Will I be wet after my prostate is removed?
Urinary incontinence is a medical condition that can occur when there's a problem with the nerves, muscles, or anatomy of the urinary system that regulates urine flow. Men who have had surgery for prostate cancer may experience urinary incontinence due to the damage to the muscles and nerves that control the bladder and urethra during the operation.
Stress incontinence is a type of urinary incontinence that results from weakened pelvic floor muscles or damage to the urethral sphincter, which can happen after prostate cancer surgery. When you cough, sneeze, or lift something heavy, the increased pressure in your abdomen puts pressure on the bladder, which can cause urine to leak out.
Another type of urinary incontinence that can develop following prostate cancer surgery is urge incontinence, which results from an overactive bladder muscle or damage to the nerves that control bladder function. This can lead to a sudden, strong urge to urinate that is difficult to control, resulting in leakage before you can reach the bathroom.
Treatment for urinary incontinence can vary depending on the underlying cause and severity of the condition. It can range from pelvic floor exercises to strengthen the pelvic floor muscles, medications to relax the bladder muscles, or surgery.
What is the prostate's role in urination?
When urine is produced in the kidneys, it is transported to the bladder and stored until your body is ready to urinate. Two sphincter muscles, one above and one below the prostate gland, control urination; they remain closed until you urinate. They then open to release urine from the bladder.
What is the rate of incontinence after prostate surgery?
If you have undergone a radical prostatectomy, which is the surgical removal of the prostate gland, one of the sphincter muscles that control urination is commonly removed. Usually, having one sphincter is enough to maintain continence. Still, damage to the nerves and muscles in the area during the surgery can also result in the weakening of the only remaining sphincter, which is why men experience urine leakage. This can lead to a medical condition known as urinary incontinence.
Studies have shown that 25% to 80% of men undergoing radical prostatectomy may experience urinary incontinence in the first few weeks or months after surgery.
However, it's essential to note that the severity and duration of urinary incontinence can vary significantly among individuals and improve over time with treatment and recovery.
Several factors can influence the likelihood of developing urinary incontinence after surgery, including age, pre-existing medical conditions, the extent of the surgery, and the surgeon's experience.
What do the National Institute for Health and Care Excellence (NICE) guidelines quote?
According to NICE, for those undergoing radical prostatectomy, around 70% of men may experience urinary incontinence.
However, it is essential to note that not all men who undergo radical prostatectomy will experience urinary incontinence.
How long does urinary incontinence after prostate surgery last?
Depending on several factors, prostatectomy urinary incontinence can last for a varying time.
Studies suggest the likelihood of regaining continence after prostate surgery improves over time. According to a study published in the Journal of Urology, approximately 40% of men regained continence within one month of surgery. In comparison, 75% and 90% of men had regained continence by three months and six months after surgery, respectively.
According to the NICE guidelines, up to 60% of men with a radical prostatectomy may experience urinary incontinence six months after the surgery, but this can improve over time. By 12 months after surgery, up to 90% of men have regained bladder control.
When should I address the incontinence after the removal of the prostate?
You should be performing pelvic floor exercises immediately once the catheter is removed.
Suppose you are still experiencing severe incontinence six months to a year after radical prostatectomy. Should this happen, your NHS Urology consultant or private urologist may suggest more tests, like a cystoscopy, post-void residual urine volume test, or urodynamic study, to help treat urinary incontinence. The exact testing and timing may vary depending on individual circumstances and the severity of symptoms.
Cystoscopy: A cystoscopy is a procedure where a thin, flexible camera tube is inserted through the urethra into the bladder under local anaesthetic. The surgeon can examine the lining of the bladder and urethra. One can assess the competency of the external sphincter valve.
Post-void residual urine volume test: using an ultrasound machine to measure the amount of urine left in the bladder after urination. This test can help determine if an issue with bladder emptying may contribute to your urinary incontinence.
