Men of all ages can suffer from bladder and/or bowel incontinence or erectile dysfunction. Correctly undertaking pelvic floor muscle exercises may help address these problems.

People generally take their bowel and bladder function and control for granted, until symptoms of urgency or incontinence are experienced. The pelvic floor is a sheet of muscle that forms the floor of the pelvis and is essential to bladder and bowel control. Pelvic floor muscles stretch from the pubic bone at the front to the coccyx/tailbone.

Functions of the male pelvic floor muscles

The pelvic floor muscles are hidden away, with many unaware of the important role they play. Not only do they keep our abdominal organs in place, but they also maintain bladder and bowel continence by relaxing and closing bladder and bowel openings to prevent or allow the passage or urine, faeces and wind. The pelvic floor can also support sexual function by helping to maintain an erection and preventing premature ejaculation.

Causes of pelvic floor muscle issues

Men may encounter problems with their pelvic floor muscles following prostate surgery; pelvic radiation; chronic constipation; heavy, prolonged lifting; chronic cough; being overweight; conditions such as multiple sclerosis, diabetes, stroke; or perineal injury.

Lack of regular exercise may lead to poor muscle tone and excess strain on pelvic floor muscles. Chronic straining can lead to excess stretching of the pelvic floor muscles, their nerve supply and supporting tissues. Some conditions may affect the nerve supply to the pelvic floor muscles. Trauma and injury to the perineum could also be factors.

Lack of regular exercise may lead to poor muscle tone and excess strain on pelvic floor muscles.

Weak pelvic floor muscles

Some of the common symptoms include:

• Stress urinary incontinence, leakage during activities such as coughing, laughing, sneezing or sports
• Urinary urgency/urinary urge incontinence: sudden feeling to dash to the toilet
• Bowel incontinence: accidental leakage of faeces, or difficulty in controlling wind
• Post-micturition dribble: leaking a few drops of urine after passing urine
• Erectile dysfunction: not being able to gain or maintain an erection
• Premature ejaculation during sexual activity

Pelvic floor muscle exercises may be helpful for all of the symptoms listed above. It is a good idea to get into a good habit of doing them to prevent problems from developing, even if symptoms are not present. A physiotherapist or other health professional can support and instruct you on undertaking pelvic floor muscle exercises.

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Poor sexual function is the most common side effect of prostate cancer treatment, but personalised healthcare can improve men’s quality of life.

When Elvin Box, now 65, was diagnosed with aggressive prostate cancer in 2016, he felt lucky that the disease had been discovered before it became incurable. However, he was unprepared for the impact on his sex life, 41-year marriage and his mental health. 

In the UK, prostate cancer is the most diagnosed cancer in men¹ and more than 395,000 were living with or beyond prostate cancer in 2018.² Prostate cancer therapies can negatively impact men’s sexual function and lead to changes in their relationships. Appropriate care and information are not always available.

Sexual side effects of treatment

According to the Movember-funded ‘Life After Prostate Cancer Diagnosis’ (LAPCD) study, 79% of men reported poor sexual function as a side effect of prostate cancer treatment.

Among many potential side effects, men on hormonal therapy may experience decreases in their sex drive because of the loss of testosterone and possible loss of orgasm. Surgery and radiotherapy can damage nerves, blood vessels and muscles which diminishes erectile function.

Unfortunately, it remains a problem that is not routinely addressed in prostate cancer care. The LAPCD study, published in The Lancet in 2019, found that 57% of men were not offered any help with sexual dysfunction following their treatment.³

79% of men reported poor sexual function as a side effect of prostate cancer treatment.

New guidelines for healthcare professionals

Earlier this year, the needs of men and their partners have finally been addressed with the publication of new clinical guidelines for prostate cancer care in The Journal of Sexual Medicine. The guidelines are based on decades of research and combined international expert perspectives.

Reasons for healthcare professionals (HCPs) not having conversations about sex include a lack of knowledge, discomfort with the conversation, perceived or imagined patient discomfort and lack of time. However, research shows that patients and partners are unlikely to initiate discussions about sexual concerns, so HCPs must feel confident and adequately equipped to introduce the topic and set realistic expectations of sexual issues early on.

