , a repeat work up and further testing can be ordered.
The main message remains. The presence of red blood cells or gross blood in the urine may indicate a serious medical condition. It should never be ignored by the patient or the clinician. A thorough evaluation is the only way to determine the possible cause.
What are the causes of UTI?
Normally, urine is sterile (free from micro-organisms). This means that it is free of bacteria, viruses, and fungi but does contain fluids, salts, and waste products. An infection occurs when tiny organisms, usually bacteria from the digestive tract, travel to the opening of the urethra (bladder outlet) and begin to grow in large numbers. The urethra is the tube that carries urine from the bladder to outside the body. Most infections arise from one type of bacteria, Escherichia coli (E. coli), which normally lives in the colon. Other bacteria such as Klebsiella, Enterococcus, Pseudomnas are less frequent.
In many cases, bacteria first travels to the urethra. When bacteria multiply, an infection can occur. An infection limited to the urethra is called urethritis. If bacteria move to the bladder and multiply, a bladder infection, called cystitis, results. If the infection is not treated promptly, bacteria may then travel farther up the ureters to multiply and infect the kidneys. A kidney infection is called pyelonephritis. A kidney infection (pyelonephritis), is typically more serious than a bladder infection (cystitis). Pyelonephritis is often associated with fever, back pain and nausea which may require hospitalization. Pyelonephritis can result in damage and scarring of the kidneys over time.
Microorganisms called Chlamydia and Mycoplasma may also cause UTIs in both men and women, but these infections tend to remain limited to the urethra and reproductive system. Unlike bacteria such as E. coli, Chlamydia and Mycoplasma may be sexually transmitted, and infections require treatment of both partners.
The urinary system is structured in a way that helps ward off infection. By far, women are more frequently affected by UTIs. In men, the prostate gland produces secretions that slow bacterial growth. In both sexes, immune defenses also prevent infection. But despite these safeguards, infections can still occur. Pyelonephritis is uncommon because the ureters and bladder normally prevent urine from backing up toward the kidneys and the flow of urine from the bladder helps wash bacteria out of the body. Maintaining adequate hydration may help patients prone to UTIs.
Some people are more prone to getting a UTI than others. Any abnormality of the urinary tract that obstructs the flow of urine (a kidney stone, for example) sets the stage for an infection. In men, an enlarged prostate gland also can slow the flow of urine and impede prober bladder emptying, thus raising the risk of infection.
A common source of infection is indwelling catheters, or tubes, placed in the urethra and bladder. A person who cannot void or who is unconscious or critically ill often needs a catheter that stays in place for a long time. Some people, especially the elderly or those with nervous system disorders who lose bladder control, may need a catheter for life. Bacteria on the catheter can infect the bladder, so hospital staff take special care to keep the catheter clean and remove it as soon as possible.
People with diabetes have a higher risk of a UTI because of changes in the immune system. Any other disorder that suppresses the immune system raises the risk of a urinary infection.
UTIs may occur in infants, both boys and girls, who are born with abnormalities of the urinary tract, which sometimes need to be corrected with surgery. UTIs are rarer in boys and young men. In adult women, though, the rate of UTIs gradually increases with age. Scientists are not sure why women have more urinary infections than men. One factor may be that a woman's urethra is short, allowing bacteria quick access to the bladder. Also, a woman's urethral opening is near sources of bacteria from the anus and vagina. For many women, sexual intercourse seems to trigger an infection, although the reasons for this linkage are unclear.
According to several studies, women who use a diaphragm are more likely to develop a UTI than women who use other forms of birth control. Recently, researchers found that women whose partners use a condom with spermicidal foam also tend to have growth of E. coli bacteria in the vagina.
Many women suffer from frequent UTIs. According to some studies, nearly 20 percent of women who have a UTI will have another, and 30 percent of those will have yet another. Of the last group, 80 percent will have recurrences.
In my opinion, women with recurrent infections should be evaluated. At a minimum, a renal ultrasound and a cystourethroscopy should be performed. This allows evaluation of the upper and lower urinary tract anatomy for possible treatable causes.
