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Tuesday, February 13, 2007

Urinary Incontinence

[Updated January 14, 2011]



There are two primary types of Urinary Incontinence (UI) after radical prostatectomy. They are associated with bladder and sphincter valve dysfunction respectively:
  1. Urge Urinary Incontinence (UUI) is caused by excessive bladder pressure or overactive detruser muscles of the bladder resulting in frequent urination, and sometimes loss of urine at night. A 5 minute video discussing this mechanism can be found here

  2. Stress Urinary Incontinence (SUI) is caused by nerve or muscle damage to the sphincter (valve) and results in loss of urine during coughing, straining, or vigorous physical activity. One study [PMID: 9751344] found that SUI represented the overwhelming majority of post prostatectomy cases.

Other types of UI, such as Overflow Urinary Incontinence exist but are not commonly the result of prostatectomy although sometimes pre-existing conditions begin to manifest themselves or become more apparent after prostatectomy. The above two types of UI are nicely summarized in the table at this link which the reader should view now: [Malecare Incontinence Table]. There is also a similar table in the article at this link: [Bus Brief: NA Pharm 2004, 2:106-110]. Attention to symptoms and urodynamic testing can distinguish between the particular causes of UI and determine whether there is a single cause or multiple causes.

Additional information may be found in the article by Leach: [PCRI Insights 2004:5, 7:2] and somewhat more technical articles: [CMAJ 1999;160:78-86] and [Stone and Nelson].

Recovery Time

"Early recovery of continence was related to the blood loss volume and the surgery period. Adequate surgical experience and a meticulous technique to avoid excessive bleeding are important factors for an early recovery". [JJCO 2004, 34:274-279]. Damage is usually temporary clearing up several weeks to 18 months after surgery. Should UI continue past 18 months it can be assumed to be permanent and other actions can be taken to address it. Additional information is provided on recovery in Post RP Urinary Incontinence Progression.

Treatment

Since the causes of urinary incontinence are often multiple its generally worthwhile to attempt simple non-invasive approaches. We discuss these under the headings: (1) Pelvic Floor Exercises, (2) Reducing bladder irritants (3) Reducing Fluid Intake and (4) Observation then discuss the main options for urge urinary incontinence (drugs) and stress urinary incontinence (surgery). The simple steps should not be discounted just because they are simple as they may have significant beneficial effects. One patient who had suffered incontinence reported that physiotherapy for his knee, unrelated to incontinence but likely also exercising the muscles involved in incontinence exercises, also appeared to improve his incontinence showing that even long term sufferers can benefit.

Pelvic Floor Exercises

Pelvic floor exercises reinforced with biofeedback and anatomy education were given to 50 post prostatectomy patients. In that group only 10% were incontinent after 3 months and 4% after 1 year vs. 44% and 17% for a set of control subjects. [Evid Based Nurs 2000:3, 122]

Incontinence After Surgery with and without Training

In that study the exercises were performed after catheter removal; however, performing them prior to the operation, as well, is generally recommended. These exercises should not be performed while the catheter is in nor for several days afterward removal.

A 2008 Norweigan study concluded that patients receiving physiotherapist-guided training throughout the year following surgery reduced urinary incontinence significantly compared to self-guided patients.No difference was seen at 3 months but after 6 and 12 months the group with physiotherapist-guided training were more likely not to require pads. [PMID: 18448233] .

A study published in 2011 JAMA concluded that 8 weeks of pelvic floor muscle training and bladder control strategies reduced incontinence episodes from an average of 28 er week to 13 per week even among those who had been incontinent for over a year. The addition of biofeedback and pelvic floor electrical stimulation did not result in greater effectiveness. [Full text] [PMID: 21224456] [Prostate Cancer Infolink Blog review].

Pelvic floor exercises work by strengthening the external sphincter muscles (the internal or proximal sphincter is the one at the bladder neck where the urethra exits the bladder and enters the prostate and the external or distal sphincter is the valve on the opposite side of the prostate from the bladder where the urethra exits the prostate downstream from both the bladder and prostate) reducing or eliminating leakage. Greater leakage later in the day is syptomatic of muscle fatigue in which case such exercises would be particularly expected to help. The exercises are described on many web sites including the following:
  • UHN Guide. Look for the link to pelvic floor exercises on this page [Guide]
  • Australian pharmacy association. See pelvic squeezes section near end of: [Guide]
  • Australian government [Guide]

  • Northern Lincolnshire Pelvic Floor Exercise Handout [Guide]

