Archive - Conditions After a Radical Prostatectomy

Questions & Answers

LEAKAGE OF URINE WITH SEXUAL AROUSAL: I underwent a radical prostatectomy one year ago. I am doing great except for leaking urine during intercourse. Is this normal and will it improve?

During sexual arousal, there is a rhythmic contraction of the pelvic muscles. This is part of the normal sexual response. In patients with borderline urinary continence, there may be leakage of urine. The practical solutions to this problem are to perform Kegel exercises to strengthen the external sphincter muscle, ensure that your bladder is completely empty before intercourse, or to use a device such as the Actis venous flow regulator to prevent the urine from leaking out through the urethra.

BLEEDING AFTER RADIATION THERAPY: My husband had a radical prostatectomy, after a year an elevated PSA required hormone treatments and radiation. Now one year later he is bleeding from the penis, what does this indicate?

The most likely explanation is that the bleeding is caused by radiation-induced effects on the bladder – sometimes called “radiation cystitis.” It usually stops on its own, but sometimes requires cauterization of abnormal blood vessels in the bladder. There are other possible causes, such as a stone, tumor, infection, etc, so the condition should be evaluated by a urologist with an excretory urogram and cystoscopy (kidney x-ray and looking in the bladder with a scope).

PREGNANCY AFTER RADICAL PROSTATECTOMY: After radical prostate surgery, and no seminal fluid is being produced, but sperm is still being produced and absorbed into the body. Is there a means (extraction method) of using that sperm for fertilization, if pregnancy is desired?

There are methods of retrieving sperm, either by aspiration with a needle or through surgical means. These sperm may then be used with in vitro (test tube) techniques for artificial insemination and pregnancy. These techniques are complicated and expensive.

POSTOPERATIVE LYMPHOCELE After a radical prostatectomy, I had a fluid buildup in the abdomen of lymph serum and it was drained. Now, I am experiencing a recurrence. The doctors think it is a lymphocele that is leaking. All tests are negative as to cancer or infection.

What is the treatment and prognosis for this condition?

BLOOD IN SEMEN AFTER SEED IMPLANTATION: I had the seed implants done three months ago. When I ejaculate there is still some blood in the semen, and there is only a small amount of semen. Will I stop having semen and just a dry ejaculation?

It is common for the amount of ejaculate to dramatically decrease after seed implantation therapy, because the radiation destroys many of the prostate cells that produce much of the ejaculate. Some patients do have dry ejaculations. Blood in the semen is common following seed implantation therapy, but bleeding usually resolves with time.

PAIN IN THE TESTICLE AFTER RADICAL PROSTATECTOMY: I had a radical prostatectomy and everything was okay. About two years after the surgery I started having pain in the right testicle after sexual intercourse. This pain is a pulsing type that radiates toward the bladder and back – at 5 to 15 seconds intervals. It also causes nausea and vomiting. It usually lasts about six hours. The right testicle is a little sensitive and this is being controlled with Ibuprofen. However, when there is sexual activity, the testicle and radiating pain makes it difficult to even walk. What is happening ?

It is difficult to say without performing a physical examination and an ultrasound examination of the testicles. It is probably related to continued sperm production in the testicles with nowhere for the sperm to go. So they are trapped in the duct system. This causes the duct system to become congested and distended and causes pain. It would be best to be evaluated for this by a urologist. Sometimes, a pelvic CT scan is also indicated to rule out any other possible cause of pain.

BLOOD IN URINE AFTER SURGERY: Three weeks postop, blood in urine constantly–clear, tea-colored. What does this mean? What to do?

I presume that the catheter has been removed. The most common cause would be that there may be some old blood clots in the bladder that are gradually dissolving. If so, when they dissolve, your urine should become clear. Other possibilities include a urinary tract infection (you could have a urine culture to rule this out) or it could be bleeding from the suture line in your bladder. This will heal with time. It is best to consult with your surgeon.

BLOOD IN URINE AFTER RADIATION: My father just had radiation last year and his urine is dark red. Is normal to have blood in the urine after radiation?

It is not normal to have blood in the urine after radiotherapy, but it is not uncommon. It is called radiation cystitis. It is best to evaluate the bleeding with a kidney x-ray and to look into the bladder with a cystoscope just to ensure that there is no other problem causing the bleeding. Radiation cystitis causes very fragile blood vessels to develop in the lining of the bladder and they rupture and bleed easily.