Urodynamic study: A urodynamic study is a series of tests used to evaluate how well your bladder and urethra are functioning. During this test, a catheter is inserted into your bladder and another into your rectum or vagina to measure pressure changes during urination. This test can help identify bladder and urethral function issues contributing to urinary incontinence.
What is the first step to address incontinence after prostate surgery?
Pelvic floor muscle exercises, or Kegel exercises, are a first-line treatment for urinary stress incontinence after radical prostatectomy. These exercises involve contracting and relaxing the muscles that control urine flow to strengthen and improve their ability to hold urine.
Studies have shown that men who perform pelvic floor muscle exercises after radical prostatectomy experience a faster recovery of urinary continence than those who do not. These exercises are most effective for men with mild to moderate urinary incontinence.
To perform pelvic floor muscle exercises, men must identify the muscles they use to stop urine flow and repeatedly contract and relax them. Performing these exercises regularly and correctly is crucial for the best results.
Am I doing too many pelvic floor muscle exercises?
The frequency and duration of the exercises may vary depending on the individual's condition and progress, but generally, it's recommended to start with three sets of 10 repetitions daily.
A physiotherapist or continence nurse can help teach men how to perform pelvic floor muscle exercises correctly and develop an exercise plan tailored to their needs.
The Squeezy app for men is a popular tool that can help with pelvic floor muscle exercises. It provides a range of exercises and reminders to ensure that the exercises are done regularly and correctly. The app is available for Android and iOS devices and can be found on the respective app stores (Google Play Store and Apple App Store).
What are the treatment options for urge incontinence after prostate cancer surgery?
Lifestyle changes
These urinary symptoms can be addressed by adjusting the fluid intake and avoiding caffeinated beverages, juices, spices, fizzy drinks and artificial sweeteners.
Bladder control training
Bladder training is often recommended as a non-invasive treatment for urge urinary incontinence after prostate surgery. Bladder training aims to help you regain control over your bladder and reduce the frequency of urgent and sudden urges to urinate.
Bladder training typically involves learning techniques to strengthen the muscles that control the bladder and to improve your ability to hold urine for extended periods. This may include scheduled voiding, which involves going to the bathroom at set times rather than waiting to urinate and delaying urination when you feel the urge to go.
Bladder training can be convenient for men who have developed urge incontinence after prostate surgery, as an overactive bladder often causes this type of incontinence. By training the bladder to hold more urine, you can reduce the number of trips you need to take to the bathroom and improve your overall bladder control.
It's important to note that bladder training can take time and patience and may not work for everyone.
Medications for urge urinary incontinence
Anticholinergic medications can be used to treat urgent incontinence after radical prostatectomy. Urgency incontinence is a type of incontinence where urine leaks due to a sudden and strong urge to urinate. Anticholinergics work by relaxing the bladder muscles and reducing the urge to urinate.
It's important to note that anticholinergics only work for urge incontinence and have no role in treating stress incontinence, the most common type after radical prostatectomy. Stress incontinence is the leakage of urine that happens when pressure is put on the bladder, for example, during coughing, sneezing, or exercise.
Anticholinergics are prescription medications and should only be used under the guidance of a doctor. Common anticholinergics used for urgency incontinence include oxybutynin, tolterodine, and solifenacin.
It's important to discuss the potential benefits and side effects of anticholinergics with your doctor, as they may not be suitable for everyone. Some common side effects of anticholinergics include dry mouth, constipation, blurred vision, and dizziness.
What surgical treatment options are there for men who experience stress incontinence after prostate cancer surgery?
- Urethral or male sling procedure
- Artificial urinary sphincter
Urethral sling procedure overview
A male sling procedure is a surgical treatment option for stress urinary incontinence in men. This procedure involves placing a sling made of synthetic material around the urethra (the tube that carries urine from the bladder out of the body) to provide support and improve control over urine flow. The sling is attached to the pelvic bones and acts as a hammock to lift and support the urethra, preventing urine leakage.
