August 16, 2017
Prognosis of recovery from post-surgery incontinence after radical prostatectomy/ progression of continence & control
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I started with close to total incontinence after surgery – except when lying down or sitting. I later came to understand that mine was not 100 per cent incontinence since I was continent while lying and sitting down. There are people (around 1 per cent) who are actually totally incontinent – see diagram below:
“Total incontinence is uncommon, but a possibility.” [Source] (“Men who are left with permanent problems tend to have no control night or day.” – Source)
CAUSE
“As a result of disruption or damage during surgery, the sphincter muscles that control the release of urine may be weakened. The level of incontinence varies; some men may have slight leaking or dripping, while others may experience complete bladder emptying. This unwanted release of urine can happen at any time. Strenuous activities and sports are a culprit, or a simple laugh, cough, sneeze or change of position may trigger it. Biologically, this type of incontinence is actually very similar to what some women experience post-childbirth. … It is important to accept that most men will experience some degree of urinary incontinence after prostate surgery. This is not an indication of long-term damage.” [Source]
HOW DOES IT RETURN?
I found this study which I believe is the most scientific to date on this subject: An objective measurement of urinary continence recovery with pelvic floor physiotherapy following robotic assisted radical prostatectomy
According to this study, “the mean daily urine leakage during the first recorded week was 408.0 mL. This decreased to 205.8 and 110.1 mL at 2 and 3 months post-RALP (P<0.05). This equated to a significant 57.1% (95% CI, 52.9% to 61.3%) and 75.6% (95% CI, 72.3% to 78.8%) improvement in urinary leakage at the same respective time points.” The following figure is from the above study:
[Sanjeev: I started with 945 ml per day in Week 2 after surgery. By the end of Week 4 I was at 695 ml, end of week 8 509 ml, end of week 10 329 ml, end of week 12 160 ml.]
“You may experience severe incontinence in the first few weeks following surgery. The best way to deal with this is to be prepared for it and learn what you should do to manage it. Incontinence after prostate surgery can take 6 to 12 months to completely resolve.” [Source]
“Regaining urinary control can take several weeks or months and some men don’t reach their full recovery capacity for a year or more. Age, weight and previous urinary issues are also factors in recovery time. Patients of Dr. Samadi’s who experienced normal continence prior to surgery can expect to regain urinary control within 12 to 13 months.” [Source]
A patient: “I have kept careful records of daily urine loss into pads from the time the catheter came out. Initially, I was losing about 450 grams per day. One dreadful day in February it topped 900g! For a few weeks after the op there was little improvement but in the spring it started to decline, although it was rather two steps forward and one back! Now, nearly 12 months on I am stuck at about 30g per day loss and have been there for about two months. That’s a huge improvement on where I started but it’s still enough to have a significant impact on my life.” [Source] (Sanjeev: I think most patients would be very happy to live with 30 ml leakage per day)
“One man who commenced pelvic floor exercises a year after radical prostatectomy kept a chart
of his monthly urinary leakage” [Grace Dorey – Pelvic Dysfunction in Men]
EVEN THOSE WITH TOTAL INCONTINENCE CAN SOMETIMES GET BACK CONTINENCE.
I DO NOT AGREE WITH THESE CLAIMS
- “97 percent regain urinary control within two to three months.” [Source] This is a massive exaggeration of the reality of incontinence after robotic surgery.
- “when continence returns, it seems to come back in large gains. In other words, you realize one day that your control is much better than it was yesterday. It takes patients, don’t try to rush it. Also, doing more Kegels than recommended does not help.” [Source] (Sanjeev: in my case – and as per the study, continence has returned slowly, and in stages. At each stage stage there has been a steady improvement in recovery.)
GENERAL PROCESS/ PHASES OF RETURN OF CONTINENCE
- see my slides here.