RECTAL BLEEDING AFTER RADIOTHERAPY: My husband had radiation therapy for prostate cancer. Over a year after treatment, he developed rectal bleeding. It is caused by the radiation treatments. What are the treatment options for this problem?

Although one cannot be certain without checking, it is most likely that the bleeding is being caused by radiation-induced changes in the rectum. Sometimes the bleeding occurs infrequently and intermittently. Other times, it poses a more serious problem that requires treatment to prevent further bleeding. It is safest to have him evaluated with a colonoscopy by a specialist.

SWELLING OF THE LEGS: How is swelling in the legs associated with cancer of the prostate?

Swelling of the legs can occur because of prostate cancer if a lymph node dissection has removed a significant proportion of the lymph nodes draining the legs, if radiotherapy has caused scarring of the lymphatics, or if a tumor is blocking the lymphatics, or a combination of these factors. However, there are other reasons for swelling of the legs such as congestive heart failure, venous disease, low albumin in the blood, etc. In my opinion, it is advisable to have the condition evaluated by a doctor.

INCONTINENCE AND IMPOTENCY AFTER RADICAL PROSTATECTOMY: I recently underwent prostrate cancer surgery and suffer from urinary leakage as a result of the operation. I also have not been able to have an erection. I am looking for is procedures that help correct my current medical condion.

If the leakage is severe, a operation to implant an artificial urinary sphincter is usually quite successful. Alternative, there are other urethral suspension operations to correct incontinence, but they are not as reliable, in my opinion. The impotency can usually be corrected either by Viagra-like drugs, a vacuum erection device, injections into the side of the penis, or suppositories placed into the urethra. Also, an operation to insert an artificial urinary sphincter is usually very satisfactory. Although these side effects are very bothersome, if the prostate cancer has been cured, you might still be better off that if you still had prostate cancer. Not all prostate tumors can be managed safely with watchful waiting. It is very likely that you can have the potency and continence problems corrected.

BLADDER NECK CONTRACTURE AFTER RADICAL PROSTATECTOMY I had RRP and since then, I’m having a problem urinating. I have been dilated a few times. My doctor cut the scar tissue but it reappears. My doctor says he has not seen such a body making so much scar tissue. Will I be ever recover from this nightmare?

This problem occasionally occurs, but usually it can be corrected. Sometimes it requires trimming out the scar tissue and injecting a cortisone-like solution to prevent the scar from returning. It is frustrating, but it will probably be taken care of.

URETHRAL STRICTURE (SCAR TISSUE)AFTER RADICAL PROSTATECTOMY: My father had a radial prostatectomy and had to leave the catheter in for 3 weeks. He developed a urinary tract infection and subsequently scar tissue formed in his urethra, causing him pain when he urinates. Are there any other options beside surgery in order to remove the scar tissue? Is it possible that the scare tissue formed a blockage because of the stitching of the catheter to the urethra?

Urethral stricture is one of the most common complications of radical prostatectomy. It can occur for a variety of reasons. In most instances it can be managed by simple dilation of the urethra. Sometimes the patient must perform intermittent self catheterization for a while to keep the channel open. However, sometimes it does require surgery to correct it. Surgery involves removing the scar tissue and sometimes injecting a cortisone-like drug to prevent the scar from coming back.

My husband had radical prostatectomy 1 week ago – his doctor took the catheter out at the end of the 3rd day. He has blood in his urine off and on and it is several different colors. Is this ok? He does not go back for 5 weeks.

It is not unusual to have blood in the urine on and off early after a radical prostatectomy. In my opinion, three days is early to remove the catheter, although it has been reported by some doctors.

Because I take many medications, I am very uncomfortable using Viagra since my radical prostectomy six years ago. I use EDEX approximately two times a week. My left testicle seems overly sensitive. Could using EDEX cause the sensitivity or could there be another reason?

Testicular discomfort is not uncommon after radical prostatectomy, because the sperm are trapped and have nowhere to go. It is probably not related to the EDEX.

I am having RP this next week and would like to fly back home soon after. My wife wants us to stay until the catheter is removed. What are your considerations in advising us?

It doesn’t matter very much. Most patients fly back and have the catheter removed at home.

I just had radical prostatectomy. I am experiencing new blood from my penis anytime I strain at all (while having bowel movement or getting up out of chair). Is that normal? While catheter is still inserted, should I be doing pelvic floor (kegel) exercises?

It is normal to have bleeding around the catheter when straining. You should not do pelvic floor exercises until the catheter is out.

