Archive - Continence (Urinary Concerns)

Questions & Answers

INCONTINENCE AND ARTIFICIAL INFLATABLE SPHINCTER: It has been 13 years since my radical prostatectomy with postoperative radiation. My incontinence has progressively gotten worse. I have looked at the artificial inflatable sphincter, but have heard horror stories about it. Half of the men I have spoken to have had to have it removed.

For men who have severe urinary incontinence, the artificial inflatable sphincter usually very dramatically improves their quality of life. Most of the technical problems of these sphincters have been solved, and the results usually are quite durable. However, if the artificial sphincter becomes infected or constricts the urethra too much, it will have to be removed. The risks are higher in patients with diabetes and in those who have been treated with radiation therapy. It is important that an expert who specializes in this type of surgery perform the operation.

PROSTATE CANCER TREATMENT AND PARKINSON’S DISEASE: For a man in his mid-40s with early onset Parkinson’s disease, which is the better treatment option for a Gleason 7 localized prostate cancer in 4 of 17 biopsy cores: radiation or prostatectomy? More specifically, is the lower likelihood of urinary incontinence with radiation for a person with already compromised bladder control (from Parkinson’s) worth the possibly less-effective cancer control?

The risk for urinary incontinence with radiation is lower than with radical prostatectomy; but it is not zero. In my opinion, I believe the best choice for the young patient you describe is to optimize chances for a cure with a radical prostatectomy.

KEGEL EXERCISES / SPHINCTER EXERCISES: How do the exercises given after my operation work to help bladder incontinence?

Exercises work by increasing the bulk and strength of the one remaining sphincter muscle. This muscle helps to create a seal by approximating the walls of the urethra. There is a fine line between being wet and being dry. It’s like a leaky faucet that can be fixed by replacing a washer that differs very little in appearance from the old washer. It is just a little more plump and flexible and stronger, but that makes the difference between wet and dry. (See other Q & As and Quest articles on this topic posted on this website.)

PENILE CONSTRICTION DEVICES: You mentioned an “Actis Venous Flow Regulator” for stopping urinary incontinence upon sexual arousal. What exactly is this? Also I read about a topical cream being researched to replace Viagra. Do you know anything about this?

The Actis device is a tourniquet-like device that constricts the penis to prevent blood leaking out through the veins during erection. It also compresses the urethra and prevents urine from leaking out during sexual arousal. Other penile constriction devices serve the same purpose.

TOO MANY KEGEL EXERCISES? My doctor recommend five sets a day of 20 second muscle contraction 20 times. Is this overexercising?

Many patients pass through a phase during the recovery of continence where they are dry during the morning and incontinent in the afternoon and evening. This occurs because of muscle fatigue that develops over the course of the day. If one exercises the muscles too much, the muscles will be fatigued most of the time and it might be counterproductive. Accordingly, I recommend four sets of ten spaced 3-4 hours apart when the patient is not urinating, and starting and stopping the stream during urination to make certain that the proper muscle is being exercised (if the stream stops, it’s the right muscle).

INCONTINENCE 9 MONTHS AFTER RADICAL PROSTATECTOMY: I am 9 months post-radical prostatectomy. I do about 40-50 Kegels a day. I still leak, using about 2-3 pads per day, despite making frequent trips to the bathroom when I feel leaking. I’ve read your Q&As about continence recovery. I’ll be 72 years old. Do you think I could have a stricture of the urethra that is preventing control of urine? I’m confused about how tolerant I should be of the incontinence, should I give it more time or what my next step should be?

It would not hurt to have your urologist check you to rule out development of a stricture. Continence can continue to improve for up to 12 to 18 months after radical prostatectomy. Hopefully, yours will resolve completely with time. In my opinion, I would be patient and do the Kegel exercises faithfully. If continence hasn’t returned by 18 months, I would recommend you discuss other treatment options with your urologist.

