Post-Prostatectomy Incontinence: The Problems and Solutions
Incontinence can be a complication of prostate surgery done for either benign or a malignant disease. I am going to concentrate on incontinence following surgery for prostate cancer, although many of the same principles apply for incontinence caused by surgery done for benign enlargement of the prostate such as TURP or open prostatectomy. The current quoted complication rate of incontinence following radical prostatectomy is between 4-8 percent Pre-existing conditions causing incontinence, especially certain neurological disorders, may inflate this number. Recent advances in the surgical technique in radical prostatectomy have improved this percentage. In the not too distant past, the figure was 20 percent or more. A better understanding of the prostatic anatomy, the neuro-physiology of continence and incontinence, and improved surgical technique have all contributed to the lower percentage rate of incontinence. We primarily have Dr. Patrick Walsh, at John Hopkins to thank for improvements in surgical technique.
There are three types of incontinence seen following prostate surgery, stress incontinence, total (dripping faucet) incontinence, and detrusor instability (caused by bladder muscle and nerve instability seen following many types of pelvic surgery). Both stress incontinence and total incontinence are caused by injury to the urethral sphincter muscle during surgery. The prostate itself also contributes a great deal to continence in males, as it contains a large amount of smooth muscle that helps control urinary flow. Many times patients will have transient forms of any of these types of incontinence that will resolve with time or conservative measures.
- Stress incontinence occurs when the patient coughs, sneezes, or lifts a heavy object with straining to put the "stress" of the increased abdominal pressure on the bladder and overcoming the holding pressure of the urethral muscles.
- Total incontinence is caused by severe damage to the pelvic muscles so that urine is constantly leaking like a dripping faucet.
- Damage to the nerve and muscle fibers of the bladder itself, causing "spasms", urgency, and urge incontinence (the need to rush to the bathroom at a moment's notice) cause Detrusor instability.
All pre-existing conditions that may contribute to this problem should be investigated, especially neurological or neuromuscular diseases. Pre or post-operative irradiation to the prostate and prior prostatic surgery will also make the problem worse. Simple causes of incontinence such as urinary tract infection must also be investigated. In the vast majority of cases, time will help to improve urinary control by both healing and the shifting of some of the muscular control to other muscles in the urinary tract. Most men will see a gradual improvement up to one year after surgery.
A complete evaluation must be undertaken if the problem does not resolve within six months to one year. Urodynamics and or video urodynamics need to be done. This will test for bladder pressures and capacity. A cytoscopy also may be done to inspect the urethra for evidence of sphincter damage and urethral narrowings called strictures. All of these tests will help the doctor and patient arrive at the correct treatment plan for incontinence.
The tincture of time and healing will cure the vast majority of cases within six months. If testing reveals the detrusor muscle instability ("spastic bladder") type, this will be treated usually with medication. Sometimes pelvic floor nerve stimulation may also improve this type of incontinence.
Kegel exercises, which relax and contract the pelvic floor muscles, may help to regain urinary control following surgery. It may be necessary to learn these from a professional trained in this such as a urology nurse practitioner.
If conservative treatment fails, injection of fat or collagen to bulk up the urethra may sometimes help stress incontinence. However, these have had a high eventual failure rate. In the case where there is a coexisting stricture or the patient has had radiation therapy also, the treatment usually is doomed to fail.
Another new treatment is the male sling procedure. This is a minimally invasive, same-day surgery procedure that has resulted in a high initial success rate. The procedure requires minimal recovery time, allowing men to resume a normal, active lifestyle. The sling procedure augments the normal sphincter function, providing an enhanced level of continence. The system uses an incision below the scrotum to place a sling below the urethra to provide a compression effect to help restore voiding function. Most men have their continence or control restored immediately after the surgery and go home completely dry. A small number of men will need a catheter for a few days until they recover from the surgery.
Finally, there is the artificial urinary sphincter. This is a prosthetic implantable cuff and pump which mimics the function of the patient's urinary sphincter. This requires surgical implantation. A cuff is placed around the urethra which is activated by a pump placed in the scrotum which when pumped, allows the water to flow out of the cuff so that the cuff relaxes and allows urine to flow out naturally. Within about 30 seconds, the cuff automatically refills with water to maintain continence until the patient needs to urinate again. For further explanation, see this article on the internet, The Artificial Sphicter/Artificial Incontinence Device.
The important things to realize is that incontinence treatment rates are improving with more refined surgery. Also, time and patience along with conservative measures will allow a lot of patients to heal. As a last resort, the surgical correction can be used after waiting at least 6 months to one year after the original surgery. Patients with coexisting diseases or who have had radiation therapy will have a less favorable outcome over all.
Reprinted with permission from Dialog Medical, dialogmedical.com.
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