Gary E. Leach, MD
Start by doing what’s necessary; then do what’s possible; and suddenly you are doing the impossible.
– Francis of Assisi
INCONTINENCE
Loss of bladder control (urinary incontinence) after prostate surgery can be a devastating complication that can have a very negative impact on quality of life. The good news is that, with appropriate evaluation and treatment, incontinence is usually treatable.
PERCENTAGE OF MEN WITH BLADDER CONTROL PROBLEMS AFTER TREATMENT
Bladder control problems for the first few months following radical prostatectomy are to be expected. A biofeedback program (explained later) may be helpful during this period to help restore bladder control. When urinary incontinence persists for more than three to six months, appropriate bladder testing, called “urodynamics,” is critical to evaluate the function of the bladder and sphincter (valve) muscle to determine the exact cause. Urodynamic testing is performed in the doctor’s office and takes about 20 minutes. It involves filling the bladder through a special catheter inserted in the penis while measuring pressures in the bladder. During the test, various maneuvers are performed to evaluate the muscular function of the bladder wall and to evaluate the ability of the urinary sphincter to control the flow. Basically, the goal is to define the cause of the urine loss.
Normally, as the bladder fills to capacity, there is very little change in bladder pressure and the sphincter remains closed, allowing a man to stay dry. When incontinence occurs following prostatectomy, this normal balance of bladder pressure and sphincter strength is disturbed.
Our own internal research has defined three main causes of incontinence based upon urodynamic findings, listed below. (Note that these percentages are not necessarily applicable to all prostate cancer patients but represent the patients who came to us for help with incontinence).
- High bladder pressure with muscular “spasms” of the bladder that develop as the bladder fils occurs in 50 percent of men. It is possible that these bladder spasms are related to nerve damage from prostatectomy. Bladder spasms may cause urge incontinence (the need to rush to get to the bathroom), frequent urination, and, sometimes, loss of urine at night. This type of “high-pressure” bladder dysfunction can also occur following pelvic radiation therapy.
- Damage to the sphincter muscle occurs in 35 percent of men after surgery. This results in stress incontinence with loss of urine during change in position, coughing, straining, or vigorous physical activity.
- A combination of bladder spasms and sphincter damage occurs 10 percent of the time. Men with this combined problem usually experience “mixed incontinence” symptoms, with a combination of both urge and stress incontinence.
BIOFEEDBACK
Biofeedback is also known as “Pelvic Floor Training.” It may be the preferred treatment choice in men who desire immediate treatment for urine loss right after surgery. Biofeedback is also useful for long-standing incontinence with lesser severity. The treatment program involves weekly one-hour visits with a trained therapist. A special sensor is inserted into the rectum and attached to a biofeedback computer. During the treatment session, the patient is taught to contract and strengthen the pelvic muscles. His muscular contraction is displayed on a computer screen. Also, and electrical signal can be sent to his pelvic muscles to further strengthen them. Each week, the goal is to make the muscles progressively stronger through repetition. Many men experience significant improvement in bladder control with this biofeedback program.
When the main reason for incontinence is high bladder pressure, medications such as Enablex, Vesicare, Ditropan XL, Detrol LA, the Oxytrol patch, oxybutynin 3% gel and imipramine can relax the muscle in the bladder wall. Common side effects are dry mouth, constipation, and blurry vision. These drugs can’t be used in patients with glaucoma or in men who do not empty their bladder well. A new medication, Myrbetriq, does not cause dry mouth or constipation. However, 10 percent of the men who take Myrbetriq will have an increase in blood pressure.
Another option for controlling high bladder pressures, when oral medications are not successful, is Botox injections into the bladder delivered through a scope inserted in the penis. The success rate is approximately 50 percent and the effects usually last for three to six months. There is, however, a five percent risk of urinary retention, necessitating self-catheterization three to four times per day until the effect wears off.
INTERSTIM BLADDER PACEMAKER
When the treatments to decrease high bladder pressures such as those described earlier are unsuccessful, the Interstim “bladder pacemaker” may be an excellent alternative. To determine if Interstim is likely to be effective, an initial one-week test with an external battery pack delivers an electrical signal that “tells” the bladder to relax. If the initial test is successful, about 70 percent of men will benefit by surgical placement of an internal Interstim device.
The permanent Interstim device requires placement of a stimulation electrode in the lower back, next to the main nerve that controls the bladder. Separately, an internal “pacemaker” generator that is attached to the stimulation electrode is implanted. The generator is similar to a heart pacemaker, with a battery that usually lasts eight to 10 years. This “bladder pacemaker” only helps patients who have bladder dysfunction from an overactive, spasmodic bladder wall.
