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Incontinence is one of the major complications after a prostate cancer treatment. The rates of incontinence after radical prostatectomy are estimated to be between 5% up to 35% and after radiation therapy between 5 to 10%.
Risk factors for incontinence after prostate cancer treatment include the patient’s age as well as prior urinary symptoms. Generally older patients tend to have a higher risk of incontinence than younger patients and patients who have had prior urinary symptoms are at higher risk for having incontinence also.
Probably the two most important factors are the extent of cancer and the experience of the surgeon doing the radical prostatectomy. More aggressive cancers often require a wider resection to be cancer free. The wider resection increases chances of damage to the urinary sphincter which in turn increases the chances of incontinence. Surgeon experience is critical as well with high-volume prostatectomy surgeons having better outcomes than low-volume prostatectomy surgeons. One of the best ways to minimize the chances of incontinence after your surgery is to pick the right surgeon before surgery.
There are different kinds of incontinence that can occur after prostate cancer treatment and it is important to understand the distinctions between them. After a prostatectomy, the most common kind of incontinence is stress urinary incontinence. With stress incontinence increasing abdominal pressure during exercise, or for example laughing or coughing can cause urinary leakage. Stress incontinence occurs from damage to the sphincter during surgery; in a small percentage of patients after surgery urge incontinence arises from an overactive bladder. With urge incontinence patients feel a sudden, strong urge to urinate and can’t hold off on urination and leak. With radiation therapy urge incontinence can predominate but radiation can damage both the bladder and the sphincter. Bladder damage causes urge incontinence and sphincter damage causes stress incontinence. Before undergoing any kind of treatment it’s important to have a better understanding of what type of incontinence you have.
I evaluate incontinence after prostate cancer treatment in a variety of ways beginning with a history and exam. After prostatectomy most patients will recover significant amount of sphincter function but the recovery can take up to one year. Because of this I generally like to wait at least one year before offering any kind of surgical treatment for incontinence. After radiation therapy incontinence generally is worse initially but can develop later even many years after radiation. Other tests useful in the evaluation of incontinence include a 24 hour bladder diary and a 24 hour pad test. On the bladder diary, patients are instructed to record the time of urination, the amount, and the degree of urgency that prompted urination. We have fairly sophisticated tools now to evaluate the bladder diary that help us understand the causes of incontinence. The 24 hour pad test involves saving all of the pads used for 24 hours and bringing in a dry pad as well. We then weigh the dry weight against the weight of the dry diapers to determine exactly how many grams of leakage occurred during the 24 hour period. In my opinion the 24 hour pad test is a more accurate assessment of incontinence than just measuring the number of pads or diapers used. For example some patients may change their pads every time they the bathroom because of discomfort with any moisture – these patients can use many pads a day but actually have little incontinence, or, alternatively some patients may allow single pad to get almost soaking wet before they change it. The 24 pad test incorporates these types of variables in its evaluation.
Other tests that can be useful include cystoscopy and videourodynamics to evaluate sphincter and bladder function.
For patients who have a predominance of stress incontinence there are a variety of treatment options available. One is to try pelvic floor exercises such as Kegel exercises and biofeedback. In my opinion these exercises can speed up the process of recovery but rarely will change the overall extent of recovery. For mild to moderate incontinence the Advance Sling may be an option. The advantage to the sling is that there is no devices of buttons to press and the sling can be placed typically in an outpatient surgery in under one hour. The disadvantage to the Advance sling is that it tends not to work in patients who have had radiation therapy or have urge incontinence as their primary symptom. In addition there is an increasing concern about mesh in the body causing chronic inflammation and potentially pain.
Another option is placement of an artificial urinary sphincter. The artificial urinary sphincter can be used for any level of incontinence. Surgery typically takes about one hour and patients are kept in the hospital overnight. Because of long experience with this surgery it is still considered the gold standard treatment for male incontinence.
There are however some disadvantages with the artificial urinary sphincter. Over time the artificial urinary sprinter can cause urethral atrophy requiring a revision operation. Also after the sphincter is placed patient should let their doctors know anytime they may have surgery that requires catheterization as catheterization can damage the sphincter. If there is a problem with the sphincter it can be removed fairly easily with surgery.
In patients who have a predominance of urge incontinence medical treatment such as overactive bladder medications or even Botox injected into the bladder can be useful.