Usually, the latest infection stems from a strain or type of bacteria that is different from the infection before it, indicating a separate infection. Even when several UTIs in a row are due to E. coli, slight differences in the bacteria indicate distinct infections.
Research funded by the National Institutes of Health (NIH) suggests that one factor behind recurrent UTIs may be the ability of bacteria to attach to cells lining the urinary tract. A recent NIH-funded study found that bacteria formed a protective film on the inner wall of the bladder in mice. If a similar process can be demonstrated in humans, the discovery may eventually lead to new treatments to prevent recurrent UTIs. Another line of research has indicated that women who are genetically "non-secretors" of certain blood group antigens may be more prone to recurrent UTIs because the cells lining the vagina and urethra may allow bacteria to attach (dock) more easily. Further research will show whether this association is sound and proves useful in identifying women at high risk for UTIs. Probiotics and vaccines are also being investigated.
Reconstructive Urology: Dr Angelo Gousse is fellowship trained training in upper and lower urinary tract reconstruction:
Procedures can include:
1- Ureteral reconstruction and Reimplantation. The procedure is typically indicated after ureteral trauma or injury of the ureter by cancer or other disease processes. The ureter can be refashioned, reconstructed, and then re-implanted into the urinary bladder On occasion, the urinary bladder has to be reconstructed or moved prior to the reimplantation / reconstruction (Psoas Hitch Procedure or Boari Flap) . A typical hospital stay is 3-4 days with a Foley catheter in the bladder for 1 or 2 weeks.
2- Bladder augmentation using intestinal segments such as colon or small intestines to enlarge the urinary bladder. This procedure is usually performed in patients with neurogenic bladder after spinal cord injury , spina bifida or multiple sclerosis. Urodynamic (bladder testing) may indicate a very high bladder pressure that is dangerous to the kidneys or leakage per urethra (incontinence) . The findings are caused by high bladder pressures or involuntary (spastic) contractions. Making the bladder larger by patching a segment (10-20 cm) of intestine into the bladder will decrease the bladder pressure and help protect the kidneys and achieve urinary continence.
On occasion, it is not possible to catheterize per urethra and a catheterizable tube (channel) has to be constructed using intestinal segments or the appendix (Mitrofanoff) . An anti-incontinence valve is created using intestines and special surgical techniques to allow the catheter to go in the augmented bladder very readily without allowing urine to leak out. Dr Gousse has performed more than 250 bladder augmentation procedures. The average hospital stay is 7 days after this procedure.
3- Urethral reconstruction.
Benign diseases of the urethra which affect urine flow and/or blaldder emptying very often require surgical intervention. Urethral strictures and urethral narrowing (stenoses) are treated by various techniques. The treatment for urethral strictures include numerous options, such as dilation with sounds or plastic dilators, urethrotomy (cutting scar tissue with a knife by going through the penis), stent and open reconstructive surgical techniques. The treatment choice will be dictated by the specific urethral condition or the surgeon’s preference. Although less effective long-term, urethral dilation and direct visual urethrotomy (DVIU) continue to be the most commonly used techniques.
They have a high failure rate with recurrence in at least 50% of patients. Most patients who undergo these procedures require repeated interventions for recurrences. Often the patients progress to surgical repair. Persistent use of dilation or urethrotomy for the treatment of urethral strictures may be the result of the urologist unfamiliarity with the published literature and inexperience with urethroplasty surgical techniques. Open urethral reconstruction (Urethroplasty) is the international gold standard treatment for urethral strictures. Urethroplasty is not a routine operation and a lack of the necessary skills should prompt a referral to a specialist skilled in urethroplasty.
There are two types of Urethroplasty. Many surgical techniques with or without grafts have been developed to allow the aesthetic reconstruction of the glans and the penis while repairing the strictured areas.
