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Articles by Dr. Leach    Page 1 | Page 2

Urinary Continence in Men: A Treatable Problem Advances in the Repair of Vaginal Weakness

Incontinence Research at Tower Urology Urinary Incontinence: A Treatable Problem

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Urinary Continence in Men:
A Treatable Problem

Gary E. Leach, M.D., F.A.C.S.

Millions of American suffer from urinary incontinence (loss of bladder control). It has been estimated that up to 18% of men will experience loss of bladder control during their life and that $ 10 billion is spent in the United States every year on pads and other incontinence related problems. Also, in previous surveys, only 1 of 10 people with an incontinence problem sought help for their problem. The most common reasons for not seeking help included thinking that loss of bladder control is a "normal" part of aging (not true), that nothing could be done about the problem (also not true), or the incontinent person was too embarrassed to seek help. With current methods of evaluation and treatment, almost all bladder control problems can be either eliminated or significantly improved.

Types of Urinary Incontinence

There are four basic types of urinary incontinence: The first type is called Stress Incontinence, which is the loss of urine with coughing, straining, lifting, or other strenuous activity. In men, the most common cause of Stress Incontinence is damage to the valve muscle after prostate surgery (especially after prostate cancer surgery).

The second type is called Urge Incontinence. This type of leakage occurs when the man feels the urge to urinate, but cannot get to the bathroom "in time". Urge Incontinence is usually caused by an "overactive" bladder. This over activity in men is usually caused by an enlarged prostate "blocking" the flow of urine. It is also known that after prostate surgery, about 25% of men will continue to experience urge incontinence due to an overactive bladder.

The third type of incontinence is called "Mixed Incontinence" which is the combination of stress and urge incontinence (the man experiences urine loss with coughing and straining and must also rush to get to the bathroom to avoid leakage). Mixed incontinence is commonly seen in men after cancer surgery on the prostate who had some damage to the valve muscle combined with an overactive bladder (probably related to a change in the nerves that control the bladder).

The fourth type of incontinence is called "Overflow Incontinence". In this situation, the bladder never empties and with frequent "dribbling" of urine as the urine overflows. The most common cause of overflow incontinence in men is long-standing blockage to the flow of urine from the prostate where the bladder muscle eventually becomes stretched out and unable to contract. Also, some men with diabetes may have damage to the nerves that control the bladder resulting in loss of the bladder's ability to contract and retention of urine. With overflow incontinence, it is important to empty the bladder on a regular basis (usually with a program of clean intermittent self-catheterization.

Defining the exact cause of each of these types of incontinence is critical in directing successful treatment. The cause of incontinence is determined by performing special tests (called "urodynamics") of the bladder and valve muscle. The urodynamics tests require special equipment and arc performed by urologists with special training in bladder control problems. The tests are not painful, require no special preparation, and are done in the office with the person fully awake. With these tests, the exact cause of the incontinence can be defined and further treatment options can be discussed.

Types of Treatment Available

Pelvic Floor training / Biofeedback
Various types of medical, or non-surgical, treatments are available and may be useful depending on the results of tile urodynamic evaluation. For Stress Incontinence, these treatments include biofeedback. For "urge" or "mixed" incontinence, biofeedback, "bladder training", and medications called anticholinergics to "relax" the bladder be helpful.

Medications to Improve Control
Medications to help "tighten" the valve muscle (called "alpha stimulators"), may be useful in men with mild Stress Incontinence. Medications to relax the bladder (called anticholinergics) may help relax the overactive bladder.

When non-surgical treatments are not effective, various types of surgical procedures are available to help restore control For stress incontinence, the most common form of surgery is called an artificial urinary sphincter (AUS). This procedure involves insertion of an artificial valve which can be highly effective in certain situations depending on the results of the urodynamic studies.

Components and Function
The AUS consists of three components: the cuff goes around the urethra, the pump which goes inside the scrotum, and the balloon which holds the fluid for the device. The balloon is available in different pressure ranges and is filled with a fluid which is very safe even if it leaks out of the device. The device works hydraulically with the cuff around the urethra staying closed at all times. When the person wants to urinate, the pump is squeezed and the cuff opens. Automatically, in 3-5 minutes, the cuff closes again. The refilling of the cuff is controlled by a resistor mechanism inside the pump.

Technique of Implantation in the Male
The AUS insertion is performed in the hospital operating room with either a general or spinal anesthetic. Two small incisions are made: one in the groin area and the other between the scrotum and the rectum. The proper size cuff is placed around the urethra and the robing from the cuff is passed up to the groin area. The small pressure regulating balloon (which is about the size of a golf ball) is placed beneath the abdominal muscles and the pump which controls the device is tunneled down into the scrotum just beneath the skin. All connections between the 3 components are made in the groin area and the incisions are closed. At the conclusion of the operation, the cuff is "locked open" until pain and swelling in the scrotum resolves (usually 4-6 weeks).

