Post Prostatectomy Urinary Incontinence

Introduction

Urinary incontinence is involuntary urination – leaking of urine that you can't control. Men who leak urine when they are doing activities that increase intra-abdominal pressure (e.g., laughing, sneezing, lifting heavy objects) are said to have stress urinary incontinence. The sphincter (a ring of muscle under the bladder), which acts as a tap for the bladder, can be damaged because of prostate surgery.

Causes of Post Prostatectomy Urinary Incontinence

It happens more commonly in men who had their prostate removed because of cancer (up to 60% have mild leakage, and 2-3% have severe leakage). It can happen in about 1% of men who had a transurethral resection of the prostate (TURP or prostate ‘reboring’ surgery) for benign enlargement of the prostate. About 5% of patients undergoing radiotherapy treatment for prostate cancer may get mild to moderate incontinence. Radiotherapy patients usually develop urinary incontinence later compared to those who had surgery.

What other problems can occur in these patients?

Bladder neck contracture

About 5 – 7% of men after open radical prostatectomy may develop scarring of the anastomosis (where the bladder neck was joined to the urethra) called a bladder neck contracture. The incidence is reduced in those who had robotic radical prostatectomy. This can cause a weak flow and straining during urination. Often this must be surgically released endoscopically, and the scarring must stabilise before incontinence surgery can proceed. This is to prevent the repeated passage of instruments in the urethra over where the compression device (cuff) is, resulting in erosion of the device.

A bladder neck contracture can also mask stress incontinence and the leakage would become worse or apparent after the scarring is released.

Bladder dysfunction

Men after radical prostatectomy can also develop bladder dysfunction and can sometimes develop an overactive bladder, underactive bladder or one with poor compliance (stiff-walled, inelastic bladder causing high pressures). The estimated incidence of this is about 30%. Hence, the urinary incontinence may not solely be due to stress leakage, and may have an urge leakage component, which must be treated as well. Sometimes patients may need ongoing treatment for this bladder dysfunction even after the stress incontinence is treated.

Incontinence during sexual activity

Men can also get urinary incontinence during sexual activity, and this can be very embarrassing and distressing for the couple. Helpful tips include watching your fluid intake, emptying your bladder before sex, and wearing a condom.

How is a diagnosis of stress incontinence made?

For patients contemplating incontinence surgery, a urodynamics study is recommended. This is to assess the severity of the leakage and help in deciding which surgery is more suitable. It can also assess for bladder dysfunction (see above).

Sometimes, a 24-hour pad weight test can be helpful to quantify the amount of leakage.

Conservative treatment options

Pelvic floor exercises were first described by Dr Arnold Kegel in the 1940s and they aim to strengthen the pelvic floor muscles and improve bladder neck support. A trained physiotherapist can assist in this.  Often, men are instructed to start doing these exercises even before their prostate surgery. For instructions on how to do this, see how to do pelvic floor exercises.

Other conservative treatment options include:

• Lifestyle: Watch fluid intake.
• Absorbent products – pads, diapers.
• External collection devices - condom catheters, penile clamps.
• Internal collection devices - intermittent or long-term catheter.

Surgical treatment options

Continence can continue to improve up to one year after radical prostatectomy, especially for those with mild to moderate stress incontinence. Therefore, patients are often advised to continue doing pelvic floor exercises till then before considering surgery. However, those with severe stress incontinence may not show further improvement with pelvic floor exercises after 3 to 6 months, and may be suitable for assessment and treatment earlier. Men who have combined surgery and radiotherapy treatments, have an increased risk of complications from incontinence surgery.

Urethral bulking agents

• Success rates are much lower than the other options. Therefore, it is not a common option.
• Can be done under local anaesthesia or sedation.
• This involves the injection of bulking agents into the urethra, creating wall-to-wall apposition and hence increasing the outlet resistance.
• Examples of agents that can be used are collagen (now no longer manufactured), Macroplastique (silicon particles in a viscous gel) and Bulkamid (hydrogel with synthetic polymer).
• Considered in patients who have high anaesthetic risks.

Advance male sling

This involves the surgical placement of a synthetic mesh sling under the urethra, with the arms of the sling exiting through a small incision in each inner thigh. This surgery is only suitable for mild to moderate stress incontinence (not for severe stress incontinence). Studies have shown the success rate is slightly lower in men who had radiotherapy but is still reasonably good.

Advantages compared to the artificial urinary sphincter:

• Shorter operation time and is less invasive.
• Shorter hospital stays (overnight) and faster recovery.
• No deactivation time post-operatively – patients see results immediately.
• No device activation is required during day-to-day use.
• Less risk of erosion.

For more information, see male sling.

Artificial urinary sphincter (AMS 800)

This is considered the gold standard operation for moderate to severe stress incontinence. This surgery has high success rates with long-term durability.

It consists of 3 components that are interconnected:

• A pump that is implanted in the scrotum.
• An inflatable cuff around the urethra.
• A balloon reservoir implanted in the lower abdomen.

During urination, the pump is squeezed to move fluid out of the cuff that is compressing the urethra, and back into the reservoir. After 1-2 minutes of urination, the fluid automatically returns from the reservoir to the cuff, squeezing the urethra closed again.

This surgery is not suitable for those with:

• Poor hand dexterity or mental capacity to know how to use the device.
• High anaesthetic risks.
• Known allergy to rifampicin, minocycline or other tetracyclines (antibiotics impregnated into the device).
• Unresolved overactive bladder or poor bladder compliance (‘stiff’ bladder that does not stretch) – because of the risk of building up pressure in the bladder by closing off the urethra, causing damage to the kidneys.

For more information, see artificial urinary sphincter.

Related Information

Read A/Prof Gani’s publication - Does active surveillance alter the risk of developing urinary incontinence later?:
Download Active surveillance failure for prostate cancer does the delay in treatment increase the risk of urinary incontinence - PDF (157 Kb)

Read A/Prof Gani’s publication - Concurrent bladder dysfunction can affect the treatment of post-prostatectomy urinary incontinence:
Download Impact of bladder dysfunction in the management of post radical prostatectomy stress urinary incontinence - PDF (464 Kb)

Read A/Prof Gani’s publication - Does the timing of radiotherapy after radical prostatectomy affect the risk of developing urinary incontinence?:
Download Long term complications in men who have early or late radiotherapy after radical prostatectomy - PDF (4000 Kb)

Read A/Prof Gani’s publication - Analysing if the amount of striated sphincter muscle on prostate specimens is related to developing stress urinary incontinence:
Download Striated muscle in the prostatic apex does the amount in radical prostatectomy specimens predict postprostatectomy urinary incontinence - PDF (583 Kb)