Urinary sphincter problems in men: causes and solutions

Male urinary incontinence affects nearly 10 to 15% of men after the age of 60, significantly impacting the day-to-day lives of millions of people. At the heart of this issue is often a dysfunction of the urinary sphincter, an essential muscle that acts like a valve to control the flow of urine. Far from being an inevitable part of ageing, sphincter-related problems can now be treated effectively, with success rates reaching up to 90% depending on the treatment chosen.

If you experience urine leakage, especially during physical effort, coughing, or sneezing, your urinary sphincter may be involved. While this can feel difficult to talk about, it deserves your full attention because effective solutions exist, ranging from pelvic floor rehabilitation to advanced surgical procedures. The key is to understand that you are not alone, and that the right care plan can significantly improve your quality of life.

How does the male urinary sphincter work?

The male sphincter system is a remarkably precise anatomical mechanism that ensures urinary continence 24 hours a day. Contrary to common belief, it is not a single muscle but a complex system made up of two complementary sphincters that work together in close coordination.

The smooth sphincter (or internal sphincter) is located at the bladder neck. Made of involuntary muscle fibres, it remains constantly contracted without any conscious effort. It provides passive continence, particularly during sleep. In men, its close proximity to the prostate explains why prostate conditions can directly affect its function.

The striated sphincter (or external sphincter) surrounds the urethra at the level of the pelvic floor. Made of voluntary muscle fibres, it can be consciously controlled. It is the muscle you engage when trying to hold back urine. Measuring approximately 2 to 3 cm thick in men, it forms a powerful muscular ring capable of maintaining a closing pressure greater than bladder pressure, even during significant physical effort.

Coordination between these two sphincters and the bladder relies on a sophisticated neurological mechanism. As the bladder fills, sensory receptors send signals to the brain via the spinal cord. In response, the nervous system maintains sphincter contraction and inhibits bladder contractions. When you decide to urinate, the brain reverses this process: the sphincters relax while the bladder’s detrusor muscle contracts to expel urine.

This coordination differs significantly from the female system. In men, the urethra is around four times longer (approximately 20 cm, compared with about 4 cm in women), providing greater natural resistance. In addition, the prostate, located between the two sphincters, offers additional mechanical support. This anatomical configuration explains why urinary incontinence is around three times less common in younger men than in women of the same age.

The main causes of a weakened sphincter

Sphincter dysfunction in men can result from a variety of mechanisms affecting either the anatomical structure or the neurological control of these essential muscles.

Surgical causes: the major impact of prostatectomy

Radical prostatectomy, performed as part of prostate cancer treatment, is the leading cause of sphincter insufficiency in men. According to data from the French Urological Association (AFU, 2024), approximately 70% of patients experience temporary incontinence in the weeks following surgery. This is due to several factors: the close anatomical relationship between the prostate and the smooth sphincter, which is inevitably affected during removal; changes to urethral anatomy; and, in some cases, nerve damage despite nerve-sparing techniques.

Fortunately, recovery is usually favourable. Around 76% of patients regain satisfactory continence within 3 months, and 90% within one year, according to Professor René Yiou, a specialist in functional urology. Other pelvic surgeries (rectal or bladder surgery) can also compromise sphincter integrity, with incontinence rates ranging from 5 to 15% depending on the procedure.

Neurological causes: when control pathways are disrupted

Neurological disorders interfere with signal transmission between the brain, spinal cord and sphincters. Diabetes, affecting millions worldwide, leads to peripheral neuropathy in around 30% of cases after 10 years of disease. This nerve damage gradually impairs sphincter control.

Parkinson’s disease affects sphincter control in approximately one third of patients, according to EM Consulte (2024). Damage to the basal ganglia disrupts bladder–sphincter coordination, resulting either in overactive bladder (around 70% of cases) or dyssynergia with impaired sphincter relaxation.

Stroke causes urinary leakage in around 40% of patients in the acute phase (Progrès en Urologie). The type of dysfunction depends on lesion location: frontal strokes often cause urge incontinence, while pontine lesions may lead to retention with overflow leakage.

Spinal cord injuries almost always result in sphincter disorders, with patterns depending on the injury level. Lesions above T12 often cause detrusor hyperreflexia with dyssynergia; lesions below T12 more commonly lead to flaccid sphincter insufficiency.

Mechanical causes: ageing and trauma

Natural ageing leads to progressive sarcopenia that also affects the sphincter muscles. After the age of 70, sphincter contraction strength decreases by approximately 1 to 2% per year. These changes explain the sharp rise in incontinence prevalence: around 3% at age 50, 10% at age 70, and up to 30% after age 85.

