Injectable Bulking Agents for Male

Incontinence Dr.Ali Alsharkawy Dr.Ehab Dr.Ali Alsharkawy Dr.Ehab

FodaFoda

Urinary Incontinence Is Common and Treatable

About 3.4 million men in the U.S. are estimated to be dealing with incontinence right now. And the good news is that it’s contrary to what a lot of patients think, urinary incontinence is not a normal sign of aging and it's not inevitable. It's a treatable condition.

In men, incontinence is often related to prostate problems or treatments.

Drinking alcohol can make urinary incontinence worse. Taking prescription or over-the-counter drugs such as diuretics, antidepressants, sedatives, narcotics

can be short-term or chronic different types of chronic urinary

incontinence: Stress incontinence. Overflow incontinence Urge incontinence Total incontinence Functional incontinence

What does it mean?What does it mean? Stress incontinence means that you leak urine when you sneeze, cough,

laugh, lift something, change position, or do something that puts stress or strain on your bladder.

Urge incontinence:  is an urge to urinate that's so strong that you can't make it to the toilet in time. It also happens when your bladder squeezes when it shouldn't. This can happen even when you have only a small amount of urine in your bladder. Overactive bladder is a kind of urge incontinence. But not everyone with an overactive bladder leaks urine.

Overf low incontinence:  means that you have the urge to urinate, but you can release only a small amount. Since your bladder doesn't empty as it should, it then leaks urine later.

Total incontinence :  means that you are always leaking urine. It happens when the sphincter muscle no longer works.

Functional incontinence : means that you can't make it to the bathroom in time to urinate. This is usually because something got in your way or you were not able to walk there on your own.

Treatment:Treatment: Behavioral strategies may be enough to control your symptoms.

These include simple changes to your diet, lifestyle, and urinary habits. Kegel’s excercises

Medicines that treat infection or bladder muscle spasm may help. Urinary pads

Self-catheterization may help you manage overflow incontinence from a weak bladder or blockage. It may also be used if surgery is not the best option for you.

Surgery is usually considered when it is the only treatment that can cure the incontinence, such as when the condition is caused by a bladder blockage.

Different treatmentsDifferent treatments

Medications

Can help with some types of urinary incontinence. For overf low incontinence : If incontinence is caused by an enlarged prostate , medicines to treat benign prostatic

hyperplasia may be prescribed. But these medicines don't always improve incontinence. For urge incontinence :

Anticholinergic and antispasmodic medicines such as oxybutynin and tolterodine. Taking an alpha-blocker medicine with an anticholinergic may help with symptoms of urge incontinence and overactive bladder better than either medicine alone.

Antidepressant medicines, such as imipramine. Botox (botulinum toxin). Botox may be an option when other medicines don't work. A

Botox shot helps relax the bladder muscles. get a shot every 3 months. For stress incontinence:

Anticholinergic medicines may help, especially if you have both stress and urge incontinence

Antidepressant medicines: such as imipramine

Incontinence Surgery and Other Options

Surgical options include a male sl ing for stress incontinence; material is wrapped around the urethra to compress and prevent leaking due to coughing, sneezing, or vigorous activities. An implanted art if icial sphincter is also for stress incontinence and uses a cuff to close the urethra. Squeezing the pump opens the cuff and releases urine when you want to urinate. Apacemaker-l ike devic Sacral nerve stimulation (SNS) (shown above) stimulates nerves which relax the bladder and pelvic floor muscles.

Injectable materialsInjectable materials synthetic materials: bovine collagen , or autologous substances augment the urethral wall and increase

urethral resistance to urinary flow. More recently, investigations of stem cell injections have shown

promise for use.

The injection of bulking agents to treat a dysfunctional urethra is a minimally invasive method of correcting intrinsic sphincteric deficiency

less frequently in current practice.

Evidence in major reviews shows low efficacy rates compared with surgical incontinence therapies,

Rationale:Rationale: Urethral bulking procedures are designed to treat stress urinary

incontinence due to intrinsic sphincter deficiency by :

artificially inflating the submucosal tissues of the bladder neck and urethra. These procedures involve injecting synthetic and autologous fillers into the wall of the urethra to >>>aid in coaptation of the mucosa. Bulking the bladder neck with particulate matter effectively closes the lumen of the urethra by improving urethral coaptation and restores the mucosal seal mechanism of continence. However, issues with migration, leakage, and resorption of injected agents challenge therapeutic durability.

Methods used to bulk the female urethra include transurethral and periurethral injection techniques. The delivery techniques for the male urethra are largely transurethral.

Indications

Social indications for surgical intervention include any stress urinary incontinence that interferes with quality of life

Pathologic indications for correcting intrinsic sphincter deficiency and stress urinary incontinence include primary urethral dysfunction, failed previous bladder neck surgery, and severe attenuation of endopelvic fascia.

injectable therapy can be considered in cases in which surgery is contraindicated or as an adjunct to surgery if symptoms persist.

Men experiencing stress urinary incontinence after a transurethral prostatectomy, however; Men with stress urinary incontinence after radical prostatectomy generally have a lower success rate with injectable bulking agents and may benefit most from a sling procedure or anartificial urinary sphincter.

Contraindications pure urge incontinence or bladder outlet obstruction. A patient with mixed incontinence (ie, stress and urge urinary

incontinence) in whom the urge component predominates should ideally address the overactive bladder prior to treating the stress incontinence component.

Patients with a hypersensitivity to collagen. urinary tract infection or bacterial colonization of the urinary tract, owing

to the risk of abscess formation and potential for sepsis.