I had radical prostatectomy 4 months ago. After the first month I was unable to urinate so a cystoscopy was done and scar tissue removed (cold knife). After another month the same problem occurred and cyctoscopy again was done (Loop). I’ve now had my 4th cyctoscopy done. This time the Doctor said he opened me up the diameter of a pencil. I am in pain and I’ve had to cath myself twice with unbearable pain, and I only dribble when I am able to go. I’m also having raw pain in my lower back and hips. I had an infection that was cleared up with antibiotics and there is no infection at this time. I also had a dilation procedure done 6 weeks ago that caused unbearable pain that and lasted for 2days. When I tried to urinate the pain almost made me pass out. Is there anything I can take for inflammation of the bladder?

Please read the Q&As on the website regarding postoperative stricture at the junction of the bladder and the urethra. It appears that you have a difficult case, but it usually can be solved by trimming out the scar tissue. Sometimes injections of a cortisone-like medication into the scar can be helpful. It is not uncommon for patients to have to perform intermittent catheterization or self-dilation to keep the channel open while it heals.

Having read your article the method and frequency of doing Kegel exercises, I have to comment from experience. I have done light weight lifting most of my life, and early on I learned, the hard way, that daily exercises actually weaken muscles because they do not allow enough time for muscle tissue rebuilding. Therefore, I did my Kegels as you suggested, but only on my workout days, three times a week. This seems to have worked for me, as I am completely continent after my RRP. I also started the exercises three months before the surgery. Hopefully this can help some of your patients.

Your point is well taken.

SEVERE INCONTINENCE – My husband is 57 yrs old, he had radical prostate surgery 6 months ago. He is totally incontinent. He uses at least 10 heavy pads a day.

He should do Kegel exercises faithfully in sets of 10 four times a day. If he does not improve after a year from surgery, he should strongly consider having an artificial urinary sphincter implanted, in my opinion.

I had a radical prostatectomy and my PSA and DRE have been good (normal) since the surgery . My continence was good but now, in the last six months, I have had a minor problem with incontinence. When I cough I have a little dribble. I know that that is considered to be “normal” but I did not have that from early on since the surgery. I was wondering if restarting the Kegel exercises would help this situation.

Yes, they probably would help to strengthen and increase the bulk of the sphincter muscle. It is important to have both bulk and strength so that a seal can be achieved and maintained by holding the walls of the urethra together.

My 52 year old husband had a nerve sparing radical prostatectomy (both nerves spared). On pathology, both seminal vesicles were involved with tumor. It is 4 l/2 months post surgery and my husband is still incontinent, and impotent (fully potent before surgery).His first PSA after surgery is undetectable. How long should my husband wait to regain his continence before having adjuvant radiation? If he does not become continent, should he forgot about having the radiation until his PSA begins to rise?

I usually advise patients not to start postoperative radiotherapy until continence has returned. Otherwise, the radiotherapy might interfere with the healing process and continence might not be as good as it otherwise would be.

Incontinence while walking after RRP. It has been 2 weeks since the removal of my catheter. I have made great improvement with incontinence at night and while seated, but don’t see any improvement when I walk. Is this something that can be expected in the normal recovery from RRP?

Two weeks postoperative is very early. It sounds like you are “on track,” and the incontinence should improve.

Last week I had the catheter removed and had my first lesson on self catherization but unfortunately I blocked up again for the 6th time. I really am discouraged. I even changed doctors today. There does not seem to be any help for me. Will I live the rest of my life with a catheter?

This problem can usually be fixed. I would consult with an experienced urologist at one of the larger medical centers in your area. I would ask for one who specializes in reconstructive urology and stricture disease and has experience with radical prostatectomy patients.

It has been six months since my radical prostatectomy. I am now self catherizing each and everytime I need to urinate. I did have blockages but since I can dilate myself, the doctor says that part is okay however he doesn’t understand why I cannot uurinate on my own. He also says he has never encountered such a problem. He says perhaps time will take care of it. With all your experience have you heard of another case like mine?

Yes, I have. This problem usually can be taken care of by removing the scar tissue and sometimes injecting a cortisone-like medication to prevent its recurrence. Please see other

My husband is 45 years old and had a radical Prostectomy . 12 weeks after surgery he finally would experience an occasional episode of holding his urine (only after sitting for a while and then racing to the bathroom) He was then released back to work with no restrictions, noting he is on his feet constantly and also does lifting. Since his return to work, he has no control what soever It seems his incontin ence has gotten worse. He is becoming more and more discouraged. Does the fact that he has no control at this point mean he may never regain control again? Or do you have any advice on what he can do to help the process along?

