Managing The Catheter After Prostatectomy Part II: After The Catheter Is Removed

In my last post, I explained the need for maintaining a catheter after a prostatectomy.  I also described what to expect with the catheter in place as well as red flags that may signal that something is wrong.  For men undergoing prostatectomy, the catheter can, indeed, be a daunting part of the journey.  Most men are quite relieved when the catheter is finally removed 1-2 weeks after the surgery.  Removing the catheter, however, is just another step in the recovery after prostatectomy.  After the catheter is removed, a whole new set of expectations and warning signals emerge that need to be understood by men after prostatectomy.  In this post, I will cover what to expect and look out for in the period immediately following the removal of the urinary catheter.

The Catheter Comes Out

For most men, the removal of the catheter is a very much anticipated milestone in the journey of recovery after prostatectomy.  The actual process of removing the catheter is not a huge undertaking, although it may appear a little daunting.  As I explained in my last post, the catheter is maintained in place by means of a balloon inflated within the bladder.  In order to remove the catheter, the doctor or nurse will attach a syringe to a port on the catheter and suck out the fluid from the balloon.  Once the balloon is deflated, the doctor can simply slide the catheter out from the penis.  Most patients describe the feeling of the catheter coming out as a “pop” that lasts for 1-2 seconds and then is associated with a feeling of relief.  In some men, the sensation can be more painful and last a little longer.

Some doctors will fill the bladder with fluid through the catheter prior to removing it.  The doctor will infuse water or saline through the catheter until the patient feels full and needs to urinate.  At that point, the catheter is removed and the patient is allowed to urinate.  The reason for this extra step is to make sure that the patient is able to urinate after the catheter is removed.  Other doctors simply remove the catheter and have the patient return if they cannot urinate.  Either way, the process last 1-5 minutes and is usually much less traumatic than anticipated.

What to Expect Post Catheter

1. Leakage:  As I explained in a previous post, most if not all men leak urine immediately after the catheter comes out.  This leakage is due to the fact that the muscle responsible for controlling urination, the sphincter, needs to strengthen after the surgery.  While some men leak only a few drops with heavy activity, others leak profusely without much exertion at all.  Regardless, most men will regain continence within the first year after surgery.  As I mentioned in a previous post, some actions can be taken to expedite the process and regain continence sooner: http://myprostatedoc.blogspot.com/2011/06/managing-urinary-incontinence-after.html
2. Frequent urination:  A prostatectomy is generally very traumatic for the bladder.  First, the plumbing below the bladder is rearranged.  In addition, during the surgery, the bladder is opened and repeatedly manipulated. Finally, the bladder is continuously irritated by the catheter for 1-2 weeks after surgery.  As a result, by the time the catheter is removed, the bladder is usually very irritated.  The same contractions of the bladder that occurred with the catheter in place often continue after it is removed.  These bladder spasms cause the frequent urge to urinate even when not much urine is present.  As a result, men sometimes complain that they are constantly running to the bathroom to urinate after the catheter is removed.  Fortunately, as the bladder adjusts to life without the catheter, this frequency and urgency of urination diminishes.
3. Slight blood in the urine: While in the bladder, the urinary catheter often puts pressure on the bladder and urethra, holding back any minor bleeding from some small veins that may be opened or cut during the surgery.  Once the catheter is removed, these veins may ooze a little.  Also, some old blood trapped by the catheter may be released once the catheter is removed.  As a result, some men do complain of some blood in the urine after the removal of the catheter.  This usually makes the urine look pink or cranberry colored and resolves within a few days.
4. Burning with urination: After a prostatectomy, the urethra and bladder are often “raw” from irritation from both the surgery and the catheter.  As a result, many men do complain of some burning each time they urinate.  This feeling usually goes away after a day or two.

