Urinary Incontinence After Prostate Cancer Surgery
Dr. JERRY BLAIVAS: Okay, so once you have healed from the surgery, after two or three months, if the incontinence is not getting better, it is time to do a preliminary evaluation to see why. Remember we said that almost always the problem is the sphincter muscle being not working properly but we want to check that out for sure. So what we will ask to do is to keep a diary for 24 hours where you record the time and the amount of each urination and to also wear your pads as you usually do, bring them back the next day to the doctor’s office and then the doctor could just look at them or even weigh them and weigh a dry pad and get a sense of how much urine you actually loose.
Then the next thing he is going to want to do is to examine you with a full bladder and when he examines you, he is going to ask you to cough and push down and he is going to see if any urine leaks out. If urine leaks out when you cough or push down, then that is a sphincter weakness. That is present in about 95% of patients that have urinary incontinence after prostate surgery. A small percentage, may be about 5%, have actually a different problem. Their sphincter works okay but the problem is that their bladder contracts involuntarily. That means that you actually start to urinate without control and it is very very important to make the distinction of which these things are because if the problem is urinating without control we call involuntary bladder contractions, that may be paradoxically due to a blockage, so it is possible that surgery worked well to remove the prostate but you are left with a scar that causes a partial blockage. You can still urinate but that blockage then causes the bladder to contract involuntarily. So at this period time, several months afterwards, depending upon which of the two abnormalities you have and it is possible to have both, the doctor could institute some kinds of preliminary treatments.
We do not really do anything or we do not even consider surgery at this stage but based on the bladder diary and whether or not you have these involuntarily bladder contractions, it might be reasonable for you to use some behavioral techniques to try to improve the continence. Then overtime we expect the continence to get better and by one year after the surgery, we expect that at least 90% of the patients would either be no longer incontinent or so much improved that they do not feel like they need any further surgery. If you are one of the unfortunate ones in whom the urinary incontinence did not get better, then it is time to consider treatment options, more prominent treatment options and those options are basically surgical. The surgery falls into two kinds, an artificial sphincter or sphincter prosthesis or what is called a sling. The sphincter prosthesis, without getting into all the detail, simply replaces the sphincter with a plastic-like device that is completely implanted within your body and that works very very well. It has been time tested but it is a mechanical device. The sling operation is a much newer procedure. It is made of different kinds of mesh, and the sling actually puts this synthetic tissue underneath the urethra and the idea is that when you cough or move about, the urethra gets actually compressed by the sling.
That is a much newer operation. In my own judgement, the sling operation, although it is done very commonly in this country, is still a little new for it to be adopted as widely as it has been. The way it works is we put this tissue underneath the urethra and when the patient coughs or moves, it compresses the urethra and it is effective in certain a percentage of patients but again in my judgement not nearly as effective overtime as the artificial sphincter or sphincter prosthesis. If you are considering one of these operations, it is really important that you ask your doctor the pros and cons and that you and he or she make a decision based on what is best for you, because in some patients with mild incontinence, the sling actually may be a reasonable option. The other cause of incontinence only accounts for about 5% of patients are involuntary bladder contractions, and in that case what is happening is you are simply urinating without control. There are some important causes of that that need to be ruled out before any definitive kind of treatment is undertaken. The three most important causes of this overactive bladder incontinence or incontinence due to involuntarily bladder contractions, are blockage due to a scar from the surgery, bladder cancer and bladder stones.
So these things need to be checked out first and then if they are found then they need to be treated. If they are not found, then you embark on a treatment for the involuntarily bladder contractions, which could range from behavioral therapy based on your bladder diary, or medications or sometimes electrical stimulation or neuromodulation. There are a number of different modalities that could be effective for this urinary incontinence due to involuntarily bladder contraction.
Dr. JERRY BLAIVAS: Okay, so once you have healed from the surgery, after two or three months, if the incontinence is not getting better, it is time to do a preliminary evaluation to…By: Best Doctors