Urinary incontinence in men is usually seen after surgical interventions on the prostate, urethra and bladder neck region or after serious accidents hitting these areas. It is the valve system called “sphincter” that provides urine retention in normal people. The external sphincter, located just below the prostate, is very important in urinary retention. The part of the prostatic urethra and the bladder neck act as internal sphincters. It is the external sphincter that is active in urinary retention. If this place is severely damaged, permanent urinary incontinence occurs.

If urinary incontinence has become permanent, is very serious and negatively affects the social life of the patient and does not respond to treatments, the last option is to insert an artificial urethral sphincter.

In this article, I will give current and general information about the artificial urinary sphincter, taking into account our own experiences.

What does urinary incontinence mean?

Urinary incontinence is an involuntary urinary incontinence that disturbs the person socially and hygienically and negatively affects his daily life. It occurs as a result of various diseases or as a result of damage to the valves that hold urine (sphincter) unintentionally during some surgeries. The sphincter is located just below the prostate in men and is a muscular layer that surrounds the urethra. Urinary incontinence occurs in men as a result of damage to this muscle.

What are the types of urinary incontinence?

There are different types of urinary incontinence. In general, we can classify the types of urinary incontinence as follows;

• Urge incontinence: It is urinary incontinence with a sudden sense of urination. Also called urge urinary incontinence.
• Stress incontinence: In cases where intra-abdominal pressure increases (such as laughing, coughing, sneezing, moving), it is urinary incontinence without increasing the pressure in the bladder.
• Overflow incontinence: In cases where the bladder does not function, which is usually seen in flaccid type neurogenic bladder, the bladder fills up to its last capacity and overflows. Since the feeling of bladder filling disappears here, patients do not realize that their urine is coming. Also called overflow urinary incontinence.
• Total incontinence: It is the continuous incontinence of urine day and night.
• Mixed type incontinence: It is the coexistence of different types of urinary incontinence. Often urge and stress incontinence coexist.

What does artificial urinary sphincter mean?

Artificial urinary sphincter is a device made of special materials for urinary retention incontinent men. It is usually applied to patients with severe urinary incontinence and impaired quality of life after prostate surgery in men. In a way, it does the job of a sphincter muscle that normally loses its function. It wraps around the urethra and creates pressure, closing the urethra and keeping the patient’s urine. The success rate is 61-100%, and the social continuity rate is 79%.

Who gets the artificial sphincter?

Artificial urinary sphincter is inserted in patients with severe urinary incontinence. In these patients, the urine-holding valves (sphincter) are severely damaged, so patients involuntarily leak their urine constantly. Artificial urinary sphincter is usually inserted in men for the following reasons;

• Prostate cancer surgery: Those who have undergone surgery for prostate cancer with robotic, laparoscopic and open methods
• Bladder cancer surgery: If permanent damage to the sphincter has occurred in patients who underwent radical cystectomy and artificial bladder (orthotopic bladder, neobladder) for bladder cancer
• After BPH surgery: TUR-P due to benign prostate enlargement (BPH), open prostate surgery and extremely rarely HOLEP surgery
• In patients with severe trauma: Patients with severe pelvic trauma and permanent damage to the sphincter
• If other treatments have been inadequate: In men with mild to moderate urinary incontinence, the last option is to insert an artificial sphincter if other treatments have been unsuccessful.
• Neurogenic causes: Some neurological diseases that involve the nervous system and damage the sphincter nerves

Who can not have artificial sphincter surgery?

Very rarely there are some situations where the artificial sphincter cannot be inserted. These;

• Untreatable detrusor hyperreflexia or bladder instability.
• Patients not suitable for surgery or anesthesia (physical and mental reasons)
• Patients with urinary incontinence due to irreversible obstruction in the lower urinary tract.
• Patients with advanced age and who cannot use the sphincter
• Patients who cannot actively use their hands

What are other surgical procedures for urinary incontinence?