Warning Signs After Catheter Removal

1. Inability to urinate: A small minority of men are unable to urinate after the catheter is removed.  For most men, this problem is caused by swelling at the surgical connection between the bladder and urethra called the anastamosis.  This problem is usually solved by reinserting the catheter and keeping it in for another week or so to allow time for the swelling to subside.  Some doctors also give medicine to help speed up the process.  Either way, with a little time, the swelling usually goes away and the ability to urinate returns.  As I mentioned in my previous post, replacement of the catheter after a prostatectomy should only be performed by the urologist.  Improper placement can lead to a disruption of the anastamosis, an emergent return to the operation room, and a lifetime of incontinence.
2. Significant blood in the urine:  While a small amount of blood in the urine is normal, urine that looks like pure blood is not.  This is especially true if large blood clots are also noted to pass in the bloody urine for a prolonged period of time.  This type of blood in the urine is a sign of ongoing bleeding that needs to be addressed.  Usually, it is due to bleeding from outside the prostate and bladder that is seeping in through the anastamosis.  Without a catheter in place, such bleeding can create a large blood clot (called a hematoma) in the pelvis and actually rip open the anastamosis, separating the bladder from the urethra.  Such a complication can be prevented through early recognition and management of the problem.  Again, such problems after prostatectomy should only be managed by the urologist and not by emergency room staff. 
3. Air or debris in the urine:  Occasionally, after the catheter is removed, a patient may complain of passing some air through the penis when urinating.  While this can be normal for the first few times after catheter removal (because air was introduced into the bladder from the indwelling catheter), sustained air in the urine is definitely not normal.  Similarly, small bits of debris in the urine can be occasionally seen after the catheter is removed.  These bits are old blood clots.  However, continued passage of air and debris in the urine after catheter is a sign of a fistula between the urethra and the rectum.  A fistula is an artificial connection which allows contents from one organ to be passed to another.  In this case, an unrecognized injury to the rectum during a prostatectomy allows a hole in the rectum to attach itself to the anastamosis or a small hole in the urethra.  With time, this fistula grows and matures, allowing more and more air and stool to be passed into the urine from the rectum.  On occasion, urine is also allowed to pass into the rectum, causing diarrhea.  If this problem is not addressed in a timely fashion, the mixing of urine and stool can cause a serious and occasionally life threatening infection.

Take Home Message

The removal of the urinary catheter is an important milestone in the recovery from a radical prostatectomy.  The actual process of removing the catheter is usually very quick and straightforward, resulting in minimal discomfort.  Nonetheless, some common issues should be expected after removal, including leakage and some burning with urination.  In addition, patients having their catheters removed should know about red flags such as the inability to urinate as well as blood, air, or debris in the urine.  Reporting these issues to the urologist expediently can prevent significant problems from becoming dramatically worse.

Check out my new Book: 

   Prostate Doc’s Guide to Life After Prostatectomy

Bladder Neck Contractures After Prostatectomy

Men undergoing radical prostatectomy need to be aware of a potentially serious complication called a bladder neck contracture.  This narrowing at the connection between the bladder and urethra can cause significant symptoms including a slow stream and incontinence.  These symptoms are often ignored until full retention of urine occurs.  In this post I discuss bladder neck contractures, their etiology, and how to treat them.

What is a Bladder Neck Contracture?

The prostate is usually located between the bladder and the urethra.  I often describe the relationship to patients in the following manner: the bladder is like an upside down fishbowl which is connected to a donut (the prostate) which is subsequently connected to a straw (the urethra).  Urine leaving the bladder goes through the donut hole of the prostate and out the urethra.  During a prostatectomy, the prostate is removed, requiring this plumbing to be rerouted.  In order to do this, the “neck” of the bladder, which was previously attached to the prostate, is sewn directly to the urethra tube.  In 2-20% of cases, that connection gets scarred down to form a bladder neck contracture.  The extent of this contracture can be variable, ranging from a mild narrowing to a complete obliteration of the connection.  Either way, a bladder neck contraction can create significant difficulty with the passage of urine from the bladder to the urethra.

What Causes a Bladder Neck Contracture?

While the true causes of bladder neck contractures have not been definitively elucidated, numerous theories have been presented.  The two most popular explanations include:

1) Gaps in anastomosis:  When the anastomosis (the surgically created connection between the bladder neck and urethra) is made during a prostatectomy, several problems can occur.  First, the sutures placed in the bladder or urethra can tear.  Also, bleeding from the surgery can create a large clot called a hematoma which can insinuate itself between the stiches and stretch the anastomosis.  Either of these situations will create gaps in the anastomosis between the bladder neck and urethra.  The human body has a natural tendency to fill gaps with fibrotic tissues or scar.  As a result, gaps in the anastomosis allow scar tissue to form which, in turn, creates a bladder neck contracture.
2) Poor blood supply:  Many urologists have postulated that bladder neck contractures occur due to decreased blood supply to the anastomosis.  Generally, when a tube or connection in the body does not get an adequate supply of oxygen-rich blood, it gets obliterated by scar tissue.  This situation, the theory proposes, is exactly what creates a bladder neck contracture.  So what causes poor blood supply to the anastomosis?  Several factors have been implicated.  First, tying down the sutures connecting the bladder and urethra too tightly can strangulate the blood vessels to the area and decrease the flow of blood.  Others have argued that prostatectomies performed without nerve sparing can also decrease blood supply to the area.  Finally, some men are simply predisposed to problems with blood vessels.  Men with diabetes, high cholesterol, and heart disease, for example, demonstrate poor blood flow to all parts of the body, including the anastomosis.  Not surprisingly, older men (who are more prone to problems of blood flow) are more likely to experience bladder neck contractures than their younger peers.