The guidelines provide a framework to prepare HCPs to initiate these sensitive conversations, provide tailored care to enhance sexual health and facilitate shared decision-making between clinicians, patients and their partners. They provide a holistic model of care that recognises cultural, ethnic, racial, sexual and gender diversity as well as differences across healthcare systems.

Assessment of sexual function and wellbeing, prior to, during and after treatment would ensure that issues are raised in a timely way and early interventions can be implemented to address someone’s physical, emotional and social needs.

Rebuilding your sex life

The good news is that, with appropriate care and support, sexual health and intimacy can be re-established and enhanced after prostate cancer treatment for men and their partners.

Addressing sexual health and recovery is the responsibility of every HCP who touches the life of a prostate cancer patient. Now, we have an inclusive roadmap that will allow healthcare providers to address the needs of their patients.

Understanding that many prostate cancer patients live long lives — some with and without partners — requires us to help protect and enhance the quality of their lives during and beyond treatment. By including sexual health as a part of usual care, we will be responding to significant unmet needs and achieving a new standard of care.

Box, now an ambassador for Movember, says: “If only the guidelines had been there for me. If they’re now used by healthcare professionals, it will help so many men faced with the trauma of dealing with prostate cancer to make an informed decision about their choice of treatment and how they can rehabilitate.”

[1] https://gco.iarc.fr/today/
[2] https://www.cancerdata.nhs.uk/prevalence
[3] Quality of Life in Men Living with Advanced and Localised Prostate Cancer: A UK population-wide patient-reported outcome study of 30,000 men – The Lancet Oncology, January 2019. 

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Prostate cancer is the most common cancer in men, and one in eight men will be diagnosed in their lifetime. For Black men, that figure doubles to one in four.

Early prostate cancer is very treatable, but be aware that it doesn’t normally have symptoms in the early stages. So don’t wait until you’re feeling unwell to think about prostate cancer.

In many cases, once symptoms have appeared, the cancer will have already spread and become more difficult to cure. Every man must know his risk of getting the disease, which is why I’d encourage everyone to use the Prostate Cancer UK online risk checker.

Who is most at risk of prostate cancer?

Prostate cancer mainly affects men over 50, and this risk increases with age. If you are a Black man or have a family history of prostate cancer, your risk is significantly higher, so you should speak to your GP about regular PSA blood tests from age 45.  

Prostate cancer screening

I’m excited to write that the UK might now be in a position to roll out a national screening programme for prostate cancer, which would undoubtedly save thousands of lives. Recent research carried out by Prostate Cancer UK shows that tests for the disease are now far more accurate and less harmful than they used to be, thanks to newer scans and safer, targeted biopsies.

We’ve submitted this evidence to the National Screening Committee, and we hope that they’ll decide we are ready for the screening programme we so desperately need.

In Scotland, 35% of men with prostate cancer
receive their diagnosis at an advanced
stage, when it’s too late for a cure.

Check your risk in seconds

Routine NHS screening would be a vital step forward in giving men everywhere a fighting chance against prostate cancer, especially as data revealed this year shows a huge North-South divide in the UK when it comes to men getting diagnosed early enough to be cured.

In Scotland, 35% of men with prostate cancer receive their diagnosis at an advanced stage, when it’s too late for a cure. This figure is around 20% in Northern Ireland, Yorkshire and the Northeast of England — and drops to just 12.5% of men diagnosed in London.

Until all men in the UK receive regular screening, it’s still up to you to decide if you want a PSA blood test. The most powerful thing you can do is check your risk of getting prostate cancer and get the information you need to decide if it’s right for you.

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Patient engagement interventions save lives. Effective communication between urologists and their patients is vital to improving treatment outcomes and long-term patient quality of life.

Patient engagement will revolutionise medicine. That was the message at the Patient Day of the biggest urology congress in Europe. There is new scientific evidence proving that involving patients in the decision-making process of treatments will improve outcomes.

Aspects like quality of life, anxiety, depression and fatigue are often neglected but deserve more attention in the treatment of urological patients. However, the subject demands greater attention, and additional research is required.

Both medical experts and patients need to recognise that contemporary patient advocacy must take a comprehensive and holistic approach, encompassing not only direct support for patients but also guidance for research initiatives and influence over the healthcare and regulatory policies that affect patients’ lives.

