Male Urinary Incontinence

Abstract

The aim of the current study was to determine the demographic characteristics and risk factors associated with male urinary incontinence (UI) and to assess the effectiveness and the effect on the quality-of-life of a pelvic floor muscle training (PFMT) protocol with electromyography-biofeedback (EMG-BFB) with surface electrodes. A prospective, quasi-experimental before-and-after study with a sample of 61 men out of 372 patients referred to the Pelvic Floor Unit from October 2005 to June 2012 was performed. The protocol consisted of 20 sessions of EMG-BFB supervised by a physiotherapist twice a week. The session durations were 30 minutes (118 work/rest cycles of pelvic muscles). Work lasted 3 seconds and rest 7 seconds. Patients were given standards of conduct and questionnaires (International Consultation on Incontinence–Short Form and Incontinence Quality-of-Life Measure) at the beginning and at the end of the treatment. The average age was 64.85 ± 14.34 years; 44.3% (n = 27) had benign prostatic hypertrophy, 41.9% (n = 25) had prostate malignant neoplasm, 86.9% (n = 53) had undergone prostatectomy, 16.4% (n = 10) had undergone abdominal surgery. Abdominal surgery and radical prostatectomy were significantly associated with UI (p < .05). Stress urinary incontinence was the most common type of UI (86.67%), followed by mixed urinary incontinence (8.33%) and urge urinary incontinence (5%). A significant improvement (p < .05) in both International Consultation on Incontinence–Short Form and Incontinence Quality-of-Life Measure questionnaires was observed when making comparisons regarding the results before and after the EMG-BFB treatment protocol. These results support that male UI is significantly associated with urological and abdominal surgery (including radical prostatectomy) and that EMG-BFB for PFMT improves incontinence and quality of life (social embarrassment, limiting behavior, and psychosocial impact) in the three types of UI on an overall basis.

Introduction

The International Continence Society defines urinary incontinence (UI) as the manifestation of any involuntary leakage of urine (Haylen et al., 2010). This concept differs from the previous accepted definition, as the leak had to be demonstrable and of such magnitude to cause a hygienic or social problem (Abrams, Blaivas, Stanton, & Andersen, 1990; Bates, Bradley, & Glen, 1977), which emphasized the real prevalence of the disease.

However, it remains an underdiagnosed disease, since the problem is attributed to age and due to the shame feeling or lack of information. UI has an important economic, social, and psychological impact (Van Oyen & Van Oyen, 2002). Between 2 and 6 million people suffer UI in Spain, with a prevalence from 15% to 50% (Damián, Brenes, Pastor-Barriuso, & Salinas, 2008; Parazzini, Lavezzari, & Arbitani, 2002). Although prevalence is higher in females and it is commonly related to them, it is estimated that 1.7 million men could be incontinent in Spain (Damián et al., 2008; Parazzini et al., 2002), so male incontinence is a problem that should be taken into account, although few studies have been carried out on this issue.

From the clinical point of view, UI is divided into stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence (MUI; Espuña Pons, 2003; González Rebollo, Blázquez Sánchez, Romo Monje, & Rioja Toro, 2003). SUI is also divided into three grades, according to the scale of Obrink (Rioja Toro, González Rebollo, & Estévez Poy, 2005).

UI is not a life-threatening process, but it significantly impairs quality of life (QOL) of patients, limits their autonomy, and reduces their self-esteem (Espuña Pons, 2003). QOL can be even more affected than in other chronic diseases such as diabetes or hypertension (Kelleher, 2001; Robles, 2006). Therefore, the International Continence Society advises including QOL parameters in the UI treatment assessments. There are different specific questionnaires/scales (Rioja Toro et al., 2005), including the Incontinence Quality-of-Life Measure (I-QOL) and the International Consultation on Incontinence–Short Form (ICIQ-SF), both validated in Spanish and frequently used together with the King’s Health Questionnaire.

Regarding the different therapeutic methods for UI treatment, biofeedback (BFB) is considered within the conservative measures as an instrumental technique for pelvic floor muscle training (PFMT). There are two types: manometric and electromyography-biofeedback (EMG-BFB; Rioja Toro et al., 2005). EMG-BFB is the most used one, and its efficacy in the treatment of SUI and MUI (Dannecker, Wolf, Raab, Hepp, & Anthuber, 2005) has been proven. The most recent data indicate that PFMT reduces episodes of UI in 54% to 72% and rates of improvement in randomized trials vary from 61% to 91% (Robles, 2006).

