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Stress Urinary Incontinence
What stress incontinence is
Stress urinary incontinence means urine leaks when pressure is put on your bladder — coughing, sneezing, laughing, lifting, bending, standing up from a chair, or exercising. The "stress" refers to physical stress on the bladder, not emotional stress.
It happens because the muscle that holds urine in — your urinary sphincter — is no longer strong enough to stay closed when that pressure hits.
This is different from urgency incontinence, where you get a sudden, overwhelming need to go and leak before you reach a bathroom. Many men have some of both. Sorting out which one is driving your symptoms is the first thing we do, because the treatments are entirely different.
Why it happens after prostate surgery
Men have two mechanisms that keep urine in: an internal sphincter at the bladder neck, and an external sphincter just below the prostate.
When the prostate is removed for cancer, the bladder neck and the internal sphincter go with it. From that point on, your continence depends entirely on the external sphincter — a single muscle that may also have been bruised, weakened, or left with less support during surgery.
That is why leakage after a prostatectomy is so common, and why it is nobody's fault. It is a predictable consequence of the anatomy that had to be removed.
Other prostate treatments can cause it too:
Radiation to the prostate, either as primary treatment or after surgery. Radiation makes the tissue less elastic and less forgiving, which matters when we plan treatment.
Surgery for an enlarged prostate (BPH), such as TURP, HoLEP, or simple prostatectomy — much less commonly, but it does happen.
How we measure your leakage
"How bad is it?" needs a real answer before we can recommend anything.
Pads per day, and what kind. A damp liner is a different problem than a soaked adult brief. Be honest about this — men routinely under-report.
A 24-hour pad weight test. You collect and weigh your pads over one full, normal day. It sounds crude, but it's the most objective number we have, and it is often quite different from what people estimate.
A voiding diary covering a few days.
Physical exam and a cough test, so we can see the leakage happen.
Cystoscopy. A small camera in the office. This is not optional. We need to see whether scar tissue has narrowed the join between the bladder and urethra, and to assess how the sphincter closes.
A bladder scan after you urinate, to be sure you are emptying.
Roughly speaking, leakage gets described as mild (about one to two pads a day), moderate (three to five), or severe (more than five). These categories are imprecise, but they help frame the conversation.
One thing we always check first
If scar tissue has narrowed the connection between your bladder and urethra — a bladder neck contracture or anastomotic stenosis — that has to be treated and stable before any incontinence surgery. Placing a device across a narrowing that is still closing down sets you up for failure. This is a common reason a man's incontinence surgery gets staged rather than done all at once.
Your treatment options
Non-surgical options
Pelvic floor muscle training
The first-line treatment, and the one worth doing properly. Not "kegels you read about online" — a referral to a pelvic floor physical therapist who can confirm you are contracting the right muscle. Many men squeeze their abdomen or buttocks instead and get nowhere for months.
Best results come from starting early and being consistent. It will not rebuild a sphincter that was badly damaged, but it improves what you have.
Everyday adjustments
Cutting back on caffeine and alcohol, spreading fluids through the day rather than drinking large volumes at once, emptying before activity that tends to make you leak, and losing weight if that applies to you.
Managing leakage while you wait
Male guards and shields designed for men fit better than generic pads. Some men prefer a condom catheter, particularly overnight. A penile clamp can be useful for short, specific situations, but it is not something to wear all day — it restricts blood flow and can damage the urethra.
What about medication?
There is no medication approved in the United States for stress incontinence in men. If someone offers you a pill for this, ask what the evidence is.
Surgical options
Once you are past the recovery window and pelvic floor therapy has taken you as far as it will, there are two established operations.
Male sling
A strip of mesh placed under the urethra through a small incision in the perineum, repositioning and supporting it.
Who it suits: Men with mild to moderate leakage who have not had radiation.
The appeal: Nothing to operate. Once it's in, it works on its own — no pump, no learning curve, no device to think about.
The limits: It is not adjustable after placement. Results are less reliable with heavy leakage, and considerably less reliable after radiation. If it doesn't give you enough improvement, the next step is an artificial sphincter anyway.