Hierarchical nature of healthcare

To help understand where patient-physician communication breaks down, social psychologist Tamás Bereczky points to the hierarchical nature of healthcare and how that facilitates barriers to functional patient-physician communication. The healthcare system often places doctors on the top of a hierarchy, while patients are often ‘reduced to a number or a line on an Excel sheet.’ This creates a system of epistemic injustice, as the patient’s experience can be invalidated based on their hierarchical status.

Best practices should include tackling
paternalistic and hierarchical approaches,
educating both physicians and patients,
limiting jargon and using empathy.

Best practices for physicians and patients

With regard to the dichotomy of clear evidence versus slow changes within the medical field, experts need to understand how fundamental these issues are to medicine and how the change needs to be systematic.

According to Bereczky: “It’s a paradigm shift, and that takes time.” Best practices should include tackling paternalistic and hierarchical approaches, educating both physicians and patients, limiting jargon and using empathy.

Instead of only considering ‘hard’ outcomes — like time limits and financial constraints — healthcare professionals should include soft outcomes in their choice for treatment, like a patient’s emotional state and understanding of their medical situation. This fundamental issue needs to be tackled early on in specialists’ medical journeys, potentially starting with training in medical school, with more research and specific, clear guidelines targeting patient education and communication.

Especially when it comes to men’s health issues, male patients are often more reluctant to discuss these softer topics than female patients. So, it is not only a matter of teaching young doctors about the importance of communication but also making male patients aware that talking about their mental health will improve their outcomes.

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While attitudes towards mental health are changing, men — particularly those lower down the socioeconomic ladder — are struggling in what has become a mental health epidemic.

The unfortunate truth is that suicide is still the biggest killer of men under the age of 45. Research shows that men in the most disadvantaged areas of the UK are up to 10 times more likely to take their own lives than those in affluent areas.

When you factor in austerity, soaring living costs and a growing number in problem debt, the outlook is worrying. This is why we need greater investment in education, benefits, affordable housing and local amenities. However, these investments also have to extend to prevention rather than firefighting alone — and that starts by addressing the culture that surrounds us.

Shifting mental health for men

Something that comes up time and time again when working with suicide survivors and their families is the stigma that stopped them from getting help. That’s because deep-rooted perceptions of what it means to be a man are hard to shift. We conflate strength and stoicism — masculine ideals that value repression and indifference.

These confused and ingrained values can lead us to think we have no worth if we don’t match them. Our own research shows 63% of men agree that the widely-held ideal of being ‘unemotional’ was harmful and offensive.¹

Far too many men feel embarrassed to admit they are struggling or feeling depressed.

At the same time, the language that surrounds mental health fails to connect with those at the tougher end of the socioeconomic spectrum who are without access to the kinds of progressive education that the more advantaged take for granted.

Words matter. Shifts in language can help reduce stigma and facilitate easier access to treatment before the point of crisis.

How to help all men

Far too many men feel embarrassed to admit they are struggling or feeling depressed. Education is key in helping men of all ages and circumstances understand they have a right to ask for help — a point supported by the fact that 56% of young men believe the best way to promote a positive perception of masculinity is to normalise getting help (CALM mandate report).

And that’s the crux of it: normalising being lost sometimes; normalising not feeling great; normalising getting help. While we’re moving in the right direction in some areas of the UK, we need to make sure no one is left behind — no matter where or what class they were born into or where they find themselves, especially now.

[1] https://www.thecalmzone.net/what-it-means-to-be-a-man-today

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Mr Jonathan Aning

Chairman, BAUS Section of Oncology Executive Committee

Although penile cancer is rare, it is important to self-examine regularly for any changes or swelling in the penis or groin. If identified early, it can be treated.

In 2018, there were approximately 700 new cases of penile cancer diagnosed (CRUK data). While penile cancer can affect any part of the penis, it most commonly affects the foreskin (16%) and the head (glans) of the penis (45%).

Risk factors for penile cancer

Penile cancer is generally more common in men over 50 years old, but the exact cause is not known. Around half of all penile cancers are thought to be caused by human papillomavirus (HPV), an infection that spreads usually through skin-to-skin contact during sexual activity and affects the genital area.

Long-term problems with not being able to retract the foreskin, medically termed phimosis, can be also associated with penile cancer. Chronic inflammation, obesity and smoking are also risk factors.