Perineal trauma, whether sports-related (intensive cycling, horse riding) or accidental (pelvic fractures), can directly damage sphincter structures or their nerve supply. Pelvic fractures involving pubic symphysis disruption lead to incontinence in approximately 15% of cases.

Medication-related causes: often underestimated

Certain medications can impair sphincter function. Alpha-blockers (such as tamsulosin or alfuzosin), commonly prescribed for benign prostatic enlargement, relax the bladder neck and can trigger stress incontinence in 5 to 10% of patients. Muscle relaxants reduce sphincter tone, while antipsychotics and some antidepressants interfere with bladder–sphincter coordination. Diuretics increase urinary volume and can overwhelm a weakened sphincter.

Symptoms of sphincter dysfunction

Recognising early symptoms helps guide timely diagnosis and treatment.

Stress incontinence: the classic presentation

Stress urinary incontinence is the hallmark of sphincter insufficiency. Leakage occurs without prior urgency and is triggered by increased abdominal pressure. Typically, symptoms progress from leakage during heavy exertion to moderate activities, and eventually to minimal triggers such as coughing or laughing.

The amount of leakage ranges from a few drops to several teaspoons. A key diagnostic feature is that leakage stops immediately once the effort ends. Wearing a washable men’s incontinence boxer brief often becomes necessary to maintain daily comfort and confidence.

Post-void dribbling

Post-void dribbling affects around 40% of men over 50 and results from incomplete emptying of the bulbar urethra. Small amounts of urine leak minutes after voiding. While uncomfortable, it reflects urethral drainage issues rather than true sphincter failure, though both may coexist.

Mixed incontinence

Approximately 35% of men experience mixed incontinence, combining stress leakage with overactive bladder symptoms such as urgency and frequent voiding (more than 8 times per day).

Natural progression

Without treatment, sphincter insufficiency typically worsens over time. Occasional leakage may progress to frequent daily episodes, requiring regular absorbent protection. Aggravating factors include weight gain, chronic constipation, recurrent urinary infections and excessive fluid restriction, which concentrates urine and irritates the bladder.

Diagnosis of sphincter disorders

A comprehensive assessment is essential to guide treatment.

Initial consultation

The medical history explores onset, triggers, frequency and volume of leakage. A 3-day bladder diary is often recommended to objectively record voiding patterns. Physical examination includes perineal inspection and digital rectal examination to assess sphincter tone and prostate status. A cough stress test helps confirm stress incontinence.

Urodynamic testing

Urodynamic studies assess bladder and sphincter pressures. Normal maximum flow rate exceeds 15 ml/s. Maximum urethral closure pressure in men is normally above 50 cmH2O; values below 30 cmH2O indicate severe sphincter insufficiency.

Additional investigations

Ultrasound measures post-void residual volume (normal < 50 ml). Cystoscopy is used when haematuria or urethral obstruction is suspected. A 24-hour pad test quantifies severity: mild (< 50 g), moderate (50–200 g), severe (200–500 g).

Conservative treatment options

Pelvic floor rehabilitation

Pelvic floor therapy is first-line treatment and improves continence in 60 to 70% of men with moderate sphincter weakness. Programmes typically include 15 to 20 sessions over 3 to 6 months.

Kegel exercises are central: contractions are held for 5 seconds followed by relaxation, progressing to longer holds over time. Learning to contract the pelvic floor before exertion significantly reduces leakage.

Biofeedback and electrical stimulation

Biofeedback improves technique and outcomes by providing real-time visual feedback. Electrical stimulation helps reactivate weakened muscles when voluntary contraction is insufficient.

During rehabilitation, wearing washable incontinence underwear provides discreet protection and reassurance. These garments can absorb up to 300 ml and are washable up to 300 times.

Surgical options

Male slings

Male slings support the urethra and offer success rates of 60 to 80% in mild to moderate incontinence. Recovery usually requires several weeks.

Artificial urinary sphincter

The artificial urinary sphincter remains the gold standard for severe incontinence, with success rates of 90 to 95%. Device cost typically ranges from £6,000 to £9,000, depending on healthcare coverage.

Living with sphincter weakness

Appropriate lifestyle adjustments and modern protection options help maintain quality of life. Washable absorbent underwear combines discretion, comfort and cost efficiency. Although the initial cost (£25 to £50 per item) is higher, it often pays for itself within a few months compared with disposable products costing £40 to £120 per month.

Conclusion

Urinary sphincter problems in men are treatable and manageable. With early diagnosis, appropriate rehabilitation, and when necessary, surgical intervention, most men can regain satisfactory continence. Modern solutions allow you to maintain dignity, confidence and an active lifestyle. Incontinence is not an ending, but a step towards recovery.