Urinary tract disorders

Overview

Urinary incontinence

Incontinence is the involuntary leakage of urine. It occurs when the sphincter, the muscle that controls urine flow from the bladder, weakens and cannot squeeze shut. Treatments for prostate cancer, including radiation therapy, radical prostatectomy and TURP (transurethral resecion of the prostate), can cause incontinence. If urinary incontinence is less common after a radiation therapy, it is immediate after surgery.

After the surgery

The catheter is usually withdrawn one to three weeks after the patient returns home. Urinary incontinence is a normal short-term complication of radical prostatectomy. Most men have some trouble regaining control of the urinary mechanism and experience a frequent urge to urinate or leakage when engaging in strenuous physical activity. For 90 percent of men, things generally return to normal between one and twelve months after the operation. After six months, most men will lose only a few drops of urine by lifting objects, sneezing or coughing during this time. Some men (3-5 percent) will have significant incontinence one year after the procedure. In a small number of men, it can be permanent. The patient can speed up the process by doing Kegel exercises.

Some men may also suffer from urge incontinence (also known as hyperactive bladder), which is a strong and sudden urge to urinate. In these cases, it may be small leaks of urine (a few drops) or sometimes large leaks or even involuntary complete urination loss. This is a common problem that is usually not too troublesome. If necessary, your physician can prescribe medication to relax the bladder muscles.

After radiotherapy

Fewer than 10 percent of men will experience incontinence. Irradiation may cause bladder irritation that triggers uncontrollable contractions. But as the irritation of the bladder subsides, contractions become less frequent and incontinence improves. Some men may also suffer from inflammation of the bladder (radiation cystitis).

There are four types of urinary incontinence:

  • STRESS incontinence is the leakage of urine as a result of physical exertion such as coughing, sneezing, lifting heavy objects, or exercising.
  • URGE incontinence 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.
  • MIXED incontinence is a mixture of symptoms of both stress and urge incontinence.
  • OVERFLOW incontinence is the loss of small amounts of urine from a bladder that is always full.

Impact of urinary incontinence

effets secondaires d’une chirurgie du cancer de la prostate

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 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

Associated symptoms are:

  • Reduced jet
  • Difficulty in initiating urination
  • Pushing effort during urination
  • Post‑void dribbling
  • Desire to urinate at night

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
  • 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 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, avoiding caffeine, and losing weight.

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.

How to Do Your Kegels

Kegel exercises strengthen are extremely effective in restoring continence after a radical prostatectomy. You should do these exercises before your surgery and continue them after the probe has been removed. With regular exercise, you should see a difference after five or six weeks.

Sitting, standing, or lying down, knees slightly apart, imagine you are fighting the urge to urinate or defecate. Contract the muscles you would use in this situation.

  • Contract the muscles for 5 to 10 seconds.
  • Relax your muscles for twice the length of the contraction time.
  • Repeat contractions 12 to 20 times.
  • Do these exercises 3 times a day.

To know if you are contracting the correct muscles, look at your penis, it should tighten and contract inward. You should also feel your rectum muscles (the muscles you tighten to hold in gas or stool) tighten.

When your muscles are stronger and you can hold it in yourself, you can reduce the exercises to a series of 10, two or three times a week.

Treatments for incontinence

Medication

Some medications with anticholinergic properties such as Oxybutynin can be used to treat URGE incontinence. They act by preventing the involuntary contractions of the bladder that cause the urgency, frequency of urination, and some forms of incontinence.

Some men experience difficulty urinating because of a urethral blockage. They constantly have a very full bladder which can lead to “overflow incontinence”, which is when the bladder can no longer retain additional urine. Medication can be taken to help with elimination.

Surgery

If lifestyle changes and medication do not alleviate your urinary problems, surgery may be an option. There are various surgical options:

  • Eliminate blockage of the urethra – Scar tissue can sometimes accumulate in the urethra, causing it to narrow, reducing urinary flow, and preventing the bladder from emptying completely. This difficulty can be corrected by making an incision in the scar tissue or by stretching the urethra.
  • Urethral prosthesis – A prosthesis introduced surgically under the sphincter to compress the urethra (muscles used to control the flow of urine from the bladder).
  • Artificial urinary sphincter – a cuff is placed around the urinary canal. This cuff is inflated and deflated using a mechanical valve.
  • Bulking agents – substances such as collagen can be injected into the neck of the bladder to reduce urine leakage, but this is not very effective for men.

