Male Bladder Control Problems: A Guide To Assessment
Overactive bladder (OAB) affects 17 to 33 million Americans.1 Symptoms such as urinary frequency, urgency, nocturia, and/or urge incontinence occur as a result of uncontrolled detrusor muscle contractions during bladder filling. Both women and men can have symptoms of OAB and the disease state affects twice as many women as men; it is generally under-diagnosed and treated.1
Many clinicians are not educated on basic evaluation techniques and treatment modalities and fail to screen patients for symptoms of incontinence.2 Furthermore, most clinical studies involve women, resulting in limited data specific to male urinary incontinence.3 Although urinary incontinence prevalence is lower in men than in women, an estimated 7% to 15% of older men experience incontinence and/or symptoms of lower urinary tract dysfunction.4 Symptoms of OAB increase as men age.1 This article discusses the screening, evaluation, differential diagnosis, and treatment options for men with symptoms of OAB and/or incontinence. A review of the literature specific to lower urinary disorders in the male population is provided.
Literature Review
A MEDLINE© and CINAHL© search revealed minimal research specific to incontinence in men. The majority of publications are descriptive studies involving older men who have had a prostatectomy. In 1990, Herzog and Fultz5 found the prevalence of incontinence in older community-dwelling men to be 7% to 13%. A cross-sectional study conducted in 2000 involving 840 male patients at three Veterans Affairs primary care clinics in Kentucky3 showed a prevalence of up to 32.3%.
A 2003 Swedish study6 using a self-administered questionnaire showed that 24% of community-dwelling men ages 40 to 80 years reported at least one symptom of urgency, stress incontinence, or post-micturition dribbling. Stoddard et al,4 conducting a cross-sectional survey among 2,000 elderly community-dwellers in 11 general practices in a city in the UK reported a urinary incontinence prevalence of 23% among men. In the 2001 Veneto study7 examining prevalence of urinary incontinence among 867 male and 1,531 female community-dwelling elders in Northern Italy, 11.2% of men reported the condition. A large European study8 conducted in 2003 surveyed 4,979 men in four countries — a prevalence of 14% was found in the Netherlands and UK, compared to 7% to 7.5% in France and Korea. A recent study conducted among 2,369 men in 26 non-urologic centers in 11 Asian countries9 found a 29.9% prevalence of OAB symptoms in men ages 18 to 70+ years. In this study, OAB symptom prevalence increased with age and urge incontinence symptoms were reported by 13% of the population studied. Varying prevalence rates may be explained by cultural variance as well as by the types of questions asked. The patients’ individual tolerance also may have influenced their reporting of symptoms.
Treatment and management of urinary incontinence in the general population have been less frequently studied. Most research focuses on post-prostatectomy incontinence. Johnson and Ouslander10 offer a comprehensive discussion of the problem, outlining assessment and differential diagnosis in aging men as well as medical and surgical treatment options.
Carlson and Nitti11 provide an in-depth discussion of prevention and management of incontinence following radical prostatectomy. Hunter et al12 in their literature assessed the effect of conservative management of post-prostatectomy incontinence and reached uncertain conclusions. During the same review, they concluded that the evidence from randomized or quasi-randomized controlled trials regarding other management strategies such as penile compression devices, external catheters, and absorbent products was found to be scarce to none.
Lower Urinary Tract Symptoms in Men
Men who present with symptoms of urinary urgency, frequency, and/or urge incontinence require a medical evaluation to determine the cause of their symptoms. The patient with an obstruction such as benign prostatic hypertrophy (BPH) may have the same urgency symptoms as the patient with detrusor instability, making it imperative to ascertain if the bladder is retaining urine. Urinary retention commonly occurs with bladder outlet obstruction and must be determined before a treatment plan is implemented.
A thorough medical history should be obtained, including a review of all systems with an emphasis on the genitourinary, neurological, and musculoskeletal systems. A review of all medications, both prescription and over-the-counter, is an essential part of assessment because many medications can cause or aggravate incontinence (see Table 1).
Differential diagnosis. Differential diagnosis begins with assessment, including patient history, physical, examination and basic diagnostic testing. Differentiating between OAB and BPH is of utmost importance when assessing the patient with lower urinary tract symptoms because the underlying cause and treatment for each diagnosis is different for each. Symptom manifestation can impact medication — for example, treating a man with an anticholinergic medication can cause urinary retention if the symptoms of urgency were related to an enlarged prostate.10
Patient history. The patient history should include medication use, previous surgeries, and events that precipitate incontinence. A 3-day voiding diary will assist the practitioner in identifying activities that provoke leakage or urgency such as consumption of bladder irritants or waiting too long to void. Self-reported symptoms also identify the number of times a person voids each day (see Figure 1).
