Urinary Incontinence Due To Prostate Cancer Treatment
What is urinary incontinence?
Urinary incontinence is the involuntary leakage of urine. This is more common in women than in men.
What are the symptoms of urinary incontinence?
There are two basic types of urinary incontinence: stress and urge.
Stress urinary incontinence: Urine leaks with activity (a.k.a. stress on the bladder). Activities could include coughing, laughing, sneezing, bending over, or physical exercise. If the incontinence is mild then a man might just have a few drops of urine leak with vigorous activity; if the problem is moderate then he might leak larger volumes with even light activity. In the most severe situations, a man might leak continuously, even when at rest.
Urge urinary incontinence: Urine leakage is preceded by an urge to urinate that you are unable to suppress. Often, the person will also feel as though they need to urinate frequently. There may be pain if they try to delay urination.
What causes urinary incontinence in men?
Stress urinary incontinence: The most common cause of stress urinary incontinence in men is prostate cancer treatment. Either prostate removal (radical prostatectomy) or radiation treatment can damage the urethral sphincter. The sphincter is the valve that helps hold the urine inside the bladder. There are two sphincters in men. One sphincter is located at the top of the prostate, where it meets with the bladder, and is controlled subconsciously. The other sphincter is located at the bottom of the prostate, where it meets with the pelvic floor, and is controlled consciously. When you are cold or nervous and can’t pee, that is the subconscious sphincter that isn’t relaxing. When you try told hold back urination by tightening your muscles, that is the conscious sphincter working.
The subconscious sphincter is removed in its entirety during a radical prostatectomy and a man becomes completely dependent on conscious tightening of the lower sphincter. But, the conscious sphincter can also be damaged during a radical prostatectomy. It wraps around the lowest part of the prostate and connects it to the pelvic floor. So, the conscious sphincter fibers must be carefully separated from the prostate during radical prostatectomy. Either due to an advanced cancer or an oddly shaped prostate or sphincter, it can be hard to save all the sphincter fibers. It takes most men a few months to learn how to tighten the conscious sphincter after radical prostatectomy. Practicing Kegel’s exercises might help regain urine control. However, if incontinence is still bothersome after 6 months, it may be time to meet with a specialist like Dr. Elliott to discuss treatment options.
Like radical prostatectomy, radiation can also damage the sphincter muscles. Its effect, though, is more gradual. Surgery causes damage immediately and things usually improve slightly after surgery. Radiation causes damage over the long-term. Radiation kills the cancer cells but will also kill some of the nearby normal cells, like the sphincter muscles. So, someone can be continent of urine right after radiation and develop incontinence 5-10 years later.
Men who undergo radical prostatectomy AND radiation combined are at particularly high risk for urinary incontinence.
One other cause of stress urinary incontinence besides prostate cancer treatment is surgery for an enlarged prostate. These surgeries hollow out the inside of the prostate when it has gotten too large and is blocking urination. Occasionally (<5% of the time) these surgeries can damage the sphincter muscle, leading to stress urinary incontinence.
Urge urinary incontinence: Urge urinary incontinence is not a problem with the sphincter muscles. Instead, it is a bladder problem. The bladder is irritable and spasms easily, causing urine to be pushed out. No amount of sphincter tightening can hold back the urine when the bladder spasms. This can be caused by an enlarged prostate, neurologic diseases like MS or a stroke, or can have no obvious cause.
What treatments are available for stress urinary incontinence?
All of the available treatments for stress incontinence work by squeezing the urethra.
Penile clamp: The simplest method to manage stress incontinence is a penile clamp. These come in several different styles and sizes and are readily available in the online marketplace without a doctor’s prescription (some examples pictured below). They are external devices (not implanted). They function like a clip that is put across the penis, squeezing the urethra; there is often a ratcheting mechanism that allows you to adjust the tightness to the minimum amount needed to control the leakage. All of them have a soft inner lining (such as foam rubber) to make them more comfortable. A man can wear the device all day and remove it to urinate. To give your skin some rest, you can remove it at night and use absorbent pads instead. The same clamp can be cleaned periodically and re-used for weeks. Because it is outside the body, there is no concern about sterility.
Urethral sling: The urethral sling is a piece of polypropylene mesh and is implanted through an incision in the perineum (the space in between your legs, in front of the rectum but behind the scrotum. The mesh is placed against the urethra and then tightened by pulling the ends of it out through two small holes in the inner thighs. Once the sling is tightened, it compresses the urethra to help with incontinence. The sling works best for men with mild incontinence 1-2 pads per day; it does not work well after radiation. People go home the same day as the procedure and a catheter is left in for 3 days.
Artificial urinary sphincter: The AUS is a hydraulically operated device that circumferentially squeezes the urethra. A doughnut-shaped silicon “cuff” squeezes the urethra and a pump (implanted below the skin in the scrotum) controls the opening of the cuff. The AUS works well for all degrees of incontinence. Dr. Elliott is among the top 1% of American urologists for this procedure.
Surgery for Urinary Incontinence in Men