Artificial urinary sphincter

An artificial urinary sphincter replaces the function of that valve mechanically. It is entirely internal — nothing is visible, nothing protrudes, and once healed it cannot be seen through clothing. Three silicone components sit under the skin, connected by fine tubing:

• A soft, fluid-filled cuff around the urethra, which keeps it gently closed.
• A small control pump in the loose skin of the scrotum — the only part you ever touch.
• A pressure-regulating balloon tucked behind the abdominal muscles, which sets the system pressure: enough to keep you dry, not so much that it compromises the blood supply to the urethra.

By default the cuff is full and the urethra is closed. When you want to pass urine, you squeeze the pump two or three times through the skin of the scrotum. That moves the fluid out of the cuff and up into the balloon; the urethra opens and you go normally. Then you do nothing — a delayed valve returns the fluid over the following three to five minutes and the cuff reseals itself.

Three things about you, as well as your bladder

• Your hands. The device is operated by feeling for a small pump in the scrotum and squeezing it firmly. Significant arthritis, tremor, Parkinson's disease or cognitive difficulty can make that unreliable — and a device that cannot be operated is worse than none. This is assessed honestly rather than assumed, and if it is a problem there are other options.
• Previous radiotherapy. Radiation leaves the urethra thin, stiff and poorly supplied with blood, which raises the risk of the cuff wearing through it. It does not rule out the operation — it changes the technique, see below — but it must be known in advance.
• Diabetes control. Poorly controlled diabetes measurably increases the risk of device failure and the need for revision. Optimising it beforehand is worth the delay.

Sling or sphincter?

For mild to moderate leakage in a man who has not had radiotherapy, a male sling is a reasonable alternative: a supportive mesh placed under the urethra, with nothing to operate and nothing mechanical to fail. Its weakness is that success falls away as leakage becomes more severe, and it relies on the natural elasticity of the urethra — so it frequently fails in irradiated tissue.

For moderate to severe leakage, for anyone who has had radiotherapy, and for men whose previous continence surgery has failed, the artificial sphincter is the more reliable operation and the evidence favours it clearly on satisfaction.

1. Anaesthetic. General or spinal, as a planned inpatient admission of one to two nights.
2. Placement. Through a small incision in the perineum — the area between the scrotum and the anus — the urethra is exposed and the cuff positioned around it. A second small incision low in the abdomen allows the pressure-regulating balloon to be tucked behind the muscle, and the pump is passed down into the scrotum. The tubing is routed under the skin and connected into a sealed system.
3. Deactivation. The device is deliberately left switched off, with the cuff locked open, before you leave theatre.

If you have had radiotherapy

Where the tissue behind the urethra is too thin to take a cuff safely — after radiotherapy, after a failed previous device, or after major urethral surgery — the cuff can be placed through the adjacent erectile bodies instead. This transcorporal approach wraps the cuff around a thick, well-vascularised protective layer as well as the urethra, and substantially lowers the risk of erosion in exactly the men most likely to suffer it. It asks more of the surgeon, and for men who are sexually active it preserves erectile function in a substantial proportion.

Preparing for the day

Because this is an implant, preventing infection outranks everything else in the preparation.

Pads

• Carry on with what you used before. Same absorbency, same product. Now is not the time to experiment.
• Change the moment it feels damp, rather than when it is saturated. A wet pad held against healing skin is exactly the situation to avoid.
• Use products made for urinary incontinence, not sanitary towels — the polymers are designed to lock urine away from the skin.

Protecting the incisions

• Wash gently. Let warm water and unperfumed soap run over the area. Do not scrub, and do not aim a shower head directly at the wounds.
• Pat dry with a clean towel kept for the purpose. Moisture trapped in the groin causes skin breakdown, and broken skin next to an implant is a genuine risk.
• Barrier cream on the thighs and groin to prevent chafing is fine. Nothing on the incisions themselves — no creams, powders or lotions.

Clothing

• Supportive but breathable — cotton, not synthetic, so air can move.
• Nothing tight enough to press a wet pad against the perineum: no stiff jeans, no belts sitting across the lower abdomen.

How well does it actually work?

The clinical measure is social continence: no pads at all, or at most one light security pad a day for reassurance during heavy exertion. Long-term series consistently report this in roughly 70% to 90% of men. Patient-reported satisfaction runs higher still — 80% to 90% describe themselves as very much improved and say they would have the operation again.

Complete dryness is common but not universal. It is worth setting the expectation honestly: a small number of men still need a light pad for occasional drops when lifting something heavy or coughing violently. Measured against several pads a day, most consider that a transformation rather than a shortfall.

Intimacy

The device is invisible and does not interfere with erections or with the sensation of orgasm — the cuff sits around the urethra and, in the standard technique, avoids the erectile bodies entirely. There is also a benefit that rarely gets mentioned: climacturia, the involuntary leak of urine at the moment of orgasm, is common after prostatectomy and deeply unwelcome. Because the cuff provides continuous closure, an artificial sphincter frequently improves it and often resolves it altogether.

Being honest about revision

This is a mechanical device working continuously inside a living body. Like a joint replacement, it does not last forever — around eight to ten years on average, and a meaningful proportion of men need a further operation within five to ten years. That is not a complication; it is the nature of the thing, and it should be part of the decision from the outset.

• Mechanical failure is the commonest late reason. Fluid slowly escapes from tubing, pump or cuff, pressure falls, and leakage returns. The failed component — or the whole device — is replaced.
• Urethral atrophy. Years of gentle compression thin the tissue under the cuff, so it becomes relatively loose and you start leaking again. Corrected by downsizing the cuff or moving it to a healthier segment.
• Erosion — the cuff wearing through into the urethra — is uncommon but serious, and means removing the device, letting the urethra heal, and considering a new one months later, often transcorporally.
• Infection is the most serious risk of any implant. Rates are low — in the low single figures for a first implant, higher after radiotherapy or revision — but an infected device almost always has to come out entirely, followed by antibiotics and a wait before another can be attempted. This is why the pre-operative protocol is as strict as it is.

Revision outcomes are generally good: after a second implantation, device survival broadly mirrors the first.