Urinary incontinence is a common condition mainly associated with women, with a ratio of nearly 2:1 (approximately 55% of women are estimated to experience incontinence) (Helfand el al, 2018). This prevalence in females is due to their numerous risk factors, especially associated with childbirth (Yates, 2017). However, urinary incontinence affects both sexes and can have a severe negative impact on quality of life (Nursing Times, 2019). Health professionals are aware that in general women's health outcomes in the UK are usually poorer than men's (Winchester, 2021); however, this does not seem to be the case for male urinary incontinence (Lancet, 2019). The above statistics have led to disparity in continence care for men, leading to most male continence needs being unmet or neglected by professionals (Stenzelius, 2005; Nursing Times, 2019; Yates, 2021). This article will identify how male urinary incontinence care can be improved by looking at the prevalence of the condition, identifying risk factors associated with male urinary incontinence, looking at the skills health professionals require to adequately assess male patients and covering the treatment and management options available.
After reading this article practice nurses will be able:
- To identify the risk factors associated with male urinary incontinence
- To identify the types of symptoms/urinary continence issues men can experience
- To identify the requisites for a basic urinary continence assessment
- Discuss how to implement conservative therapies including medication
- Identify equipment/devices used in the management of urinary incontinence in men.
Prevalence
Urinary incontinence has been defined by the International Continence Society (ICS) as ‘any involuntary leakage of urine’ (Abrams et al, 2003; Haylen et al, 2010). NHS England (2018) estimate that, in the UK, there are over 14 million people who have bladder problems and urinary incontinence. Helfand et al (2018) identified that 55% of women experience urinary incontinence, while Milsom (2000) compared studies on the prevalence of urinary incontinence in men and women and generally found that this condition is three times more common in women than in men. However, even though the condition is more prevalent in females, NHS England (2018) state that 61% of men will experience lower urinary tract symptoms (LUTS). This difference in prevalence does become less marked with age, as male incontinence is usually associated with ageing (Nursing Times, 2019). Buckley and Lapitan (2010) suggested that 1 in 3 older men have continence problems. In their systematic review, Shamliyan et al (2009) showed that the prevalence of urinary incontinence rose from 5% in men aged 19–44 years to 11% in those aged 45–64 years, and further rose to 21% in men aged over 65 years, with 8.3–9.3% experiencing daily incontinence and 4% having severe symptoms (Shamliyan, 2009; Nursing Times, 2019). Post-surgical urinary incontinence after radical prostatectomy is frequent, ranging from 7–57% (Daugherty et al, 2017). However, all prevalence figures rely on individuals reporting symptoms and we have already eluded that men do not readily access health services so these figures may be under-reported.
Lower urinary tract symptoms and risk factors in men
Lower urinary tract symptoms (LUTS) have varying types and terminologies associated with them, which vary in cause according to gender, eg stress urinary incontinence is associated with leakage on coughing, sneezing or exertion caused by an incompetent urethral sphincter. In females this is mainly associated with childbirth or menopause, while in males it is associated with prostate surgery (Yates, 2021). The National Institute for Health and Care Excellence (NICE) (2017) identify LUTS in men as problems with storage, voiding or post-micturition of urine (Table 1).
Table 1. Lower urinary tract symptoms
| Symptom | Clinical presentation |
|---|---|
| Voiding symptoms |
|
| Storage symptoms |
|
| Post-micturition symptoms |
|
While most health professionals would agree that the biggest risk factor for men to suffer some degree of urinary continence problem is associated with the prostate gland, this is not the only reason and risk factors are multifactorial. They can include physical/mobility issues, eg getting to the toilet in time or being unable to get upstairs, especially after surgery such as hip replacement. Conditions such as diabetes, stroke, spinal injuries, multiple sclerosis or cognitive impairments like dementia can also play a factor. These risk factors are summarised according to Shamliyan et al (2009) and Nursing Times (2019) in Table 2. However, practice nurses should be aware that men may suffer from LUTS or bladder dysfunction without having urinary incontinence. These men still require a full assessment and interventions/treatments.
Table 2. Risk factors for male urinary incontinence
| Poor general health |
| Physical/mobility disabilities |
| Cognitive impairment eg dementia, Parkinson's disease |
| Comorbidities |
| Urinary tract infections |
| Abnormalities or dysfunction of urethra, bladder (detrusor muscle weakness or over-activity) or sphincter muscles |
| Prostate problems/enlargement/benign prostatic hyperplasia (BPH)/prostate inflammation (prostatitis) |
| Neuropathic disease/conditions, eg stroke, diabetes, multiple sclerosis, spinal injury |
| Advancing age and frailty |
Assessment
Prior to any treatments or management being instigated, a full individual continence assessment should be undertaken to rule out any red flag presenting symptoms including (NICE, 2017; Yates, 2020):
- Haematuria (blood in the urine)
- Blood in the semen
- Painful burning sensation on urination/ejaculation
- Difficulty to start flow or straining to pass urine
- Hesitancy
- Weak flow.
