Urinary Function

Problems with passing urine can often result from prostate cancer treatments, other conditions such as diabetes, multiple sclerosis, Parkinson’s disease, stroke or simply the ageing process. Urinary incontinence tends to fall into three categories:

Stress Urinary Incontinence – involuntary leakage when coughing, sneezing or physical exertion.

Urge Incontinence – leakage with an overwhelming need to urinate.

Mixed Incontinence – leakage with both exertion and urgency.

Urinary incontinence after surgery can affect most men, but over time the majority of men will gain control of leakage problems once muscles have recovered.

There are two sphincter muscles that keep men continent, the internal urethral sphincter and the external urethral sphincter. The internal sphincter is found at the bottom of the bladder, called the ‘bladder neck,’ and in the prostate. During surgery this is removed, because the prostate cannot be taken out without removing this sphincter.

The external sphincter is the muscle used to stop the urine stream and can be strengthened with pelvic floor muscle exercises. Normally, an intact, healthy external sphincter is sufficient to provide continence. However, after radical prostatectomy, there can be some damage or dysfunction of this sphincter, which can prevent a man recovering bladder control. This may be due to damage to the nerves, blood supply, supporting structures, or the muscle itself, as the external sphincter is located at the apex of the prostate gland. Nearly all men will have some form of leakage immediately after the surgery, but this will improve over time with strengthening exercises.

Radiation therapy targets the prostate and the urethra runs through the middle of the gland, so both will receive radiation. Long-term leakage is rare, but frequency and urgency can be experienced. Radiation cystitis occurs when the lining of the bladder and urethra has been irritated by the radiation. Symptoms include frequency or difficulty in urinating, also a burning sensation while urinating, and passing blood. Cystitis can appear within the first few days of treatment, but some men don’t get symptoms until months or even years after treatment.

Brachytherapy can cause the prostate to swell and block the urethra, leading to urine retention. It can also cause the urethra to become narrow – this is called a stricture.

Some lifestyle modifications can help:

  • Try to avoid drinks containing caffeine
  • Fizzy drinks may exacerbate symptoms
  • Alcohol can increase urgency
  • Try to increase time between visits to the toilet, as this will help the sphincter muscle to strengthen
  • Do not try to hold out at night – it will only keep you awake
  • If you are overweight, try to lose a few pounds
  • Carry out regular pelvic floor exercises.

Pelvic floor muscle training

The muscles of the pelvic floor are kept firm and slightly tense to stop leakage of urine from the bladder or faeces from the bowel. Pelvic floor muscles can become weak and sag because of surgery, radiotherapy, being overweight, lack of exercise, poor posture, or just getting older. Weak muscles give you less control, and you may leak urine, especially with exercise or when you cough, sneeze or laugh.

Pelvic floor exercises help strengthen these muscles and involve tucking your bottom in and pulling your pubic bone up in front and holding it there for a few seconds. This should be performed 100+ times each day, so self-discipline is needed to keep at these exercises. Fast walking can also help. Both the exercises and fast walking have also been shown to improve erectile function. Although there is no firm evidence that pelvic floor exercises prior to treatment are beneficial, they can do no harm, and they may well help you get into the habit of routinely exercising the right muscles.

Long-term Severe Incontinence

It must be emphasised that severe long-term incontinence is rare, and nearly all men recover continence after treatment within a few months. So do not despair.

Note: The section that follows only applies to men who experience serious long-term incontinence problems that severely affect quality of life.

The external sphincter is a natural on/off valve associated with the urethra, which can become weakened or even damaged, usually during prostate surgery. In nearly all cases nowadays this strengthens over time, often with the help of pelvic floor exercises, and men usually gain full continence after 3–6 months or less. In up to 5% of cases, however, this can remain a problem after a year, requiring the daily use of incontinence pads. If this is the case, there are two methods which are now used – a male sling (an implant for mild to moderate incontinence) and an operation to fit an artificial sphincter for more severe cases.

The Sling

The sling is made from synthetic mesh and is implanted entirely inside the body during an operation under general anaesthetic. Through a small cut in the skin, the two ends of the sling are passed underneath the urethra and out through the pelvic area into the upper thigh on each side. It is then tightened enough to lift and partially compress the waterpipe. It is a minimally invasive procedure, the device operates automatically and most patients are continent immediately following the operation.

There can be some inflammation, pain and bruising at the wound site, but this will diminish with time. Very occasionally, urinary retention occurs, usually caused by incorrect sling tension, and then a catheter may be needed for a short period and further surgical intervention may be required if normal urination is not restored after the catheter is removed.

Success rates of 54.6% to 94.6% have been reported from six clinical studies involving more than 500 patients. In a study of 42 patients, 94.4% would recommend the procedure to a friend.

Note: Following the MASTER trial (AUS v. SLING) that took place in 2017/18 the ‘sling’ operation has been suspended in some NHS centres until a report has been finalised on the outcomes of the procedure. It may very well be reintroduced as an alternative to the AUS at a later date.

The Sling

The Artificial Urinary Sphincter (AUS)

The simplest way to describe this device is that it is like a miniature blood pressure cuff that is inserted around the urethra at the base of the bladder. The fitting of an AUS requires an operation done under full anaesthetic.

There are three parts to fitting this urinary control system:

  • an inflatable cuff fits around the urethra
  • a pump with a switch, is implanted in the scrotum
  • a small balloon reservoir is implanted in the abdomen

The device works by pressing the switch in the scrotum several times, this deflates the cuff around the urethra by pushing fluid from it into the balloon. The pressure on the urethra is thereby released allowing urine to flow. After a few minutes the cuff self-closes once the balloon reservoir refills the cuff with fluid, closing off the urethra again.

After the insertion of the device it is not used for several weeks to allow the tissues involved to recover. Many urologists consider this to be the ‘gold standard’ for treating male urinary incontinence. Following the operation there can be some pain, discomfort and bruising at the wound site, but the procedure can help restore quality of life and should alleviate the problem considerably.

In a study of 50 patients, 90% reported satisfaction, 96% would recommend the implant to a friend.

Artificial Urinary Sphincter (AUS)