Basically, the surgical technique for urethral reconstruction is selected according to the cause and location of the urethral stricture disease. The choice between an anastomotic versus a tissue transfer technique is aided by a radiograph (retrograde urethrogram), surgeon experience and preference. The choice must, in addition be based on the proper anatomic characteristics of the penile tissues to ensure flap or graft take and survival. Urethroplasty is a open surgical procedure for urethral reconstruction to treat urethral stricture. Urethroplasty can be performed by 2 basic methods; Excision and anasmotomis (primary repair) which involves complete excision of the narrowed part of the urethra and the subsequent rejoining of the proximal and distal patent luminal segments. The second method of Urethroplasty utilizes tissue transfer (flaps) or graft technique. In this method, tissue is grafted from penile foreskin, or buccal (inner lining of the mouth ) mucosa and is used to enlarge the caliber of the strictured (narrowed) segment of the urethra. Dr Gousse prefers buccal mucosa graft as his tissue transfer(graft technique) because the graft material is abundant , well tolerated, cosmetic, and successful in most cases. Urethroplasty is typically performed under general or spinal anesthesia. Selected patients may be discharged home on the day of the surgery. Many others will be in the hospital for a day or two. The patients typically wears an indwelling urethral Foley catheter for 2- 3 weeks to allow the repair to heal. After catheter removal, the patients are followed with clinical symptoms, urine flow rate, and post void residual volumes to ensure bladder emptying. Many patients will be able to enjoy baseline sexual function and father children after surgery.
Like all surgical procedures, the results of urethroplasty are not 100%. A recurrence urethral stricture rate of 10 % can be expected long-term. Patients with pelvic fracture associated urethral stricture and prostate involvement associated strictures have the highest recurrence rate. Erectile dysfunction is also most commonly seen in this sub-category of patients.
Erectile Dysfunction Definition, Risk Factors, and Epidemiology
Erectile dysfunction (ED) is a medical condition manifested by the inability to achieve and or maintain an erect penis adequate for satisfactory sexual function. This condition is the most common sexual problem for men. The number of men suffering from ED increases steadily with age. It is estimated that 25 million American men suffer from ED, although not all men are equally affected by the condition. While approximately 52% of men will suffer from some degree of ED by the age of 70, only 15% will have complete ( no erection at all ) ED.
How Normal Erection is Achieved
A complex process involving psychological stimulus from the brain, adequate levels of the male sex hormone called testosterone, a normal nervous system, and healthy blood vessels in the penis chambers is required in order to achieve normal erections. In the soft (flaccid) state of the penis, the blood vessels inside the 2 chambers of the penis (corpora) are contracted and blood flows easily from the penis to the rest of the body. In the rigid state (erect) , the blood vessels in the chambers , under the influence of nerve impulses, become dilated, allowing more blood flow in the penis and also trapping blood in the penis, once the penis is fully erect. The trapping of blood in the penis increases the length, width, and temperature of the penis.
The Role of the male Sex Hormone: Testosterone
There are several risk factors for the development of ED. As men age, the level of circulating testosterone decreases, which may interfere with normal erection. While a low testosterone level itself is rarely the only cause of ED (5 percent or less), low testosterone can be an additional contributing factor in many men who have other risk factors for ED. Low levels of sexual desire, lack of energy, mood disturbances and depression can all be symptoms of low testosterone. A simple blood test can determine if the testosterone level is abnormally low, and testosterone can be replaced using a number of different delivery systems (e.g., injections, skin patches, and gels ) Of note, there is no FDA approved testosterone pill.
What Can cause Erectile Dysfunction
The most common cause of the development of ED is the presence of medical conditions such as high blood pressure, diabetes mellitus, renal disease, high cholesterol levels and cardiovascular disease. These medical conditions, acting over time, can lead to a hardening of the penile blood vessels, leading to restriction of blood inflow through the blood vessels. Surgery or radiation therapy for prostate , bladder, colon, or rectal cancer can also lead to the development of ED. Cryotherapy ( freezing of the Prostate ) for cancer is highly associated with ED.