What are the Signs of a Bladder Neck Contracture?

Men usually start to experience symptoms from a bladder neck contracture between 3-6 months after surgery.  The initial symptom in most men is a subtle slowing of the urinary stream.  This symptom is often ignored until it gets substantially more dramatic.  Often times, men actually complain of urinary incontinence after a period of dryness following radical prostatectomy.  This leakage is due to the overflow of urine from a bladder distended with urine that is barely able to escape into the urethra.  Eventually, if left unattended, bladder neck contractures lead to complete urinary retention.  Unable to urinate, men present to the emergency room where doctors and nurses are usually unable to negotiate a catheter into the bladder due to the narrowing from the contracture.  At this point, an urologist needs to be called to provide treatment.

How Are Bladder Neck Contractures Treated?

Men complaining of symptoms suggestive of a bladder neck contracture first need to be evaluated with a cystoscopy.  This procedure, done in the urologist’s office with local anesthesia, involves passing a flexible camera through the penis and towards the bladder.  With this camera, an urologist can tell if there is any scar tissue creating a blockage at the anastomosis between the bladder and urethra.  In addition, he can determine if there are any other problems in the bladder or urethra that could be mimicking these symptoms.

If a bladder neck contracture is confirmed during an office cystoscopy, a decision then needs to be made to determine how to proceed.  One option is to perform a gentle dilation at that time under local anesthesia.  A dilation is performed with the use of a variety of tubes of varying diameters.  The urologist starts by passing the smallest tube through the contracture and into the bladder.  He then stretches the contracture by passing larger and larger tubes through it until a catheter (like the one in place after prostatectomy) can be successfully placed in the bladder.  This catheter usually stays in place for a few days and is then removed.

 Although definitely tolerable, a dilation performed under local anesthesia can be uncomfortable.  As a result, some men choose to have their bladder neck contractures treated in the operating room under more extensive anesthesia.  In the operating room, more extensive procedures can be offered besides just dilation.  For example, a larger camera can be advanced to the location of the contracture and a knife (within the camera) can be used to cut the contracture.  This procedure also requires a catheter for a few days.

Regardless of which procedure is chosen, bladder neck contractures are successfully managed with a single treatment in 60-80% of cases.  Some men, however, have very tough contractions that recur soon after treatment.  For these men, more aggressive operative therapy is needed.  One such therapy involves aggressively and deeply cutting the contracture with a hot knife, also through an endoscopic approach using the camera.  If this does not work, some surgeons use a permanent, metallic stent (called Urolume) which can be deployed across the contracture.  These aggressive treatments usually lead to significant incontinence.  As a result, most men that are successfully treated with such aggressive options subsequently also need to undergo placement of an artificial urinary sphincter (AUS) to help them overcome the leakage of urine.  I describe the AUS in detail in my previous post on surgical options for urinary incontinence after prostatectomy: http://myprostatedoc.blogspot.com/2011/06/managing-urinary-incontinence-after_26.html

Take Home Message

Bladder neck contractures develop in a small proportion of men undergoing radical prostatectomy for prostate cancer.  Presenting 3-6 months after surgery, this scar tissue at the connection between the bladder and urethra often causes slow stream and occasionally retention of urine.  In some men, it can also cause urinary incontinence.  Men with these symptoms after prostatectomy should seek expedient evaluation and, if necessary, treatment for bladder neck contracture from their urologist.  Such proactive management can save a great deal of potential stress and discomfort during a late night visit to the emergency room .

Check out my new Book: 

   Prostate Doc’s Guide to Life After Prostatectomy

This blog is not a medical practice and cannot provide specific medical advice. This information should never be used to replace or discount the medical advice you receive from your physician