Physical examination. The physical examination should include a neurological, abdominal, and rectal exam. Cognitive assessment includes the ability to understand instruction, motivation, and affect along with patient goals for treatment. Some patients strive for complete dryness while others desire the ability to control urgency during daily activity. The neurological examination helps rule out perineal impairment. Perineal sensation can be determined by checking sphincter tone and performing a pinprick test.13Abdominal examination should focus on detecting masses, tenderness with palpation, and suprapubic fullness.2 The genital examination includes assessment of the glans penis and foreskin and the rectal examination includes assessment of prostate size and contour. Impaction and rectal masses should be ruled out during digital exam. If the rectal exam is negative and the prostate appears to be of normal size and contour, a diagnosis of OAB should be considered.
Diagnostic testing. A urinalysis and post void residual study are recommended for all men with symptoms of incontinence. These diagnostic tests will help rule out other causes of urgency and frequency such as uncontrolled diabetes, symptomatic urinary tract infection, hematuria due to stones or bladder cancer, and urinary retention.2 If a patient presents with any abnormal test results, a detailed medical examination is indicated. Post void residual volume should be measured in all men presenting with lower urinary tract symptoms.10 Use of a catheter or a portable ultrasound will determine if bladder emptying is normal (less than 50 mL) or grossly abnormal (greater than 200 mL). Findings of between 50 mL and 200 mL bear further investigation for reversible causes of incomplete bladder emptying such as constipation, medication side effects, or prostatic enlargement. Post void residual volume must be measured no more than 20 minutes after the patient voids. A normal post void residual usually rules out retention. If a patient has a post void residual over 200 mL, he should be considered for further urological evaluation to ascertain the cause.
Benign Prostatic Hypertrophy
Assessment for BPH. Prostatic hypertrophy can cause lower urinary tract symptoms in men and should always be considered in the differential diagnosis. The diagnosis of BPH includes three considerations: prostate size, symptoms, and obstruction.14 While obtaining the history, the International Prostate Symptom Score may help the patient quantify the severity of symptoms and help the practitioner obtain a clearer history.15 A digital rectal exam must be included in the evaluation of men with lower urinary tract symptoms but it is important to note that prostate size does not necessarily correlate with symptom severity. Baseline prostate-specific antigen (PSA) should be determined for men with a life expectancy of greater than 10 years in whom the diagnosis of prostate cancer can alter management of the malignancy.15 African-American men and those with a family history of prostate cancer are at high risk for prostate cancer and should be screened annually, starting at age 50 with or without symptoms, and at age 45 with a family history of a first-degree relative with prostate cancer.16
Treatment. Patients presenting with a chief complaint of lower urinary tract symptoms and clinical findings of BPH should be offered symptomatic treatment. Treatment for BPH can include both medical and surgical modalities. Medical treatment includes alpha-adrenergic receptor antagonists (alpha blockers) that reduce the adrenergic-mediated obstruction in the smooth muscle of the prostate and proximal urethra and 5a-reductase inhibitors (antiandrogens) that decrease prostate size by blocking the conversion of testosterone to dihydrotestosterone (DHT).17 In a long-term, double-blind trial (mean follow-up 4.5 years) involving 3,047 men with BPH, McConnell et al18 found that combination therapy of these agents reduced progression of the disease and symptom severity. Table 2 lists these medications, their dosing, and common side effects. Patients who have persistent symptoms or evidence of upper tract disease should be referred to a urologist for further diagnosis.
Overactive Bladder
If BPH and retention are ruled out, transient causes have been treated, and the patient continues to report symptoms of urgency and frequency such as nocturia, a diagnosis of OAB should be considered.
Treatment. For most patients with OAB, a combined treatment approach using behavioral and pharmaceutical interventions is effective.18 Over the past several years, many drugs for the treatment of OAB have been approved (see Table 3). Multiple studies support the use of pharmacological treatment for bladder control problems and present evidence as to the safety and efficacy of these drugs. Several published summaries of clinical trials are available to guide the practitioner in seeking appropriate medications.19-23 Finally, behavioral interventions such as limiting bladder irritants (eg, caffeine and alcohol) and bladder retraining should be part of every treatment plan.
Conclusion
Despite the clinical and commercial focus on women, urinary incontinence is a significant health problem that also affects men. Men who present with symptoms of urgency and frequency, with or without incontinence, should be assessed. A history should be obtained and physical examination completed to assess anatomical causes such as bladder outlet obstruction secondary to BPH because symptoms of BPH and OAB may be similar although the cause is different. As men age, OAB prevalence increases, and as in women, should not be considered a consequence of growing older. A thorough health history, physical examination, and basic diagnostic testing that includes urinalysis and post void residual study should be performed for all men presenting with lower urinary tract symptoms. Once a differential diagnosis is made, several safe and effective treatment choices, including pharmacological management, can be implemented.
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