Recovery Period
Usually only an overnight hospital stay is required and there is minimal postoperative pain. Most men return to work 2-3 weeks after surgery. At about 4-6 weeks after surgery, the AUS is activated in the office to allow urinary control to be restored.

Results and Complications
We have published a long-term study which demonstrated excellent long-term results with the AUS in men followed for a minimum of 3.5 years (mean follow-up of 7.2 years) after AUS insertion. Since 1987, there have been very few mechanical complications requiring surgical correction and the infection rote requiring removal of the device is close to 1%. Overall patient satisfaction is very high with a significant improvement in the quality of life after the AUS placement.

It is important to remember that if you or someone you care for has urinary incontinence that with appropriate evaluation and treatment by a knowledgeable physician, bladder control can almost always be restored. Should you have further questions, or desire more information, please feel free to contact Dr. Gary Leach at the Tower Urology Institute for Incontinence in Los Angeles at the Cedars-Sinai Office Tower. Our toll-free number is 1-888-248-6937.

Advances in the Repair of Vaginal Weakness

Gary E. Leach, M.D., F.A.C.S.

There have been significant advances in the techniques for repairing the various potential weaknesses that can develop in the vagina (called vaginal prolapse). Many women with pelvic prolapse are very uncomfortable with a feeling of heaviness or weight in the vaginal area, a feeling of "sitting on a ball", discomfort during sexual activity, difficulty with bowel movement, or loss of urinary control (see article "Menopause and its Affects on the Pelvic Organs"). Besides these symptoms, significant pelvic prolapse can also result in kidney damage or damage to the bladder making it difficult for the bladder to empty and predisposing to urinary infection. With new techniques of repair utilized at the Tower Urology Institute for Continence, these problems can usually be corrected without the need to continue to live with the problem or wear a ring (pessary) in the vagina. These advanced techniques of repair include:

Repair of the Anterior Vaginal Wall: When the urethra drops (the tube that carries the urine from the bladder to the outside) women frequently have loss of urine with coughing, sneezing, or change in position (stress incontinence). Returning the urethra to its proper position with a sling procedure can now restore long-term urinary control. We have developed a new sling technique with minimal postoperative discomfort to allow the sling to be entirely performed via the vagina without the need to harvest any tissue for the sling.

Dropping down of the urethra is frequently accompanied by dropping of the bladder as well (called a cystocele). When these two problems coexist, it is important that both be repaired simultaneously. With current techniques of cystocele repair, the defect through which the bladder herniates into the vagina is closed with strong tissue with excellent long-term success.

Repair of the Top of the Vagina: Most commonly, weakness at the top of the vagina occurs after hysterectomy. This bulge from the top of the vagina is called an enterocele. Frequently, an enterocele is associated with the entire vagina dropping down, known as vaginal vault prolapse.

These weaknesses at the top of the vagina are repaired through the vagina by closing the defect in the ligaments at the top of the vagina and fixing the top of the vagina to these ligaments. Also, the hernia sac which contains the intestine is closed. These reconstructive procedures are performed entirely through the vagina without causing loss of vaginal length or narrowing of the vagina.

Repair of the Back and Opening of the Vagina: Weakness at the back of the vagina usually involves the rectum bulging through the back wall of the vagina (called a rectocele) causing a feeling of the bowel movement getting stuck and the need to push excessively to evacuate the bowel movement. Frequently, a rectocele co-exists with weakness of the muscles at the opening of the vagina. This muscular weakness can lead to loss of sensation during sexual activity or a general feeling of the vagina being "too loose". Repair of weakness in this area involves brings the separated muscles back together to strengthen both the back of the vagina and restore the muscle tone at the vaginal opening.

Summary: Symptoms of vaginal weakness are effectively treated with new surgical techniques performed entirely via the vagina with minimal postoperative discomfort and excellent results. These successful vaginal techniques now make it possible to repair any combination of vaginal weaknesses that used to require major abdominal surgery and prolonged recovery. Thus, many women who previously opted for the option of avoiding surgery or wearing a ring (or pessary) in the vagina may now elect to repair the problem and significantly improve their quality of life.

For information on a monthly incontinence support group, please contact the
Tower Urology Institute for Continence at 1-888-248-6937.

Incontinence Research at Tower Urology

Gary E. Leach, M.D., F.A.C.S.

