Treating Incontinence after Prostate Cancer Surgery
by Kevin Chan, MD
Urinary incontinence is a common side effect of prostate cancer surgery. Most men regain their urinary control within one year after surgery while some require two years. However, a small percentage of men have persistent incontinence.
Radical prostate surgery involves removal of the entire prostate, which is one of the primary mechanisms of urinary control in a man. The most common cause of urinary incontinence after radical prostate surgery is weakness of the external urinary sphincter. This is characterized by the loss of urine with any type of stress maneuver, such as coughing, sneezing, or changes in position, hence the term stress urinary incontinence. This occurs because this external sphincter muscle, previously only responsible for starting and stopping urination in midstream, has now become the primary mechanism for urinary control. Occasionally, this muscle is inadequate to generate the necessary resistance to maintain continence.
Evaluation for incontinence after prostate surgery confirms that the urinary incontinence is due to sphincteric weakness and not due to other less common causes of incontinence, such as overactive bladder or scar tissue at the bladder neck. This involves a consultation with a doctor and two relatively simple tests – a cystoscopy and a urodynamic evaluation. The cystoscopy utilizes a thin endoscope to evaluate the bladder neck for scarring and to evaluate the quality of the person’s sphincter contraction. The urodynamic evaluation tests the ability of the bladder to generate a normal bladder contraction, detects stress urinary incontinence, and also detects signs of overactivity. Once the diagnosis of stress urinary incontinence is confirmed, one can proceed with definitive treatment.
If bothersome stress urinary incontinence persists beyond one year despite a trial of physical therapy, one may consider potential surgical intervention.
The basic goal of stress urinary incontinence treatment is supplementing the existing sphincter function. An initial non-invasive treatment option is instruction in pelvic floor muscle exercises by a physical therapist to improve the sphincteric muscle tone.
If bothersome stress urinary incontinence persists beyond one year despite a trial of physical therapy, one may consider potential surgical intervention. These surgical options include transurethral collagen injection, a male sling procedure, or placement of an artificial urinary sphincter. The decision as to which procedure is best is dependent on several factors including the severity of the incontinence, a history of previous pelvic radiation, and the individual’s bladder function.
Collagen injection is performed using an endoscope in the urethra. The collagen acts as a bulking agent at the bladder neck creating more outflow resistance. It can be done under a local or general anesthetic. While minimally invasive, the effectiveness of collagen injection is limited and temporary. It should generally be reserved for individuals that are not good surgical candidates due to other medical conditions, or those who have very mild incontinence and poor bladder function.
Recent advances in male sling procedures have made them an ideal treatment option for most men with incontinence following radical prostate surgery. While several techniques exist, the basic principle of the male sling is the use of a synthetic material that externally compresses the urethra, recreating the physiological level of resistance that was originally present at the bladder neck when the prostate was present. Most slings require a general or spinal anesthetic. They require one or two small incisions just below the scrotum and sometimes in the low abdomen. At some centers, this is performed as an outpatient procedure. This is an ideal treatment for someone with mild to moderate stress urinary incontinence, normal bladder function, and no previous history of radiation to the pelvis.
Surgical placement of an artificial urinary sphincter is the treatment of choice for the individual that has severe urinary incontinence, has failed treatment with a sling, or has a history of pelvic radiation. This generally involves one small incision in the perineum or scrotum and one in the low abdomen. The implanted silicone cuff surrounds the urethra and a pump controller is placed in the scrotum. No part of the implanted device is visible. At rest, the cuff is fully inflated with fluid and occludes the urethra, effectively preventing leakage. To urinate, one simply presses the pump controller to open the cuff and allow normal urination. The cuff then inflates closed automatically within a few minutes. Despite its seemingly complex nature, there is a very high degree of satisfaction with the artificial urinary sphincter.
It is important to know that while urinary incontinence is a real possibility after treatment, there are some proven options available to help men regain their previous quality of life.
♦ ♦ ♦ ♦ ♦
Dr. Kevin Chan is a clinical assistant professor in the department of Urology and Urologic Oncology at the City of Hope National Medical Center.
This article was originally published in Coping® with Cancer magazine, January/February 2012.
Coping® does not endorse or recommend any particular treatment protocol for readers, and this article does not necessarily include information on all available treatments. Articles are written to enlighten and motivate readers to discuss the issues with their physicians. Coping believes readers should determine the best treatment protocol based on physicians’ recommendations and their own needs, assessments and desires.