Anesthesia

Urethral bulking procedures are usually done under local anesthesia in women, but men may require a general or regional anesthesia. A local anesthetic allows the person to stand up after an injection to find out if continence has been achieved. If continence has not been restored, another injection may be done immediately.

Equipment The use of transurethral injections requires a standard cystoscopy

setup. If periurethral injections are being performed, a cystoscopy setup may still be helpful in order to image the urethra to assess for coaptation and possible urethral spillage of the injected agent.

Positioning: lithotomy position Complication prevention: urine culture,

hypersestivity test(bovine collagen)&prophylactic antibiotic

Bovine collagen

 (FDA) approved in 1993 

extracted from cattle, purified, and prepared for use as a bioinjectable agent via cross-linking with glutaraldehyd

undergo a skin test approximately 4-6 weeks before surgery 

 Injected collagen gradually is replaced by host collagen over the next 9-19 months, and usually more than 1 treatment is necessary.

When collagen is injected around the urethra, the resultant bulking of periurethral tissue closes off the urethral lumen, which maintains urinary continence.

hydrCalcium oxylapatite FDA approved in 2005 for periurethral injection.

As is the case with collagen, most patients who receive calcium hydroxylapatite require additional injections after the first year.

A multicenter, prospective, randomized, single-blind study compared calcium hydroxylapatite injection with bovine collagen. A higher proportion of patients who received calcium hydroxylapatite required only 1 injection.

In addition, the initial injection volume of calcium hydroxylapatite was less than that of bovine collagen.

Carbon bead particles

more difficult to inject than collagen because of increased viscosity and the need for an 18- to 19-gauge needle.  

Nonbiodegradable bulking agents

Polydimethylsi loxane

FDA approved its use in 2006 A randomized prospective study compared it with bovine collagen and

found that it achieved excellent efficacy at 12 months.[15]

More durable than collagen with regard to length of effect.

Autologous fat

extracted from the patient’s lower abdomen Inexpensive readily available Nonallergenic. However, it is less efficacious than other alternatives. The operative time of the procedure is prolonged Polytetrafluoroethylene paste: is no longer clinically used

owing to evidence of particle migration Ethylene vinyl alcohol : NO LONGER USED Dextranomer/hyaluronic copolymer : has been withdrawn

from the market over concerns of abscess formation Fat emboli

The advantages: simple, minimal risk of associated complications.

performed on an outpatient basis and can often be done quickly in the surgeon’s office.

When an antegrade approach is chosen, the procedure must be performed in the operating room owing to the need for suprapubic access.

Disadvantages: the therapeutic effect is generally not permanent. multiple reinjections are typically necessary.

Technique

For periurethral injection:

Slowly insert a straight or bent needle next to the urethral opening and into the submucosal tissues. After ascertaining the proper position of the needle in the proximal half of the urethra, slowly inject at 3 sites around the urethra: the 2-, 6-, and 10-o’clock positions. As the injection progresses, the urethral lumen should be directly visualized to close. To ensure success, complete apposition of the urethral mucosa must be confirmed at the end of the procedure

Technique

Technique For transurethral injection, use a cystoscope with

endoscopic injection setup to infiltrate collagen beneath the urethral mucosa.

Insert the cystoscope into the mid urethra.

Under direct vision, carefully insert the tip of the needle beneath the urethral mucosa.

Ensure the needle bevel is facing the center of the urethral lumen.

Precisely deposit the collagen into the submucosal tissues until complete coaptation of the urethral mucosa is visualized.

Technique The antegrade route is reserved for men who are incontinent after

prostatectomy. Create a suprapubic tract under adequate general anesthesia if

possible.

Insert a flexible cystoscope into the bladder via the suprapubic tract.

Identify the bladder neck.

Under cystoscopic vision, carefully insert the tip of the needle underneath the bladder neck mucosa.

Precisely deposit the collagen into the submucosal tissues until complete coaptation of the bladder neck is noted.

Immediate postoperative period

PERFORM a cough stress test immediately after the injection to assess for cure. If stress urinary incontinence persists, consider immediately reinjecting additional collagen.

Antibiotics for 3 days.

analgesics.

Do not place a urethral catheter routinely after bovine collagen injection because it may cause molding of the urethra and injectable agent around the catheter.

Evidence based outcome:Evidence based outcome: Collagen is less efficacious in men with

postprostatectomy incontinence.[26, 27]

Transurethral collagen injection ;in 21 consecutive men with intrinsic sphincter deficiency was studied. A mean total volume of 18.4 mL (range, 1-44.5 mL) with an average of 2.9 injections (range, 1-5) produced a 5% cure (dry) rate and 57% significant improvement rate, but left 38% unchanged.[28]

Antegrade injection of collagen has also been performed, with 70% of men incontinent after prostatectomy reporting cure or significant improvement.[29, 30]However, only a 10% cure rate and a 35% improvement rate were noted in another study.[31] Although antegrade delivery of collagen appears promising, this therapy fails in a substantial number of patients at 2-year follow-up.

It is unclear if calcium hydroxylapatite can benefit men with postprostatectomy incontinence.

Complications

temporary urinary retention: It is the most common.

Bovine collagen and carbon bead injection: 5% rate of uncomplicated urinary tract infections, a 15% rate of temporary urinary retention, and a 1% rate of transient urethral irritation.

Hey,you are not alone, even Hey,you are not alone, even celebrities have incontinencecelebrities have incontinence

Thank youThank you