Avoid Unhealthy Daily Habits
Unhealthy daily habits can lead to degeneration of the erectile tissue and the development of ED. Cigarette smoking, illicit drug use or alcohol abuse, particularly over a long period of time, will compromise the blood vessels of the penis. Lack of physical exercise and a sedentary lifestyle will contribute to the development of ED. Psychological stressors, marital issues, and
psychogenic disorders can also cause ED. Correction of these conditions will contribute to overall health and may help correct mild ED. Medical treatment of many medical conditions can interfere with normal erections. Prescription drugs used to treat these risk factors listed above may also lead to or worsen ED
How is ED diagnosed?
For most patients, the diagnosis will require a simple medical history, physical examination and a few routine blood tests ( blood sugar ( Hemoglin A1c ) ,cholesterol, lipid profile, PSA, testosterone, ect ). Several validated questionnaires help the clinician verify and grade the severity of the diagnosis. Most patients do not require extensive testing before beginning treatment. The choice of testing and treatment depends on the goals of the individual. If erection returns with simple treatment like oral medication and the patient is satisfied, no further diagnosis and treatment are necessary. If the initial treatment response is inadequate or the patient is not satisfied, then further steps may be taken. In general, as more invasive treatment options are chosen, testing may be more complex and involved.
Benign Prostatic Hyperplasia is Different from Prostate Cancer
Not to be confused with prostate cancer, benign prostatic hyperplasia (BPH) is essentially a normal part of male aging. Most men with benign prostatic hyperplasia BPH will never developed clinical prostate cancer. While prostate cancer typically grows in the peripheral zone of the prostate , BPH is found in the transition zone which is more toward the center (the core) of the prostate gland.
After the age of 40 the prostate progessively enlarges enlarges (from size 15 grams to approximately 50 grams - rarely up to 250 grams or more ) to the point where urination starts becoming more difficult.
Typical symptoms include needing to urinate very often (frequency) during the day or during the night (nocturia). Some patients start taking a while to get started (urinary hesitancy). Other patients start to strain or push to urinate (straining) . If the prostate grows too large or the tension of the prostate muscles increases, it may constrict the urethra, block the bladder neck (outlet) and impede the flow of urine, making urination difficult and painful.
In severe cases, the patient may not be able to urinate at all.
The bladder remains full, the patient has the desire to void, yet no urine comes out of the urinary bladder.
This condition called acute urination retention is very painful and considered a medical emergency. In cases of urinary retention, a urethral Foley catheter (a straw) is typically inserted to drain the urine out of the urinary bladder. If urinary retention remains untreated, it will cause kidney damage (hydronephrosis) and / or infection or even renal failure.
The cause of urinary retention needs to be determined since other medical and neurologic conditions can cause inability to urinate or adequately empty the urinary bladder. A bladder test called (Urodynamics) can determine that the bladder pressure is high while the urine flow is low. Cystoscopy and ultrasound of the prostate may be indicated in select cases.
Once prostate cancer has been ruled out by PSA blood test and digital rectal examination, a treatment plan can be determined.
Medication is the most common treatment for mild to moderate symptoms of prostate enlargement. The options include:
When Is Minimally invasive or surgical therapy Indicated ?
Minimally invasive or surgical therapy might be recommended if your symptoms are moderate to severe or medication hasn't relieved your symptoms. Other strong indications include severe urinary tract obstruction, bladder stones, gross blood in your urine or kidney problems. Other patients prefer surgical treatment instead
Any type of prostate procedure can cause side effects. Depending on the procedure you choose, complications might include:
There are several types of minimally invasive or surgical therapy.
Transurethral resection of the prostate (TURP)
A lighted rigid scope is inserted into your urethra, and the surgeon removes the central part (transition zone) of the prostate. It is still possible to develop prostate cancer after a TURP. Therefore, the patients need continued monitoring using PSA and rectal examination.TURP generally relieves symptoms quickly, and most men have a stronger urine flow soon after the procedure. After TURP you might temporarily need a catheter to drain your bladder, and you'll be able to do only light activity until you've healed. Usually erectile dysfunction is not noted after a TURP.