It is still early, and it is likely that he will have great improvement. Continence is worse when the muscles are fatigued. I recommend the Kegel exercises in sets of 10 four times a day with about 4 hours rest in between (breakfast time, lunch time, dinner time, and bedtime.) For further information, check the “New Patient Packet” on the home page of my website.

I am a 41 year old male, recently diagnosed with T1c Gleason 3+3 adenocarcinoma identified (only 1 mm in size) from 1 out of 8 biopsies. My average PSA of 3.5 ng/mL. After a lot of deliberation, I thought that nerve sparing prostatectomy is the safest option for long term survival. I am planning surgery in another month (to allow the prostate to heal sufficiently before surgery). Is there anything I can do before the operation that will improve my recovery rate, including control of urinary function (ie the Kegel exercises ?).

Yes, it would be helpful to do the Kegel exercises in advance and to be physically active, especially walking and running.

URINARY RETENTION AFTER SEED IMPLANTS: I had seed implants, and a year later, I have been experiencing urinary blockage. I have been wearing a catheter for the last three months. I have had two Lupron shots six months apart and have been taking Avodart for about 2 months. My Urologist may recommend surgery (TURP) if I do not void soon. Is it advisable to have this procedure after having seed implants?

Sometimes it is the only solution. However, there is a fairly high risk of incontinence. Therefore, the urologist should be experienced and have a high degree of expertise with TURP.

INCONTINENCE FOLLOWING RADICAL PROSTATECTOMY IN PATIENTS WHO HAVE HAD A TURP: I underwent a TURP procedure, and cancer was discovered in 75% of the chips. My PSA after the TURP was 2, and during my last digital exam the prostate was described as soft and boggy. My Gleason score is 7 (4+3). I will probably have to have the prostate removed. What is the likelihood of my being completely incontinent after the RP?

In my experience, very low. In my series, patients who have had a prior TURP have very similar potency and continence results as those who have not.

ARTIFICIAL URINARY SPHINCTER: My husband has incontinence because of prostate surgery. His urologist is talking about putting in a valve for his sphincter muscle. Do you have any drawings or explanation of this procedure?

You can find drawings if you search on the internet for artificial urinary sphincter. It consists of a cuff that wraps around the urethra, a pressurized reservoir that holds the hydrolic fluid and a pump that allows the cuff to inflate and deflate so the urine can start and stop. I think they are a great solution for men with severe urinary incontinence, but I would advise you to have the surgery performed by a doctor who specializes in that kind of surgery.

I underwent radical prostatectomy a few months ago. I was assured by the surgeon that incontinence would be a problem for a short while, but despite 10 sessions of bio-feedback physiotherapy I still have problems, now mainly of the stress-related variety. Are there any exercises, instruments, implants, machines, or anything that could help towards a full recovery?

I recommend Kegel exercises. Please see my website for more information, and especially my “new patient packet” for how I recommend that they be done. Time is also on your side.

FAILURE OF CATHETER TO COME OUT AFTER RADICAL PROSTATECTOMY: I am 53 and underwent RP 11 days ago (PSA 3.97, Gleason 4+3, clear MRI and bone scan). Attempts by the urology nurse to remove the urinary catheter have failed. I have been told to wait a couple of days and then return to the clinic if the catheter has not “come out by itself”. 1.Why might I be having this difficulty? 2 What can be done?3.Will this reduce my chances of becoming entirely continent?

This happens usually because as the catheter balloon deflates, a ridge forms in the balloon or sometimes the “eye” of the catheter catches on a suture where the bladder and urethra are joined. Attempts to forcefully remove the catheter cause the patient to tighten his muscles, with the result being that the catheter is “grasped” more tightly. With time, the catheter will work free and slide out. It does not affect the prospects for normal urinary continence.