The aim of our study is to determine the demographic characteristics and risk factors associated with male UI, the frequency by age, type, and degree of incontinence, and to assess the effectiveness of the PFMT protocol with EMG-BFB with surface electrodes carried out at our Pelvic Floor (PF) Unit of Department of Rehabilitation at Salamanca’s University Healthcare Complex (CAUSA), as well as the potential effect on the QOL of incontinent men through the ICIQ-SF and I-QOL questionnaires.

Material and Method

A prospective, quasi-experimental before-and-after study was conducted with a sample of 61 men out of 372 patients referred to the PF Unit of CAUSA. The study period ran from October 2005 to June 2012, and it was included in the action protocol carried out in our unit.

The exclusion criteria were lack of collaboration, inability to understand the treatment, quitting, and/or failing to fulfill any of the used questionnaires.

Affiliation data, personal history, predisposing factors, and type of incontinence (age, sex, urological and prostatic pathology, urological, prostatic, and abdominal surgery) were collected at the initial assessment. The patients were given standards of conduct and the questionnaires in order to complete them at the beginning and at the end of the treatment.

The used questionnaires were ICIQ-SF and I-QOL, specific for UI and QOL.

The ICIQ-SF is a brief questionnaire that allows detecting UI as well as the severity, type, and impact of the UI in QOL (Robles, 2006). The score ranges from 0 to 21; higher scores indicate greater severity (Table 1).

Table 1.

Urinary Incontinence ICIQ-SF Questionnaire.

1. How often do you leak urine? (Circle only one answer)
	Never	0
	Once a week	1
	2-3 times/week	2
	Once a day	3
	Several times a day	4
	All the time	5
2. How much urine do you think you leak, that is, how much urine do you usually leak (whether you wear protection or not)? Circle only one answer.
	None	0
	A small amount	2
	A moderate amount	4
	A large amount	6
3. Overall, how much does leaking urine interfere with your everyday life?
1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10
Not at all                  A great deal
4. When does urine leak? Please tick all that apply to you.
□ Never
□ Before you can get to the toilet
□ When you cough or sneeze
□ When you are asleep
□ When you are physically active/exercising
□ When you have finished urinating and are dressed
□ For no obvious reason
□ All the time

Note. ICIQ-SF = International Consultation on Incontinence Questionnaire–Short Form. ICIQ-SF score: Sum scores of 1 + 2 + 3 questions. Any score more than zero is considered as urinary incontinence diagnostic.

The I-QOL specifically measures the QOL in UI (Robles, 2006). It consists of 22 items, all of which have a value from 1 (extremely) to 5 (not at all). Although the maximum value is 110, it is transformed into a 0- to 100-point scale for a better interpretation; a higher score indicates better QOL. Three subscales can be identified: Limiting Behavior, 8 items; Psychosocial Impacts, 9 items; and Social Embarrassment, 5 items (Table 2; Monz et al., 2005; Patrick et al., 1999; Schurch et al., 2007).

Table 2.

I-QOL of Urinary Incontinence Quality of Life Questionnaire.

	1	2	3	4	5
1. I worry about not being able to get to the toilet on time.	□	□	□	□	□
2. I worry about coughing or sneezing.	□	□	□	□	□
3. I have to be standing after sitting down.	□	□	□	□	□
4. I worry about where the toilets are in new places.	□	□	□	□	□
5. I feel depressed.	□	□	□	□	□
6. I don’t feel free to leave my home for long periods of time.	□	□	□	□	□
7. I feel frustrated because my incontinence prevents me from doing what I want.	□	□	□	□	□
8. I worry about others smelling urine on me.	□	□	□	□	□
9. My incontinence is always on my mind.	□	□	□	□	□
10. It is important for me take frequents trips to the toilet.	□	□	□	□	□
11. Because of my incontinence, it is important to me to plan every detail in advance.	□	□	□	□	□
12. I worry about my incontinence getting worse as I get older.	□	□	□	□	□
13. I have a hard time getting a good night sleep.	□	□	□	□	□
14. I worry about being embarrassed or humiliated because of my incontinence.	□	□	□	□	□
15. My incontinence makes me feel like I am not a healthy person.	□	□	□	□	□
16. My incontinence makes me feel helpless.	□	□	□	□	□
17. I get less enjoyment out of life because of my incontinence.	□	□	□	□	□
18. I worry about wetting myself.	□	□	□	□	□
19. I feel like I have no control over my bladder.	□	□	□	□	□
20. I have to watch what or how much I have to drink.	□	□	□	□	□
21. My incontinence limits my choice of clothing.	□	□	□	□	□
22. I worry about having sex.	□	□	□	□	□
The following scoring system is used for all the elements:1: Always; 2: Usually; 3: Sometimes; 4; Rarely; 5: NeverSubscales structure:(LB), Items 1, 2, 3, 4, 10, 11, 13, and 20(PI), Items 5, 6, 7, 9, 15, 16, 17, 21, and 22(SE), Items 8, 12, 14, 18, and 19

Note. I-QOL = Incontinence Quality-of-Life; LB = Limiting Behavior; PI = Psychosocial Impacts; SE = Social Embarrassment. Calculation of subscale score = (obtained sum by corresponding items/sum of maximum value of analyzed items) × 100%. Calculation of total score of the scale = (obtained sum by total items/110) × 100%.

