prostate cancer and incontinence

by Diane K. Newman, RNC, MSN, CRNP, FAAN

Prostate cancer is the most prevalent male cancer and the second leading cause of cancer death in men in the United States. A man with prostate cancer may not have symptoms at first, but the earliest signs of the disease tend to be those of lower urinary tract obstruction - hesitancy, post-void urine dribbling, decreased force of stream, and the feeling of incomplete bladder emptying.

The prostate gland surrounds the male urethra, the tube that urine passes through from the bladder to the outside. If cancer grows in the prostate, it squeezes the urethra causing an obstruction that allows less and less urine to pass, and the bladder has to work harder to force the urine out.

Your doctor or urologist diagnoses prostate cancer through a rectal examination that shows an enlarged prostate but will also test the blood level of prostate specific antigen (PSA) as an additional sign. PSA levels greater than 10mg/mL indicate a sixty-six percent chance that prostate cancer is present.

For men with a non-metastasized tumor (a cancer that has not spread to other organs in the body), the goal of treatment is cure, usually by surgery. Surgery - called radical prostatectomy - involves two approaches: retropubic and perineal. With retropubic prostatectomy, an incision (cut) is made in the lower part of the stomach above the pelvic bone, and for perineal prostatectomy an incision (cut) is made through the perineum (in front of the anus).

Most men experience some urine leakage or incontinence (UI) after surgery but the UI usually resolves. Men can experience urine leakage with a cough, change in position, or for no reason at all and it can be as minor as a few drops of urine lost or cause experiences of sopping wet clothes and furniture. The UI can be devastating as men wait for the problem to resolve over time.

A recent study found that thirty percent of a sample of seniors receiving Medicare benefits who had undergone a radical prostatectomy reported incontinence. Over forty-seven percent of all men responding to one survey reported dripping urine daily; and to manage wetness, thirty-one percent of the respondents used pads or clamps. Other studies have reported that stress incontinence was present in eight percent of men who underwent a radical retropubic prostatectomy, with six percent wearing one or fewer pads a day.

Incontinence after prostate surgery can be due to stress, urge or mixed UI. In men, stress incontinence can occur as a result of intrinsic urethral sphincter deficiency. The sphincter is an interwoven band of striated muscle located at the base of the bladder (the bladder outlet) and the proximal portion of the urethra. This sphincter acts as the first line defense against urine leakage. As the bladder fills under normal circumstances, the pressure in the urethra is higher than that in the bladder and the sphincter remains closed. The sphincter opens as pressure in the bladder rises and exceeds the intra-urethral pressure, and the detrusor (the large smooth muscle of the bladder) contracts to empty urine.

The sphincter may receive direct damage during surgery, which is the most common cause of sphincter deficiency. As a result, urine is lost at times when the bladder pressure exceeds the pressure in the urethra, such as during a sneeze, cough, hitting a golf ball or changing positions. Stress UI after prostate surgery may be temporary or permanent, depending on the amount of damage to the nerves and blood vessels supplying the bladder and urethra.

Urge incontinence may also occur after prostate surgery and involves an "involuntary loss of urine that is associated with a strong need to void." Urge incontinence may occur as a result of the bladder muscle’s efforts before surgery to overcome the obstruction of the bladder outlet (urethra) due to the enlarged prostate gland that “squeezes” the urethra. The bladder hypertrophies (enlarges) over time and contracts forcefully to overcome the bladder outlet obstruction. After surgery, the bladder continues to contract forcefully and the man may not be able to inhibit urination.

If urge incontinence is seen in men soon after surgery, it may be due to bladder nerve damage that affects the bladder's ability to store urine at low volume. Mixed incontinence, a combination of stress and urge incontinence, can also occur when bladder instability and urethral sphincter weakness are both present.

Some doctors have found that patients who practice pelvic muscle (Kegel) exercises before surgery experience a more rapid return to bladder control. Combining pelvic muscle exercise with bladder retraining (urge inhibition) for men with both stress and urge UI can decrease urine leakage, urine urgency and frequency (called overactive bladder).

Two surgical procedures may be used as treatments for incontinence that is caused by damage to the sphincter. One is the insertion of an artificial urinary sphincter. Approximately eighty-nine percent of men receiving this treatment achieve total dryness. The other treatment, periurethral collagen injections, has a reported success rate of approximately forty percent.

References

Fowler, F., Roman, A., Barry, M, Wasson, J., Lu-Yao, G., & Wennberg, J. (1993). Patient-reported complications and follow-up treatment after radical prostatectomy. Urology, 42(6), 622-629.

Mottet, N., Boyer, C., Chartier-Kastler, E., Naoum K., Richard, F. & Costa, P. (1998). Artificial urinary sphincter AMS 800 for urinary incontinence after radical prostatectomy: The French experience. Urology International, 60(suppl), 25-29.

Smith, D., Appell, R., Rackley, R. & Winters, C. (1998). Collagen injection therapy for post-prostatectomy incontinence. Journal of Urology, 160, 364-367.

Posted April 2003