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

Managing Urinary Incontinence After Prostatectomy Part II: When Conservative Measures Fail

In my last post, I stressed the point that most men will regain continence within 12-18 months after prostatectomy.  I emphasized that although men undergoing prostatectomy should be proactive about pelvic floor muscle exercises to regain their continence more quickly, they should also remain patient because the vast majority of men do reach almost complete if not total dryness after prostatectomy.  For some men, however, this relief from urinary incontinence never comes.  Ten to fifteen percent of men remain significantly wet even years after surgery.   For some of these men, this incontinence requires changing diapers several times per day which ruins their quality of life, destroys their self esteem, and limits their ability to take part in beloved pastimes and activities.  For these men, more aggressive options are available to limit the leakage of urine.  In this post I review the invasive, surgical treatments of urinary incontinence.  I, again, stress that these options should be reserved for intractable incontinence that persists 12-18 months post prostatectomy and beyond.

Urethral Bulking Agents

The least invasive surgical option for refractory incontinence after prostatectomy is the injection of urethral bulking agents.  Such a procedure is performed using a camera to visualize the inside of the urethra and, specifically, the area of the urinary sphincter.  Once this muscle is visualized, a bulking agent (gluteraldehyde crosslinked collagen) is injected endoscopically (through the camera) into the lining of the sphincter.  The idea behind this treatment is to “bulk up” the sphincter, increasing the resistance to urine travelling from the bladder.  Early studies on the use of urethral bulking agents after prostatectomy were encouraging.  One study reported that 58% of men with incontinence who underwent the procedure had either good or at least improved results at a follow up of 10.3 months.  More recent studies were not so positive, however, with reports of complete dryness of 8-17% and social dryness (no more than 1 pad per day) of 38% after multiple injections.  A recent study of over 300 men treated with injectable bulking agents reported that men undergoing the procedure still required an average of up to 3 pads per day.  The same study reported that the therapy was only effective for an average of 6 months, after which another injection was required.  Due to these suboptimal results, bulking agents are generally NOT recommended for men with incontinence after prostatectomy.

Male Slings

A more invasive surgical option for men with incontinence after prostatectomy is the male sling.  While numerous types of slings are commercially available, they all share a common mechanism of action: compression of the urethra.  As with the bulking agents, the idea is to compress the urethra so as to increase the resistance to urine leaking from the bladder.  Unlike the direct injection of agents into the sphincter, however, slings are secured underneath the urethra.  Created as an artificial polyester mesh, the sling is like a hammock which sits under the urethra to serve as a backstop and provide gentle pressure to restrict urinary leakage.

Various versions of male slings date back to the late 1990s.  The first male slings were fashioned after slings used for female incontinence during the same time period.  The hammock portion of the sling was connected to sutures (strings) that were pulled out above the muscles of the anterior wall of the abdomen (the muscles referred to as a “six pack” in those of us who work out).  The sutures would then be tied above these muscles(but below the skin) to secure the sling in place.  The whole procedure could be carried out through a small incision underneath the scrotum and another, even smaller, incision just over the bladder.  A study evaluating men undergoing this early version of male slings reported complete dryness in 56% and satisfaction in 90% of men undergoing the procedure.

This early version of the male sling was refined in 2001 with the development of the bone-anchored sling.  This new variant avoided passing sutures through the abdomen (and the associated risk of damaging the bladder and intestines) in order to secure the sling.   Instead, this new sling was secured in place under the urethra via sutures that were actually anchored into the pelvic bones adjacent to the urethra.  Success rates reported with the bone anchored sling have been variable, ranging from 37-87%, depending on the definition of complete continence. 

      

 Diagram of a Bone Anchored Sling

More recently, yet another version of the male sling has been developed.  This version is called the Transobturator (or AdVance) Sling.  The sling, also placed under the urethra for compression, is secured by passing it through a canal within the pelvic bones.  As such, the synthetic material is passed through an incision underneath the scrotum and out of another incision in the inner thigh (just underneath the groin crease).  The sling is then cut at the skin surface of the incision in the thigh so it is not visible after surgery.  The results of this technique mirror those of the bone anchored sling.  The transobturator sling and bone anchored sling

are currently the two most commonly used slings for incontinence after prostatectomy.

                                       Diagram of a Transobturator Sling

Like any other surgery, implantation of the male sling can result in complications.  Urinary retention can sometimes be experienced (3%) if the sling is made to tight, requiring a subsequent surgery to loosen or remove it.  Because the sling is a foreign object within the body it can become infected (6%) or can actually erode into the urethra (2%).  Either of these complications requires a repeat operation with complete removal of the sling.

