Prostate Cancer Surgical Incontinence Solutions

Written Transcript at:
https://www.cancerabcs.org/transcript-urinary-incontinence-post-radical-prostatectomy-solutions

Joel Nowak discusses why men who have a radical prostatectomy, or the surgical removal of their prostate gland to treat prostate cancer often suffer urinary incontinence.  Urinary incontinence negatively affects a man's quality of life so it is important that men know about their options so they can discuss them with their urologists.  

Surgically induced urinary incontinence can be dealt with when you have an RP to treat your prostate cancer, learn about your options as well as the risks and the rewards.

Transcript

Urinary Incontinence Post Radical Prostatectomy – Solutions

One of the problems that many men face when they have a radical prostatectomy, or prostate cancer surgery is urine incontinence, or they are unable to control their flow of urine.  

This can be a serious problem and it definitely affects their quality of life. 

But, there are solutions you can consider.

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One of the possible side effects you might experience after having prostate cancer surgery or radical prostatectomy or RP is incontinence. Incontinence or the unwanted leakage of urine can be just a minor dripping of urine, or it can be the complete and total loss of control of your urine. 

Most men will not suffer long-term with incontinence caused by prostate cancer surgery. Usually, men see quick improvement incontinence over the first several months after their catheter has been removed, but incontinence can remain troublesome for some men. 

It is helpful to understand how incontinence is defined by Urologists.   Most surgeons consider a man to be incontinent if they regularly use more than three incontinence pads a day and have occasional dripping when they are very active.  However, you should consider how bothersome your urinary incontinence is to you, as your goal should be to improve your quality of life as much as possible.

Not all men are at equal risk for developing incontinence after prostate cancer surgery. It isn’t clear why some men have troublesome incontinence that continues after surgery, while other men do not. There is some evidence that many things may contribute to the persistence of incontinence after surgery, including:

Older age

Larger prostate size

Smoking

Diabetes or some other neurological disease

Excessive blood loss during surgery

Need for cutting nerves during surgery

Size or stage of the prostate tumor

Radiation after surgery 

Previous surgery for BPH

Our anatomy dictates why incontinence is a potential problem after having the prostate surgery. Those men who do have some incontinence post-surgery do so because there are just two sphincter muscles that keep us continent, or are able to control our urine flow. They are the internal urethral sphincter and the external urethral sphincter. 

The internal sphincter is an involuntary muscle, or not under our control. It is found at the bottom of the bladder, or at the "bladder neck," and is situated within the prostate gland.  So, when the prostate gland is removed to treat the prostate cancer, this sphincter is also removed!

Even after surgery, you can still control your external sphincter, which is left intact. This sphincter muscle when it is healthy and not been damaged by the operation is capable of controlling your urine flow; you can use it to hold in your urine and to stop your urine stream. Since it is a muscle, it can be strengthened with pelvic floor muscle exercise or Kegel exercises. 

However, in some instances after an RP, there can be some damage or dysfunction to the external sphincter. If damaged, you might not fully recover your bladder or urine control. This damage may be due to damage to the nerves, to the blood supply, supporting structures, or the muscle itself as the external sphincter, although not in the prostate gland like to internal sphincter, is near to the prostate gland .

In certain instances, some men may need to have radiation after their prostatectomy. This radiation usually includes radiation therapy to the "prostate bed" or the area where the prostate had been located. The radiologist will design the radiation treatment to minimize the amount of radiation exposure to healthy tissue that is surrounding the prostate bed.  However,  some healthy tissue, including the external urinary sphincter, will be receiving a low level dose of radiation. 

The radiation treatment causes some "irritation" of the external sphincter, urethra, and bladder during the radiation therapy, and for a short time after radiation therapy, it will usually cause some incontinence. Generally, this incontinence improves in the weeks to months after completing radiation therapy. However, a small number of men will develop increased incontinence in the months to years after they have completed their radiation therapy. This incontinence is due to the development of scar tissue, making the tissue "stiff" and weak affecting the external sphincter, so it doesn’t open and close properly.

If you experience post-surgery urinary incontinence, there are two types of incontinence you might experience. 

The first is urgency incontinence. Urgency incontinence is when you feel the "urge" to urinate but cannot make it to the toilet in time. 

In my support groups, we often talk about suffering from “key syndrome,” or the sudden and often uncontrollable need to urinate when you get home and put your key into your door.  This is an example of urgency incontinence.  

