Overview

Urinary incontinence

Incontinence is the involuntary leakage of urine and can be a possible consequence of prostate cancer treatment. Any treatment that requires prostate surgery or that destroys prostate tissue, such as radiotherapy or brachytherapy, may affect continence or urination. This can be explained by the proximity of the bladder and the fact that the prostate surrounds the urethra (the channel that allows the elimination of urine). Urinary incontinence is more exceptional after radiotherapy but is immediate after surgery and improves with time.

The most common types of urinary incontinence following treatment in men

• Stress incontinence – It is the leakage of urine as a result of physical exertion such as coughing, sneezing, lifting heavy objects, or exercising. This is the most common type of incontinence in men after prostate surgery.
• Urge incontinence – It occurs when the bladder has involuntary contractions and causes leakage of urine. There is a strong feeling of having to urinate right away and not making it on time to the toilet. This is the type most often seen after radiotherapy treatment.
• Overflow incontinence – It is the loss of small amounts of urine from a bladder that is always full. Another common cause is stenosis of the urethra, a scar in or around your urethra that can reduce your urine stream or narrowing of the bladder neck as a result of the surgery.

Incontinence after the surgery

Most men do not have permanent incontinence after prostate surgery. Following radical surgery, it is most often stress incontinence. This incontinence is frequent in the days following the operation and most often improves over time.

When the probe is removed, one to two weeks after the procedure, the majority of men have difficulty controlling their urination (urgent need to urinate, loss of urine in case of stress). Urinary incontinence is a normal short-term complication. For most men, things gradually return to normal between 1 and 12 months after the operation. After 6 months, most men will only leak a few drops of urine when lifting objects, sneezing or coughing during this period.

Less than 5 to 10% of men will have significant incontinence one year after the procedure. For a small number of men, it can be permanent. To minimize the duration of incontinence, starting pelvic physiotherapy can be an excellent way to improve your continence by learning to do exercises more effectively (e.g. Kegel exercises).

Some men may also suffer from urinary incontinence, which is a strong and sudden urge to urinate. In these cases, they may be small urine leaks (a few drops) or sometimes major leaks, or even urination involuntary complete (the bladder suddenly empties so much the desire is urgent). This impetuousness may be due to uncontrolled contractions of the muscle in your bladder that causes bladder weakness. This problem is and, if necessary, your doctor will prescribe medications that will help the bladder contract less.

It is important to distinguish between the two types of incontinence – stress and urge incontinence – because medical and surgical management are very different. Most often one of the two types of incontinence predominates and its treatment will be given priority.

The narrowing of the bladder neck after surgery 

In the long term, a narrowing of the urethra may appear. In and, during the prostatectomy, the urethra, through which the urine flows, is sutured to the bladder. Sometimes this duct narrows around the suture’s location: what is known as stenosis of vesicourethral anastomosis (less than 5% of cases). It is noticeably manifested by a decrease in the strength of the urine stream, pain when urinating or even blood in the urine. However, this problem can be easily corrected. It requires an enlargement surgery through natural methods. If this complication appears, talk to your doctor who will work out a suitable solution.

Incontinence after radiotherapy

Less than 10% of men who expose their prostate to external radiation therapy experienced incontinence. Side effects of external prostate radiation therapy may include bladder inflammation that causes the urge to urinate, difficulty urinating, and burning sensations while urinating. In the acute phase, 30 to 50% of patients have a variety of symptoms – symptoms of obstructive urinary tract infections, symptoms related to radiocystitis (bladder inflammation) and incontinence symptoms – but over time, these symptoms decrease and will affect less than 5-10% of patients.

Obstructive symptoms of the urinary tract

Urinary obstruction is common due to inflammation of the bladder and the urethra from radiotherapy and particularly brachytherapy. Symptoms may include frequent urination, especially at night, the urge to urinate (urgency), difficulty urinating with a less intense stream and/or a burning sensation while urinating. Please note that radiocystic cystic fibrosis can cause blood in the urine (hematuria).

It is important to report them to your doctor in order to verify that they are not due to another cause (sometimes by carrying out additional examinations) and so that appropriate care can be offered to you.

In case of significant urinary disorders (e.g. urination every half an hour) with a very weak stream, pain in the lower abdomen and/or fever), contact your doctor as soon as possible.

Impact of urinary incontinence

Urinary incontinence in prostate cancer patients can provoke important psychological, emotional and physical reactions. It can create a lot of guilt, shame, frustration and anger. It can often result in a man being fearful and worried about wetting himself. Loss of self-esteem, self-image and confidence often follows.

Incontinence often implies restrictions on lifestyles. It affects activities of daily living such as consumption of fluids, choice of clothing, sexual activity and intimacy, practice of sports and travelling. Some people often isolate themselves out of fear of rejection. Having to purchase specialty urinary control undergarments can also become a financial burden. None of these responses need be the case, as many treatments are now available to effectively treat urinary incontinence.

The percentage of men experiencing urinary incontinence after being treated for prostate cancer has been difficult to evaluate. This may be due to different definitions of the degree of symptoms. For example, how one individual rates his “significant” incontinence may be defined quite differently by another man experiencing similar problems.

What I need to know

Symptoms to watch for and report to your doctor are: 

• Decrease in strength of stream
• Need to push to urinate
• Intermittent stream
• Stream slow to start
• Late drops
• Sensation of incomplete voiding
• Urge to urinate during the night
• Blood in the urine
• Acute urinary retention

The medical evaluation includes:

• Type of incontinence (stress/urge)
• Number of protective garments worn
• Evolution of your symptoms
• Therapies already implemented

Treatment includes:

• Lifestyle changes
• Rehabilitation of pelvic floor muscles
• Medication
• Surgery

Some forms of incontinence can lead to complications:

• Repeated urinary infections
• Skin irritation
• Sores and redness
• Risk of falls and fractures in the elderly

Management and treatment

Managing incontinence

The following are various strategies that can help you manage urinary problems caused by your prostate cancer treatment:

Lifestyle changes

Some urinary symptoms can be relieved by drinking fewer liquids, especially before bed, or by avoiding caffeine, alcohol, or spicy food. Men are encouraged to urinate regularly and not hold it until the last moment. For some people, weight loss can help improve urinary control. This approach also requires changing the medication causing the incontinence.

Kegel exercises (pelvic floor muscles) 

These exercises strengthen your pelvic floor muscles around the urethra. These muscles contract to stop the flow of urine. Strengthening these muscles can help restore continence.