Artificial Urinary Sphincter

Although more invasive then urethral bulking agents or male slings, the artificial

urinary sphincter (AUS) remains the gold standard for men with persistent incontinence after prostatectomy.  The AUS is composed of three interconnected parts.  The main part of the device is comprised of an inflatable cuff which is wrapped around the urethra (in the same location as where the male sling is usually placed).  The cuff is connected to a reservoir (containing fluid) that is implanted in the abdomen and a pump that is implanted in the scrotum.  At baseline, the cuff encircling the urethra is inflated with fluid.  As such, the cuff compresses the urethra, preventing leakage of urine from the bladder.  However, when the patient pushes on the pump within the scrotum (which can be manipulated through the skin), fluid from the cuff is transferred to the reservoir.  When all of the fluid is transferred from the cuff to the reservoir, the cuff is deflated and no longer compresses the urethra.  This allows urine to flow from the bladder and out of the penis. The fluid in the reservoir drains back into the cuff after a fixed period of time, inflating it and allowing it to compress the urethra again.  The whole process is carried out via hydraulics. 

Diagram of Artificial Urinary Sphincter

The advantage of the AUS is that it replicates normal continence.  Men with the AUS remain dry until they want to void at which time they activate the device, allowing the urine to drain for a set period of time.  Success rates with the AUS have been notable.  Initial studies reported complete dryness ranging from 79-100% with one study finding a decrease in pad usage from 2.7 to 1 per day.  More recent studies have demonstrated social continence (up to 1 pad per day) of 58-88%.  There are some drawbacks, however.  First, any man that wants an AUS needs some level of manual dexterity that will allow him to operate the pump in the scrotum.  In addition, as with all machines, the device can and does break down (6% rate over 5 years), requiring the parts to be removed or replaced through further surgery.  Other complications associated with an AUS include infection (5.5%) and erosion into the urethra (6%).  As with the male sling, either of these two complications requires removal of the device.  Another potential complication is  recurrent incontinence.  This complication usually occurs due to urethral atrophy, which prevents the cuff from successfully compressing the urethra.  In this situation, a repeat procedure is performed in which a second (tandem) cuff is added to provide additional compression of the urethra.

Take Home Message

While most men will eventually regain continence after prostatectomy, some will continue to have moderate to severe, debilitating leakage.  Fortunately, men with this complication still have hope in the form of surgical techniques.  While minimally invasive and creating the least risk, urethral bulking agents are not very effective and generally not recommended for the treatment of incontinence after prostatectomy.  Male slings, although somewhat more invasive have been demonstrated to have significant efficacy and are being used more and more commonly for mild to moderate incontinence.  The gold standard, however, remains the artificial urinary sphincter.  Although not a panacea and definitely plagued by its own risks and complications, the AUS has provided reliable dryness for men with moderate to severe incontinence after prostatectomy.  Regardless of the technique chosen, the decision to proceed with surgical management should be considered carefully after thoroughly weighing the risks and benefits with a qualified urologist.  This decision should not even be considered until at least a year after surgery.

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

Managing Urinary Incontinence After Prostatectomy Part I: Be Proactive But Patient

One of the more notorious complications of radical prostatectomy is urinary incontinence.  Ranging from a few drops to complete lack of control, leakage of urine after prostatectomy can be a debilitating side effect that has a dramatic impact on quality of life.  Reading numerous posts from men on various prostate cancer forums, I got the impression that many men feel that urinary leakage after prostatectomy is inevitable, permanent, and devastating.  In reality, the presence, extent, and timing of urinary incontinence is highly variable and, to a significant extent, can be successfully managed.  In this post I will explain who should expect to have urinary incontinence after prostatectomy, how long such leakage usually lasts, and how to prevent and treat it. 

Who Experiences Urinary Incontinence After Prostatectomy?

The reported rates of urinary incontinence after radical prostatectomy are variable at best.  Studies have reported rates of urinary incontinence between 3 and 74%.   One reason for this tremendous disparity is the definition of “dry.”   While some studies categorized men as dry if they did not use any pads after prostatectomy, others were more lenient, designating men that use 1-2 pads per day as dry as well.  Other studies did not even rely on pad usage and simply asked men whether they subjectively felt wet or dry. 

In truth, immediately after surgery, most men will leak urine.  When the catheter is removed, the majority of men will require pads or diapers, if even for a short period of time.  The reason for this initial leakage has to do with damage to the urinary sphincter, the main mechanism for controlling urination.  During prostatectomy, this muscle complex, which is located near the tip of the prostate, is damaged to varying degrees.  As a result, when the catheter is removed soon after surgery, the debilitated sphincter is often not strong enough to control the flow of urine from the bladder, particularly during times of increased abdominal pressure while coughing, straining, or lifting heavy objects. 