I am a 58 year old who recently had a prostatectomy. During my surgery, a also had hernia repair. In your opinion, how soon should I be able to resume normal athletic activities?

Begin gradually after 6 weeks.

Dr. Catalona. You performed nerve-sparing prostatectomy on my husband when he was 61 years old and had a PSA of 11. He was of an appropriate weight and was extremely active prior to the surgery. Afterwards, he had slight incontinence when lifting things, but did the exercises you recommended and discontinued wearing pads after a few weeks. He also began taking Viagra a few weeks after the surgery and we were patient, like you said. Within a few months, we were having normal sex again and now he doesn’t usually even need the Viagra. Thank you Dr. Catalona. I hope this inspires other patients to heed your advice and be patient – but most of all have a positive attitude!

This advice about patience and a positive attitude is very important. It takes time for the body to recover after major cancer surgery, and patients often get discouraged and doubt that they will recover.

Is Peyronies disease a result of penile injections? Can Peyronies disease be helped?

Yes, it can be caused by injections. Please see other Q&As on Peyronies disease on the website for information about its management.

I had a RP almost two years ago and have experienced no problems with incontinence. I have noticed that on occasion, especially when some time has passed since I last urinated, that the inital part of the urine stream appears cloudy then quickly clears as I continue to urinate. I am experiencing no pain or difficulty in urinating but was curious what would cause this “milky” appearance of the first part of the urine stream. I’m speculating it must be connected in some way with my surgery.

Sometimes the urine can be cloudy because of the presence of crystals that form in the urine when it is alkaline, such as after a meal. You should have a urinalysis performed on a cloudy urine sample.

After my RRP, I have had problems with urine blockage. I have had my catheter replaced four times. Each time I could urinate on my own for a couple of days, and then the blockage started again. What are the possible causes of this problem?

One of the complications that can occur after radical prostatectomy is the formation of scar tissue between the bladder and the urethra. (When the prostate is removed, the bladder and the urethra must be connected, sewn together, to fill the empty space.) Mild scarring can be treated by simply replacing the catheter for a few more days to allow the healing to become more complete. Slightly more severe cases can be treated by the doctor dilating the stricture or scars with a dilating instrument. More severe cases require the patient to perform intermittent self catheterization to keep the stricture open. Even more severe cases require the scar tissue to be incised by a procedure that is performed through a scope with the patient under anesthesia. Usually, a catheter is left in place for several days after this procedure.The most severe cases require the scar tissue to be trimmed out with a resectoscope (a scope designed to remove tissue). When this procedure is performed, it is often helpful to inject a cortisone-like medication into the scar tissue to prevent another stricture from re-forming.The bottom line is that this problem can be fixed, but it sometimes takes patience on the part of the patient and the doctor alike.

I am thinking of having laparoscopic surgery. I talked to a surgeon who does traditional surgery and he mentioned about the catheter being in longer for this type of surgery. He went on to say that he does not understand why with laparoscopic surgery they take it out in possibly 3 days. It takes the body longer to heal than 3 days. My question is why is Laparoscopic surgery the catheter is out sooner than with traditional surgery. Is there any danger in it coming out sooner?

In my opinion, the catheter should stay in for at least one week, regardless of how the operation is performed. In some patients, the catheter can be succesfully removed before, but there is an appreciable chance that it will have to be re-inserted. In general, it is best not to have to re-insert the catheter through a healing connection between the bladder and the urethra.

I am 60 years old and had a RRP ten months ago with good results. My PSA is <.05 and the doctor says the cancer was contained, but I have a lingering problem for which the doctor has no real answer. Although I have resumed normal activity, by each evening, I continue to have swelling in my lower abdomen which becomes uncomfortable when sitting. I have had several CT Scans, but no sign of free fluid and no enlarged lymph nodes are present .Is this normal and do you have any suggestions on what could cause the swelling and puffy feeling which seems to be accelerated by activity i.e. golf, minimal yard work etc.?

What you describe is probably lymphedema from the lymph node dissection. With increasing activity the tissue fluid accumulates faster than it can be drained away. This will probably resolve with time as the existing lymphatic channels dilate and collateral lymphatic channels develop.

PEYRONIES’ DISEASE AND RADICAL PROSTATECTOMY: I had RP surgery two years ago. I had what I thought was a very good recovery except for one aspect. I developed a curve in my penis when erect. My urologist, without checking, told me I had Peyronies’ disease. The curve did not exist before surgery and I don’t have the pain associated with Peyronies’. Could the curve be a result from nerve damage due to the surgery?