The used equipment was Myomed® 932, which allows performing EMG-BFB with two channels and delivering audio and visual signal connected to a computer. Two semifrozen adhesive electrodes were placed around the anus at 3 and 9 hours in order to record the electrical activity of the pelvic floor muscles and another indifferent electrode was placed in an area distant from the working area (front thigh). The second channel was used to avoid contraction of the parasite’s musculature (abdominal muscles, gluteus, and adductors), thus isolating the exclusive work of the PF musculature.

Our protocol consisted of 20 sessions of EMG-BFB, which were supervised by a physiotherapist and performed twice a week. Each session lasted 30 minutes. At each session, the patient faced the computer screen for visual control in supine position with lower limbs in semiflexion. The recorded signal of the muscle activity acted as a catalyst for motor learning. The patient performed 118 work/rest cycles of pelvic muscles. Work lasted 3 seconds and rest 7 seconds.

In the first 18 cycles, the intensity of the work to be performed for each patient was assessed according to his ability, using the mean value in micro-volts (µV) given by the equipment in order to perform the rest, not exceeding 15µV in men.

SPSS® 14.0 software was used for the statistical analysis. Means and standard deviations were used for the descriptive analysis of quantitative variables; frequencies and percentages were used for qualitative variables. The chi-square test was used for qualitative variables contrasts. After checking that the population did not meet a normal distribution, according to the Kolmogorov–Smirnov test, a nonparametric test (Kruskal–Wallis) was performed in order to examine whether the observations of each group were or were not independent during the study of quantitative variables.

Nonparametric tests were used for the comparative analysis, since the variables were not distributed according to a normal distribution. Wilcoxon test was used for two related samples in order to determine the difference between pairs of each scale (median). The nonparametric Mann–Whitney U test was used in order to make comparisons between the medians of the surveys before and after the treatment.

Results

A total of 63 men were included as final sample out of a total of 372 patients, both men and women, referred to the Unit. All women were excluded; two men were excluded: one died and another left the study, leaving a total of 61 patients (n = 61).

The average age was 64.85 ± 14.34 years. Concerning the predisposing factors, 44.3% (n = 27) had benign prostatic hypertrophy, 41.9% (n = 25) had prostate malignant neoplasm, and 86.9% (n = 53) had undergone prostatectomy.

Regarding the surgical history, 85.2% (n = 52) had undergone a surgery due to urological problems, and 16.4% (n = 10) had undergone abdominal surgery (hernias, appendectomy, or cholecystectomy).

From the above, urological and abdominal surgery and radical prostatectomy have demonstrated significant association (p < .05). There is no proved significant association of benign hypertrophy or prostate malignant neoplasm (Table 3). SUI was the most common type of UI. It was present in 86.87% of cases (n = 53), followed by MUI (8.2%, n = 5) and UUI (4.91%, n = 3).

Table 3.

Demographic Characteristics and History of Patients of the Studied Population (n = 61).

Characteristic		AV	SS a
Age (years, average, SD)	64.85 ± 14.34	61	—
Men (n, %)	61 (16.4%)	372	—
Waiting time (days, SD)	93.08 ± 98.59	61	—
Urological surgery men (n, %)	52 (85.2%)	61	.00
Abdominal surgery men (n, %)	10 (16.4%)	61	.00
Prostate benign hypertrophy (n, %)	27 (44.3%)	61	.37
Prostate malign neoplasm (n, %)	25 (41.9%)	61	.16
Radical prostatectomy (n, %)	53 (86.9%)	61	.00

Note. AV = analyzed value; SD = standard deviation; SS = statistical significance.

a

Statistical analysis type: chi-square.

Urological and abdominal surgery and radical prostatectomy have demonstrated significant association with UI.

According to Obrink classification of SUI, Grade 3 was the most common one (65.38%). The three types of UI identified a progressive and exponential increase of prevalence with increasing age (Figure 1).

Figure 1.

Behavior of male urinary incontinence types by age groups.

