Urinary Incontinence After Treatment for Prostate Cancer

What is incontinence?

Incontinence is when you can’t hold your urine. This can lead to the leaking of urine. Incontinence can be a side effect of treatment for prostate cancer. 

Why does incontinence happen after prostate cancer surgery?

There are two sphincter muscles that help men control their urine, also called “being continent.” These sphincters are: 

• The internal urethral sphincter: You do not control your internal sphincter. It is found at the bottom of the bladder, called the "bladder neck.” This is removed during a radical prostatectomy (RP). The prostate cannot be taken out without also taking out the sphincter.
• The external urethral sphincter: The external sphincter is found below your prostate. You can control your external sphincter and use it to stop your urine stream. You can strengthen this sphincter with pelvic floor muscle (Kegel) exercises (described below).

Normally, an intact, healthy external sphincter is enough to help you remain continent after surgery. However, RP can damage nerves, blood supply, supporting structures, or the muscle which can affect the external sphincter. This damage can lead to incontinence.

What types of incontinence can happen after RP?

There are two main types of urinary incontinence after RP:

• Urgency incontinence is when you feel the need or urge to urinate but cannot make it to the toilet in time. This is often due to bladder spasms and medication can help. This type of incontinence is caused by changes in the way the bladder behaves after surgery.
• Stress urinary incontinence (SUI) is leakage of urine with movement or effort and can happen when you cough, sneeze, lift something heavy, change position, or exercise. This type of incontinence may be caused by damage to your external sphincter muscle. Almost all men will have some degree of SUI right after their urinary catheter is taken out. A urinary catheter is placed short term to collect urine during and while recovering from surgery. You may be taught how to do pelvic floor exercises to help with urinary control.

Do all men have incontinence after RP surgery?

Incontinence gets better quickly in most men during the first few months, once the urinary catheter is taken out. For some men, incontinence can be an issue up to 1 year after surgery. Most surgeons will consider a man continent if he does not regularly use incontinence pads and only has dribbling with lots of activity. They also take into account how your urinary incontinence is affecting you. The goal is to improve your quality of life as much as possible.

Who is at risk for developing incontinence?

It is not known why some men have incontinence that continues after surgery and others do not. SUI after surgery could be caused by::

• Older age.
• Larger prostate size before its removal.
• Smoking.
• Diabetes or other neurological diseases.
• A lot of blood loss during surgery.
• Need for cutting nerves during surgery.
• Size or stage of prostate tumor.
• Radiation after surgery (see below).
• Previous surgery for BPH.

How can radiation therapy after prostatectomy affect incontinence?

Some men need radiation after a prostatectomy. This treats the "prostate bed" (the area where the prostate was located). Some normal tissue will receive a low dose of radiation, including the external urinary sphincter. The radiation may irritate the external sphincter, urethra, and bladder during radiation therapy and for a short time after. This can lead to worsening incontinence that often gets better in the weeks to months after radiation. Some men may have more incontinence in the months to years after radiation therapy due to the buildup of scar tissue. This can cause the external sphincter to not open and close as it should.

What should I do after radiation therapy to reduce incontinence?

Men should keep doing daily pelvic floor (Kegel) exercises. Pelvic floor exercises help strengthen the muscles at your bladder outlet, which helps to improve, regain, or maintain bladder and bowel control.

To identify your pelvic floor muscles, stop urination in midstream or tighten the muscles that keep you from passing gas. If you tighten your pelvic floor muscles while looking in the mirror, the base of your penis will move closer to your belly and your testicles will rise. Do not tighten the muscles in your belly, thighs, or buttocks.

Try to do 3-10 sets of 10 repetitions every day. Some sets should be with long muscle contractions (tightening of the muscles) and others with quick muscle contractions:

• Long contractions: Slowly increase the time you can hold the contraction until you can hold for 10 seconds. Rest for 10 seconds between each contraction.
• Quick contractions: Quickly tighten then relax the muscles.