Since establishing the Institute for Continence at Tower Urology one year ago, a very active research program is underway to find new, more effective treatments to correct urinary incontinence (loss of bladder control) especially in women. For many of these studies, we are the only center in the Western United States employing these new forms of treatment. All of these research programs have been formally approved by an institutional review board and follow strict guidelines as to how the research is performed. We are hopeful that the following programs which are currently underway will provide a significant opportunity to improve bladder control even in women who have failed previous attempts at treatment.

Urethrin Injection Study

This study focuses on a "non-invasive" treatment for women who have severe leakage when they cough, laugh, sneeze, or change position (i.e., severe "stress" incontinence). The study is designed to compare the results of two different materials that are injected into the urethra to help "strengthen" the sphincter or valve muscle. These two materials are collagen from beef (called Contigen which has been available for about three years) and Urethrin (which is a synthetic material). The injection is performed in the office with local anesthesia in about 15 minutes. Repeat injections may be required and patients in the study are followed to compare the results obtained with the two different injected materials.

New Method of Performing "Sling" Procedure

When a women with severe incontinence fails injection therapy, is not a candidate for injection therapy, or elects to undergo a surgical repair to correct her urinary leakage, the sling procedure is the procedure of choice with the best long-term outcomes. The sling procedure is a one-hour operation done in the hospital. The procedure involves placing a strip of material beneath the urethra (the tube that carries the urine from the bladder to the outside) to help close and support the urethra, thus eliminating the incontinence. This study utilizes specially processed, sterile cadaveric fascia (strong material from the leg) to restore bladder control without having to harvest the patient's own fascia, thus avoiding a significant amount of postoperative pain and shortening the recovery process. Patients undergoing this type of sling procedure will be followed to determine the outcomes after surgery.

Inflow Device to Empty the Bladder

A rarer cause of incontinence where the bladder never empties completely and "overflows". Most commonly this problem is seen with nerve problems affecting the bladder such as multiple sclerosis and spinal cord injury. Thus far, the most effective treatment to empty the bladder is the perform intermittent cathetherization 34 times throughout the day. We are currently investigating a new device produced in Israel (called the Inflow device) that sits in the urethra and allows the bladder to empty with a unique "pump" design activated by an external controller without having to catheterize to empty the bladder. The early results with this device are quite encouraging in well selected patients. This study involves placement of the inflow device in the urethra (performed in the office) with visits to change the device on a regular basis.

New medication for "Overactive Bladder"

Lastly, we have been approved to begin studying a new oral medication to help control the symptoms of urgency (having to rush to get to the bathroom), frequency (urinating very often), and urge incontinence (losing control of the urine in your can't get to the bathroom in time) This medication, called Tolterodine, helps to relax the bladder and thus control the urgentt need to urinate. This study looks at the results and side effects associated with this new oral medication. Preliminary results have suggested that the side effects (i.e., dry mouth, etc.) associated with Tolterodine may occur less often that with other commonly used medications to relax the bladder The study will involve regular visits with a gradual increase in dose of the new medication.

Should you be interested in obtaining more information regarding any of these studies, please contact Dr. Leach at the Tower Urology Institute for Continence. Our toll free number is 888-248-6937. If you have seen another of the Tower Urologists, feel free to request information from that physician regardmg any of the above studies. In order to continue our Urology research program, we have established the Tower Urology Research Foundation. Contributions to this foundation will help us test new treatments, devices, and procedures as well as further patient education activities. Brochures outlining the details of the Foundation are available through our office.

Dr. Leach is the President of the Urodynamics Society and immediate past-president of the Los Angeles Urologic Society. He has written more than 100 scientific articles and book chapters related to evaluation and treatment of incontinence in men and women.

Urinary Incontinence:
A Treatable Problem

Gary E. Leach, M.D., F.A.C.S.

Millions of Americans suffer from urinary incontinence (loss of bladder control). It has been estimated that up to 30% of women will experience loss of bladder control during their life and that $8 billion is spent in the United States every year on pads and other incontinence related problems. Also, in previous surveys, only 1 of 10 people with an incontinence problem sought help for their problem. The most common reasons for not seeking help included thinking that loss of bladder control is a "normal" part of aging (not true), that nothing could be done about the problem (also not true), or the incontinent person was too embarrassed to seek help. With current methods of evaluation and treatment, almost all bladder control problems can be either eliminated or significantly improved. I have seen many physically active women who quit performing any physical activity because of loss of urine control who have been able to resume activities such as aerobics after appropriate treatment.

