Andrew Siegel MD 3/7/2020
A newly diagnosed patient with prostate cancer generally receives sufficient educational information concerning prostate cancer prognosis and treatment from his urologist. However, counseling about issues that may result from prostate cancer treatments are at times given short shrift or neglected. Urinary and sexual side effects often receive incomplete attention, perhaps understandable as being lower in the hierarchy of priorities since prostate cancer is potentially a life-and-death oncological issue. Urinary side effects—particularly bladder control issues—can be psychologically and emotionally devastating, capable of causing depression, loss of self-esteem and avoidance of activities (including sex) that contribute to a healthy, productive and active lifestyle.
The intent of today’s entry is to provide information and realistic expectations regarding urinary function following the various treatments for prostate cancer. Although urinary control issues are common consequences of treatment, they are manageable, and in most cases resolve, if not substantially improve, over time. Fortunately, severe and permanent urinary control issues are rare events nowadays, coinciding with refinements in the techniques of treating prostate cancer.
A Brief Review of Urinary Anatomy and Function
Illustration from Prostate Cancer 20/20: A Practical Guide to Understanding Management Options For Patients And Their Families
The bladder is a balloon-like muscular organ that stores and empties urine. The urethra is the tubular channel that conveys urine out from the bladder. The innermost part of the urethra is surrounded by the prostate gland.
The urinary sphincters are the specialized valve-like muscles that surround the urethra and provide urinary control. The “main” sphincter is the internal sphincter, a.k.a. bladder neck sphincter, composed of smooth muscle and located at the neck of the bladder (where the urinary bladder and urethra meet). It is an involuntary muscle designed for sustained control and its location at the bladder neck gives it a mechanical advantage. The “assistant” sphincter is the external sphincter, a.k.a., striated sphincter, comprised of skeletal muscle and contributed to by pelvic floor muscles and located below the prostate. It is a voluntary muscle that is situated downstream from the internal sphincter and is designed for emergency control.
Nice metaphor: I liken the internal sphincter and the external sphincter to a car’s brakes and emergency brakes, respectively.
The “guarding” reflex is a gradual increase in the contraction level of the external sphincter in direct response to the extent of filling of the bladder, a means of helping to maintain urinary control as bladder urine volume increases. The “cough” reflex is a contraction of the external sphincter that occurs with coughing, a means of helping to maintain urinary control when there is a sudden increase in intra-abdominal pressure.
The prostate envelops the urethra and is located between the bladder neck and external sphincter. The sphincters have an intimate anatomic relationship with the prostate gland, hence the potential for urinary control issues following prostatectomy.
The bladder is able to store urine by virtue of the fact that during bladder filling the bladder muscle remains relaxed at the same time that the sphincter muscles are contracted (squeezed). When the desire to urinate arises as the bladder fills to capacity (about 12 ounces), the coordinated contraction of the bladder muscle and relaxation of the sphincter muscles effectively empties the bladder.
Urinary Problems After Radical Prostatectomy
With respect to urinary function, on a positive note, radical prostatectomy can alleviate obstructive and irritative lower urinary tract symptoms in men who have symptomatic benign prostate enlargement in addition to prostate cancer. Furthermore, men who undergo prostatectomy should never develop symptomatic benign prostate enlargement that many aging men will encounter and that often necessitates medication or surgery to improve their symptoms.
When the prostate is surgically removed, a gap remains between the bladder and the urethra. This gap is bridged by carefully sewing the bladder neck to the urethra, with a catheter left in the bladder for a week or so to facilitate the healing process. Most men who undergo surgical removal of the prostate will experience short term urinary incontinence immediately following catheter removal, since the surgery impacts the muscles and nerves responsible for urinary control. This incontinence will persist for the long term in only a small subset of men.
In most cases, the reconstructed connection between the bladder and urethra heals nicely, resulting in the preservation of bladder storage and emptying functions. However, at times the reconstructed connection can heal with scarring, which can cause urinary incontinence because of impaired sphincter function with the bladder neck scarred in a fixed and open position. When the internal sphincter is scarred in such a fixed and open position, it no longer has the elasticity and suppleness to provide the appropriate opening and closing necessary for urinary control. Urinary control then becomes dependent upon the external urinary sphincter. This auxiliary system is not designed for sustained contraction and although there is virtually constant tone to this muscle, only a relatively brief intense contraction can be achieved, insufficient to completely compensate for the dysfunction of the internal sphincter.
At other times, the reconstructed connection between the bladder and urethra heals in such a way that the scarring results in the bladder neck being in a fixed and narrowed position. The narrowing can give rise to obstructive lower urinary tract symptoms, including difficulty urinating with a hesitant, intermittent, weak stream, prolonged voiding time, the sensation of incomplete emptying and at times, the inability to urinate (urinary retention). This narrowing is referred to as a “stricture” or “contracture.” When this problem is surgically addressed with a procedure to enlarge the narrowing by stretching or cutting into the scar tissue, the obstruction is relieved but urinary incontinence may result.