When to seek help

It is not unusual to feel embarrassed about noticing something is not right in your genital area. However, you should see your doctor if:

• You notice a growth, rash or sore area on your penis that does not heal within four weeks
• You notice bleeding or unusual discharge coming from under your foreskin

It is not unusual to feel embarrassed about noticing something is not right in your genital area.

Diagnosis for penile cancer

Penile cancer can be diagnosed by examination in expert hands; the hospital specialist will examine the genital area and may arrange for a biopsy.

You may also need scans to image your penis such as Magnetic Resonance Imaging (MRI) or a CT scan. These tests are to see how much of the penis is involved and whether any cancer has spread to other areas.

What are the treatment options?

Due to the rarity of the disease, penile cancer treatment in the UK is delivered in specialist centres. In England, there are nine specialist penile cancer centres (currently termed ‘supra-regional centres’).

The first treatment is usually surgery. The type of operation that needs to be performed depends on the extent of the cancer. Specialists will aim to remove the cancer but preserve as much of the functional penis as is safe. In more advanced cases, chemotherapy or radiotherapy may be involved, or further surgery may be required to remove groin lymph nodes.

This is why penile cancers must be picked up early. By increasing awareness of penile cancer across the UK and offering the most advanced treatments, we can save lives and aim for better recovery after treatment.

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Men benefit from objective information about the sexual, urinary and mental health implications of each prostate cancer treatment option.

Most men who come to our clinic are anxiously seeking a second opinion following a diagnosis and treatment recommendation for localised prostate cancer which is likely to significantly impact their quality of life. Our primary focus is to ensure men have the information they need to make an optimal decision on treatment. 

PSA testing and precision diagnosis 

Early detection is key to curative and non-invasive treatment, and men should get a regular PSA test from the age of 50. Prostate cancer is often symptomless and regular testing gives a baseline against which to measure changes.

If the PSA rises significantly, an imaging technique called mpMRI will enable your doctor to determine if the rise is due to prostate cancer on the gland or something else, such as inflammation. The images will show the exact location and size of any suspicious areas on the prostate, providing a precise map for a biopsy if required.

Knowing the precise characteristics of suspicious areas means that a diagnosis is definitive. If a biopsy determines that an area is cancerous and confined to the gland, targeted treatment options are available — which do not compromise sexual or urinary function.

HIFU uses ultrasound to treat cancerous lesions, and NanoKnife uses electric current.

Treatment without worrying side effects 

A diagnostic map is the backbone of targeted prostate cancer treatments called focal therapy. Focal therapies are non-invasive procedures — hey have minimal impact on sexual or urinary functions. Often described as the ‘male lumpectomy,’ focal therapy removes the cancerous tissue but retains the prostate gland itself. They allow men to recover quickly and to get back to normal life. 

The Focal Therapy Clinic offers men with localised prostate cancer targeted focal therapies using energy sources best suited to their clinical diagnosis. HIFU uses ultrasound and NanoKnife uses electric current to eliminate cancerous lesions within the prostate gland. Evidence and detailed information on each approach can be found on our website.

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A surgeon sees both sides of the operating table after being paralysed and turns an unfortunate accident into an opportunity to become a better doctor, empathising with patients.

Mohammed Belal, a neuro-urology surgeon, suffered an accident which led to paralysis in his lower body. In February 2021, he was biking in the West Midlands when he was hit by a fallen tree. “There was no time to react. The next thing I knew, I woke up and tried to get up and realised I was paralysed,” he recalls. His injuries included a broken back, shoulder blade and ribs.

A hopeful patient’s point of view

Mr Belal initially underwent a 14-hour operation which was later followed by multiple more spinal operations, eight months in various hospitals and over 1,000 hours of rehabilitation. As this happened during the Covid-19 pandemic, his wife was only allowed to visit him once a week. This led Mr Belal to reflect on life as a patient and how his three children would react to seeing him in a wheelchair. It took over a year after the accident before he was able to go home and be with his family.

“What I’ve learnt as a patient is hope is very important,” he says. “I recognise from the other side that I accept what has happened to me, but having hope, I will work to get better. It allows me to push and push in rehab — to do the next thing that’s needed.”