Most improvement take place in the initial months: “Incontinence can continue to improve for up to a year although the majority of the improvement takes place in the first few months postoperatively. If the leakage continues beyond a year then it is unlikely that there will be further significant improvement.” [source] (Sanjeev: I do not agree that there can’t be improvement after one year: Peter Dornan’s case is solid proof that incontinence can be dramatically improved with exercise even after four years]
I DO NOT AGREE WITH THIS SIMPLISTIC STATEMENT:
Stress incontinence may therefore be classified into four stages or degrees : stage 1, incontinence only
on coughing or straining ; stage 2, incontinence on assuming upright posture ; stage 3, incontinence on
sitting up in bed ; and stage 4, incontinence when recumbent (Some Common Complications After Prostatectomy, J. Cosbie Ross and L. F. Tinckler, The British Medical Journal, Vol. 2, No. 5153 (Oct. 10, 1959).
For most men, this process happens in three distinct stages:
- Phase one is when a man can remain dry when he’s lying down. [“My only sign of progress with continence is more ability now than 4 weeks ago to hold it from a chair or bed to the bathroom by squeezing.- source] [Also: “Gradually with constant exercise I gained some control. The first big breakthrough was making it through the night with out leaking ( 3rd-4th week).-source] One other thing, do the cup routine with urine in the bladder. You will not believe how quick you will isolate the proper muscles for continence. ALSO SEE THIS: “I retain urine in my bladder when I’m lying down (usually have to get up and try to reach the toilet every 1 to 1 1/2 hours at night..I don’t think my bladder capacity exceeds 3 ounces) but..during the day when I sit or stand or walk, I retain nothing in my bladder!” – FROM A MAILING LIST. This suggests that the second stage of Phase one is BEING DRY WHEN SITTING DOWN.
- In phase two, you’re dry when you’re walking around. If you can walk to the bathroom and not urinate until you get there, that’s a great sign- it means the sphincter is intact. [Sanjeev: This is incorrect. The first stage of phase 2 is when you are dry while standing. Unless this is achieved, there is little prospect of being dry while walking. Then would come walking > then change in posture > coughing/ sneezing > running.]
- In phase three, you are dry when you stand up (using muscles that put pressure on the sphincter) after sitting. [Source]
Urinary control returns in 3 phases [Source]
- Phase I – You are dry when lying down at night. [“You may notice that you have better control when you are lying down. That is because the weight of the urine is spread over the sides of the bladder instead of pressing down on the urethra”] [“the fact that he is dry at night suggests that he will eventually be dry during the day as well. Men who are left with permanent problems tend to have no control night or day.” – Source]
- Phase II – You are dry when walking around.
- Phase III – You are dry when you get up from a seated position. This is the last part of continence that returns. Everyone is different and it is hard to know when you will be dry. [“I find the leakage is worse for me when I squat or sit with my legs apart. I presume this opens up the tubing.” – source]
“The usual order of recovery is: leak all the time, continent while lying down, continent while sitting, while standing, while walking, continent while standing up from sitting. etc. The rough numbers are: 2/3 of men will be continent at 3 months post surgery. Of the remaining 1/3, 2/3 will be continent at one year. For the soggy 1/9 left over (I was in that group) most likely some form of remediation will be necessary.” [Source]
You will notice an increase in being able to control your urine. Generally, this is better in the morning than in the afternoon. [Source]
Why? “The bladder, Emory and the nurse explained patiently (they had obviously done it before), was like a bowl. When I was seated or lying down, it was turned on its side, so the urine tended to stay in it, but when I stood up the open end was inverted, as if the bowl were turned upside down, and the urine simply ran out. Ordinarily, the urethral sphincter would hold the urine back, of course, but since the sphincter was still in shock, there was simply nothing to impede the urine from flowing out when I stood up or walked around, nor would there be until the sphincter resumed its function.” [Michael Korda in his book, MAN TO MAN]
Signs of improvement [Source]
- Using less incontinence pads
- Getting up less than 2 times a night and remaining dry
- Being dry in the early part of the day
- Being dry all day
- Not leaking when you cough, sneeze, laugh or lift
- Being dry with sport and exercise
Continence Products after Radical Prostatectomy
FURTHER STAGES, BY A NSW GOVERNMENT WRITER
Virginia Ip: The following recommendations are based on experience shared by men who had this surgery as well as my own clinical experience. As each person progresses differently, this is only a guide.