Transurethral microwave thermotherapy (TUMT)
Your doctor inserts a special electrode through your urethra into your prostate area. Microwave energy from the electrode destroys the inner portion of the enlarged prostate gland, shrinking it and easing urine flow. This surgery is generally used only on small prostates in special circumstances because re-treatment might be necessary.
Transurethral needle ablation (TUNA)
In this outpatient procedure, a scope is passed into your urethra, allowing your doctor to place needles into your prostate gland. Radio waves pass through the needles, heating and destroying excess prostate tissue that's blocking urine flow. This procedure might be a good choice if you bleed easily or have certain other health problems. However, like TUMT, TUNA might only partially relieve your symptoms and it might take some time before you notice results. Laser therapy
A high-energy laser destroys or removes overgrown prostate tissue. Laser therapy generally relieves symptoms right away and has a lower risk of side effects than does nonlaser surgery. Laser therapy might be used in men who shouldn't have other prostate procedures because they take blood-thinning medications. There is no evidence that Laser prostate surgery is superior to TURP .
In this newly FDA approved transurethral procedure, special tags (like staples) are deployed through the urethra to compress the sides of the prostate to increase the flow of urine by retracting the lateral obstructing lobes of the prostate. Long-term data on the effectiveness of this procedure aren't yet available.
When the prostate is very large, usually much greater than 100 grams as measured by a prostate ultrasound and the patient needs surgery, many urologists prefer an open or robotically assisted prostatectomy because it is safer and more effective. In this surgery the core (Transition Zone) of the prostate is removed after opening the bladder and/ or prostate. The peripheral zone is left behind. The recovery and bladder catheterization is typically much longer than TURP. It is important not to confuse this surgery with complete removal of the prostate performed for prostate cancer. In other words -Open prostatectomy is performed for benign prostatic hyperplasia (BPH) while Radical Prostatectomy is only recommended for prostate Cancer .
Epidemiology of Prostate Cancer
Prostate cancer remains one of the most common cancers in men in the United States, and is the second leading cause of cancer death in men. In 2015 approximately 220, 800 new cases of prostate cancer were diagnosed and roughly 28,000 of these men will die from their disease.
What are the symptoms of Prostate Cancer
Contrary to popular belief, most men with early prostate cancer never experience any symptom whatsoever. Symptoms usually do not become apparent until the disease has progressed beyond the prostate and therefore, prostate cancer is considered a silent killer. Advanced stage prostate cancer can present with symptoms such as difficulty or pain with urination, painful ejaculation, blood in the urine or semen. Pain or stiffness related to the cancer growing in the bones can also develop.
It is important to note that that sexual dysfunction is not associated with the risk of developing prostate cancer.
Is it Possible to Prevent Prostate Cancer ?
Risk factors for prostate cancer include age, family history and race. One in seven men will develop prostate cancer. One in five if you are African-American and one in three if you have a family history of the disease. Therefore, family history of first degree relative is a significant risk factor.
There are no proven preventative measures to diminish the chance of developing prostate cancer. No food choice or vitamin has been shown to completely prevent prostate cancer. It is possible to lower your risk of prostate cancer by making healthy lifestyle choices including exercising regularly and eating a balanced diet which is low in animal fat and high in fruits and vegetables.
The best defense against prostate cancer remains early detection. Most cases diagnosed at an early stage are detected during routine prostate cancer risk assessment which includes a PSA blood test and digital rectal examination.
In Haitian men, prostate cancer risk assessment should be initiated at the age of 40-45.
What to Do Once Prostate Cancer Has been diagnosed
The first decision to be made in managing prostate cancer is to determine whether treatment is needed. Not every patient with prostate cancer is treated the same way. Treatment is largely dependent on the aggressive of the disease (Gleason score) and expected life span. Other factors to consider are the number of positive biopsies and, PSA level, age and a person's views about potential treatments and their possible side effects.
Prostate cancer, especially low-grade (Gleason less than 7, PSA less than 10ng/mL ) found in elderly men, often grows so slowly that no treatment is required. Treatment may also be inappropriate if a person has other serious health problems or has an expected lifespan of less than 10 years.