Decreasing your use of caffeine, alcohol, and bladder irritants (sugary juices, acidic foods like tomatoes, and carbonated drinks) can also help decrease incontinence. Drink plenty of water every day.

What if the incontinence does not get better?

In these cases, you should see an incontinence provider to talk about available treatments. They will ask you questions about your health history, the symptoms you are having, the number of pads you use, and what treatments you have already had. They will also do an exam and may ask for a urine sample. They may do a bladder scan (ultrasound) to see how much urine is in your bladder. 

The incontinence specialist will likely talk about conservative treatments at first. More pelvic floor exercises might be recommended. You may also be given a biofeedback machine that allows you to see how strong your pelvic floor muscles are. The specialist may talk about medication options.

What if these treatments do not work?

If these do not work, you may be sent to a urologist for more tests on your bladder and sphincter. These tests will help decide what type of incontinence you have, how well your bladder is working, and what other treatments might be best for you. A urodynamic test and cystoscopy may be done. They are both done in the office, often during the same visit. The results help decide which procedure might be best for you.

• The urodynamics test places a very small catheter in your bladder, fills it with fluid, and measures bladder activity and pressure during filling and voiding (urination). You will also be asked to cough and strain so your provider can see if and how easily you leak urine.
• A cystoscopy may also be done to look at the urethra, the anastomosis (the area where the bladder is put back together with the urethra after the prostate is removed during surgery), and the bladder. After these tests, your provider will go over the results with you, and together you can decide what treatment would be best.

What are the different surgeries for incontinence?

There are three main types of surgery for men who have incontinence after an RP:

1. Urethral bulking procedures are done endoscopically (through a cystoscope). A material is injected just under the lining of the urethra. This makes the urinary passageway smaller. It is often done as an outpatient procedure, either with or without anesthesia. You can often return to normal activity right away. Your body often reabsorbs the material over time so it needs to be repeated every 9-15 months. The side effects can be bleeding, urinary tract infection, and temporary urinary retention (not being able to fully empty your bladder). Rarely, patients may feel that their incontinence is made worse by the procedure.
2. Male perineal sling procedures are done in the operating room under anesthesia. A small incision is made in your perineum (the area between the scrotum and anus). A strip of mesh is placed under the urethra and is used to elevate and slightly press on the urethra. You will be asked to limit your activity for 4-6 weeks after surgery to allow the sling to scar into place so it does not move after the procedure. There is little discomfort or pain after the procedure. Success tends to be best in men with minimal to moderate incontinence (1-3 pads per day). Side effects can be bleeding, skin or mesh infection, pain, erosion into the urethra (rare), inability to urinate (rare), and no improvement in continence.
3. The Artificial Urinary Sphincter (AUS) is the most reliable and often most effective surgical treatment for incontinence after RP. It is a silicone implant with 3 parts: a cuff that goes around the urethra and squeezes it closed, a small fluid reservoir, and a control pump that is placed under the skin in the scrotum. The cuff is normally closed and squeezes the urethra shut, which prevents leakage of urine. You must squeeze the small pump in the scrotum to open the cuff and urinate. The cuff refills and closes on its own after 3-4 minutes. You are kept overnight in the hospital. The operation can be done either through one small incision at the top of the scrotum or through two incisions with one in the perineum and one in the groin. Recovery is short with this procedure. The device will not be activated for 4-6 weeks after surgery. Your incontinence will not change until the device is activated in the office. This procedure can be used for all degrees of incontinence. This surgery has slightly more risk of serious issues mostly related to the implant. They are bleeding, skin or device infection, erosion into the urethra, the device not working, and urethral atrophy (the tissue around the urethra becomes compressed and thin over time which may lead to incontinence).

Treatment for prostate cancer and the side effect of incontinence can be a challenge. Talk to your provider about the possible side effects of surgery and radiation. If you have incontinence after treatments, talk to your urologist about your options.