Stage I: Severe urinary incontinence: Immediately after removal of urinary catheter till up to 2 weeks. The bladder does not hold any urine and leaks constantly, needing the use of large capacity incontinence products.
Stage 2: Moderate urinary incontinence, approximately from week 3 to week 8
Stage 3: Mild incontinence, after 8 to 12 weeks: Small amount of leakage may occur especially during sports, coughing, walking or other physical activities. By this time, the pad usage is on average one small pad per day.
Stage 4: Occasional leakage (few drops) a day: This may be a few drops after passing urine.
THE ISSUE
“Some men dribble urine, whereas others will experience a total leakage. When removing the prostate, surgeons try to save as much of the area around the bladder and the sphincter muscles around the urethra, thus limiting damage to the sphincter. Still, at this point, any man who is undergoing … surgery to treat prostate cancer should expect to develop some problems with urinary control. With newer techniques, some men will have only temporary problems controlling their urine, and many will regain full control of their bladder in time.” [Source]
Once the catheter is removed after your surgery, you may experience symptoms ranging from light urine leakage (a few drops when you exercise, cough or sneeze) all the way to a complete inability to control your urination.[Source]
Once the catheter is removed you will most likely leak variable amounts of urine. Almost everyone requires urinary pads or some other form of collection device (briefs, drip collector, condom catheter etc) for a period of time. Patients should be advised they will likely be using pads for weeks to months. Most men will experience leakage with activity (laughing, coughing, exercising). Leakage may range from just a few drops intermittently to a large volume of continuous leakage. Others will have the sudden unexpected urge to urinate and feel the need to rush to the restroom. [Source]
For some men, urinary problems may not occur or are quickly resolved. For other men, they can be more problematic, requiring further support and help from members of their healthcare team who specialise in prostate cancer and urinary problems. [Source]
LET THIS ISSUE ALWAYS BE SEEN IN PERSPECTIVE
At age 51, I wouldn’t choose to be incontinent, to wear “male guards,” but in the end it’s just a biomechanical flaw. Same with impotence. Don’t get me wrong, I like the physical life. It’s important to me. I regularly walk five miles a day, and I’ve started running and lifting light weights again. But I decline to feel diminished by incontinence, to be defined by biological drizzle. [Source]
INCONTINENCE AFTER SURGERY IS A HUGE ISSUE
[Source for the above diagram]
“Men have a very high prevalence of incontinence after prostate cancer, but in the research world the understanding about how men actually recover continence after they have surgery is far from complete” [Source]
“a range of 8%-63% of men will report some degree of stress urinary incontinence (SUI) to be a significant problem one year after their prostatectomy”.[Source]
One study that sent periodic surveys to 279 patients to proactively seek their responses both before and after treatment for prostate cancer, which was published in the Journal of Clinical Oncology, found that at three months after surgery, 58% of men reported wearing an absorbent pad in the previous week, and at 12 months after surgery, 35% reported using a pad in the previous week. [Source]
In one of his studies he prospectively followed a group of 70 men, with a median age of 57, undergoing open RRP. Patient-reported continence rates, defined as “no pads” at 3, 6, 12, and 18 months post-operatively were 54%, 80%, 93%, and 93% among the 59 men who had complete follow-up (Walsh et al 2000) . This study is a good example of what can potentially be achieved with arguably the best open surgeon and a relatively young cohort of patients. [Source]
at three months after surgery, 24% of men reported leaking urine “a lot” in the previous week, and at 12 months, 11% were still experiencing the problem. [Source]
an analysis of the outcomes of 1,291 men who underwent radical prostatectomy, published in the Journal of the American Medical Association, found that 8.4% remained incontinent 18 months or longer after surgery. Another study of 901 men treated with surgery, published in the Journal of the National Cancer Institute,found that 14% to 16% were incontinent five years after treatment. Finally, an analysis of the Medicare claims records of 11,522 men who underwent radical prostatectomy, published in the New England Journal of Medicine, found that, depending on age, anywhere from 18% to 24% of men continued to experience incontinence more than one year after surgery, and 7% to 9% sought out some type of corrective procedure, such as the placement of an artificial sphincter. [Source]
More data (including of robotic surgery) available here.
