Throw us a bone

by Donna Canada, RN, CURN

Urinary incontinence symptoms due to bladder irritation may occur after prostate cancer treatments, especially after a Foley catheter is removed. It is better to be prepared for some urine leakage as urinary incontinence (UI) is common and includes increased urinary urgency and frequency. While urinary incontinence immediately after prostate surgery is usually temporary and often mild, it may take months or years to resolve. In a few patients, it may be a persistent problem. Exercises, rehabilitative services, and surgery to control incontinence are sometimes required.

The risk factors for urinary incontinence after radical prostatectomy are:

• age
• presurgical sphincter control
• dissection and anastomosis (reattaching) technique
• resection of neurovascular bundles (whether the nerves were spared) and
• prior TURP (transurethral resection of the prostate).²

The Agency for Health Care Policy and Research Guideline, Urinary Incontinence in Adults: Acute and chronic Management recommends that the first treatments for incontinence should be the least invasive options: bladder re-training, timed urinating meaning emptying the bladder on an every two to three hour schedule, and pelvic floor exercises.³

Urinary incontinence after prostate treatment

Urinary incontinence is one of the most bothersome outcomes of prostate cancer treatment. Although it is more commonly associated with radical prostatectomy, it may also occur after interstitial seed therapy, EBRT, and Cryotherapy.⁴

If you experience persistent urinary incontinence after surgery or radiation therapy, your doctor will want to identify the degree and type of incontinence. You may be asked questions regarding the number of pads you use per day, what activities precipitate the incontinence, how frequently you urinate, if you have frequency or urgency, how strong your urine stream is, if you feel you are emptying your bladder well, and what types and how much fluid you are drinking.⁴

Several types of UI exist, different types may co-exist, and treatments vary based on the type. Men who have been treated for prostate cancer may encounter stress, overflow, and/or urge incontinence.

The best way to determine the type(s) of urinary incontinence you are experiencing is to undergo a fluoroscopic urodynamic study, a group of tests designed to measure pressures in your bladder during voiding and at the time of urinary leakage (if it occurs during the study). The tests also allow the clinician to look at the urethra and bladder during bladder filling and urinating. The study involves the placement of a catheter through the penis into the bladder. The catheter is connected to a pressure monitor, and sterile contrast fluid (or saline) is infused through the catheter into the bladder. The catheter is connected to a pressure monitor, and you will be asked to bear down during the procedure to see if leakage occurs with pressure changes. The doctor is interested in your "leak point pressure" numbers, overactivity of the bladder muscle, and other factors that can help determine your treatment options.⁴

Causes of and Treatments for Urinary Incontinence After Prostate Surgery

Once the cause and the severity of the urinary incontinence is determined, treatments can be chosen. A variety of conditions may have been found for which specific treatment options include:

• Bladder neck contracture (narrowing)
  Treatment may consist of dilation (expansion) or incision (cut). There is a risk of stress incontinence after incision of a bladder neck contracture so this is usually done very conservatively.
  
  
• Overflow incontinence (after interstitial seed therapy)
  Usual treatment is with medications called alpha-blockers (that relax the prostate) and an anti-inflammatory drug as well as clean intermittent catherization (CIC) until you are voiding on your own. CIC means non-sterile, irregularly timed self-catheterization.
  
  
• Overactive bladder (urge incontinence) is treated with medications that relax the bladder muscle, the most common of which are called anticholinergics. Vesicare, Toviaz, Enablex, Detrol, Oxytrol, Sanctura and Ditropan are some of the more commonly used anticholinergics.
  
  
• Stress urinary incontinence (SUI) or urinary leakage with activity may also be called "intrinsic sphincter deficiency" by your physician. Continence depends on the ability of the remaining urethra (below where the prostate once was) to close (coapt) on the external sphincter. When we have normally funcitoning sphincters, we should be able to cough or "bear down" vigorously without leaking urine. This is sometimes treated with the "off-label" use of the medication Imipramine (Tofranil), in addition to Kegel exercises, various penile clamps and collection devices, collagen injection, a male sling, or an artificial urinary sphincter.⁴
  
  Medications have been shown to be beneficial in treating stress urinary incontinence. In conjunction with exercise and behavioral strategies, they are recommended as the third treatment step in the Clinical Practice Guideline published by the Department of Health and Human Services.³ Medication may improve symptoms in approximately half of the individuals with stress or mixed incontinence, but few become symptom free. Medications used for stress incontinence (currently considered off-label use as they have not been approved by the FDA for stress urinary incontinence) have fewer side effects than those used for urge incontinence.⁵

Stress urinary incontinence following radical prostatectomy

The diagnosis and management of male stress urinary incontinence is complex. Various causes exist, with radical prostatectomy being the most common reason that men seek treatment. SUI in this setting is often temporary and resolves within the first postoperative year. Therefore, it is important to understand the nature of male SUI before initiating treatment.

