Urologists must differentiate between bladder outlet obstruction and pure OAB in male patients, according to Osvaldo F. Padron, MD.
According to the AUA, more than 25 million people in the United States suffer from urinary incontinence (bit.ly/auaincontinence). The condition is common in both men and women, but there are some gender-related differences in causes and considerations for treatment. Osvaldo F. Padron, MD, past president of Florida Urology Partners, Tampa, discussed these issues with Urology Times. Disclosure: Dr. Padron is a consultant for Axonics and Boston Scientific and owns stock in Axonics.
Which aspects of urinary incontinence are common to both men and women?
Overactive bladder exists in both genders. It tends to be overlooked more in men who can have pure OAB. Compared with women, men are more likely to have symptoms of frequency, urgency, and nocturia than urinary urgency incontinence (UUI). Frequency, urgency, and nocturia by themselves can be very bothersome and adversely affect quality of life for both genders. While UUI from OAB is less common in men, it is very troubling when it occurs.
Which aspects of incontinence are unique to each gender?
Uniquely in men, the prostate can play a role in OAB, and it can also confuse the diagnosis. Clinicians should consider OAB in men with UUI and recognize that men can have both bladder outlet obstruction (BOO) and OAB rather than assuming that the incontinence is just associated with BOO. This is especially true in men who do not have a large residual of urine and an enlarged prostate. I would estimate that about 25% of the time, UUI does not resolve after surgery to reduce the size of the prostate, and in some cases, the surgery can make the incontinence worse.
What types of incontinence are more common in men than in women?
Mixed incontinence is more common in women. Men can have stress urinary incontinence (SUI) and UUI, but SUI in men is usually a complication of prostate surgery, such as radical prostatectomy.
Are there causes of UUI that are specific to each gender?
In both genders, the intrinsic problem leading to UUI is detrusor overactivity, but the root cause of the overactivity can differ in men and women. While environment or genetics are common risk factors in both populations, in men, the overactivity can be due to BOO.
Do the gender-related differences in causes for UUI have implications for management decisions?
It is my opinion that urologists in general underestimate OAB in men and do not differentiate between BOO and pure OAB. Consequently, they tend to err on the side of performing prostate surgery to relieve outlet obstruction rather than treating the overactivity.
Are certain treatment options for OAB and UUI more suitable or more effective for one gender versus the other?
I do not believe that any particular treatment is more suitable for use in men versus women. The potential for urinary retention to develop with intravesical botulinum toxin injection and the fact that self-catheterization is more difficult for men than women is a consideration if tertiary therapy is needed.
Otherwise, I do not believe there are any data showing a gender-related difference in response to any therapies. Rather, I believe the data support the idea that OAB can be treated the same in men and women.
I have had success treating frequency, urgency, and UUI using anticholinergics, antimuscarinics, and the beta-3 adrenoceptor agonist in both genders. In men, these medications work best if the patient has a smaller prostate and does not have a high residual urine volume.
For refractory cases, I would still offer botulinum toxin along with sacral neuromodulation and tibial nerve stimulation to men as I do to women. I do not consider botulinum toxin to treat OAB in any patient carrying a high residual urine volume. Anecdotally, in my experience, tibial nerve stimulation works better for women than men, and so I tend to use it more often in women.
Is behavioral therapy underused more often in women or men?
I believe behavioral therapy is probably underused in both genders. In general, urologists tend to treat incontinence actively. Although we counsel patients about lifestyle and behavioral interventions, I am not sure that patients necessarily listen to the advice and implement the recommendations, especially in the long term. I believe patients are more willing to accept treatment options that involve medications or a procedure.