Patients with minimal, low risk prostate cancer (defined as PSA less than 10 ng/ml, less than 3 positive biopsy cores all with low volume disease [no more than 5 %-10% in any core]) can be managed by active surveillance without the need for immediate treatment. This option can prevent patients from experiencing the morbidities of prostate cancer treatment without increasing their cancer specific mortality.
Active surveillance includes careful monitoring after diagnoses with PSA testing at regular intervals with repeat prostate biopsies and proceeding with treatment if the cancer parameters change.
Radical prostatectomy and radiation treatment remain the most common choices to treat clinically localized prostate cancer. Cryotherapy (freezing of the prostate) and ultrasound ablation (not approved in USA) are less popular choices. All treatment options carry the risk of significant side effects such as erectile dysfunction, urinary incontinence and difficulty voiding. Therefore prior to deciding upon definitive therapy, detailed discussions with patients are undertaken which focus on balancing the goals of therapy with the risks of lifestyle alterations.
Benign diseases of the urethra which affect urine flow and/or blaldder emptying very often require surgical intervention. Urethral strictures and urethral narrowing (stenoses) are treated by various techniques. The treatment for urethral strictures include numerous options, such as dilation with sounds or plastic dilators, urethrotomy (cutting scar tissue with a knife by going through the penis), stent and open reconstructive surgical techniques. The treatment choice will be dictated by the specific urethral condition or the surgeon’s preference. Although less effective long-term, urethral dilation and direct visual urethrotomy (DVIU) continue to be the most commonly used techniques. They have a high failure rate with recurrence in at least 50% of patients. Most patients who undergo these procedures require repeated interventions for recurrences. Often the patients progress to surgical repair. Persistent use of dilation or urethrotomy for the treatment of urethral strictures may be the result of the urologist unfamiliarity with the published literature and inexperience with urethroplasty surgical techniques. Open urethral reconstruction(Urethroplasty) is the international gold standard treatment for urethral strictures. Urethroplasty is not a routine operation and a lack of the necessary skills should prompt a referral to a specialist skilled in urethroplasty.
There are two types of Urethroplasty. Many surgical techniques with or without grafts have been developed to allow the aesthetic reconstruction of the glans and the penis while repairing the strictured areas. Basically, the surgical technique for urethral reconstruction is selected according to the cause and location of the urethral stricture disease. The choice between an anastomotic versus a tissue transfer technique is aided by a radiograph (retrograde urethrogram), surgeon experience and preference.
The choice must, in addition be based on the proper anatomic characteristics of the penile tissues to ensure flap or graft take and survival. Urethroplasty is a open surgical procedure for urethral reconstruction to treat urethral stricture. Urethroplasty can be performed by 2 basic methods; Excision and anasmotomis (primary repair) which involves complete excision of the narrowed part of the urethra and the subsequent rejoining of the proximal and distal patent luminal segments. The second method of Urethroplasty utilizes tissue transfer (flaps) or graft technique. In this method, tissue is grafted from penile foreskin, or buccal (inner lining of the mouth ) mucosa and is used to enlarge the caliber of the strictured (narrowed) segment of the urethra. Dr Gousse prefers buccal mucosa graft as his tissue transfer(graft technique) because the graft material is abundant , well tolerated, cosmetic, and successful in most cases. Urethroplasty is typically performed under general or spinal anesthesia.
Selected patients may be discharged home on the day of the surgery. Many others will be in the hospital for a day or two. The patients typically wears an indwelling urethral Foley catheter for 2- 3 weeks to allow the repair to heal. After catheter removal, the patients are followed with clinical symptoms, urine flow rate, and post void residual volumes to ensure bladder emptying. Many patients will be able to enjoy baseline sexual function and father children after surgery.
Like all surgical procedures, the results of urethroplasty are not 100%. A recurrence urethral stricture rate of 10 % can be expected long-term. Patients with pelvic fracture associated urethral stricture and prostate involvement associated strictures have the highest recurrence rate. Erectile dysfunction is also most commonly seen in this sub-category of patients.