Types of Urinary Incontinence

There are four types of urinary incontinence: The first type (which is the most common) is called Stress Incontinence, which is the loss of urine with coughing, straining, lifting, or other strenuous activity. In women, Stress Incontinence is caused by "dropping down" of the urethra (the tube that carries urine from the bladder to the outside) which causes the valve muscle or sphincter to be weak. This relaxation (or dropping down of the urethra) is caused by weakness of the muscles in the area of the vagina, stretching of the tissues after vaginal delivery, changes in hormone levels with aging, and changes in nerve function of the urethra with aging. In men, the most common cause of stress incontinence is damage to the valve muscle after prostate surgery.

The second type is called Urge Incontinence. This type of leakage occurs when someone feels the urge to urinate, but they cannot get to the bathroom "in time". Urge Incontinence is usually caused by an "overactive'' bladder. This overactivity can be related to a nerve problem affecting the bladder, but more commonly, it occurs without a specific identifiable cause.

The third type of incontinence is called "Mixed Incontinence" which is the combination of stress and urge incontinence (the person experiences urine loss with stressful activities and must also rush to get to the bathroom to avoid leakage). This is the most common type or urine leakage seen in women. It is thought that the urgency feeling (i.e., the need to rush to get to the bathroom) may be caused by urine leaking into the beginning of the urethra due to a weak valve muscle. Frequently, the urgency feeling improves after treatment to improve the strength of the valve muscle.

The fourth type of incontinence, called "Over-flow Incontinence" is rare (especially in women). In this situation, the bladder never empties and the person expenences frequent "dribbling" of urine. The most common cause of overflow incontinence in women is diabetes affecting the nerves that control the bladder or previous surgery which affects the ability of the bladder to contract or causes blockage of the urethra. With overflow incontinence, it is important to empty the bladder on a regular basis (usually with a program of clean intermittent self-catheterization) as well as to define the cause of the incomplete emptying.

Defining the exact cause of each of these types of incontinence is critical in directing successful treatment. This is determined by performing special tests (called "urodynamics") of the bladder and valve muscle. The urodynamics tests require special equipment and are performed by urologists with special training in bladder control problems. The tests are not painful, require no special preparation, and are done in the office with the person fully awake. With these tests, the exact cause of the incontinence can be defined and further treatment options can be discussed.

Types of Treatment Available

Pelvic Floor Training / Biofeedback
Various types of medical, or nonsurgical, treatments are available and may be useful depending on the results of the urodynamic evaluation. For Stress Incontinence, these treatments include pelvic muscle exercises, or Kegal exercises. An excellent instructional audio tape is available from NAFC, a non-profit group at 1-800-Bladder. For Urge or Mixed Incontinence, biofeed-back and "bladder training" and medications called "anti-cholinergics to "relax" the bladder may be helpful.

Medications to Improve Control Medications to help "tighten" the valve muscle (called "alpha stimulators"), and female hormone replacement to strengthen the valve muscle after menopause are also helpful for those with Stress Incontinence. For women with a significant urgency problem, oral medications called "anti-cholinergics", can be very helpful when taken two or three times per day. These medications work to relax the bladder and control any spasms of the bladder that may cause urgency as the bladder fills. Side effects of anti-cholmergic medications indude dry mouth, constipation, and (rarely) blurry vision. These side effects can be minimized by starting out at a low dose of the medication and slowly increasing the dose as tolerated.

Surgical Treatments
When non-surgical treatments are not effective, various types of surgical procedures are available to help restore control. For Stress Incontinence, the most common form of surgery is called a "bladder neck suspension". These operations return the urethra which has dropped to its normal position. Newer forms of bladder neck suspension can be performed mainly through the vagina with local anesthesia as an outpatient. Urologists have also been injecting collagen to help strengthen the valve muscle in certain women with Stress Incontinence. This injection is performed as an outpatient under local anesthesia. In general, multiple injections are usually required and about 60% of women are either dry or significantly improved after collagen injection. Other operations such as a "sling" procedure or insertion of an artificial valve can be highly effective in certain women depending on the results of the urodynamic studies. For Urge Incontinence which cannot be controlled with medications, surgery to enlarge the bladder can be very helpful.

It is important to remember that if you or someone you care for has urinary incontinence that will appropriate evaluation and treatment by a knowledgeable physician, bladder control can almost always be restored. Should you have further questions, or desire more information, please feel free to contact Dr. Gary Leach at the Tower Urology Institute for Incontinence in Los Angeles at the Cedars-Sinai Office Tower.

The toll-free number is 1-888-248-6937 or 310-854-9898.
Dr. Leach can also be reached via E-mail at DrDorado@aol.com.