Artificial urinary sphincter (AUS)
The artificial urinary sphincter is the most effective and most durable treatment for stress incontinence in men, and the only one that works across the full range of severity — including severe leakage and leakage after radiation. It has been in use since the 1970s and remains the reference standard.
What it is
Three connected parts, all placed inside the body, all invisible from the outside:
A cuff that encircles the urethra in the perineum. This is the part that does the work — it gently holds the urethra closed.
A pressure-regulating balloon, placed in the lower abdomen, which sets and maintains the pressure in the system.
A control pump, placed inside the scrotum, where you can reach it easily.
The whole system is filled with sterile fluid and sealed. There are no batteries and nothing to charge.
How you use it
At rest, the cuff is closed and you stay dry.
When you want to urinate, you squeeze and release the pump in your scrotum a few times. That moves fluid out of the cuff, the urethra opens, and you urinate normally. Over the next couple of minutes the cuff refills on its own and closes again. You do not have to do anything to re-close it.
Most men find it becomes automatic within a few weeks.
What it requires from you
This is a device you operate, several times a day, for the rest of your life. Before we recommend it, we make sure you have:
Enough hand strength and dexterity to work the pump — significant arthritis or tremor matters here
The memory and understanding to use it reliably and to protect it
The motivation to manage a permanent implant
If those are a genuine problem, we will talk about alternatives honestly rather than implanting a device you can't use.
The operation and recovery
The device is placed through a small incision in the perineum and a second small incision in the lower abdomen or groin. It is usually same-day surgery.
The device is deliberately left switched off for about six weeks after implantation. This is intentional — the tissue around the cuff needs to heal before it takes any pressure. During those six weeks you will leak exactly as you did before, which can be discouraging if you aren't expecting it. Then you come to the office and we activate it, which takes a few minutes and requires no anesthesia.
What results to expect
Most men go from heavy, daily leakage to no pads or a single light pad a day, and satisfaction rates are high.
It is important to be clear-eyed, though: the goal is usually social continence — dry enough to live normally, exercise, travel, and stop planning your day around bathrooms — rather than an absolute guarantee of never leaking a drop. Most men consider that trade an easy one.
Risks, and the honest part about longevity
An artificial sphincter is a mechanical device implanted in the body, and it will not last forever. Over the years, some men need a revision or replacement. The main reasons are:
Mechanical failure of a component
Urethral atrophy — the tissue under the cuff gradually thins, so the cuff no longer seals well and leakage returns
Erosion, where the cuff wears through the urethral wall
Infection, which usually means the device has to be removed and replaced later
Radiation raises the risk of erosion, and so does a history of prior urethral surgery or repeated catheterizations. That does not rule out an AUS after radiation — it remains the preferred choice in that group — but it changes the conversation about risk.
The right way to think about it: an AUS is not a one-time fix, it's a long-term relationship with a device that works very well and may occasionally need service.
Common questions
Will I be completely dry? Most men get to zero or one light pad a day. Complete dryness happens but isn't promised. The realistic goal is being dry enough that leakage stops shaping your life.
Do I really have to wait a year? In most cases, yes. Leakage keeps improving for a long time after prostate surgery, and operating too early risks doing surgery you didn't need.
I had radiation. Does that rule me out? No. The artificial sphincter is specifically the preferred option after radiation. Your tissue is more fragile, so the risk of erosion is higher, and we plan accordingly.
Will people know I have it? No. Everything is internal. Nothing shows.
What happens if it stops working? We evaluate why — mechanical failure, atrophy, or erosion all look different — and in most cases the device can be revised or replaced.
My leakage is mainly urgency, not stress. Is this page relevant? Partly. If your main problem is a sudden urge you can't defer, that's a different condition with different treatments. Many men have both, and we treat them separately.
Questions worth asking at your consultation
Is my leakage stress, urgency, or both?
What did my pad weight test actually show?
Do I have any scar tissue that needs treating first?
Am I a candidate for a sling, a sphincter, or only one of them?
Given my radiation history, what risks apply specifically to me?
What happens at the six-week activation visit?
What is your own revision rate, and how many of these do you do a year?
To schedule a consultation and discuss which option is right for you, please visit our CONTACT page.