PATIENT EXPERIENCE
I have had a radical prostatectomy and my incontinence is good when lying down or sitting…if I move…I urinate. Doing Kegels. No change. Do you people have ANY idea how depressing…disheartening and thoroughly frustrating this whole mess is. I am 54…otherwise healthy…in very good shape and my life…as I knew it…is over. I can’t cycle…work out at a gym…and can barely get through a walk without completely soaking a heavy duty pad…or those stupid underpants that make you look like you are walking around with a load of crap in your pants. [Source]
[Source – FOR ABOVE IMAGE]
EXPERIENCE OF PATIENTS
PHYSICAL CAUSE
“This is how my consultant explained things to me: Before surgery I had 2 sphincter muscles to control urine flow…….. …..One internal sphincter muscle which was / is situated near the base of the prostate and bladder neck. This was either partly removed along with the prostate or possibly damaged / disturbed during surgery and reconstruction of the urethra in order to remove all of the prostate and associated tumour(s)….. The second is an external sphincter muscle which is located and works in conjunction with the pelvic floor muscles ….
This muscle was secondary in urine control before surgery……. After surgery it now needs to be stronger to in effect do the extra work of the missing / damaged internal sphincter muscle….hence pelvic floor exercises may help urine control by strengthening this muscle and aid continence…. although there is no guarantee full continence will be achieved if the internal sphincter has been too badly damaged… Pelvic floor exercises may well help in regaining continence quicker, but the overall outcome will be dependent on how much trauma the internal sphincter muscle has endured during surgery.” [source]
EXTERNAL SPHINCTER DAMAGED??
“The reason that post-operative leakage occurs is that the apex of the prostate is intimately associated with the sphincter muscle that controls urinary continence. In order to remove the prostate this muscle needs to be divided. It is therefore fairly common for patients to have a period of post-operative urinary leakage after surgical treatment for prostate cancer.” [Source]
OTHER EXPLANATIONS
When your prostate gland is removed entirely by radical prostatectomy, two things occur during the surgery that can cause urinary side effects: a) A gap is created between the bladder and urethra, which is
then surgically reconnected; b) the bladder neck (where the bladder and urethra join) can
be affected and this can cause urinary problems; and (c) the external sphincter may be weakened, or very rarely, damaged during surgery, and this can cause urinary problems as well. [Source]
At the point where the bladder and urethra join, there is a ring of muscles, known as the bladder neck sphincter, which opens and closes like a camera-shutter. The bladder neck sphincter is closed most of the time to prevent urine leaking out but when it gets permission from the brain, it opens to allow urine to be passed. Another (external) sphincter is part of another set of muscles below the prostate called the pelvic floor. These muscles are also involved in bladder control. If the bladder neck sphincter is damaged during prostate cancer surgery, the pelvic floor muscles are now relied on to control the bladder more often. If the pelvic floor is weak you may experience urinary incontinence. [Source]
Post-prostatectomy continence is dependent on the distal sphincter system, primarily the intrinsic striated sphincter. With its slow-twich fibres it maintains the ‘passive’continence. – see figure below.
