Many men, upon receiving a diagnosis of prostate cancer, fail to register anything else their urologist tells them. Thoughts of impending death block out any additional information provided. And if they are to undergo surgery, many men focus on erectile dysfunction as the major complication of radical prostatectomy.
But recovery of urinary control is far more important. If that happens slowly, or never happens at all, incontinence will cast a far greater shadow on their lives than impotence would. Hence, many men are surprised and embarrassed by the urinary incontinence they typically encounter following prostate surgery.
Prostate surgery is a shock to the system, and incontinence—the inability to contain urine— affects both quality of life and self-esteem. Although the incontinence itself isn’t life threatening, the stigma attached to wet clothing and offensive odor can have profound consequences that may lead to humiliation and social withdrawal.
Causes of incontinence
The reason incontinence develops is because the healthy tissue responsible for urinary control is at high risk during a prostate procedure due to its nearness to the prostate itself. Surgically removing the prostate entails separating the part of the urethra that passes through the prostate at the point where it joins the remaining sphincter located just downstream. It also may mean removal of part of the sphincter muscles when the tumor is extensive and possible damage to the nerves that control sphincter action if the operation is difficult to perform because of prostatic size or variations in anatomy.
Depending on how extensive the tumor is, the surgeon may also remove tissue at the bladder neck, which adjoins the prostate. The bladder neck is a tapering ring of muscles that act as shut-off valves, and these muscles funnel down to the urethra and can affect how well the new connections between the bladder and the urethra form. Experienced surgeons are certainly aware of these technical aspects of the surgery and generally keep this in mind when counseling patients about the relative safety of radical prostatectomy as opposed to other forms of treatment for the disease.
After the prostate has been removed, the surgeon reattaches the bladder to the urethra. When the sphincter has been damaged, it remains partially or fully open after healing is complete. Even when the surgery is performed expertly, there may be strain or damage to these muscles and leakage can result.
After almost all prostate surgeries, a urethral catheter is left in place for a few days to a few weeks, depending on the type and nature of surgery. In the first few weeks after removal of the catheter, most patients will experience temporary urinary frequency and incontinence. It doesn’t matter whether a robot or a scalpel was used in the surgery. No one escapes from some degree of urinary leakage. A few drops of urine may leak out after getting up from a chair, during a walk in the park, or after lifting a bag of groceries. This is called stress incontinence. Others experience urgency—the sudden need to urinate—with many leaking uncontrollably before making it to the bathroom. A small subset of men experience a combination of stress and urge incontinence.
How common is incontinence following a radical prostatectomy? At medical centers of excellence, incidence of serious incontinence appears to be low, in the 3 percent range. However, if you look at overall national patient survey data, the incontinence numbers are dramatically higher, in the range of 50 to 60 percent.
When incontinence persists
Most incontinence, fortunately, is temporary. As the pelvic floor that supports your bladder heals and the external sphincter muscle that controls urine flow becomes more efficient, continence typically returns within a few weeks or months after catheter removal. (Even at this early stage, it is important that your doctor exclude two treatable conditions—urinary tract infection and urinary retention—that may be causing the problem.) The time frame varies, depending on the extent of the surgery, your age, and the surgeon’s experience in rebuilding the urinary tract and preserving the urinary sphincter.