Urinary control devices

There are many products available in pharmacies and home health stores that can help you manage the loss of urine, though they are not considered to be treatments or a cure.

Protective undergarments

Many types of diapers and pads are now available in pharmacies and general stores. Many of these have been adapted to comfortably fit male anatomy.

Texas condom catheters

Texas condom catheters resemble a condom (see image), with an opening at one end so that it can be connected to a bag attached to the leg. When the bag is full of urine, it is emptied manually. The chance that you will need such a device is extremely low, i.e. less than 1%.

Urethral compression devices (external clamps)

It is important here to know that the chance you will need such device is extremely low—less than 1%. Both clamps apply light pressure on the urinary canal, located on the underside of the penis, and prevent leakage. Proper tightness of the clamp is important in order to avoid pressure sores on the skin underneath the device.

N.B.: These clamps should not be worn for excessive periods of time. Some urologists suggest using them for only an hour or two at a time. You can ask your urologist for advice.

Your resources

You are not alone

Just like prostate cancer itself, you do not have to suffer the effects of incontinence alone. Although it may seem like a delicate issue that is hard to share with others, there are many people that can help and support you. There are many resources at your disposal that can help make it easier for you to manage this problem from amongst both health professionals and various other groups.

Health professionals

Many people in the medical community, including your urologist and doctor, can help treat incontinence caused by your prostate cancer treatment and provide you with options or a plan to manage this issue. Your pharmacist can also provide you with the appropriate medication or products to limit the unpleasant side effects of urinary leakage.

A physiotherapist can be an excellent resource in helping you retrain you bladder. The website Ordre professionnel de la physiothérapie du Québec can help you find a professional close to you.

Organizations and other groups

It is difficult to live through with a health problem when we are all alone, especially after undergoing treatment for prostate cancer. Fortunately, you can manage your incontinence by contacting specialized institutions or with other people who are going through the same thing as you.

Urinary continence clinics such as the Clinique de continence urinaire de l’Institut universitaire de gériatrie de Montréal, offer a therapeutic follow‑up focused on urinary control in persons over the age of 65 who have bladder problems. There are also associations that you can consult for more information to help you manage your incontinence, including:

In addition, you can visit blogs and discussion forums on sites like Sphère-santé and PasseportSanté.net, to share your difficulties anonymously with people suffering from similar problems. The methods that they found worked for them will no doubt work with you too!

Bladder inflammation

Radiation cystitis

Radiation therapy used to treat prostate cancer can irritate the bladder lining and urethra and cause inflammation. This can in turn lead to a urinary tract infection.

Possible signs and symptoms:

  • Urinary tract infection
  • Need to urinate more frequently, both during the day and at night
  • Urgency to urinate
  • Bladder spasms
  • A burning sensation while urinating
  • Difficulty urinating
  • Presence of blood in the urine
  • Incontinence

The appearance of symptoms linked to radiation cystitis differs from man to man. Symptoms can start a few days after the first treatment. Symptoms usually decrease when the treatment is finished.

Some men may continue to have symptoms for several months after treatment, while other will have no symptoms until several months after their last treatment.

It is important to talk to your doctor about your symptoms.

Treatments

There are pain medications that can help relieve the symptoms of radiation cystitis. You can also change your lifestyle to prevent or diminish symptoms associated with cystitis:

  • Drink plenty of water (between 1.5–2 litres a day).
  • Avoid soft drinks, caffeinated drinks (tea, coffee, cola), and alcohol, as they can irritate the bladder.
  • Some men find that cranberry juice helps to reduce symptoms, but you should avoid cranberry juice if you are taking Warfarin.

Bladder wash‑out

This is a liquid treatment that covers and protects the mucosa of the bladder, and soothes the irritation. A small tube (catheter) is inserted through your penis and fills your bladder with the medication. After the treatment is complete, you go to the bathroom to empty your bladder.

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