Managing Urinary Incontinence After Prostate Cancer Treatment
Michael Guralnick, MD, Associate Professor of Urology
and R. Corey O’Connor, MD, Associate Professor of Urology
Urinary incontinence is a well-recognized and potentially devastating complication of prostate cancer treatment (surgery, radiation) that can have a significantly negative impact on quality of life. Typically, incontinence is activity-related (e.g., stress urinary incontinence) and caused by injury/weakness of the urethral sphincter muscle. Fortunately, less than 10 percent of patients treated for prostate cancer have urinary incontinence significant enough to warrant aggressive medical or surgical therapy. Several treatment modalities exist to help patients with post-prostatectomy stress urinary incontinence, including physical therapy/behavior modification, duloxetine, urethral bulking, male slings and artificial urinary sphincters.
Initial therapy for managing post-prostatectomy stress incontinence includes behavior modification (managing fluid intake, timed urination) and pelvic floor physical therapy (Kegel exercises). The exercises are performed to strengthen the urinary sphincter muscle to minimize/prevent incontinence. Published studies have demonstrated that men who perform pelvic floor exercises have an earlier return of continence when compared to patients who do not following prostate surgery. Some patients benefit from a more aggressive form of therapy involving biofeedback to help teach proper exercise technique.
Duloxetine, a selective serotonin (5-HT) and norepinephrine (NE) reuptake inhibitor, has been shown to decrease incontinence by increasing urethral sphincter contractility. The drug is routinely used in Europe for stress urinary incontinence, but is only FDA approved in the United States as an antidepressant. However, daily (off-label) use of the medication has been demonstrated to improve urinary control in more than 60 percent of men with post-prostatectomy urinary incontinence. Approximately 40 percent of men report side effects such as drowsiness, lightheadedness, nausea or dry mouth.
Transurethral injections of bulking agents (collagen, Durasphere®, Coaptite®, Macroplastique®) are routinely used in women with stress urinary incontinence. The procedure has also been utilized in men with post-prostatectomy stress incontinence for decades. The injected materials bulk the urethral lining at the level of the bladder neck to create a better “seal” and thus, improve closure of the urinary sphincter muscle. Success rates are often short-lived and patients usually require repeat injections. Complications are rare.
Transobturator Male Sling (AdVance Male sling™)
The transobturator male sling has been commercially available for treating mild to moderate post-prostatectomy stress incontinence since 2004. The surgically implanted mesh supports the proximal urethra to allow for better external sphincter contractility. The result is improved continence. Ideal patients for male slings use three or fewer absorptive pads per day, are able to volitionally contract the external sphincter and have not had pelvic radiation. The procedure can be performed as outpatient surgery and typically requires overnight urethral catheterization. Cure rates in appropriately selected patients approach 85 percent in our institution. Potential complications include urinary retention (usually transient), infection (rare) and sling erosion (rare).
Artificial urinary sphincter (AMs 800)
The current gold standard for treating post-prostatectomy incontinence is the artificial urinary sphincter (AMS 800). The implantable, fluid- filled prosthesis consists of three components: a cuff, a control pump and a pressure-regulating balloon. The fluid-filled cuff encircles the bulbar urethra and gently compresses the urethra closed during bladder storage. The patient squeezes the pump, located in the scrotum, to open the cuff and allow for bladder emptying. Overall patient satisfaction is high, with 90 percent of patients reporting 90 percent or better continence improvement. This is generally the treatment of choice in patients with severe incontinence. Potential complications include infection (~5 percent) and cuff erosion into the urethra (5 percent to 10 percent). While a history of pelvic radiation therapy may increase the risk for these complications, it is not a contraindication to the procedure.
Incontinence after prostate cancer therapy is a greatly feared condition that can adversely affect a patient’s quality of life. The reconstructive urology team at Froedtert & The Medical College of Wisconsin offers multiple therapeutic modalities to manage this condition and allow patients to lead more normal lives.