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Remembering Men

Most of the studies and published articles about urinary incontinence focus on women. Two-thirds of the estimated 12 million people in the United States with urinary incontinence are women, according to the American Academy of Family Physicians. The disease is most common in women older than 50 and in younger women who have recently given birth.

But as many as 4 million men have urinary incontinence as well. Although men are the minority of patients, there are still significant numbers of them in that minority. Urinary incontinence affects an estimated 17% of men older than 60 in the United States - more than 3.4 million men.

The overall economic burden for urinary incontinence in men is more than $18.8 billion a year in direct medical costs. The annual medical spending of patients with urinary incontinence was $7,702, more than twice that of other patients ($3,204). Medical expenditures for male Medicare beneficiaries have doubled since 1992 (Stothers L, Thom D, Calhoun E. Urologic diseases in America project: urinary incontinence in males demographics and economic burden. JUrol. 2005. 173:1302-1308).

"The CDC has a list of the top disease entities, and No. 6 is folks with some sort of voiding problem," says Connecticut urology physician assistant Mike Gould, PA-C. "It's mostly older guys, starting as early as the 50s. It's uncommon to see [urinary incontinence] in younger men. When anyone younger walks in, you get your antenna up" for something atypical, he says.

The Basics
There are four main types of urinary incontinence. Urge incontinence occurs when the need to urinate comes on quickly, and patients have difficulty holding their urine until they can reach a toilet.

Overflow incontinence is the constant dripping of urine resulting from an overfilled bladder. Patients feel that they can't empty their bladders completely and often strain during urination. Overflow incontinence occurs frequently in men and can be caused by an enlarged prostate blocking the urinary flow.

Functional incontinence occurs when patients with normal urine control have trouble making it to the bathroom in time. It can be a result of arthritis or other diseases that cause a decrease in mobility. Functional incontinence also occurs in patients with dementia, who have normal urine control but have cognitive limitations that cause them to be incontinent. Stress incontinence is common in women and is the involuntary leakage of urine with exertion, sneezing or coughing.

Psychological Factors
Significant differences exist between urinary incontinence in men and women. The physiology of the urinary system differs between men and women, but there are psychological differences as well.

Although studies report a prevalence of urinary incontinence in women ranging from 45% to 55%, fewer than half of those women consult health care providers about the problem.

Embarrassment isn't usually a problem that keeps men from seeking treatment. Men with urinary incontinence usually consult a health care provider quickly.

"These guys tend to come to you," says Dan Vetrosky, PA-C, a urology PA and an assistant professor at the University of South Alabama PA program in Mobile.

Causes of Incontinence in Men
Prostate problems contribute to urinary incontinence in several ways. Radical prostatectomy is one of the main causes of urinary incontinence in men. Up to 30% of patients who've had a radical prostatectomy experience some incontinence following surgery.

Benign prostatic hyperplasia (BPH) causes prostate enlargement and often pressure on the urethra. The wall of the bladder thickens and becomes irritable, and the bladder contracts even when it contains small amounts of urine. More than 50% of men in their 60s and up to 90% of men older than 70 have some BPH symptoms, according to the National Institute of Diabetes and Digestive and Kidney Diseases. External beam radiation used to treat the prostate can result in loss of bladder control and inflammation of the bladder wall, although the incidence is relatively low.

Functional incontinence is very common in elderly male patients. More than half of male nursing home residents report difficulty controlling their urine and needing help from another person or medical equipment.

"Nursing homes send us a lot of people," Gould says. "[Many patients] have dementia, and their cognitive abilities are so limited that they don't recognize the [urge to urinate]. Sometimes the hard wiring from the brain to the bladder is so disrupted that it can't be fixed."

Overactive bladder (OAB) causes the bladder to constrict at the wrong time. It may occur without any clear cause or result from nerve damage. Patients with OAB can have urge incontinence, urinary urgency and frequent urges to urinate.

Nerve damage and neurological disorders can result in urinary incontinence in men. Long-term diabetes can result in nerve damage and urinary incontinence. Parkinson's disease, multiple sclerosis, stroke and spinal cord injury can cause urinary incontinence. Parkinson's patients can be particularly difficult to treat, Gould says.

Once the cause of urinary incontinence is determined in men, it can usually be treated successfully, Gould says.

"It's predominantly a medication issue, either with a single drug or a combination of drugs," he says. "Once you can pin down what the problem is, you can attack it aggressively. For instance, if it's overactive bladder, we can really target that. I think we can help in a lot of cases."

Alpha-blockers such as Flomax (tamsulosin), Hytrin (terazosin), Cardura (doxazosin) and Uroxatral (alfuzosin) are useful for urinary incontinence caused by prostate enlargement and bladder outlet obstruction. They relax the smooth muscles of the prostate and bladder neck to promote normal urine flow and prevent bladder contractions that result in urge incontinence, according to the NIDDK.  

Proscar (finasteride) and Avodart (dutasteride) are 5-alpha reductase inhibitors that decrease the production of the male hormone DHT and reduce prostate enlargement. Antispasmodics can be used to relax the bladder muscle and reduce spasms. Combination therapy with a 5-alpha reductase inhibitor and an alpha-blocker have been shown to slow the clinical progression of BPH more than either drug alone.

The Medical Therapy of Prostatic Symptoms (MTOPS) study demonstrated that long-term therapy with a combination of finasteride and doxazosin was safe and reduced the risk of overall clinical progression of BPH more than single-drug therapy (McConnell, J.D., Roehrborn, C.G., Bautista, O.M., et al.) The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. (NEJM. 2003. 349:2387-2398).

The NIDDK suggests Kegel exercises, fluid limitations, timed voiding and biofeedback. But behavioral modifications are usually more effective in women than in men. "We usually don't do behavior modification with [urinary incontinence]," Gould says. "People seem to be less receptive to that."

Stephen Cornell is senior associate editor at ADVANCE for Physician Assistants. Reach him at


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