Watertight by remote
During a routine urinary test at the Queen Elizabeth Hospital seven years ago, doctors found an abnormality in Mr Cao's prostate - a walnut-shaped gland that wraps around the urethra and is located between the rectum and bladder. A biopsy revealed that Cao (full name withheld for patient confidentiality reasons), 69, had prostate cancer.
The tumour, however, was localised and the cancer was in its early stages so it could be successfully treated by removing the prostate. However, such an operation carried the risk of causing erectile dysfunction and urinary incontinence in addition to the risks of surgery. Despite an initial reluctance, Cao was finally persuaded by his family to undergo the prostatectomy.
When he came to, he discovered it was a mixed result. On one hand, the surgery was a success and he was cancer-free, but his newfound health came at a cost: he could no longer control his bladder.
Normally, healthy males have two mechanisms that enable urinary continence - the prostate and a sheet of muscle under it act as sphincters that constrict to prevent the flow of urine from the bladder to the urethra and out of the body.
When the prostate is removed, only the sheet of muscle remains to compress the urethra, thereby reducing one's bladder control. Furthermore, the nerve that controls the sphincter muscle goes around the prostate and is inevitably damaged to some degree during the prostatectomy.
The damage, which is irreversible, in Cao's case was severe - he experienced urine leakage almost constantly. As medication was ineffective, doctors advised him to do pelvic floor exercises to strengthen his sphincter muscles.
Cao also tried other methods, including a penile clip, which clamps down on the penis to compress the urethra within. However, the clip would cause pain if it was too tight, but urine would leak if it wasn't tight enough. He tried a catheter and bag, where a condom-like sheath was worn on the penis and a tube drained urine from the tip of the sheath into a bag that was strapped to the leg. But this was clumsy and inconvenient - Cao found it difficult to ensure the sheath stayed attached.
Cone-shaped pads that encase the penis to absorb fluid was not an option: his leakage was severe.
Finally, Cao resorted to adult diapers, which he had to change at least four times a day. Already living on social assistance, the cost of containing the urine leaks was an additional burden.
The embarrassment and discomfort of his condition wore on him. He lost sleep and grew depressed, and even contemplated suicide. After an embarrassing incident where urine soaked his pants while he was out with his wife, Cao refused to leave home.
In 2010, he saw an advertisement in the newspapers for a talk on male incontinence by Queen Elizabeth Hospital's associate consultant in surgery, Dr Ho Lap-yin. Cao attended the talk and learned about how an artificial urinary sphincter (AUS) or male sling could help him.
The AUS entails inserting a three-part device into the body. An inflatable cuff is affixed around the urethra. It is connected via a tube to a small capsule reservoir installed in front of the bladder, slightly higher in the pelvis where it holds about 20cc of normal saline fluid. Finally, a small peanut-sized control button is placed in the scrotum.
When the saline fluid drains from the reservoir into the cuff, the cuff inflates and constricts the urethra, which prevents the fluid from leaking out of the penis. When the patient wants to urinate, he will press the button in his scrotum twice, which causes the saline fluid to flow up into the reservoir, thereby deflating the cuff and releasing the pressure on the urethra. The patient can then pass urine. The saline fluid in the reservoir will slowly drain back into the cuff to inflate it and keep the patient continent until he chooses to urinate next.
This method is very effective as 70 to 90 per cent of AUS users experience fewer than one leak a day. It is most suitable for patients like Cao who have experienced severe leakage, but its HK$70,000 cost is prohibitive for many.
The male sling is a more recent development. A piece of abdominal or synthetic tissue is inserted into the pelvic area to replicate the function of the pelvic floor muscles constricting the urethra. It helps to strengthen the natural sphincter muscle and slightly elevates the bladder outlet higher into the abdominal cavity. This increases the intra-abdominal pressure on the bladder outlet to help keep it closed. The sling costs HK$30,000, but has a lower success rate - only 60 per cent of patients experience relief - and is only suitable for much milder cases of incontinence.
Happily for Cao, the Hong Kong Cancer Fund, the territory's largest cancer support organisation, stepped in to help subsidise his AUS treatment.
Last August, he underwent treatment. After the device was implanted, Cao rested at home for six weeks to enable the inflammation in the area to subside and the tissue to heal and strengthen. During this time, he continued to use adult diapers. Then, he returned to the hospital where the AUS was activated and, immediately, the leaks stopped.
Delighted with the results, Cao, now 76, helps to counsel other prostate cancer and incontinence sufferers.