The main type of urinary incontinence that occurs after prostatectomy is stress urinary incontinence, urinary leakage associated with sudden increases in abdominal pressure as may happen with exercising, sneezing, coughing, bending, etc. The incontinence can be highly variable in degree, ranging from minor urinary volume leakage to major volume leakage that can occur with little provocation. Fortunately, for most men the situation improves, if not resolves completely over the course of the ensuing weeks, although at times it can take 6-12 months for full recovery.
Risk factors for urinary incontinence following prostatectomy are age (younger patients less incontinence), general health and body mass index (healthier and lower BMI less incontinence), extent of bladder control before the surgery (better pre-surgery control less incontinence), prior prostate surgery (more incontinence), skill of the surgeon and ability to do a nerve-sparing procedure (more skilled and nerve-sparing less incontinence), membranous urethral length (longer length less incontinence), prostate cancer stage (advanced stage more incontinence), adjuvant or salvage radiation therapy following prostatectomy (more incontinence), salvage prostatectomy following radiation therapy that has failed to arrest the prostate cancer (substantially more incontinence), and post-operative stricture requiring a procedure to fix it (more incontinence).
Of the men who never fully recover 100% of their urinary control, the resultant leakage is usually minimal and tolerable and tends to happen only when the bladder is full and during exercise or gravity-defying activities, such as bending over and standing upright. A small subset of men (less than 5%) may experience persistent, significant incontinence, a major quality of life issue that will need to be addressed.
Although stress leakage is the main type of incontinence that occurs after prostatectomy and other forms of prostate cancer treatment, other types of incontinence may occur as well. Urgency incontinence is leakage that occurs in transit to the bathroom associated with a strong sense of urgency, often on the basis of involuntary bladder muscle contractions. Overflow incontinence is a situation where the bladder leaks because it is over-distended with urine, as can occur with a stricture of the bladder neck. At times, urinary leakage can occur during sexual activities: foreplay, sexual intercourse and/or at the moment of sexual climax. Note that although medications can be highly beneficial for urgency incontinence, there is no effective pill to manage stress urinary incontinence.
Urinary Problems After Prostate Radiation Therapy
Urinary incontinence is less prevalent after radiation as compared to surgery. However, surgical procedures performed to address lower urinary tract obstructive symptoms following radiation therapy increase one’s risk for urinary incontinence.
Urinary issues following radiation therapy can be divided into early-phase and late-phase. Acute (early-phase) urinary problems occur during and shortly after the radiation because of the prostate swelling and inflammation resulting from the ionizing radiation. The symptoms are similar to those of any inflammatory process of the bladder and are often temporary and will improve substantially, if not disappear completely, in time. Any preexisting lower urinary tract symptoms can be exacerbated from radiation, resulting in bladder irritation, urinary urgency, frequency, pain while urinating, difficulty urinating with straining and an intermittent urinary stream and perhaps urinary incontinence. Typically, within a few months following completion of the radiation therapy, resolution of the symptoms will occur.
Chronic (late-phase) urinary issues may sometimes occur years after completing radiation and are thought to be on the basis of radiation-induced alterations in bladder blood flow and scarring. This is known as radiation cystitis and can cause symptoms including blood in the urine, burning or painful urination, urinary frequency and difficulty urinating. Urinary bleeding due to radiation cystitis is oftentimes provoked by straining, particularly with bowel movements, as well as participation in vigorous activities. Cystoscopy (a visual inspection of the bladder with a narrow fiberoptic instrument) usually reveals a classic pattern of prominent, exuberant, vibrantly colored, tangled blood vessels. If the urinary bleeding does not respond to hydration and temporary restriction of activities, at times cauterization of the bleeding vessels will be necessary and is usually successful. If cauterization fails to stop the bleeding, other options can be used, including medications that can be placed into the bladder as well as hyperbaric oxygen therapy, in which 100% oxygen is administered in a total body chamber where atmospheric pressure is increased to enhance healing.
Urinary Problems After Prostate Focal Ablative Therapies (HIFU and Cryotherapy)
Ablative therapies result in the destruction of prostate tissue via heat or freezing, both of which can cause lower urinary tract symptoms because of tissue swelling and sloughing. Voiding difficulties following focal ablative therapies may occur because of passage of sloughed tissues or scar tissue causing urethral narrowing. Urinary incontinence can be a long-term complication. At times, dystrophic calcification may occur, a condition that results from chronic inflammation, tissue damage and tissue death. In this situation, the inner lining of the prostate becomes calcified and sometimes mechanically blocked from the presence of stones that form on chronically inflamed tissues.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.
The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Prostate Cancer 20/20 on Apple iBooks
PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now on sale at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours).
Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Tags: Andrew Siegel MD, male stress incontinence, overactive bladder, prostate cancer, Prostate Cancer 20/20, urethral stricture, urinary function after prostate cancer treatment, urinary incontinence
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