While most men will leak immediately after a prostatectomy, studies have demonstrated that some men are more prone to significant incontinence than others.  Older men, for example, are more likely to leak, presumably due to less muscle mass in their sphincters as compared to those of younger men.  In addition, overweight men are more likely to suffer from incontinence.   As I mentioned in my post about obesity and prostate cancer   (http://myprostatedoc.blogspot.com/2011/04/prostate-cancer-and-obesity-deadly.html), overweight men pose a technical challenge during surgery, making damage to the sphincter and subsequent leakage more likely.  Similarly, men with larger prostates and those with more aggressive cancers have been shown to develop urinary incontinence more frequently, also due to the fact that their more challenging anatomy can increase the risk of damaging the sphincter during surgery.  Of course, while such risk factors may increase the risk of incontinence after surgery, they by no means guarantee it.

Despite the tremendous variation as to the incidence of incontinence reported after prostatectomy, there appears to be a consensus about its resolution.  Fortunately, the majority of studies demonstrate that most men eventually regain control of urination after surgery.  These studies report a progressive return of continence over time with 51-71% of men regaining urinary control after 3 months, 70-87% enjoying continence after 6 months and 80-92% reporting dryness at 1 year.  While this data does not provide solace for the minority of men that don’t reach continence, it does provide evidence that incontinence after prostatectomy needs to be approached with patience.

Managing Incontinence After Prostatectomy

Although most men will regain continence after prostatectomy, a proactive approach can significantly decrease the time to reach this sought after dryness.  The best way to ensure a quicker path to continence is to strengthen the sphincter.  Like any muscle in the body, the sphincter becomes stronger and more efficient if it is exercised.  In a sense, men need to take their sphincters to the gym.  The main exercises developed to “work out” the sphincter are the Pelvic Floor Muscle Exercises (PFME).  These types of exercises are better known to women as “Kegels.”  These exercises are performed by trying to stop urinary flow once it has begun.  Once men identify the muscles needed to accomplish this task, they can then perform the exercises even when they are not urinating. 

Some men find it difficult to identify the exact muscles they need to exercise.  For these men, biofeedback therapy may be appropriate.  This therapy involves placing a probe in the rectum, which can measure the force with which the sphincter is contracted during PFME.  Through such a device, a therapist can provide feedback to the patient as to whether they are contracting the right muscles.   After such biofeedback, patients can be more confident that they are performing the PFME correctly.  However, studies have not demonstrated significant differences in continence between men undergoing biofeedback versus those treated with PFME alone.

The more PFME that can be performed on a daily basis, the better.  Urologists generally recommend a hundred or more a day.  Studies have demonstrated significant decreases in the time to continence in men performing such exercises after surgery.  In fact, randomized studies demonstrated that 74-88% of men regularly performing PFME were dry 3 months after prostatectomy as opposed to only 30-56% of men who did not perform the exercises.  Interestingly, these same studies did not demonstrate a significant difference in continence between the two groups at 1 year after surgery, signifying that while PFME can decrease the time to continence, most (although certainly not all) men will achieve dryness by 12-18 months after surgery, regardless.

Preventing Incontinence Before it Starts

While PFME performed after prostatectomy have been demonstrated to decrease the time to continence, this benefit is even more dramatic for those men that start to perform the exercises prior to surgery.  A randomized study of 118 men undergoing radical prostatectomy, for example, compared continence rates at 1 and 3 months after surgery for those men starting PFME 1 month prior to surgery versus those starting these exercises postoperatively.  The study demonstrated that men starting PFME prior to surgery were only 40% as likely to have incontinence at 1 and 3 months after surgery as compared to those men that did not start the PFME until after prostatectomy. 

Another way to prevent or at least limit incontinence after prostatectomy is through nerve sparing prostatectomy.  Investigators have suggested that the nerves around the prostate may not only provide nerve impulses to the penis (to stimulate erections) but also to the sphincter.  As a result, sparing these nerves during surgery may better preserve nerve signals to the sphincter and maintain its function after surgery.  Such a theory was supported by a study which demonstrated that men undergoing nerve sparing surgery recovered their urinary control twice as quickly (5.3 versus 10.9 months, respectively) as those men who did not have their nerves spared during the procedure.  Of course, the decision to perform nerve sparing is not simple in men with high risk disease for whom the benefits of nerve sparing must be weighed against the potential for positive margins and recurrent cancer.

Take Home Message

Urinary incontinence is a common side effect of radical prostatectomy.  While almost all men suffer from some degree of leakage of urine immediately after surgery, most regain their continence within 12-18 months.  Men with risk factors for incontinence such as advanced age, obesity, high risk disease, and large prostates, need to be aware before surgery that they may be challenged by more severe incontinence for longer periods of time.  All men planning to undergo prostatectomy should learn PFME and begin such exercises prior to surgery.  In addition, when safe and possible, nerve sparing surgery should be performed.  Through such precautions, most men will be able to regain the ability to control their urination more quickly and effectively.  Despite all of these efforts, however, some men have debilitating, persistent incontinence.  After failure of conservative management for 12-18 months (and sometimes longer), appropriately qualified men need to be offered more aggressive, surgical management of their incontinence.  I will cover these options in my next post.

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