Male sling for stress urinary incontinence

What is the evidence base for this information?

This leaflet includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence based sources; it is, therefore, a reflection of best practice in the UK. It is intended to supplement any advice you may already have been given by your urologist or nurse specialist as well as the surgical team at Addenbrooke’s. Alternative treatments are outlined below and can be discussed in more detail with your urologist or specialist nurse.

What does the procedure involve?

The male sling is a treatment for male stress urinary incontinence. It involves placement of a synthetic sling (a plastic polypropylene mesh that does not dissolve) that supports the waterpipe (urethra). The procedure will involve a cystoscopic examination of the urethra and bladder and an incision in the area behind the scrotum (perineum), with two further small cuts in the groin crease.

Satisfaction rates for the procedure are around 70%. Most men will likely still require up to one pad a day or a safety pad. Once the sling is placed there is nothing required day to day to help empty the bladder.

In July 2018 a ‘high vigilance restriction’ for vaginal mesh surgery in women was announced and mesh use in women for stress incontinence is currently paused in the UK. Though this does not apply to men, we recommend you discuss this with your surgeon. It is the independent medicines and medical devices (IMMDS) report “First do no harm”. It is also called the Cumberlege review. There is a lack of long term outcomes in men thus if mesh removal is required in men it is important to know that it is complex and may not be possible.

What are the alternatives to this procedure

Incontinence into a pad, a urethral catheter, penile sheaths, penile clamps, an artificial urinary sphincter or urinary diversion with a stoma. Urethral bulking agents in men are not currently recommended by NICE (the National Institute for Health and Care Excellence). The male sling has been shown to be non inferior to the artificial urinary sphincter.

What should I expect before the procedure

You will usually be admitted on the same day as your surgery. You will normally undergo pre assessment on the day of your clinic or an appointment for pre assessment will be made from clinic, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team which may include the consultant, junior urology doctors and your named nurse.

You will be asked not to eat or drink for six hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure. In some patients, the anaesthetist may also use an epidural anaesthetic which improves or minimises pain post operatively.

Please be sure to inform your urologist in advance of your surgery if you have any of the following:

• an artificial heart valve
• a coronary artery stent
• a heart pacemaker or defibrillator
• an artificial joint
• an artificial blood vessel graft
• a neurosurgical shunt
• any other implanted foreign body
• a prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban or clopidogrel, ticagrelor or blood thinning medication
• a previous or current MRSA infection
• high risk of variant CJD (if you have received a corneal transplant, a neurosurgical
• dural transplant or previous injections of human derived growth hormone)

What happens during the procedure?

You will have a small incision, about 0.5cm, in the area between the scrotum and anus (the perineum, which is about 5 to 10cm in size) and two further small cuts in the groin crease. The sling will sit in this area. You will also have a urinary catheter placed.

What happens immediately after the procedure?

You will be given fluids to drink from an early stage after the operation and you will be encouraged to mobilise as soon as you are comfortable to prevent blood clots forming in your legs. You will be given intravenous antibiotics through your vein. You will normally be discharged the day after your operation, usually after your catheter has been removed.

Are there any side effects?

Most procedures have a potential for side effects. You should be reassured that, although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.

Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction:

What should I expect when I get home?

It is important to undertake light duties for six weeks following surgery. This will help prevent any sling slippage which may affect the efficacy of the sling.

What else should I look out for?

Men who undergo surgery in the perineum (between the anus and the scrotum) may find it easier to sit with their weight shifted onto one buttock. You may find it more comfortable to sit using an air filled donut, soft cushion or another type of pillow, especially for the first four weeks after surgery. Any activity that requires you to straddle anything, such as riding a bicycle, motorcycle or a horse, should be avoided for four to six weeks. You will get some swelling and bruising of your groin, perineum and occasionally scrotum lasting several days.

Are there any other important points?

You will be reviewed in outpatients to see how you have got on. It is likely you will be asked to complete a questionnaire on your symptoms.

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery. You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than three months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and/or specialist one-to-one care is required.

Hair removal before an operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team need to see or reach your skin and if this is necessary they will use an electric hair clipper with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself or use a razor to remove hair, as this can increase the risk of infection. Your healthcare team will be happy to discuss this with you.

References

• Surgical site infection Clinical Guideline October 2008 (opens in a new tab)

Is there any research being carried out in this field at CUH?

All operative procedures performed in the department are subject to rigorous audit at a monthly audit and clinical governance meeting. During 2014 and 2015 Addenbrooke’s Hospital was recruiting men to the MASTER trial. This a national trial funded by the NIHR.

Who can I contact for more help or information?