Generally, the initial management of SUI that persists after twelve months consists of conservative measures, such as pelvic floor muscle exercises (Kegel exercises). Several treatment options are available for men whose continence does not improve after pelvic floor muscle exercises. In order of increasing complexity they are:

• urethral bulking agents
• male slings, and
• the artificial urinary sphincter (AUS)

With over thirty years of published data suggesting excellent long-term outcomes, the AUS is considered the gold standard treatment for male SUI. Male slings have recently demonstrated efficacy for selected patients and are likely to be used more often in the future as experience with these devices grows. Increased adoption of male slings and satisfactory published outcome data will ensure that they continue to gain in popularity. Stem cell therapy to regenerate the urethral sphincter musculature and new devices will continue to be evaluated and might be used in the future.⁶

References:

1. SUNA 2010 Clinical Practice Guideline Prevention and Control of Catheter Associated urinary Tract Infection. Available at: http://www.suna.org. Accessed Feb.2, 2010.
2. Eastham et.al. Risk Factors for urinary incontinence after radical prostatectomy. J urol 1996;156L1707.
3. U.S. Dept of Health and Human Services,1996, Clinical Practice Guideline number 2 (Update). Rockville, MD Agency for health Care Policy and Research.Publication No. 96-0682.
4. Ellsworth et al. 100 Q & A about Prostate Cancer, 2007, 184,185,187,189.
5. Hulme Janet a. Beyond Kegels s 2nd Edition Phoenix Publishing Co. 2002; 124,11,120,72,73.
6. Sandhu J.S. Nat Rev Urol.7, 222-228 (2010);doi1038/Nrurol.2010.26.
7. Newman D, Wein A. Managing and Treating Urinary Incontinence, Second Edition, Health Professionals Press-Baltimore, MD. 2009, 234,235,371,459.
8. Mayo Clinic. Kegel exercises for men: Understand the benefits. Available at: http://www.mayoclinic.com/health/kegel-exercises-for-men/MY01402. Accessed on June 9. 2011.
9. Bernier F, Sims TW. Management of clients with urinary disorders. Medical-surgical nursing: Clinical management for positive outcomes (8th ed. P 727-778). St Louis, MO. Elsevier Saunders; 2009.
10. Ribeiro LH. Gomes CM et al. Prostate Cancer. Journal of Urology 184: 1034-9,2010.
11. Bauer et al. Contemporary Management of post prostatectomy incontinence. European Urology (volumes 59 issue 6 page(s) 985-996 EOI: 10.1016/j.eururo.2011.03.020) European Urology 2011/03/18. Available at: http://www.ncbi.nlm.nih.gov./pubmed/20518761. Accessed on June 9, 2011.
12. Bioderm. Liberty 3.0. Available at: http://www.bioderm.us/index.php?option=com_content&view=article&id=52&Itemid=168. Accessed June 9, 2011.
13. SeekWellness. Afex for managing male incontinence. Available at: www.seekwellness.com/male_incontinence/afex.htm. Accessed June 9, 2011.
14. Omni. URINCare. Available at: www.urinCare.com. Accessed on June 9, 2011.
15. NIH consensus conference. Impotence. NIH Consensus Development Panel on Impotence. JAMA 1993: 270 (1): 83-90.
16. Mulhall. Saving Your Sex life. Munster, IN: Hilton Publishing Company. 2008.
17. International Journal of Impotence Research. 2008:20, 121-126.
18. Nature Reviews. Urology. Volume 6, August 2009. p.424.
19. Urologic Nursing. December 2007:27:6-563.
20. Albaugh. Urologic Nursing. May-June 2010;30-3.
21. Raina R, PahlajaniG, Agarwai, Zippe C. The early use of transurethral alprostadil after radical prostatectomy. BJU Int. 1998;100;1317.
22. Burnett AL. Erectile dysfunction following radical prostatectomy. JAMA 2005;293(21).
23. J Urol 1997; 158 (4): 1408-1410.
24. Walsh PC, Worthington JF. Dr. Patrick Walsh's Guide to Surviving Prostate Cancer, Second Edition. New York: Wellness Central; 2007.
25. Moyad M. Promoting Wellness for prostate Cancer patients, 3rd edition, Ann Arbor: Ann Arbor Editions, 2010:93-104.
26. Radiation Oncology, Division of Nursing, James Cancer Hospital and Solove Research Institute, Patient Education Handout, The Ohio State University Medical Center.
27. Bostwicket al. Complete Guide to Prostate Cancer. Atlanta: American Cancer Society; 2005:306-308.

This article has been reviewed by a member of the Wellness Partners Editorial Board.

Posted June 2011