One of the more notorious complications of radical prostatectomy is urinary incontinence. Ranging from a few drops to complete lack of control, leakage of urine after prostatectomy can be a debilitating side effect that has a dramatic impact on quality of life. Reading numerous posts from men on various prostate cancer forums, I got the impression that many men feel that urinary leakage after prostatectomy is inevitable, permanent, and devastating. In reality, the presence, extent, and timing of urinary incontinence is highly variable and, to a significant extent, can be successfully managed. In this post I will explain who should expect to have urinary incontinence after prostatectomy, how long such leakage usually lasts, and how to prevent and treat it.
Who Experiences Urinary Incontinence After Prostatectomy?
The reported rates of urinary incontinence after radical prostatectomy are variable at best. Studies have reported rates of urinary incontinence between 3 and 74%. One reason for this tremendous disparity is the definition of “dry.” While some studies categorized men as dry if they did not use any pads after prostatectomy, others were more lenient, designating men that use 1-2 pads per day as dry as well. Other studies did not even rely on pad usage and simply asked men whether they subjectively felt wet or dry.
In truth, immediately after surgery, most men will leak urine. When the catheter is removed, the majority of men will require pads or diapers, if even for a short period of time. The reason for this initial leakage has to do with damage to the urinary sphincter, the main mechanism for controlling urination. During prostatectomy, this muscle complex, which is located near the tip of the prostate, is damaged to varying degrees. As a result, when the catheter is removed soon after surgery, the debilitated sphincter is often not strong enough to control the flow of urine from the bladder, particularly during times of increased abdominal pressure while coughing, straining, or lifting heavy objects.
While most men will leak immediately after a prostatectomy, studies have demonstrated that some men are more prone to significant incontinence than others. Older men, for example, are more likely to leak, presumably due to less muscle mass in their sphincters as compared to those of younger men. In addition, overweight men are more likely to suffer from incontinence. As I mentioned in my post about obesity and prostate cancer (http://prostatecancersymptomstips.blogspot.com/2011/04/prostate-cancer-and-obesity-deadly.html), overweight men pose a technical challenge during surgery, making damage to the sphincter and subsequent leakage more likely. Similarly, men with larger prostates and those with more aggressive cancers have been shown to develop urinary incontinence more frequently, also due to the fact that their more challenging anatomy can increase the risk of damaging the sphincter during surgery. Of course, while such risk factors may increase the risk of incontinence after surgery, they by no means guarantee it.
Despite the tremendous variation as to the incidence of incontinence reported after prostatectomy, there appears to be a consensus about its resolution. Fortunately, the majority of studies demonstrate that most men eventually regain control of urination after surgery. These studies report a progressive return of continence over time with 51-71% of men regaining urinary control after 3 months, 70-87% enjoying continence after 6 months and 80-92% reporting dryness at 1 year. While this data does not provide solace for the minority of men that don’t reach continence, it does provide evidence that incontinence after prostatectomy needs to be approached with patience.
Managing Incontinence After Prostatectomy
Although most men will regain continence after prostatectomy, a proactive approach can significantly decrease the time to reach this sought after dryness. The best way to ensure a quicker path to continence is to strengthen the sphincter. Like any muscle in the body, the sphincter becomes stronger and more efficient if it is exercised. In a sense, men need to take their sphincters to the gym. The main exercises developed to “work out” the sphincter are the Pelvic Floor Muscle Exercises (PFME). These types of exercises are better known to women as “Kegels.” These exercises are performed by trying to stop urinary flow once it has begun. Once men identify the muscles needed to accomplish this task, they can then perform the exercises even when they are not urinating.
Some men find it difficult to identify the exact muscles they need to exercise. For these men, biofeedback therapy may be appropriate. This therapy involves placing a probe in the rectum, which can measure the force with which the sphincter is contracted during PFME. Through such a device, a therapist can provide feedback to the patient as to whether they are contracting the right muscles. After such biofeedback, patients can be more confident that they are performing the PFME correctly. However, studies have not demonstrated significant differences in continence between men undergoing biofeedback versus those treated with PFME alone.
The more PFME that can be performed on a daily basis, the better. Urologists generally recommend a hundred or more a day. Studies have demonstrated significant decreases in the time to continence in men performing such exercises after surgery. In fact, randomized studies demonstrated that 74-88% of men regularly performing PFME were dry 3 months after prostatectomy as opposed to only 30-56% of men who did not perform the exercises. Interestingly, these same studies did not demonstrate a significant difference in continence between the two groups at 1 year after surgery, signifying that while PFME can decrease the time to continence, most (although certainly not all) men will achieve dryness by 12-18 months after surgery, regardless.
Preventing Incontinence Before it Starts
While PFME performed after prostatectomy have been demonstrated to decrease the time to continence, this benefit is even more dramatic for those men that start to perform the exercises prior to surgery. A randomized study of 118 men undergoing radical prostatectomy, for example, compared continence rates at 1 and 3 months after surgery for those men starting PFME 1 month prior to surgery versus those starting these exercises postoperatively. The study demonstrated that men starting PFME prior to surgery were only 40% as likely to have incontinence at 1 and 3 months after surgery as compared to those men that did not start the PFME until after prostatectomy.
Another way to prevent or at least limit incontinence after prostatectomy is through nerve sparing prostatectomy. Investigators have suggested that the nerves around the prostate may not only provide nerve impulses to the penis (to stimulate erections) but also to the sphincter. As a result, sparing these nerves during surgery may better preserve nerve signals to the sphincter and maintain its function after surgery. Such a theory was supported by a study which demonstrated that men undergoing nerve sparing surgery recovered their urinary control twice as quickly (5.3 versus 10.9 months, respectively) as those men who did not have their nerves spared during the procedure. Of course, the decision to perform nerve sparing is not simple in men with high risk disease for whom the benefits of nerve sparing must be weighed against the potential for positive margins and recurrent cancer.
Take Home Message
Urinary incontinence is a common side effect of radical prostatectomy. While almost all men suffer from some degree of leakage of urine immediately after surgery, most regain their continence within 12-18 months. Men with risk factors for incontinence such as advanced age, obesity, high risk disease, and large prostates, need to be aware before surgery that they may be challenged by more severe incontinence for longer periods of time. All men planning to undergo prostatectomy should learn PFME and begin such exercises prior to surgery. In addition, when safe and possible, nerve sparing surgery should be performed. Through such precautions, most men will be able to regain the ability to control their urination more quickly and effectively. Despite all of these efforts, however, some men have debilitating, persistent incontinence. After failure of conservative management for 12-18 months (and sometimes longer), appropriately qualified men need to be offered more aggressive, surgical management of their incontinence. I will cover these options in my next post.