  • In the July 2006 issue of the Queensland Prostate Cancer News [link], Peter Dornan describes four levels of incontinence exercise to be adopted successively:
    1. three exercises which simulate control of flatulence, control of urine flow and control of perineal (between anus and scrotum) area muscles
    2. integration of pelvic and abdominal muscles
    3. retraining of reflexes
    4. aerobic conditioning to boost the vascular system
  • In the right margin of this article entitled Pelvic Power (taken from Our Voice, 2008, 4(4)) physiotherapist Bill Landry describes 3 pelvic floor exercises and recommends performing them daily for 6 months after the catheter is removed and once or twice a week for the rest of your life after that. They should be performed "in postures/positions where leakage occurs" in order to get maximum benefit.

Reducing bladder irritants

For bladder dysfunction try to relate level of coffee consumption to incontinence symptoms and adjust. [Mayo Clinic]. This link may be helpful in eliminating coffee as an irritant: [How to Give Up Coffee]. A lesser known bladder irritant is diet soft drinks. For more information on incontinence and diet soft drinks see the post [here].

Reducing Fluid Intake

. In a Feb 2008 study Hashim and Abrams [PMID: 18284414] concluded that patients have fewer "urgency, frequency and nocturia episodes if they reduce their fluid input by 25%" and even more so if they reduce fluids by 50% although that latter level is generally hard to achieve. Patients in the study were not prostate cancer patients but more generally patients with overactive bladder; however, there is a possibility that this applies to prostate cancer patients too and its cheap and easy to try.

Observation

A relatively simple step that can make a material difference is observation -- either simple observation or even better, observation plus measurement. In Stop the Leak (pages 8 and 9) Emmi Champion, a urodynamic nurse says: "What if you were told that by using some simple self observation skills that you could cure or improve incontinence?" Keeping an intake and voiding diary (a sample form is shown at the end of Champion's article or see this voiding diary) "can be an eye-opener and will help you understand how you function."

A patient, John Tobin, had this to say about this experience with observation:
"Getting proactive makes a big difference. I spent two months just waiting for the problem to go away. I'd been using 1 or 2 pads a day. But very slight improvement. Then I bought an electric scale and resorted to weighing the pads each day to get an idea of relating what I was eating and doing and it made a difference. I came to realize there were distinct times of day when most of the flow happened. Anyway, improvement was actually measureable from then on, though it took two more months before I pronounced myself pad free from the stress incontinence."

Treatment for Urge Incontinence

Urge incontinence is due to bladder dysfunction. Bladder dysfunction may be treatable with anticholinergic, i.e. antispasmodic, drugs. The Pharmacotherapy section of this 2007 Cleveland Clinic article has further discussion of drug therapy. Currently no drug therapy is available for stress incontinence according to Jeffrey Albaugh in an article in the supplement to the May 2007 US Too newsletter.

Treatment for Stress Incontinence

Stress incontinence is caused by sphincter dysfunction. The sling involves a surgical procedure and is described in this article: [Urology Times, 2006/12/01]. According to this comment and [PMID: 17382743] the sling is only effective in mild to moderate cases. [sentence added April, 2007] The artificial sphincter and other treatments are discussed in the previously cited Leach article which is recommended: [PCRI Insight, 2004(5), 7(2)]. Both the sling and artificial urinary sphincter address stress incontinence (where the sphincter is damaged), not urge incontinence (where its a bladder problem). In this viewpoint paper [PMID: 16763622] the authors review the literature and conclude that the artificial sphincter is superior to the sling.

In [abstract] [PMID: 17982438], Comiter provides the following summary:
Stress urinary incontinence in men is usually a result of intrinsic sphincter deficiency following prostate cancer surgery. Active conservative management with fluid restriction, medication management and pelvic floor exercises is indicated for the first 12 months. If bothersome incontinence persists, urodynamic evaluation is indicated in order to assess detrusor storage function, contractility and sphincteric integrity. Standard surgical options include urethral bulking agents, artificial urinary sphincter (AUS) and male sling. Periurethral injection of bulking agents is satisfactory in only a minority of patients, leaving AUS and male sling as the most common surgical treatments. In patients with severe urinary incontinence, AUS seems to have a higher rate of success than the male sling. Furthermore, AUS is indicated in men with detrusor hypocontractility as adequate detrusor contractility is needed to overcome the fixed resistance of the sling. In patients with milder levels of stress incontinence, the two techniques have approximately equal efficacy in the short-to-intermediate term. While current reports of the male sling are generally limited to 1-4 years' follow-up, the infection, erosion, and revision rate for the male sling seem somewhat lower than that for the AUS in appropriately chosen patients.
A March 2008 review [PMID: 18271880] of randomized clinical trials for SUI treatments concluded that Pelvic floor muscle training (PFMT) and other physical treatments, estrogens and duloxetine were better than no treatment. This review did not specifically deal with post-prostatectomy patients but rather SUI patients, in general.