NICE (2017) recommend that the initial assessment should include the individual's previous medical/surgical history, taking into account any comorbidities, eg diabetes, stroke, mobility problems, BMI, smoking status and any allergies. Current prescribed, over the counter, herbal or recreational medication taken should be recorded. A frequency volume chart/bladder diary should be completed (usually for 3 days) including details of fluid type and amount consumed, and a urinalysis completed to screen out or detect any abnormalities, eg glucose, protein, blood. A post-void residual urine (PVRU) bladder scan should be performed (if presenting with symptoms of poor flow, feelings of incomplete emptying and recurrent UTIs, or there is an underlying neuropathy). Volumes of 100–150 ml are usually considered significant, but this will depend on total bladder capacity and physical examination (if competent) of abdomen, external genitalia and digital rectal examination (DRE) of the prostate. Advice should also be given about prostate specific antigen (PSA) testing. There are a number of validated assessment documents, which can assist professionals in their assessment. These include the International Consultation Incontinence Questionnaire (ICIQ), which also comes in a shortened version (ICIQ – short form) (Yates, 2019), and the International Prostate Symptom Score (I-PSS), which poses seven questions, six relating to urinary continence symptoms and one relating to quality of life (Yates, 2019). Also check for constipation, which can be a contributory cause to bladder symptoms, and erectile dysfunction, which is often associated with bladder dysfunction.
Conservative therapies/treatments
According to presentation of symptoms, treatments should initially consist of simple, conservative lifestyle changes (Burkhard et al, 2020), which can include fluid advice. It is usual to advise individuals to drink 1.5–2 litres daily and to decrease caffeine intake if possible, as experts agree that it may have a stimulant effect on the bladder and exacerbate urgency, frequency and nocturnal voiding (Burkhard et al, 2020). Caffeine is mainly found in coffee, tea, drinking chocolate, cola and other carbonated drinks. Burkhard et al (2020) state that all individuals who are overweight or obese and suffer from urinary incontinence should be encouraged to lose weight. While smoking cessation and physical activity/exercise are encouraged for general health, there is little evidence and no conclusive data on their effects on continence. Pelvic floor rehabilitation has been shown to be a stand-alone therapy for the treatment of urinary incontinence and bladder retraining/bladder drill improves bladder urgency, frequency, time between voids, increases bladder capacity and reduces incontinence episodes (Herbert, 2019). It is recommended that the programme is continued for at least 6 weeks (Herbert, 2019).
Pharmacological therapies should only be initiated following a trial of conservative therapies, but can often be used as an add-on to these therapies. Table 3 lists the drugs used to manage urinary incontinence, with the most common group being anticholinergics/antimuscarinics. Unfortunately, there are side effects for these drugs including dry mouth, drowsiness, constipation, nausea and vomiting, blurred vision/dry eyes, skin reactions eg rash, photosensitivity, gastric disturbances and reduced sweating. This sometimes makes individuals non-compliant with taking as prescribed. There is a growing concern about the use of antimuscarinics due to the association with declining cognitive function, especially in the elderly and over 65s (Herbert, 2019). An antimuscarinic burden scale (ABS) has been developed to assess an individual's risk with regards to this type of medication (Tooz-Hobson and Robinson, 2019).
Table 3. Summary of medications used in bladder problems
| Medication | Recommended use |
|---|---|
| Anticholinergics/antimuscarinics |
|
| Mirabegron |
|
| Desmopressin |
|
| Alpha blockers |
|
| 5-alpha reductase inhibitors |
|
Adapted from Burkhard et al, 2020
Management
While treatment options are always the best outcome, not all urinary incontinence can be cured completely and even those who are successfully treated may have to endure incontinence for a time (ICS, 2017). The management will depend on the type of bladder problem, ie if unable to empty bladder then there may be use of an intermittent catheter or indwelling catheter (dependent on patient's presentation and abilities). If urinary leakage is the main issue with no retention, then use of male urinals, urinary sheaths, penile clamps, pad products or pubic pressure devices may be appropriate. Due to the many different types of devices available, the choice for health professionals to select an appropriate one can be confusing and overwhelming, as all of these devices come in different sizes, different applications and pad products come in different shapes/absorbencies. To assist in this, the ICS have collaborated to make information available via a website at: www.continenceproductadvisor.org.
Conclusion
Male urinary incontinence, although not as well documented or as frequently occurring as female urinary incontinence, is still an area whereby practice nurses who have some knowledge of the condition can make a huge impact on the lives of individuals. Basic understanding of the causes of incontinence that affects males, the risk factors that may make them more prone to urinary incontinence, understanding the requirements for a basic assessment and then conservative treatments or even progressing to management options will provide their male patients with better outcomes that may not be available at present. This is an area whereby an incredible amount of good can be done.
KEY POINTS:
- Although incontinence is more prevalent in females, 61% of men will experience lower urinary tract symptoms and 1 in 3 older men have continence problems
- Prior to any treatments or management being instigated, a full individual continence assessment should be undertaken to rule out any red flag presenting symptoms
- Treatments should initially consist of simple, conservative lifestyle changes
- Pharmacological therapies should only be initiated following a trial of conservative therapies, but can often be used as an add-on to these therapies
- While treatment options are always the best outcome, not all urinary incontinence can be cured completely and even those who are successfully treated may have to endure incontinence for a time
CPD reflective practice:
- Can you identify the risk factors associated with male urinary incontinence?
- What types of symptoms/urinary continence issues can men experience?
- How could you help patients manage their incontinence?