MEN WHO HAVE SPHINCTER DAMAGE
Options for the treatment of sphincter damage include biofeedback, surgical placement of an artificial urinary sphincter, and a surgical procedure called the “male sling.” Men with “mixed” bladder and sphincter malfunction usually undergo initial treatment with anticholinergic drugs or Botox to improve their bladder function and lower their bladder pressure. If that is successful, subsequent treatment to address the weak sphincter may be considered.The urodynamic studies described above are repeated periodically to evaluate the response to each stage of therapy.
THE ARTIFICIAL URINARY SPHINCTER (AUS)
The artificial urinary sphincter is used to correct incontinence in men with sphincter damage. The AUS has three components: a cuff that surrounds and helps close the urethra, a pump placed inside the scrotum, and a pressure-regulating balloon that is placed in the lower abdomen. When a man wants to urinate, he squeezes the pump in the scrotum, which opens the cuff around the urethra. After three to five minutes, the fluid returns into the cuff causing it to close automatically.
With the current model of the AUS, the mechanical malfunction rate is 15 percent at 10 years. However, despite these favorable results, some men are attracted to a less-extensive surgical procedure. For these men, as well as for those with more minor degrees of incontinence, the male sling is a promising alternative.
MALE SLING PROCEDURE
The best candidates for the male sling are men with more minor degrees of stress incontinence (using only one pad per day) and men with no previous history of pelvic radiation therapy. The sling compresses the urethra to reduce the risk of urine loss with coughing, sneezing, or vigorous activity. Surgical implantation takes about one hour and is placed via an incision between the scrotum and rectum. A catheter is usually left in place for 24 hours, with most men being able to urinate with good control immediately after the catheter is removed. Approximately 30 percent of men are completely dry, 40 percent are significantly improved, and 30 percent show no improvement. Should the male sling prove ineffective, an artificial urinary sphincter is often considered as a backup alternative.
CLIMACTURIA: EJACULATION OF URINE
“Climacturia” is defined as ejaculating urine at the moment of orgasm. Although the exact number of cases of climacturia after surgery for prostate cancer is unknown, different studies have estimated the incidence to be between 20 percent and 95 percent! Climacturia is thought to be more common in men who also have posttreatment erectile dysfunction and those who complain of penile shortening. Although the exact mechanism of climacturia has not been well studied, men who have climacturia usually have urinary incontinence as well. Thus, the pooling of urine in the urethra, along with relaxation of the sphincter mechanism during orgasm, are thought to be predisposing factors for climacturia. As a result of this problem, many men suffer from decreased libido and decreased sexual satisfaction.
Treatment suggestions for climacturia have included behavior modification (urinating before sexual activity), the use of condoms, and the use of a constriction ring at the base of the penis during intercourse. Although the results of these various treatments have not been well studied, patients should be informed regarding the possibility of this rather common posttreatment complication of radical prostatectomy, which can have a very significant impact on quality of life. Though there is very limited data, complaints of climacturia after radiation or focal therapy have been very uncommon.
STRICTURE
“Urethral stricture,” scarring and constriction of the urethra, may occur after any invasive treatment of prostate cancer. Recent literature suggests that robotic prostatectomy is associated with much lower rates of urethral stricture than older surgical techniques, occurring in about two percent of men. Most strictures develop within three to six months of treatment. Stricture is also frequently associated with urinary incontinence (which commonly becomes even worse after stricture treatment).
Stricture treatment options include dilation of the stricture, incision of the stricture area, repeated self-catheterization and, in rare cases, major urethral reconstruction. The treatment of incontinence with any of the invasive options listed above should be postponed for at least three to six months to ensure that “stability” has been achieved, confirming that further stricture recurrence has been avoided.
SUMMARY
Recent advances in the evaluation and treatment of men with incontinence following prostate surgery offer hope for men to regain their urinary control and improve their quality of life. Men with significant incontinence following treatment for prostate cancer should have an appropriate evaluation (including urodynamic testing) to determine the exact cause of their incontinence. Appropriate treatment based upon the results of this testing usually results in significant restoration of bladder control and improvement in quality of life. Both climacturia and urethral strictures are potential complications following prostate surgery, with a major negative impact on quality of life.
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References
- GE Leach and others. Post-prostatectomy incontinence: Urodynamic findings and treatment outcomes. Journal of Urology 155.4: 1256, 1996.
- F Haab and others. Quality of life and continence assessment of the artificial urinary sphincter in men with minimum 3.5 years of followup. Journal of Urology 158.2: 435, 1997.
- E Chung and G Brock. Sexual rehabilitation and cancer survivorship: A state of art review of current literature and management strategies in male sexual dysfunction among prostate cancer survivors. Journal of Sexual Medicine 10.S1: 102, 2013.
- R Wang and others. Risk factors and quality of life for post-prostatectomy vesicourethral anastomotic stenoses. Urology 79.2: 449, 2012.