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Posts Tagged ‘medtronic interstim’

when you are young and not a liberal...you don't have a heart. when you are older and not a conservative...you don't have a brain... w churchill

Usually not. But there  is a situation where it could be of value. But first an overview of incontinence as it pertains to the male, the sphincter, the bladder, and the body with and without a prostate. The following is an excerpt from my book and explains the caveat about an overactive bladder in the face of a recent prostatectomy. The Medtronic Interstim device can be placed in a test fashion as an  out patient. I have inserted dozens over the years, not in a post prostatectomy patient, and when it works- it works very well and negates the need for medications that are either partially effective or have pesky side effects (dry mouth and constipation).  This Medtronic video on Facebook is actually quite informative and explains the physiology of this situation.

  • the most common type of incontinence after prostatectomy is stress incontinence-you leak with activity
  • there is also total incontinence you leak all the time and there is no sensation that you need to void
  • uncommonly however is the situation in a male patient that had an enlarged prostate and significant obstructive voiding symptoms in which the bladder over years has been working really hard to bypass the obstructive nature of the prostate-in doing so the muscles of the bladder are larger and more hyperactive
  • this situation results in “detrusor hyperactivity” and the patient will experience irritative symptoms as well
  • irritative symptoms are frequency, urgency with and without incontinence, and getting up at night
  • so….this particular person is found to have prostate cancer and then has his prostate removed
  • the prostate is gone but the bladder has not gotten the memo and continues to be over active
  • with the prostate gone and all that obstructive resistance gone, the patient now experiences all the symptoms of an overactive bladder very similar to females
  • the medtronic interstim device would help in this situation
  • it would not help if the prostate were still in the patient
  • it will not help stress incontinence
  • it would help the “revved up bladder” that is over active and has detrusor hyperactivity

If you and your doctor have done your homework on the decision-making process, how you void “before” surgery or radiation will be an important aspect to factor in, in your decision.

From “The Decision”

Case study 3: S.P.

 Age 69

Retired

Married

Good health, marginal sexual function, significant obstructive voiding symptoms.

Pathology of biopsy: Gleason’s score 6 and 7, moderate volume

Prostate exam: no nodule but two plus enlarged (B.P.H.)

This patient had no bias but was very aware of his obstructive voiding symptoms.

This patient’s driving force in deciding to remove the prostate was his wife’s and his desire for cure and being able to remove the obstructive voiding symptoms related to the enlarged prostate. Men who have had obstructive symptoms for years will sometimes develop hyperactive symptoms due to the bladder having to work harder to overcome the obstructive nature of the prostate. This in turn thickens the bladder wall musculature and causes what is called detrusor hyperactivity (irritative voiding symptoms, frequency, urgency, and nocturia). These symptoms are usually more prominent than the patient realizes as they come on slowly over the course of many years. The patient in this case had these symptoms prior to surgery, and it complicated his postoperative course. This patient did extremely well with the surgery and after two years is free of cancer, but continues to have incontinence from an urgency standpoint. He will have days that he is dry, and other days in which without warning his bladder will have a contraction and he will leak urine. Various medicines have been of limited help, and it has been a frustrating situation for the patient and his wife. He does not regret his decision, as he is pleased with a negligible PSA, but obviously the incontinence has hampered his quality of life.

Caveat: When urologists perform a TURP (transurethral resection of the prostate), prostate tissue is removed and results in opening the prostatic urethra.  This improves obstructive voiding symptoms and is similar to taking “a core out of an apple” and often referred to by patients as having a “roto-rooter.” Although obstructive symptoms will improve, any pre-existent irritative symptoms will most probably continue, sometimes to the point of urgency incontinence.

What happens here is that with the restriction of flow corrected by the TURP, the urgency symptoms become more prominent. It can take weeks to months for the bladder to “calm down” and the urgency symptoms to improve. Sometimes they don’t, particularly in older men whose symptoms have been present for a long time. It is my feeling that the surgical patient described in this case was experiencing this phenomenon.  His situation would probably not be better if he had had radiation. If he had had radiation without doing something to relieve the obstruction before, his obstructive symptoms would have worsened, with no surgical options. If he had had a procedure to open the prostate before seeds, he would have still had the urgency symptoms from the detrusor hyperactivity in addition to the irritative symptoms related to the radiation. This case is just a difficult situation resulting from longstanding obstructive voiding symptoms that were more significant than the patient or the doctor realized preoperatively. This patient’s current plight could not have been prevented, but a doctor can always do a better job of anticipating it and better prepare the patient and his wife for it.

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