Yes, it is Peyronies’ disease.  There are patients who have nerve damage and no curvature, and there are patients with curvature who don’t have nerve damage.  Peyronies’ disease is not uncommon after radical prostatectomy and it is due to scarring of the cavernosal tissue.

SHOULD I GO ON VACATION? Will my husband need help after this surgery? He claims he won’t, and is wanting me to go on a family vacation with the kids we had planned over a year. I feel he will need me and I just dont feel good about leaving him. What do you think

You should stay and take care of him, in my opinion.

PAIN WITH ORGASM AFTER RADICAL PROSTATECTOMY: Three years ago, my husband underwent nerve-sparing radical prostatectomy. Although he has erections and experiences orgasm, he says he has pain in the lower rectal area during sex (he describes it as centered on the lowest point of his spine). He also states it feels like a bruise when he is sitting. He has had a colonoscopy within the last six months and had a few benign polyps removed. Any ideas on what might be causing his pain/discomfort?

Some men experience pain with orgasm following surgery for which no explanation can be made after thorough evaluation. Sometimes, we attribute it to adhesions in the pelvic tissues from the surgery that restricts the normal mobility of different tissues. However, it is always wise to rule out other causes. I would advise a CT scan of the abdomen and pelvis to rule out any other process and then consider consultation with a neurologist and a possible MRI scan of the spine to rule out neurologic causes for the pain. In many instances, the discomfort with orgasm goes away with time.

Do kegels stimulate the pudendal nerve and help it to recover?

The pudendal nerve carries sensations from the external genitals, the lower rectum, and the perineum (the area between the genitals and the rectum). Kegel exercises do not stimulate the pudendal nerves, nor do they stimulate the cavernosal nerves that are responsible for erections. Kegel exercises are meant to strengthen and increase the bulk of the sphincter muscles that are responsible for closing the urethra sufficiently tightly to prevent urinary leakage.

After a radical prostatectomy, my husband says he doesn’t feel “like himself.” He is back at work and functioning well but he says that while his heart is happy, his brain is not. Could this feeling be a side effect of the RRP?

It is not uncommon for a man to have a “let down” (feel mildly depressed) after a radical prostatectomy. This mood usually resolves as he moves along the road to recovery. It can be prolonged, if side effects of surgery persist longer than hoped for.

For reasons that are unclear, some men have a temporary decrease in plasma testosterone levels after surgery. The cause is not clear.

Changes in testosterone levels may affect a man’s mood – making him feel less vigorous.

In most instances, testosterone returns to pre-treatment levels within a matter of months after surgery.

Does testicle swelling happen after radical retro-pubic prostatectomy?

Yes, and it is more marked if the patient spends too much time sitting. For the first few weeks after surgery the patient should not sit for more than 1 hour without getting up and walking around.

Dr. Catalona, in your opinion, is low testosterone a common result of a radical prostatectomy?

In my experience, some men do have a low testosterone after radical prostatectomy for reasons that are not entirely clear. In most instances, it is transient and gradually returns to normal.

MEASURING PSA AFTER SURGERY: I had a radical prostatectomy 6 weeks ago. Can you please tell me how long it takes before all the PSA is washed out of the blood, and when can the PSA value be reliably measured for the first time? My PSA value 6 weeks after the operation is still 0.2 ng/ml.

PSA in the blood exists in several forms, including free floating PSA and PSA bound to proteins. Some of these proteins have a very slow rate of turnover. Therefore, it usually takes 30-60 days for all of the PSA to be cleared. In my practice I check the PSA 1 month after surgery and if it is not undetectable, repeat it 2 weeks later. It should become less than 0.1. Of course, the higher the PSA level before surgery, the longer it takes for it to be cleared from the blood after surgery.

I have chronic low-back issues that flared up right after my prostatectomy. What can I take to relieve the pain, and how long would you expect it to last?

It is perfectly normal for patients with pre-existing spine issues to have a severe back ache for about 72 hours after their prostate cancer surgery because we have their back arched on the operating table. Heat (especially in the shower) and walking are most effective in relieving this kind of pain. What makes it worse is lying in bed. Torodol is hard on the kidneys and cannot safely be continued. Tylenol is hard on the liver, but less dangerous in moderate doses. Therefore, I would recommend Tylenol 325 mg every 4-6 hours, heat, walking, and patience.

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