Incontinence After Prostate Cancer

Original Editor - Mandy Roscher Top Contributors - Mandy Roscher and Tarina van der Stockt

Introduction

Incontinence is a term that describes any accidental or involuntary loss of urine from the bladder (urinary incontinence) or bowel motion, faeces or wind from the bowel (faecal or bowel incontinence). This page addresses urinary incontinence (UI) that occurs as a side effect in men who have undergone treatment for Prostate Cancer

Normal Continence

Normal continence is maintained when the closure pressure of the urethra is greater than the pressure from the bladder above it. It requires the complex interaction between the autonomic nervous system that controls the more proximal smooth muscles in the urethra (internal sphincters) as well as the somatic nervous system that controls the striated muscles surround the urethra (external sphincter). [1]

Problems can occur for a variety of reasons. There can be problems with the closure mechanism of the urethra which would result in stress incontinence or problems with the bladder itself which could result in frequency, urgency and urge incontinence.

Important Definitions

Stress Urinary Incontinence

Stress UI is leaking of urine that occurs during any exertion. This could be coughing or sneezing but also just a simple activity such as sit to stand. Stress incontinence occurs when the pressures, or stresses in the bladder are greater than the closure force in the urethra.[2]

Urgency / Overactive bladder

Urgency is when a person has a strong, sudden need to urinate. This is also known as an overactive bladder. When the detrusor muscle of the bladder contracts it signals the need to urinate so when the bladder is overactive then “urgency” can develop.[2]

Frequency

Frequency is the need to urinate frequently. This is often accompanied by urgency and frequency is characterised by the inability to delay urination.[2]

Urge Urinary Incontinence

Urge Incontinence occurs when a person experiences urgency and that is then followed by an involuntary loss of urine.[2]

Mixed Urinary Incontinence

Mixed UI is a combination of frequency-urgency and stress incontinence.[2]

Nocturia

Nocturia is the need to wake up at night to go urinate.[2]

Nocturnal Enuresis

Nocturnal Enuresis is leaking of urine during sleep[2]

Post-Micturition Dribble

A post micturition dribble is leaking that occurs immediately after urination[2]

Continuous Urinary Leakage

Continuous urinary leakage is the inability to maintain any continence[2]

Types of Incontinence in Men following Prostate Cancer

The treatment for prostate cancer can result in various side effects, of which urinary incontinence is common.

Urinary Incontinence after Radical Prostatectomy

Prostate Cancer surgery, specifically a radical prostatectomy is commonly used as a curative measure to treat prostate cancer, and surgeons aim to retain urinary continence and sexual function during the procedure of removing the prostate [3][4]. A Radical Prostatectomy, however, remains a challenging urologic procedure because the prostate is in close proximity to the bladder, rectum, and neurovascular supply to the penis. An adequate resection of the prostate without damaging surrounding tissue presents tradeoffs between cancer control and preservation of functional outcomes such as continence and potency.[5]

There are many different surgical techniques and approaches for radical prostatectomy. The technique, approach and skill of the surgeon will influence the rate of incontinence and recovery thereof[1]. Initial urinary incontinence is present in up to 98% of patients post-prostatectomy [6]. With correct management, the majority will achieve continence within a year. Approximately 90% of men will achieve continence 6 months after laparoscopic robotic prostatectomy and after that, there is a minimal improvement with only 4% more gaining continence after 6 months. [2]

A radical prostatectomy involves the removal of the proximal urethra and as such the removal of the proximal smooth muscle that forms the internal sphincter.[1] There is also the possibility of damage to the striated muscle during surgery or the nerves supplying this muscle. As such the urethral closure pressure is compromised and men will present with stress incontinence after radical prostatectomy. Initially, the urethral closure pressure may be very poor and they can experience incontinence with simple activities such as walking or sit to stand. The striated muscles of the external sphincter are still intact and as these are under voluntary control they form the main target of rehabilitation of incontinence post-prostatectomy. [7]

There are a number of other factors that affect continence after radical prostatectomy. The removal of the prostate results in the bladder descending onto the pelvic floor muscles, ligaments as well as fascial connections and support.[1] This can result in poor support of the bladder and can affect urethral closure mechanisms. The bladder can also become overactive and reports of urgency in men post-prostatectomy may even be as high as 48%[8].

Urinary Incontinence after Radiation

Radiation of the prostate, whether it is external beam radiation or brachytherapy can affect the soft tissue surrounding the prostate (urethra, bladder and pelvic floor). Radiation causes long term damage to the smaller capillaries and as such a condition called soft tissue radionecrosis can develop where the soft tissue becomes more fibrotic and may eventually become necrotic[8].