A significant improvement (p < .05) in both ICIQ-SF and I-QOL questionnaires and its subscales was observed when making comparisons regarding the results before and after the EMG-BFB treatment protocol (Figure 2), and for SUI when studying all types of UI, but clinical improvement was seen for all UI types (Table 4, Figure 3) and the different subscales of I-QOL (Figure 4). ICIQ-SF was the only questionnaire that presented nonsignificant worsening for MUI; contradictorily, overall I-QOL reported significant improvement (p = .04) for the same type of incontinence (Table 4).

Figure 2.

Medians of ICIQ-SF and I-QOL surveys at the beginning and at the end of the treatment in global UI patients.

Table 4.

Results of Biofeedback on the Medians of the ICIQ-SF and I-QOL Scales Total and by Items (LB, PI, SE), at the Beginning (b) and the End (e) of the Intervention, in Global Urinary Incontinence and by Types (n = 61).

IU		ICIQ-SF b-e	I-QOL b-e	LB b-e	PI b-e	SE b-e
Global	Median	14.0-11.0	72.0-83.5	28.0-32.0	31.5-34.5	15.0-18.0
	SS	.000	.000	.000	.000	.000
SUI	Median	14.0-10.5	72.0-83.0	28.0-32.0	32.0-34.0	15.0-18.0
	SS	.000	.000	.000	.000	.000
UUI	Median	10.5-8	82.5-92.5	31.5-34.5	33.0-37.0	18.0-21.0
	SS	.18	.32	.32	.32	.32
MIU	Median	12.0-13.0	77.0-90.0	23.0-33.0	30.0-39.0	14.0-15.0
	SS	.20	.04	.08	.22	.07

Note. UI = urinary incontinence; SUI = stress urinary incontinence; UUI = urge urinary incontinence; MUI = mixed urinary incontinence; b-e = beginning to end; SS = statistical significance; LB = limiting behavior; PI = psychosocial impacts; SE = social embarrassment. Type of statistical analysis: Mann–Whitney U.

Figure 3.

Medians of ICIQ-SF and I-QOL surveys at the beginning and at the end of the treatment in SUI, UUI, and MUI patients.

Figure 4.

Medians of I-QOL survey subscales at the beginning and at the end in SUI, UUI, and MUI patients.

Discussion

UI is an entity usually attributed exclusively to females, but it may appear in both sexes. Studies support that it is more common in women; nevertheless, the difference of prevalence varies according to different studies (Robles, 2006), reaching 20:1. This great difference is explained by the author as men being reluctant to admit the problem (Cervera Deval, Sarralta Davia, Macia Pareja, Moreno Alzuyet, & Mayoral Azofra, 2004). In our study, men accounted for 16.4% out of the total of incontinent (female/male ratio = 4:1).

Among the predisposing factors of UI in men described in the literature, prostate cancer and its treatment stand out as the most prevalent risk factor, and together with sexual impotence are the most common secondary symptoms (Juan Escudero et al., 2006). Prostatectomy is associated to SUI or MUI, while radiotherapy is associated to UUI. In fact, prostatectomy causes UI in 19% of patients (Juan Escudero et al., 2006). Nevertheless, it can also be associated with neurological or motor impairment and other chronic diseases in both men and women (Cervera Deval et al., 2004).

MUI occurs in older patients under radiotherapy and/or hormonal treatment (Glazer & Laine, 2006; Serdà, Vesa, del Valle, & Monreal, 2010). Prostate cancer and prostatectomy are associated to SUI, UUI, and sexual impotence (Serdà et al., 2010). The cause of UI in prostatectomized patients may be sphincter deficiency, detrusor overactivity, or urinary obstruction (Tarcía Kahihara, Ferreira, Nardi Pedro, Matheus, & Rodrigues Netto, 2006).

In elderly patients, prostate hyperplasia is also a risk factor for UI (Verdejo Bravo, 2007). Our study findings identify, as well as the published literature, statistical association with previous urological or abdominal surgery and radical prostatectomy. Surprisingly, benign prostatic hypertrophy or neoplasm did not demonstrate any association with UI in our study.

These findings are consistent with the assertion of Robles (2006), who claims that wall prolapse, PF weakness, and urological surgery are factors associated to UI. On the other hand, Tarcia Kahihara et al. (2006) claim that radical prostatectomy causes an incidence of postoperative UI from 0.5% to 40%.

As for the most prevalent clinical presentation, our data match most of the studies, being SUI the most common one (Robles, 2006). There are various data: Espuña Pons (2003) points in her work SUI as the most common one, but UUI is more common than MUI; by contrast, Flores Sánchez et al. (2004) report a higher prevalence of MUI, followed by UUI and finally by SUI. Some authors also argue that MUI may be overstated (García Bascones et al., 2012).