I spent a lot of time looking after people with spinal cord injuries, so I know both sides now.

Return to work after intensive rehabilitation

Most might think that paralysis would lead to the end of one’s career as a surgeon. However, in November 2022, Mr Belal returned to work at Queen Elizabeth Hospital, Birmingham as the first paralysed medic in the UK to perform an operation. This also makes him one of the few surgeons in the world who was able to return to work after becoming paralysed.

So Mr Belal could operate on patients once again, he was given a special electric wheelchair with a hydraulic seat by the University of Birmingham Hospitals NHS trust. It is designed to be able to raise and support him in a standing position, with knee support allowing him to lean over patients during procedures.

“I feel incredibly lucky. Not many people come back from a catastrophic, life-changing event to a job like this,” says Mr Belal, whose return to work started with fitting an artificial urinary sphincter — an operation that takes around two to three hours.

A chance to give back to patients

As a neuro-urology surgeon, he works in a multidisciplinary field treating bladder, bowel and sexual dysfunction in individuals with neurological disorders. For Mr Belal, this involved treating patients with spinal cord injuries similar to his.

“I spent a lot of time looking after people with spinal cord injuries, so I know both sides now,” he says. “I feel positive as I’ve been overwhelmed by the support I’ve had, and while it’s about accepting, I am privileged — and it’s about not giving up.”

Instead of retiring, he wanted to take advantage of his second chance at life to help other people. “I want to bring some positivity back to the NHS if I can. We’ve been through a difficult time,” he adds. “I still have my hands, my brain, my family, friends and colleagues — what’s not to be grateful for?”

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Male urinary incontinence can be a sensitive and embarrassing issue for patients, but there are numerous ways to manage the condition.

Specialists urge people to have confidence in approaching their GP about incontinence treatment. Mohammed Belal, a consultant urologist at the Queen Elizabeth Hospital in Birmingham, underlines the importance of putting patients in control of their incontinence issues through education and information about support and treatment while working to break down the stigmas associated with the condition.

Urinary incontinence is normal with age

A key element lies in ‘normalising the condition.’ “It’s important to reassure patients that urinary incontinence is a common condition that affects many people — particularly as they age — and that they are not alone and help is available,” Mr Belal says.

Explaining the types of urinary incontinence and their causes is also important, alongside making information available about treatment options and strategies for people to manage their symptoms.

“Keeping a diary to identify patterns in symptoms, such as triggers that lead to leaks, is of value and can also be a basis to enable patients to communicate more effectively with their GP,” he adds.

There are effective treatments available, and he encourages patients to make an appointment with their GP to discuss their concerns. Brochures, videos and websites can help patients learn more about the condition and its management, and they can also get support from healthcare professionals, friends, family members and specialist support groups.

What causes urinary incontinence?

Causes and symptoms of urinary incontinence in men can include overactive bladder syndrome where there is a need to urgently or frequently go to the toilet. “This affects up to 12% of the population over 40 and increases with age,” explains Mr Belal.

In cases of benign enlargement of the prostate gland, the urethra is squeezed, making it difficult to control urine flow. Prostate cancer treatment can also be a cause, either from surgery or radiation therapy as nerves responsible for continence can be damaged.

In addition, neurological disorders such as Parkinson’s disease, multiple sclerosis and spinal cord injuries can interfere with the signals between the bladder and brain, leading to urinary incontinence.

This affects up to 12% of the population over 40 and increases with age.

Behavioural and medicinal treatment options

Treatment options depend on the underlying cause and severity of the condition. Behavioural therapy involves exercises to strengthen the pelvic muscles; bladder re-training techniques to improve bladder control; while medication may be prescribed to relax the bladder muscles, reduce urinary frequency and reduce the size of the prostate gland.

Surgery may be recommended in more serious cases. Another option is electrical stimulation where an implantable device delivers electrical impulses to the sacral nerves to improve bladder and bowel control, such as Medtronic’s InterStim system.

“In rare cases, a catheter may be used to manage urinary incontinence,” adds Mr Belal.

A range of absorbent products such as pads, liners and adult nappies are also available to manage incontinence.

Actively breaking the stigma

An important step with male incontinence is to break the stigma associated with it.