These changes occur slowly over time and as such men may only present with symptoms 2-5 years after radiation[9]. It is interesting to note that while initial rates of urinary incontinence after radical prostatectomy are much higher than radiation the recovery from incontinence post-prostatectomy is very high. This is in contrast to radiation where at a 4 year follow up the symptoms of incontinence were worsening in men who had undergone radiation therapy[10].

Radiation can cause changes in tissue compliance and can affect the detrusor muscles of the bladder. It can cause changes in bladder capacity (the bladder cannot fill as much as it used to). A smaller bladder capacity would lead to frequency as the bladder simply cannot hold the same volume of urine as previously.[11] Radiation can also lead to detrusor overactivity.[11] This would result in urgency or an overactive bladder. If this is accompanied by an involuntary loss of urine the men would be classified as having urge incontinence.

Radiation can also cause changes in the striated muscles of the external sphincter and as a result, these men can experience stress incontinence as well as a mixed incontinence picture[8].

Additional Videos

Urinary Incontinence Following Radical Prostatectomy

Overactive bladder and Prostate Cancer

Lecture on Incontinence after Prostate Cancer

References

  1. 1.0 1.1 1.2 1.3 Hodges PW, Stafford RE, Hall L, Neumann P, Morrison S, Frawley H, Doorbar-Baptist S, Nahon I, Crow J, Thompson J, Cameron AP. Reconsideration of pelvic floor muscle training to prevent and treat incontinence after radical prostatectomy. InUrologic Oncology: Seminars and Original Investigations 2019 Dec 25. Elsevier.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Abrams P, Andersson KE, Apostolidis A, Birder L, Bliss D, Brubaker L, Cardozo L, Castro-Diaz D, O'connell PR, Cottenden A, Cotterill N. 6th International Consultation on Incontinence. Recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse and faecal incontinence. Neurourology and urodynamics. 2018;37(7):2271-2.
  3. Trinh QD, Bjartell A, Freedland SJ, Hollenbeck BK, Hu JC, Shariat SF, Sun M, Vickers AJ. A systematic review of the volume–outcome relationship for radical prostatectomy. European urology. 2013 Nov 1;64(5):786-98.
  4. Heidenreich A, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, Mottet N, Schmid HP, van der Kwast T, Wiegel T, Zattoni F. EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease. European urology. 2011 Jan 1;59(1):61-71.
  5. Wennberg JE, Roos N, Sola L, Schori A, Jaffe R. Use of claims data systems to evaluate health care outcomes: mortality and reoperation following prostatectomy. Jama. 1987 Feb 20;257(7):933-6.
  6. Nelson CJ, Deveci S, Stasi J, Scardino PT, Mulhall JP. Sexual bother following radical prostatectomy. The journal of sexual medicine. 2010 Jan;7(1pt1):129-35.
  7. Nahon I, Waddington G, Adams R, Dorey G. Assessing muscle function of the male pelvic floor using real time ultrasound. Neurourology and urodynamics. 2011 Sep;30(7):1329-32.
  8. 8.0 8.1 8.2 Sandhu JS, Breyer B, Comiter C, Eastham JA, Gomez C, Kirages DJ, Kittle C, Lucioni A, Nitti VW, Stoffel JT, Westney OL. Incontinence after prostate treatment: AUA/SUFU Guideline. The Journal of urology. 2019 Aug;202(2):369-78.
  9. Gaither TW, Awad MA, Osterberg EC, Murphy GP, Allen IE, Chang A, Rosen RC, Breyer BN. The natural history of erectile dysfunction after prostatic radiotherapy: a systematic review and meta-analysis. The journal of sexual medicine. 2017 Sep 1;14(9):1071-8.
  10. Freiberger C, Berneking V, Vögeli TA, Kirschner-Hermanns R, Eble MJ, Pinkawa M. Quality of life up to 10 years after external beam radiotherapy and/or brachytherapy for prostate cancer. Brachytherapy. 2018 May 1;17(3):517-23.
  11. 11.0 11.1 Hoffman D, Vijay V, Peng M, Sussman RD, Rosenblum N, Brucker BM, Peyronnet B, Nitti VW. Effect of Radiation on Male Stress Urinary Incontinence and the Role of Urodynamic Assessment. Urology. 2019 Mar 1;125:58-63.