Age is considered as a risk factor for UI. This entity has even been considered as a problem associated to age. Various studies indicate that the prevalence of UI increases as the population ages (Cervera Deval et al., 2004; Córcoles et al., 2008; Flores Sánchez et al., 2004; Juan Escudero et al., 2006; Robles, 2006; Verdejo Bravo, 2007), which matches with our study. Age causes urethral sphincter dystrophy, which would be the cause of development of UI (Juan Escudero et al., 2006). In relation to this, Robles (2006) says that the UUI is most common in those over 75 years.

Conservative and surgical techniques are used for the UI treatment, and neuromodulation is considered a mixed technique. The modalities of conservative treatment include drug treatment, behavioral therapy, changing of hygienic-dietary habits, active PFMT, BFB and electrostimulation, having better results than those that produce active contractions (Lorenzo Gómez, Silva Abuín, García Criado, Geanini Yagüez, & Urrutia Avisrror, 2008; Pena Outeiriño, Rodríguez Pérez, Villodres Duarte, Mármol Navarro, & Lozano Blasco, 2007).

PFMT activates perineo-detrusor inhibitory reflex, which acts in episodes of UUI, the tone of these muscles increases, which increases resistance in efforts (Pena Outeiriño et al., 2007), and the right mobility and position of the urethra is maintained, which is essential for continence, especially in women (Lorenzo Gómez et al., 2008). Passive containment elements and stretching nerve structures (Sengler & Grosse, 2001) are also protected. This technique can be used both for mild and moderate UI in women (Lorenzo Gómez et al., 2008) and for postprostatectomy UI in men (Juan Escudero et al., 2006; Serdà et al., 2010).

The BFB is a technique by which a physiological process, which is usually subconscious, is presented to the patient and the therapist through a visual or audio signal or a combination of the two signals. This signal is subsequently used to teach and correct the physiological process achieving a therapeutic effect (Pena Outeiriño et al., 2007). This PFMT technique facilitates learning, creates a strong motivation, allows self-assessment, control, and customized work, and is an effective technique for perineal recovery (Pena Outeiriño et al., 2007).

In this study, patients treated with EMG-BFB had a significant improvement in both ICIQ-SF and I-QOL questionnaires, the latter both for the overall score and for the subscales. For the different UI types, significant improvement in QOL of SUI and clinical improvement of MUI and UUI are observed (Table 4).

MUI showed nonsignificant worsening measured by ICIQ-SF; however, there was significant improvement (p = .04) of QOL measured by I-QOL, which is perhaps justified as the ICIQ-SF scale is softer measuring changes than I-QOL. That is to say, for ICIQ-SF, one point of difference is considered a change, while a change of 2.5 points is needed for I-QOL to be considered minimal clinically important difference (Yalcin, Patrick, Summers, Kinchen, & Bump, 2006).

PFMT improves female SUI and MUI (Robles, 2006). Few studies have reported improvement in men, and there are no results about UUI improvement. In their studies, Sari and Khorshid (2009) stated that a PFMT exercises plan improves I-QOL by 7%. Serdá et al. (2010) proved that PFMT improves prostate cancer patients’ QOL by improving IU. Tarcia Kahihara et al. (2006) claim that early PFMT after prostatectomy decreases urinary frequency and improves symptoms of urine leakage by improving PF muscular contraction, which improves UI. Robles (2006) argues that PFMT is an inexpensive technique, without any side effect and which has good success rates, improving the QOL of incontinent patients.

García Bascones et al. (2012) report that BFB reduces the ICIQ-SF score in female UI. Lorenzo Gómez et al. (2008) showed that EMG-BFB with surface electrodes in women with SUI improves ICIQ-SF questionnaire score. Glazer and Lane (2006) presented seven studies where BFB significantly improved UI.

Conclusions

UI should be an entity regarded equally in both sexes due to the interference it causes in the QOL of patients and their partners. In men it is significantly associated to urological and/or abdominal surgery and to radical prostatectomy.

With the data reported in our study and the reviewed literature, the EMG-BFB for PFMT improves incontinence and QOL in the three types of UI on an overall basis, and should be included in the treatments offered to men with UI after radical prostatectomy or other abdominal surgeries.

Study limitations

Nowadays, there is controversy regarding to frequency, intervals of treatment, and type of muscle exercise in the published studies. It would be of interest to compare the protocol of the PF unit at CAUSA with the protocols of other centers, or different study protocols in the same sample.

A larger sample would enhance the data and conclusions stated in this study.