By Kalli Spencer
Defining it
"Sexual incontinence is a broad term that encompasses climacturia (urinary incontinence at the time of orgasm) and arousal incontinence (urinary incontinence at the time of physical or psychological arousal or both)." Climacturia is thought to be associated with a reduced urethral length and incompetence of the internal urethral sphincter at the bladder neck. Arousal incontinence is thought to be due to disruption of the external urethral sphincter and relaxation or fatigue of the pelvic floor. A lot of research has been done on climacturia (to be discussed in a separate blog) but little around arousal incontinence. Dr Darren Katz, a Melbourne based urologist with a special interest in men's sexual health, and Dr Bach and the team from Memorial Sloan Kettering have conducted research into this little-known entity.
The study design
A specialised survey was created. Questions focused on timing in relation to surgery, changes in amount of leakage, frequency and symptoms and triggers (fantasy or visual stimulation versus manual stimulation). The amount of leakage was quantified as follows: "small" (drops); "moderate" (tablespoon), and "severe" (more than a tablespoon). Patients were also asked about personal and perceived partner distress, preventative measures, avoidance behaviours, and whether they had stress urinary incontinence.
Important study findings
There were 226 participants in the study with an average age of 65. Three quarters of them had a radical prostatectomy anywhere from a year to 2 years prior. Most participants were not using pads anymore and had minimal urinary symptoms.
Half of the respondents experienced arousal incontinence (AI) at some point, with most of them still actively experiencing it. Eighty five percent of this group experienced AI within 3 months of surgery. Those no longer experiencing AI reported that it resolved on average after 9 months.
Most (76%) men had leakage with physical stimulation, with about one-third of those reporting urine leakage related to psychological arousal as well. A few men reported leakage only with psychological arousal.
Subjective improvement over time was reported by 62% of men. Almost 60% of men reported AI in less than half of their sexual encounters, with the amount of urine leakage being estimated at about a tablespoon or less in 88% of men.
Those participants who have worsening stress urinary incontinence are at increased risk of also developing AI.
The researchers have postulated that AI is related to the commencement of sexual activity after a radical prostatectomy and therefore those who commence earlier are more likely to experience the onset of AI.
Treatment implications
There is little evidence to guide the optimal treatment approach. Simple measures such as voiding before intercourse, limiting fluids or using a condom yield varied success. Some studies have shown a latex ring applied to the base of the penis prior to foreplay could be beneficial, whereas others recommend more definitive treatment of urinary incontinence which includes placement of an artificial urinary sphincter or male sling. The authors recommend the use of a variable tension ring for those with significant bother from AI but have noted this device can be difficult to incorporate into sexual play as arousal is often unpredictable.
Psychological implications
The study team found that AI leads to avoidance of sex in 42% of participants. This could be due to lower confidence in erection duration and feeling like a failure. A potential explanation may be rushed sexual relations for fear of developing AI. Feelings of failure may stem from the inability to control AI and embarrassment related to that.
Proper patient education is crucial before surgery to set realistic expectations. Management strategies to manage AI if it develops after treatment should also be highlighted.
References
1. Bach PV, Salter CA, Katz D, Schofield E, Nelson CJ, Mulhall JP. Arousal incontinence n men following radical prostatectomy: prevalence, impact, predictors. J sex Med 2019; 16:1947-1952.
2. Bach PV, Salter CA, Katz D, Schofield E, Nelson CJ, Mulhall JP. The relationship and psychosocial impact of arousal incontinence after radical prostatectomy. J sex Med 2020; 17:94-98.
About the Author
Kalli Spencer
MBBCh, FC Urol (SA), MMed (Urol), Dip.Couns (AIPC)
Kalli is an internationally renowned Urological Surgeon, specialising in oncology and robotic surgery. He trained and worked in South Africa, before relocating to Australia where he has worked at Macquarie University Hospital and Westmead Hospital. His passion for what he does extends beyond the operating room, through public health advocacy, education and community awareness of men's health, cancer and sexuality.
Kalli has been involved with the Prostate Cancer Foundation of Australia for many years, advocating for improved cancer care and facilitating community prostate cancer support groups.