The procedure is typically done under general anaesthesia. It can be done through a small incision in the perineum (the area between the scrotum and anus). The surgeon will make a small incision and place the sling around the urethra, securing it to the pelvic bones. The surgery usually takes about 1-2 hours to complete.
The male sling procedure is particularly effective for men with stress urinary incontinence when physical activities such as coughing, sneezing, or lifting cause urine leakage.
What is the recovery process after the urethral sling procedure?
Most patients must stay in the hospital overnight or for a day following surgery to monitor their condition and ensure they can urinate easily.
After leaving the hospital, patients may need to limit their physical activity and avoid heavy lifting or strenuous exercise for several weeks to allow the sling to heal correctly. Pain and discomfort may be managed with medication prescribed by the doctor.
Most patients can return to work within a few days to a week after surgery, depending on the nature of their job. It is important to avoid activities that strain the pelvic area and follow the doctor's instructions for postoperative care to ensure proper healing.
What are the complications of a male sling procedure?
As with any surgery, there are potential risks and complications associated with the urethral sling procedure, including;
According to the British Association of Urological Surgeons (BAUS), several potential complications are associated with urethral sling surgery. These include:
Infection: Any surgical procedure carries a risk of infection. Patients may be given antibiotics before and after the surgery to help prevent this.
Difficulty with urination: Some patients may experience difficulty urinating after the surgery. This can be caused by swelling or other factors and may require temporary catheter use.
Urinary retention: In some cases, the sling may be too tight and cause difficulty with urination or even complete urinary retention. This may require further surgery or adjustment of the sling.
Sling erosion: In rare cases, the sling may erode through the tissues of the urethra or surrounding structures. This can cause pain, bleeding, and other complications.
Bladder or urethral injury: During the procedure, there is a risk of injury to the bladder, urethra, or other nearby structures. This can lead to complications such as bleeding or difficulty with urination.
Pain: Some patients may experience pain or discomfort after the surgery. This is usually temporary and can be managed with pain medication.
Artificial urinary sphincter overview
An artificial urinary sphincter (AUS) is a medical device implanted to help manage severe urinary incontinence in men who have had their prostate removed. The AUS is made up of three parts: a cuff that fits around the urethra, a pressure-regulating balloon that sits in the lower abdomen, and a control pump that is placed in the scrotum.
When the bladder is full, the pressure builds up and triggers the control pump to release the pressure in the cuff. This allows urine to flow out of the bladder and through the urethra. After urination, the pressure-regulating balloon fills up, inflating the cuff and creating a seal around the urethra. This stops any urine from leaking out of the bladder and helps to prevent urinary incontinence.
The AUS is a reliable and effective treatment option for men with urinary incontinence following radical prostatectomy. Studies have shown it can improve continence rates in up to 90% of patients. However, it is essential to note that the AUS is not a permanent solution and may require periodic adjustments or replacements over time.
How is the procedure performed?
The AUS procedure is usually performed under general anaesthesia, but in some cases, spinal or epidural anaesthesia can be used. It typically involves three main steps:
The first step is to make an incision in the scrotum to create a pocket for the inflatable cuff portion of the AUS. This cuff is placed around the urethra and is designed to prevent urine from leaking.
The second step is to create a small incision in the lower abdomen to place the pressure-regulating balloon filled with saline solution. This balloon controls the pressure of the cuff around the urethra.
The third step is to place the control pump, a small device implanted in the scrotum or labia majora, depending on the patient's gender. Small tubes connect the control pump to the cuff and pressure-regulating balloon.
What is the recovery process after an artificial urinary sphincter procedure?
After the procedure, patients typically stay in the hospital for 1-2 days for monitoring and pain management. The device is inactivated, and the patient has a catheter.
The patient is instructed on how to operate the device and to avoid physical activities that may damage the device. They are also advised to avoid lifting heavy objects or engaging in strenuous physical activities for up to six weeks.
According to the American Urological Association (AUA), patients who have undergone AUS should avoid sexual activity and strenuous exercise for at least four weeks after the procedure. Patients are also advised to avoid sitting for long periods, which can pressure the device and lead to complications.