“That requires a multifaceted approach which involves educating people about the condition and its causes, raising awareness and providing support to individuals who experience the condition,” he says.

As the common problem affects millions of people worldwide, he also advocates encouraging open conversations about urinary incontinence to normalise the condition.

There are public awareness campaigns and support groups which can provide a safe and supportive environment for individuals with urinary incontinence to share their experiences and receive emotional support.

“Healthcare providers can play a crucial role in facilitating these conversations and providing support to patients,” Mr Belal concludes. “Breaking the stigma associated with urinary incontinence will take time and effort, but with education, awareness and support, we can work towards a more inclusive and accepting society.”

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Mr Rick Popert

Urological Consultant, Guy’s and St Thomas’

A revolutionary, heat-free treatment to tackle urinary problems in men, while reducing major side effects, has taken a step towards wider implementation across the NHS.

A robotic, heat-free technique treats a non-cancerous problem known as Benign Prostatic Hyperplasia (BPH), where men have difficulty passing urine due to an enlarged prostate.

Consultant urologist Neil Barber explained that the prostate enlarges in men from their late-40s and can lead to BPH. “That may start to affect the dynamics of urine flow out of the bladder and cause symptoms,” he says.

Treatment options for benign prostatic hyperplasia

The standard treatment for BPH has been Transurethral Resection of the Prostate (TURP), which is effective in relieving urinary symptoms but can damage nerves and parts of the prostate gland essential for sexual function.

Another option is a more radical laser technique known as HoLEP (Holmium Laser Enucleation of Prostate). While men can manage the condition by watching fluid intake, they may need medication or even surgery as their condition deteriorates.

Untreated BPH can lead to infections, bladder stones, incontinence or urinary retention resulting in a catheter being inserted into the bladder while waiting for treatment.

New therapy with NICE validation

Now, Aquablation Therapy, a new minimally invasive heat-free robotic therapy is being offered to patients. Recent recognition by the National Institute for Health and Care Excellence (NICE) as a technology that is effective, safe and has advantages for patients and healthcare systems effectively paves the way for wider use in the NHS.

Barber, a consultant at Frimley Health NHS Foundation Trust and a specialist in BPH surgery says the procedure sees a patient’s anatomy mapped on-screen using live ultrasound before a precise robotically controlled water jet clears a channel in the enlarged prostate, allowing urine to flow unimpeded, while preserving critical anatomy.

“A big positive for patients is that it achieves a successful procedure at a lower risk of affecting sexual function,” he says. “We now also have high-quality, long-term data which makes surgeons and urologists more comfortable talking to patients about this being a realistic option.”

A big positive for patients is that it achieves a successful procedure at a lower risk of affecting sexual function.

Phil Dyer

Life after benign prostatic hyperplasia

Former chef Phil Dyer had retired to enjoy life and his passion for golf, but he suffered urinary retention as his bladder enlarged.

Tablets initially worked, but as his condition deteriorated, he had a catheter fitted before treatment with the Aquablation technique last December.

Phil, 69, from Whitstable in Kent, says: “Living with a catheter before the procedure, I was in a bad way, both physically and emotionally. Since being treated, I have my life back — not suffering pain, able to travel again, playing 2–3 rounds of golf a week, and it’s so nice to be back in the same bed with the woman I love.

The lives of many older men can be transformed by this procedure.

Predictable and efficient procedure

The procedure provides real-time imaging and automated tissue removal, combining the experience of the surgeon and precision of robotic execution to standardise outcomes for patients.

Rick Popert, Consultant Urological Surgeon at Guy’s and St Thomas’, says: “It offers lots of improvements for people who have enlarged prostates. It also provides us with the ability to treat larger, more complex anatomy than the standard of care. Using this robotic technique, not only we can treat more patients, but we can provide patients with a more consistent outcome in relation to symptom relief and preservation of ejaculatory, erectile and continence function. It is supported by five-year randomised control trial data.”

Procept BioRobotics Corporation’s day-case Aquablation is offered at Frimley, and the faster treatment and quicker recovery times can help increase patient throughput and free up beds to reduce NHS waiting times, says Barber.

It is also available at Berkshire Independent Hospital, Hampshire NHS Trust and Guy’s and St Thomas’ in London which has successfully used the robotic technique to treat as many as 10 patients in a day.

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