Generally, urgency incontinence is due to bladder spasms and usually will respond with medical therapy. Urgency incontinence is thought to be mostly due to changes in the way the bladder behaves after surgery.

The other type of incontinence experienced post-surgery is called Stress Urinary Incontinence or SUI.  SUI is best described as leakage of urine with exertion.   It can happen when you cough, sneeze, lift something substantial, change your position, swing a golf club, even pass gas and of course exercise. This type of incontinence can usually be traced back to damage to your external sphincter muscle during the surgical procedure.  

Almost all men will have some degree of SUI immediately after their catheter is removed, but it should improve if you do the pelvic floor or Kegel exercises that your doctor described to you. 

Since incontinence negatively affects your quality of life, you should take advantage of several possible treatments that are available.  They range from regularly performing your pelvic floor exercises known as Kegel Exercises to three different types of surgical interventions. 

There are three main types of surgical interventions or treatments for men who have incontinence following an RP, and they are:

1. Urethral bulking procedures- Urethral bulking procedures are minimally invasive treatments performed through a cystoscope.  The procedure is to inject one of several materials just underneath the lining of the urethra, making the urinary passageway smaller. This process can lead to an improvement in urine control. 

This procedure is usually performed as an outpatient procedure, sometimes with or sometimes without anesthesia. Generally, most men return to normal activity immediately after the procedure, and the risks of the procedure are minimal. 

Since your body usually reabsorbs the inserted material over time, this procedure often needs to be repeated every 9-15 months as the incontinence may reoccur. 

Risks of this procedure are generally minor and can include, but are not limited to, bleeding, urinary tract infection, and temporary urinary retention. Rarely, patients may feel that their incontinence is made worse by the procedure.

2. Male Perineal Sling – The Male Perineal Sling procedure is performed under anesthesia in an operating room. The operation entails making a small incision in your perineum, which is the area between the scrotum and your anus. A strip of mesh is placed underneath the urethra and used to elevate and slightly compress the urethra to provide continence. 

The procedure generally takes 45 minutes to an hour, and you can expect to go home either the same day or the next day after the procedure. Recovery time is short, and there is usually minimal discomfort or pain after the procedure. 

You will be asked to limit your activity for 4-6 weeks after the surgery to allow the sling to scar into place, so it does not move. 

Experience shows that the men who are the best candidates for the Sling Procedure are those who have minimal to moderate incontinence, or use only 1 to 3 pads a day. 

Risks of the procedure include but are not limited to bleeding, skin and mesh infection, pain, and rarely erosion into the urethra, or an inability to urinate, and failure of the surgery to improve continence.

3. The Artificial Urinary Sphincter (AUS) – The AUS is the most reliable and often most effective surgical treatment for incontinence after a radical prostatectomy. The procedure involves implanting a silicone implant with three parts, a cuff that goes around the urethra and squeezes it closed, a small fluid reservoir, and a control pump that is placed underneath the skin in the scrotum. 

The cuff, in its normal state, is closed by the fluid inside of it so that it squeezes the urethra shut, preventing urine leakage. To open the cuff, or remove the fluid from the cuff so that the urine can flow out, you press the small pump in the scrotum which allows the fluid to flow from the cuff to the reservoir, opening the cuff.  The cuff refills and closes on its own after 3-4 minutes. 

This surgical operation usually takes about 90 minutes and is done under anesthesia. You should expect to be kept overnight in the hospital. 

The operation can be performed either through one small incision at the top of the scrotum or through two separate incisions: one in the perineum and one in the groin. 

You should be aware that the device will need to be activated 4-6 weeks after surgery. Your incontinence will not change until the device is activated. Activation can take place in your  doctor’s office. 

This procedure is suitable for all degrees of incontinence severity. This surgery, however, has slightly more risk of serious complications compared to the other surgical interventions, mostly relating to the implant itself. Risks include but are not limited to bleeding, skin or device infection, erosion into the urethra, device malfunction, and urethral atrophy where the tissue surrounding the urethra becomes compressed and thin over time which may lead to a recurrence of your incontinence.

Cancer ABCs recommends that if you are suffering from surgically induced incontinence that you talk with your urologist for more details about your options and the risks and benefits in you might experience.

This has been Joel Nowak for Cancer ABCs.

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