There are other treatment methods that are not as effective as the artificial sphincter in the treatment of severe urinary incontinence in men. These;

• Male urethral sling surgery: Similar to female urethral sling surgeries
• Urethral bulking agent injection: Mass-forming agents are injected endoscopically under the urethral mucosa.
• Urinary diversion surgeries

What are the alternative methods to the artificial sphincter?

The last option in patients with urinary incontinence is artificial sphincter surgery. Existing treatment options are applied to the patients before this surgery, and if positive results are not obtained, the last option is artificial sphincter insertion. Although these treatments are applied for 8-12 months, if the patient has moderate and severe urinary incontinence that will negatively affect his daily life, sphincter surgery is performed. Treatment methods that can be applied before sphincter surgery are as follows;

• Conservative measures
  • Fluid restriction before bedtime
  • Restricting alcohol and coffee intake
  • lose weight
• Bladder training
• Pelvic floor exercises
• Electrical stimuli (sacral and tibial nerve stimulation)
• Medications (anticholinergics, alpha blockers, mirabegron, botulinum toxin A)
• Permanent urethral catheter

What should be done before the operation?

Artificial sphincter surgery is performed with general anesthesia or spinal anesthesia. Patients stay in the hospital overnight or are discharged on the same day when the effect of anesthesia wears off.

Pre-operative preparations are as follows;

• If patients are using blood thinners, these drugs are discontinued at least one week before as they will increase bleeding.
• Medicines used for chronic diseases are used if they do not interfere with anesthesia.
• Routine blood tests required for surgery are requested.
• Chest X-ray and ECG are taken in elderly patients.
• If the anesthesiologist deems it necessary, he/she requests a cardiology and endocrinology consultation (if there is diabetes). Echo may be requested from some patients if necessary.
• Do not eat or drink anything by mouth for at least 5-6 hours before the operation.
• If the surgical examinations are normal, the patients are admitted to the hospital on the day of surgery.
• Information forms required for the surgery are read, explained and signed by the patient.

How is artificial sphincter surgery performed?

Patients are placed supine under general or spinal anesthesia. The feet are lifted open and bent at the hips and knees. This position is called the lithotomy position. After the patient is prepared in the lithotomy position, the surgery area is cleaned with special disinfectants and closed. A urethral catheter is attached to the patient.

• By opening the area between the scrotum and anus (perineum), the urethra is found and freed from the surrounding tissues.
• A cuff is placed around the urethra appropriately.
• Then the pump is placed on the side of the testis by opening a pouch.
• The reserve (balloon) is placed in the lower part of the snow and finally these three structures are connected to each other.
• After checking whether the artificial sphincter is working or not, the operation is terminated by closing the incision.

The catheter inserted into the urethra is then removed after 24 hours and the patient waits for the healing process. Recovery takes an average of 4-6 weeks. During this period, the patient continues to leak urine as before. The system is activated and starts to be used after 4-6 weeks.

How does the artificial sphincter work and what is its structure?

The artificial urinary sphincter has 3 parts. All of these three parts are placed inside the body and are not visible from the outside.

• Cuff part (sleeve): This part surrounds the urethra and when it is filled with liquid, it compresses the urethra and prevents the urethra from closing and thus urine leakage.
• Pump: It is a pump system placed inside the scrotum, next to the testis. By pressing this system, the fluid in the reservoir comes to the cuff and the urethra is closed to prevent urine leakage.
• Reservoir (balloon): It is placed inside the abdomen.

Using the artificial urethral sphincter is very easy. There are some of our patients who have been using it for 17 years without any problems and very effectively, without any leakage of urine and technical problems. After the postoperative recovery period is completed, we explain the use of the system to the patients. Patients keep the sphincter closed in their normal lives. When the feeling of urine comes and they want to urinate, the pump next to the testis is pressed to fill the fluid in the cuff to the reservoir. In this way, the cuff filled with water empties, the urethra opens and the patient urinates. In a short time after urinating, the fluid in the reserve fills the cuff again, presses on the urethra and closes the urethra canal, and the patient begins to hold his urine.

