Loss of bladder control (urinary incontinence) after surgery can be a devastating complication with a very negative impact on quality of life. The good news is that, with appropriate evaluation and treatment, incontinence is usually treatable. Bladder control problems for the first few months following radical prostatectomy are to be expected. A biofeedback program (see below) may be helpful during this period to help restore bladder control. The problem is that in some men incontinence persists beyond the usual three to six-month recovery period.
Biofeedback is also known as “Pelvic Floor Training.” Biofeedback is a useful option for incontinence of lesser severity. The treatment 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 session, the patient is taught to contract and strengthen the pelvic muscles. Also, an electrical signal can be sent to his pelvic muscles to strengthen them. Each week, the goal is to increase muscle strength by repetition.
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 men develop increased blood pressure.
Another option for controlling increased 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 5 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 described above are unsuccessful, the Interstim “bladder pacemaker” may be an alternative. The permanent Interstim device requires the surgical placement of an electrode in the lower back, next to the main nerve that controls the bladder. Separately, an internal “pacemaker” is attached to the stimulation electrode and surgically implanted. This only helps bladders that are overactive and spasmodic.
Surgical Option for Men Who Have Sphincter Damage
One option for the treatment of sphincter damage is a surgical procedure called the “male sling” (see below). Another option is the surgical placement of an artificial urinary sphincter (AUS). 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. To urinate, the pump in the scrotum is squeezed, which opens the cuff around the urethra. After three to five minutes, it closes automatically. The risk of mechanical malfunction is 15 percent at 10 years.
Male Sling Procedure
The best candidates for the male sling are men with minor degrees of stress incontinence (using only one pad per day) and without a history of pelvic radiation. Surgical implantation takes an hour and is placed via an incision between the scrotum and rectum. A catheter is left in place for 24 hours. Approximately 30 percent of men are completely dry, 40 percent are significantly improved, and 30 percent show no improvement.
Climacturia: Ejaculation of Urine
“Climacturia” is defined as ejaculating urine during orgasm. Although the exact number of cases of climacturia after surgery for prostate cancer is unknown, the estimated incidence after surgery is between 20 percent and 95 percent. As a result, many men suffer from decreased libido and decreased sexual satisfaction. Treatment suggestions for climacturia have included behavior modification (urinating before sexual activity and refraining from drinking water), 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 that ejaculating urine is a rather common post-treatment complication of radical prostatectomy.
“Urethral stricture,” or 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 2 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 surgical options listed above should be postponed for at least three to six months to ensure that “stability” of the stricture been achieved, confirming that further stricture recurrence has been avoided.
Recent advances in the evaluation and treatment of incontinence offer hope for men to regain their urinary control and improve their quality of life. Bladder control problems for the first few months following radical prostatectomy are to be expected. The good news is that incontinence is usually treatable.
Gary Leach, MD is former Chief of the Department of Urology and Director of the Urodynamics Laboratory at Kaiser Los Angeles Medical Center. He completed his medical training at Wayne State University in Detroit, Michigan. Dr. Leach is the past president of the Los Angeles Urologic Society and past president of the Urodynamic Society, whose members specialize in the diagnosis and treatment of incontinence. He has written many scientific articles and has contributed to several definitive textbooks on Iincontinence and serves as a member of the Multiple Sclerosis Society Advisory Board. Dr. Leach has written over 100 scientific articles related to urology.