The AUA recommends that patients be followed up regularly after the AUS procedure to ensure proper device functioning and to monitor for any complications.
What are the complications of artificial sphincter surgery?
According to the British Association of Urological Surgeons (BAUS), some of the potential complications of an artificial urinary sphincter (AUS) implantation procedure include:
Infection: Infection is a potential complication of any surgical procedure and can also occur with AUS implantation. Patients are given antibiotics before and after surgery to reduce the risk of infection.
Mechanical failure: The AUS device can malfunction due to mechanical failure, leading to urinary incontinence or urinary retention. This complication usually requires re-operation to replace or adjust the device.
Erosion: The AUS device can erode through the surrounding tissue and skin, leading to pain and infection. This complication can also require revision surgery.
Migration: The AUS device can migrate from its original location, leading to incontinence or retention. This complication can also require revision surgery.
Pain: Pain is a common complication after AUS implantation, and various factors, including surgical trauma, device pressure, or infection, can cause it.
Device-related complications: There can be issues with the device, such as device migration, urethral atrophy, and urethral erosion.
Device adjustment complications: Over time, the AUS device may need to be adjusted to maintain optimal function. The adjustment process can lead to complications such as infection or device malfunction.
If I do not wish to explore further surgery, is there a non-invasive alternative?
The penile clamp is a non-invasive treatment option for men who experience urinary incontinence after undergoing radical prostatectomy. Penile clamps can be part of a comprehensive treatment plan or are particularly suitable for those who do not want further surgery.
They are simple for the patient to apply and remove and come in a variety of sizes and styles. They are typically made of soft silicone or foam material and have an adjustable locking mechanism to provide a customized fit for individual patients.
What is the best treatment for urinary incontinence after prostate surgery, urethral sling procedure, or artificial urinary sphincter?
No one-size-fits-all answer is whether a urethral sling or artificial urethral sphincter is better for treating urinary incontinence after prostate surgery. Treatment choice depends on various factors, including the type and severity of incontinence, overall health status, and personal preferences.
A review of studies published in the journal European Urology says that both urethral slings and artificial urethral sphincters are good ways to treat incontinence after prostatectomy. The review found that the urethral sling had a success rate ranging from 48 to 100%, while the success rate for the artificial urethral sphincter ranged from 60 to 100%.
Another study published in the Journal of Urology compared the outcomes of a urethral sling and an artificial urethral sphincter in treating post-prostatectomy incontinence. The study found that the artificial urethral sphincter had a higher success rate than the urethral sling (84% vs. 65%), but also had a higher rate of complications (38% vs. 21%).
Ultimately, the choice between the urethral sling and artificial urethral sphincter depends on individual patient factors. Discuss the options with a urologist who can make a personalised recommendation based on the patient's condition and preferences.
Reflection from a robotic prostate surgeon.
Incontinence problems after prostate cancer treatment (radiation treatment or prostate surgery) are recognized complications. Urinary leakage dramatically affects the quality of life of men. Going through many absorbent pads can also have an economic impact on some men.
Leaking urine incessantly means that daily activities cannot be performed, going back to work may be an issue, and not uncommonly, some men can fall into isolation, depression, and anxiety. This can have a toll on their stable relationships. Leaking urine affects sexual performance.
Urinary problems should be discussed openly with your surgeon or survivorship nurse, as treating urinary incontinence after prostate cancer surgery is possible.
Various options can be explored, from lifestyle changes to kegel exercises under the guidance of professional physical therapy specialists to medications and surgery. All of these have their indications, pros, and adverse effects. Not everyone will be eligible for all, as general health and fitness are crucial to treatment access. That is why it is vital to maintain a healthy and active lifestyle. This ensures a good level of fitness, no matter your age.
In-depth conversations and patient empowerment are vital to finding a reasonable way to regain control. There is nothing to be ashamed of. There is always help.
