Dr. John Hairston is an Associate Professor of Urology at the Feinberg School of Medicine and a member of the Integrated Pelvic Health Program.
Betsy Haberl is the editor of QUEST.
BH: Many men with prostate cancer choose to have a prostatectomy. However, some men are concerned about the side effect of urinary incontinence. Is this a valid concern?
JH: Of course. However, incontinence is not inevitable. About 8-10% of men seek treatment for leakage problems after prostate surgery. A number of treatment options are available. Men don’t have to live with incontinence.
I counsel patients that first and foremost, they’re treating cancer and they should focus on finding the best treatment. I can always address any consequences afterwards. I don’t want patients to hesitate treating prostate cancer because of possible side effects, such as urinary incontinence.
BH: What is urinary incontinence?
JH: Urinary incontinence is the inability to hold urine in your bladder. There are two types of incontinence: urge incontinence, also called overactive bladder, and stress incontinence. People with urge incontinence experience frequent urination and urgency of urination. It is caused by bladder muscle contractions. People with stress incontinence have loss of urine control with increased abdominal pressure or physical activity, such as when coughing or swinging a golf club. Stress incontinence is more common than urge incontinence after prostate surgery and radiation treatment.
BH: Why do some men have stress incontinence after prostate cancer treatment?
JH: Surgery or radiation can result in a sphincter (the muscle that holds urine in the bladder) that does not function properly, which causes the stress incontinence. Men who have surgery tend to have incontinence problems sooner. Men who have radiation could experience incontinence several years after treatment.
BH: What’s a typical experience with incontinence after prostate surgery?
JH: It’s normal to have some mild urine control problems after a man’s catheter comes out. He might wear one or two pads a day. His urologist will counsel him on this.
“I don’t use a one-size-fits-all approach to treat stress incontinence. There’s no treatment that’s better than the others, so it’s based on patient selection.”ĖDr. John Hairston
BH: When does the mild incontinence normally go away?
JH: A man needs time for his pelvic floor to rehabilitate. The usual period for recovery is between 3 and 12 months. Unless the problem is severe, he probably wouldn’t need to see an incontinence subspecialist until 6 to 12 months after surgery.
BH: When should a man seek treatment if he continues to experience symptoms of incontinence beyond the typical recovery time?
JH: He should seek treatment whenever he feels incontinence is a problem. One man might feel it’s a problem to wear one pad a day; another might wear five pads and feel okay about it.
BH: How do you address a patient’s incontinence problems?
JH: All the treatment options address sphincter control. There’s a continuum of treatment, so if one treatment doesn’t work perfectly, the patient could try the next option.
BH: Where do patients usually start?
JH: Physical therapy is the first and most conservative approach. Kegel exercises strengthen the pelvic floor and can help improve urinary control. They tend to be more successful if learned in a formal setting with a physical therapist, particularly for milder degrees of incontinence.
Men don’t need to wait a year to go to physical therapy for incontinence. Itís also an easy first step for men who still have mild incontinence years after surgery.
BH: What are some options for someone with a more problematic degree of leakage?
JH: He could try the male sling or the artificial sphincter. These options are more invasive than physical therapy.
BH: How does the male sling work?
JH: The surgeon makes a tiny incision in the man’s scrotum and inserts a piece of synthetic mesh underneath the urethra to compress it. The sling acts like a hammock that provides support underneath the urethra. The procedure takes about an hour, and then the patient can go home. He may need a catheter for a day or two.
BH: Is the male sling effective for most men?
JH: It works best for men with mild or moderate degrees of leakage. Sling procedures have been performed on women for decades, but we don’t have long-term data on rates of effectiveness for men. However, the 2-year data is very good.
BH: How does the artificial sphincter work?
JH: The artificial sphincter is a mechanical device implanted during surgery. An inner tube filled with fluid surrounds the urethra and closes it off. This is connected to a pump in the scrotum. When a man wants to urinate, he pushes the pump in his scrotum 3-4 times. This releases fluid from the inner tube, allowing the urethra to open so the man can urinate. After he urinates, the tube self-times and re-fills with fluid, closing the urethra again.
The artificial sphincter has been in use for almost 30 years and has the longest track record of success. Patient satisfaction is about 97%. It’s meant for men with moderate to severe incontinence, through it will work for all degrees of incontinence.
BH: How do you decide which is the best treatment for a patient?
JH: Ultimately, I help guide the patient by evaluating his problem and educating him on the merits of each option.
For the patient’s evaluation, I first gather his subjective concerns: how bad does he feel the problem is? I also take his clinical history because many variables can effect voiding.
For the objective evaluation, I ask him to weigh his pads before and after he urinates. This helps quantify the amount of urine he is losing. I also perform urodynamic testing. I put small catheter in a man’s bladder and recreate a full bladder. This allows me to see how the bladder is behaving and how much urine it can hold. It can also measure the strength of his urinary sphincter muscle.
BH: Are there risks to the treatment options?
JH: The risks are low for most noncomplicated patients. The male sling and the artificial sphincter require surgery, and complications include infection and erosion, in which the implanted material moves out of place. The artificial sphincter is a mechanical device that occasionally may malfunction. Currently, 10-15% of men over a 12-year period require revision on the sphincter. Rates are higher for men with diabetes or those who have had multiple surgeries or radiation. Long-term statistics for male sling complications aren’t available because they haven’t been used for very long. The rates appear to be slightly lower than with the sphincter.
Learn more: listen to Dr. Hairston on the ihealth podcast at www.nmh.org/nm/ihealth-male-incontinenceprostate-surgery.