Artificial Sphincters

Incontinence is a fairly common issue that directly compromises the quality of life and relationships besides affecting personal and genital hygiene (Genital Hygiene | Maintenance). According to the results of a study published in World Journal of Urology (1), investigators reported that artificial sphincters are by far an excellent choice in individuals who experience refractory incontinence (Non-Surgical Treatment of Incontinence) with an overall patient satisfaction rate of 90%. In addition, artificial sphincters can be used to manage anal incontinence in patients who are refractory to other therapeutic modalities (Therapeutic Modalities Wiki Page) (2)

Artificial Urinary Sphincters

In certain situations when incontinence is due to sphincter dysfunction (in the setting of chronic diseases, malignancy, genital reasons, neurological disconnect or injury) a rubber silicone device can be used for the management of genitourinary incontinence.Most frequent candidates of artificial sphincters are middle-aged men who have compromised sphincter or valve function as a result of prostate surgery or pelvic trauma.

Working Principle of Artificial Urinary Sphincters

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Artificial Sphincters The device consists of an inflatable cuff that is capable of fitting around the urethra (Urethral Injury Early Treatments) (where it communicates with the urinary bladder). The pressure of the cuff is maintained via fluid (usually water/ normal saline). The deflation and inflation of the cuff is controlled by the bulb. After preliminary assessment, the balloon is carefully placed in the pelvic area as part of the surgical process or separately at another occasion. The control pump is usually installed within the scrotum. In order to prevent urinary leakage, the cuff is kept inflated. When there is an urge to urinate, the cuff can be deflated to allow micturition. This is then followed by automatic closing in 3-5 minutes. Cuff’s refilling is under the control of a resistor mechanism within the pump itself.

Artificial Sphincters | Implantation Techniques

• Males: The implantation procedure is usually performed under spinal or general anesthesia while employing optimal aseptic measures. Two incisions are made – one in the groin area whereas the other is between the rectum and scrotum. A proper sized cuff is then inserted around the urethra and the tubing originating from the cuff is passed onto the groin area. The balloon regulating the pressure is paced below the abdominal muscles whereas the pump controlling the device is passed down to the scrotum, under the skin. In the groin area the connections between the three components is established before closing the incisions. By the end of surgery, cuff is locked open for nearly 4-6 weeks until the tissue healing is complete.

• Female: Women who experience refractory incontinence are also ideal candidates for artificial sphincter. The key advantage is that women may urinate after releasing the cuff without going through intermittent catheterization. The device can be implanted via vaginal or abdominal approach. Other options for such women are pubo-vaginal sling procedure or periurethral injection therapy.

Complications of Using Artificial Sphincter in Females

• Chances of experiencing mechanical problems associated with the device along with the urethral thinning known as urethral atrophy, just below the cuff.

• Rarely intermittent postoperative catheterization is required.

In short artificial sphincters should be picked very carefully for selective females only.

Artificial Sphincters | Indications For Use

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Artificial Sphincters Artificial sphincters are an ideal choice for individuals experiencing incontinence due to:

• Surgical procedures like prostate surgery (PSA Test and Prostate Cancer)

• When urine continues to leak from the urethra despite bladder training and other psychological/ mechanical interventions.

• When other methods fail to yield fruitful results.

Artificial Sphincters | Expectations After

It is imperative to study the exact cause of urinary leakage before opting for artificial sphincters. This can be accomplished by a specialized urinary function test - urodynamics. For artificial sphincters to function properly, it is mandatory that urinary bladder is normal and functional (in terms of storing urine under pressure).Most patients report significant improvement in the quality of life after this procedure.

Artificial Sphincters | Risk factors That May Affect The Quality of Results

• History of smoking (rate of complications is higher in patients who are chronic smokers)

• Age of the patient (elderly patients over the age of 65 years are more likely to experience complications after the procedure)

• History of pelvic radiotherapy

Artificial Sphincters | Procedure Associated Complications

Some common risks involved with artificial sphincters are:

• Infection

• Erosion of urethral skin

• Inability of artificial sphincters to remain functional for longer period of time

• Patient factors

• Re-surgery - Required in almost 10-15% cases according to data reported by Vayleux (3) and associates.

Besides this method, some men prefer the symptomatic management of incontinence via non-pharmacological methods such as; continence products like pressure cuffs, incontinence clamps and absorbent pads, and changes in their habits to avoid artificial sphincters. It is imperative to seek the help and guidance of a trained medical professional before making the final decision about the surgery.

References:

• Leibovich, B. C., & Barrett, D. M. (1997). Use of the artificial urinary sphincter in men and women. World journal of urology, 15(5), 316-319.

• Lehur, P. A., Michot, P. F., Denis, P., Grise, P., Leborgne, J., Teniere, P., & Buzelin, J. M. (1996). Results of artificial sphincter in severe anal incontinence. Diseases of the colon & rectum, 39(12), 1352-1355.

• Vayleux, B., Rigaud, J., Luyckx, F., Karam, G., Glémain, P., Bouchot, O., & Le Normand, L. (2011). Female urinary incontinence and artificial urinary sphincter: study of efficacy and risk factors for failure and complications. European urology, 59(6), 1048-1053.

• Ravier, E., Fassi‐Fehri, H., Crouzet, S., Gelet, A., Abid, N., & Martin, X. (2014). Complications after artificial urinary sphincter implantation with or without prior radiotherapy. BJU international.