PERSISTENT INCONTINENCE AFTER RADICAL PROSTATECTOMY: I had RP done at 57 yrs of age (PSA 5.5/GL 3+3). Was totally incontinent for 3+ months. Then, urologist put me on Detrusitol 4mg daily, this allowed me to return to work later. Recovery was around 65%. My urologist said that if I could stop/start passing water (which I could do) I’d get continence back, but on next visit 3 months later, he mentioned artificial sphincter option after telling him I was still at 65% incontinence recovery. He then put me on Cystrin which improved me more at first, had little fluid loss (still wearing pad. Do you think I can regain my continence at some point in the future? Would continuing medication help me to return to continence under my own steam? (Cystrin makes mouth even more dry + mouth ulcers). Also, sphincter not without its probs too? Can you advise?

Although anticholinergic drugs help patients who have an unstable bladder, they cannot cure incontinence due to sphincter muscle weakness. Kegel exercise are helpful in strengthening the muscle. Continence usually gets about as good as it is going to be by 18 months after surgery. If really bothersome incontinence persists after that time, I usually advise the patient to consider an artificial urinary sphincter.

I am taking tamsulosin (Flomax), and it does seem to be helping with frequent urination during the day. However, I am still having problems with incontinence at night. It happens two or three times per week on an irregular basis. I cannot determine a pattern other than it seems to occur when I wake up with an erection. I don’t drink anything after dinner and retire about 10 p.m. I am totally unaware that this is happening. I just wake up and I am wet. I don’t know if I am just “leaking” at night or if it is a case of full-blown urination. Sometimes I am wetter than others. As you can imagine, this is quite depressing and demoralizing. What are your thoughts?

Having a very large prostate prevents you from emptying your bladder completely. During the day, when you are awake and alert, you can sense the signal to need to urinate. Late at night, when you are sleeping, you might sleep through the signal, and your bladder might go ahead and empty without your permission. You may need to have a procedure to enable you to empty your bladder adequately. I would suggest the next step would be to schedule an MRI scan of the prostate to see whether there are any regions that are concerning for cancer. Then we could plan the next steps.

While going through a 24-hour urine collection my urination was unevenly distributed in time. The volume I urinate during the day is about 400 mL while during the night I urinate 2,000 mL. On a normal night I get up to urinate five to six times. The only times I urinate during the day is after a nap, if I take one. It seems like for my bladder to fill, my body has to be horizontal.

This is called “nocturnal polyuria.” It is uncommon in children in whom urination occurs mainly during the day when they are drinking more fluids and less at night when they are not. It occurs in about 3% of the older population in whom fluids tend to accumulate in the lower part of the body during the day and at night, when they are horizontal, the fluid gets “dumped” into their kidneys, and they have to urinate frequently. Also, it can be caused by diseases such as diabetes insipidus, diabetes mellitus, congestive heart failure, and sleep apnea. The management may include avoiding fluid intake during the evening, taking any diuretic medication in the afternoon rather than the morning, or taking a medication called desmopressin at bedtime under the regulation of a primary care physician, internist, or endocrinologist.

I had a radical prostatectomy for prostate cancer 12 years ago followed by salvage radiation therapy to the prostate bed one year later. My PSA began to rise slowly over the course of the last 10 years and has been treated with hormonal therapy. My pressing issue, however, has been my bladder. I’ve had severe spastic pain with urgency over the last six months and am voiding small volumes every one to two hours. I have tried bladder relaxing and anti-inflammatory medication with little relief. My urologist performed Botox injections into my bladder; that did nothing but make my symptoms worse. I do not retain urine, and my bladder can’t hold more than 200cc without having to void. The working diagnosis is radiation cystitis. My urinalysis and urine cytology are negative. I started Trental with vitamin E recently. Might you have any recommendations?

There have been numerous studies suggesting there is a benefit of hyperbaric oxygen therapy for radiation cystitis. The first prospective randomized trial (from Sweden: Oscarsson N et al, Lancet Oncol 2019; 20:1602-14) demonstrated that it relieves symptoms and is safe and well tolerated. Fortunately, there are hyperbaric centers in the U.S. that can provide this form of treatment. I have had several patients who state that they improved after hyberbaric oxygen therapy.

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