A comprehensive review of the literature and urodynamic results concluded that the male urethral
sphincter has two parts and is composed of an inner smooth muscle layer that is more pronounced proximally at the bladder neck and an outer skeletal muscle layer which is more distinct distally at the membranous urethra. It is thought that prostatectomy can potentially damage both the smooth muscle sphincter mechanism and the skeletal muscle component. It should be noted that this alone is not
responsible for all post-RP UI and other factors such as detrusor overactivity and damage to nerves have a role. [Source: An objective measurement of urinary continence recovery with
pelvic floor physiotherapy following robotic assisted radical prostatectomy by Niranjan Jude Sathianathen1, Liana Johnson, Damien Bolton, Nathan L. Lawrentschuk]
The impairment of both the sphincter and the supportive system, including the endopelvic fascia,
the Denonvilliers fascia, the puboprostatic ligament, the LA muscles and the arcus tendineus
fascia, is responsible for UI after RP. [Source]
CAUSE 1: INTERNAL PROXIMAL SMOOTH MUSCLE SPHINCTER DAMAGED DURING SURGERY
“The internal sphincter is removed during all forms of prostatectomy, as it is anatomically at the junction of the prostate and bladder”. [Source]
“the internal sphincter muscle, the muscle that involuntarily controls bladder output, is removed with the prostate.” [Source]
“After the operation, men who had three layers for holding back urine – the internal sphincter muscle, the prostate lobes pressing against each other, and an external sphincter muscle – have only one, the external sphincter.” “The external sphincter can do all the necessary work to hold in the urine, but it has to be strong. That’s why the Kegel exercises, both before and after surgery, are so important,” Dr. Catalona said. [Source]
It is alleged that Dr Samadi’s SMART method does not cut off the internal sphincter: “In the hands of an experienced robotic surgeon like Dr. Samadi, preservation of the urinary sphincter and competent rebuilding of the urinary tract can eliminate the risk of longterm incontinence. Uniquely, Dr. Samadi does not sever the endopelvic fascia and cuts the bladder neck very narrowly during robotic prostatectomy.” [Source]
“Whereas conventional laparoscopic prostatectomy utilizes an outside–in approach, SMART prostatectomy uses an inside–out methodology, avoiding damage to surrounding nerves and tissues. This is how I achieve 96 percent continence and approximately 80 percent preserved sexual function rates.” [Source]
CAUSE 2: EXTERNAL SPHINCTER MAY TAKE UP TO A YEAR TO HEAL
Stitches in the valve take 6 weeks to dissolve and the scar tissue surrounding it takes up to a year to soften, so we need to help it after the operation. By creating a strong pelvic floor with your exercises, the muscles are able to squeeze around this valve and help it to close during the recovery period. [Source]
You can do NOTHING about this – it will heal on its own. Just don’t stress the healing process excessively.
CAUSE 3: BLADDER BECOMES LAZY AFTER SURGERY AND BEFORE CATHETER REMOVAL
“When the catheter is removed, the bladder is a shrunken version of itself.” [Source]
Basically, the bladder atrophies when there is no need to inflate (by holding urine). The remedy for this is NOT Kegel exercises (!!) BUT re-filling it and bloating it in whichever position it doesn’t leak (in my case it is the lying down position – in the initial days after catheter removal). Once it is filled and there is an insistent urge to urinate, that’s when the bladder is re-activated.
As the bladder is reactivated, the external sphincter can start “remembering” its function and start tightening on its own. This is the hypothesis of the brilliant physiotherapist Stuart Doorbar-Baptist [see this].
PROGNOSIS
“Use of one pad per day after surgery” is strongly linked with EARLY recovery of continence [Source]. SEE FULL LIST OF FACTORS AT PAGE 4.
” Craig feels that some men use the smooth muscle of the prostate as their primary continence mechanism before surgery and these men are apt to have much more UI after surgery if they are not able to get the PFM working. Other men use the PFM for continence beforesurgery and will do better after surgery as the PFM is still working.” [Source]
Pad use at 4 to 7 days, however, was highly correlated with median time to continence. The median time to continence for men using one pad was 35 days, two pads was 42 days, and for three or more pads was 73 days (P=0.0001). [Source]
five and a half percent of his patients have a very mild incontinence 18 months after surgery and one and a half percent have severe incontinence. Age figures strongly into these outcomes and so does the fact that some men go into the surgery with previous incontinence. [Source]
[Source]
REMEDY/ SOLUTION >> CLICK HERE