Imipramine. Although anticholinergic drugs, and drugs in general, are normally thought of as addressing urge incontinence rather than stress incontinence, Bob Southard has had good experience with imipramine (also see [wikipedia] and particularly note [cautions]) for stress incontinence. It acts on the bladder neck muscles. (Note that typically the effect of drugs is on the bladder muscles themselves rather than the bladder neck muscles which is why drugs are normally associated with urge, rather than stress incontinence.) The following is quoted with permission:
Quick story... Had my RRP in 1994 at Johns Hopkins, and have had minor incontinence since, usually 1 pad per day. Last year I had a medical procedure that required a catheter. Apparently my bladder was quite unhappy with this, and my incontinence got significantly worse afterward (yes, I warned them). I was starting to get surprised by full pads, leaking pads. I needed 3 and sometimes 4 pads per day.
In December I went to a new urologist, and he prescribed imipramine Hcl 25mg, twice per day. It worked. I went back to 1 pad per day with LESS leakage than before the medical procedure. Note that this is an off label use for this relatively inexpensive generic drug.

I thought, maybe something else was going on, like I had an infection, or some irritation, or whatever. So to be sure, I tried going off the imipramine a few weeks ago. Yep, back the incontinence came. I went back on the imipramine, and it's gone again.

This is the 6th uro I've seen since my RRP, and the first to mention this drug. I ask myself, why are uros not bringing this to patients' attention? There have been many times in the past where it would have been useful to me in circumstances of dealing with a lot of stress incontinence.

I believe that my incontinence is MOSTLY stress incontinence. Typically, my leakage is MUCH worse when I am walking or working on my feet all day, much less when sitting and standing, and nil when sitting. I use no pad at night while sleeping.

So it's mostly stress incontinence, but I do occasionally feel bladder spasms; rarely, but they do occur. I never have sudden onset of the urge to urinate, or other symptoms of urge incontinence.

New Treatments

An article by Allen in Urology Times indicated that an Austrian urologist is having good results in treating stress urinary incontinence with stem cells: [Urology Times, 2005/10/15] [Urology Times, 2007/11/1] [Urotoday, 2008]. In a May 15, 2007 Urology Times article [link] Dr. Raz says that botlinum toxin may be an alternative to anticholinergic drugs for overactive bladder (associated with urge urinary incontinence). This 2007 human study of 23 patients on the effect of RTX on UUI showed that it was effective in about 2/3rds of subjects with refractory urgency (i.e. nothing works). Its not a cure but it reduces the number of episodes somewhat: [link]. Also see this 2004 animal study on the same subject: [link] . Dr. R. A. Appell of Baylor College of Medicine is having encouraging results with calcium hydroxylapatite (CaHA; Coaptite). See: [PMID: 17482925] and this BCM News Release.

A review at the 2007 AUA meeting of new incontinence treatments is given here. (Signup is required but it is free.)

Complementary Therapies

One patient has claimed that eating dry roasted peanuts reduce his leakage at night: [alt.support.cancer.prostate]

Other Resources

This Mayo Clinic article [link] provides a good general overview of incontinence and this Jan 2007 Cleveland Clinic article provides an excellent review of incontinence treatments. A Supplement to the US Too May 2007 newsletter is devoted entirely to urinary incontinence. There are also a number of resources available in the incontinence section of Robert Young's web site: [Phoenix5: Incontinence] or if that link fails then [Phoenix5: Incontinence - alternate link]. There is a presentation on Post-Prostatectomy Incontinence here: [pdf] [flash] and a general presentation on incontinence (skip the first part which is about a Dutch city and has nothing to do with incontinence) here: [flash]. An excellent one page review by Committee 13 at the ICI 2088 conference in Paris presented on July 17, 2008 is availabe [here]. We have also added the Committee 13 Guidelines to the European Guidelines in the right margin of this site for easy reference under the tag [UI]. Although not up to date, an older set of guidelines for managing urinary incontinence can be found here.


Readers may also be interested in this post on Post RP Urinary Incontinence Progression.

1 comment:

Gretchen said...

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