What should be considered after the operation?

The operation takes approximately 1-1.5 hours. If the operation is normal and there is no serious problem due to the chronic diseases of the patient, the patients are taken to their rooms after the effect of the anesthesia wears off.

• After the operation, protective antibiotics and painkillers are started in the serum.
• Patients do not eat or drink orally for 4-5 hours after the operation.
• After 5 hours, water is taken by mouth and if there is no nausea and vomiting, liquid foods are taken.
• After 5-6 hours, if spinal anesthesia is not given, they get up and start walking, if spinal anesthesia is given, they stand up later.
• If the general condition of the patient is good after the operation, they are discharged the same day or stay in the hospital for one night.
• The catheter inserted into the patient during the surgery is removed the next day.
• After 10-14 days, patients start their normal lives and can work in light jobs.
• For 4-6 weeks, it is recommended that patients do not lift heavy weights, do heavy sports, and not use a bicycle.
• After 4-6 weeks, the system is activated and started.

When should a doctor be called after surgery?

If the patients discharged from the hospital follow the recommendations, they have a comfortable recovery period. In the following cases, the doctor performing the surgery should be called;

• If there is a high fever
• In case of inability to urinate
• If there is swelling, bleeding and severe pain at the operation site
• If there is excessive bruising, pain and swelling in the scrotum

What are the risks of the artificial sphincter?

It does urinary sphincter does not have serious risks. The possible disadvantages are:

• Few patients may have urine leakage in the form of dripping during heavy physical activity and weight lifting.
• There may be a wound infection
• The sphincter may malfunction later.
• There may be a sphincter infection
• There may be injury to the urethra
• There may be bleeding at the wound site
• There may be bruising, swelling and redness at the wound site.
• Inability to urinate when removing the catheter

What is the success rate of the artificial sphincter?

It is a surgery with a very high success rate. Success was reported in 91.8% of patients and complete dryness in 83.6%.

How long does the artificial sphincter stay in the human body?

Artificial sphincter can stay in the human body for a long time. Studies have shown that it can stay in the body for more than 10 years without any problems, and in some, it can stay in the body for more than 20 years. In our own patients, we have patients who have lived for 17 years without any problem and completely dry.

Can patients with urinary sphincter use a bicycle?

It is important for patients to avoid pain and physical activities for 4-6 weeks after surgery. In order to be able to use a bicycle, it is necessary to wait 4-6 weeks after the operation.

What are the advantages?

Artificial urinary sphincter surgery has many advantages. We can list them as follows;

• The success rate is very high
• It is the most effective method for urinary incontinence in men.
• It can remain trouble-free for a long time
• Easy to use
• It is not visible in any way outside the body.
• Since it is covered with antibiotics, the risk of infection is low
• Low risk of adjacent organ injury
• It is a method used in the world since 1972.
• The risk of glob development is low
• Urge incontinence risk is extremely low
• Very low failure rate

What are the disadvantages?

The disadvantages of artificial sphincter surgery are extremely few. These;

• There is a low risk of infection of the sphincter.
• There is a risk of erosion of the urethra
• Mechanical problems may occur
• Urinary incontinence will continue for 4-6 weeks after surgery (recovery period)
• Reaction to anesthesia may occur

What are the cases when the sphincter requires revision?

Revision may be required, albeit infrequently, after surgery. Situations where artificial sphincter revision is required are as follows;

• Sphincter infection (common in diabetics)
• Urethral atrophy
• Urethral erosion
• Technical malfunctions

In summary; Artificial sphincter prostate surgeries (radical prostatectomy, TUR-P) are performed in cases with moderate to severe urinary incontinence due to surgeries such as radical cystectomy or other reasons that do not respond to other treatments. It has a high success rate, low complications, and easy to use. It is a system that can remain in the body for a long time without any problems.

Prof. Dr. Emin OZBEK

Urology Specialist

Istanbul -TURKIYE