Persistent urinary leakage following prostate surgery (e.g. open, robotic or laparoscopic prostatectomy for prostate cancer, TURP, HoLEP) can occur in up to 40% of men. Some men do not find this bothersome but when they do, it is important to seek help as it can be treated.
What symptoms will I have?
Urinary leakage following prostate surgery may be related to an overactive bladder (OAB), stress incontinence or to a combination of both. Symptoms include:
Needing to pass urine very frequently (it is thought that passing urine up to 8 times during waking hours is normal)
Waking from sleep to pass urine in the night
The sudden desire to pass urine which cannot be deferred, known as urgency
Urine leakage/incontinence if you cannot reach the toilet in timeUrine leakage/incontinence when coughing/sneezing, walking or being active (e.g. walking up and down the stairs, gardening or playing golf
What tests will I need?
Following a thorough history and examination, you may be asked to have the following tests:
A urine sample will be taken to rule out an infection
A flexible cystoscopy link to ensure there is no scarring within the waterpipe (urethra) and at the junction between the bladder and waterpipe.
A videourodynamic study link to differentiate between stress incontinence and OAB.
You will also be asked to complete a bladder diary and a 24-hour pad test (see below)
How do I complete a 24-hour pad test?
A part of your urinary incontinence evaluation includes an assessment of the quantity of urine you leak in one day. Please follow the instructions below
What you will need to perform this test:
2x water-tight bags e.g. sandwich bags or ziplock bags
Your regular pads
1 dry pad
How will this test be performed?
1. During a 24 hour period prior to your clinic appointment (e.g. from 8 AM to 8 AM) collect every pad you use. Be sure to use the same type pad during this period of time.
2. Place the wet pads into a water-tight bag such as a ziplock plastic bag or sandwich bag. Place one dry pad in a separate water-tight bag ready for your appointment (the same type of pad as those worn for the 24 hours collection).
3. Continue your normal routine during the 24-hour test.
4. Bring the bag containing your wet pads and the bag containing the clean dry pad (in a separate ziplock bag) with you on the day of your clinic appointment.
What will we do with the pads?
The wet pad(s) will be weighed and the dry pad will be weighed separately. The dry pad weight is multiplied by the number of wet pads worn over the 24-hour period. By taking away the weight of the dry pad(s) from the wet pad(s), a calculation of how much urine leaks over a 24 hours period can be made. If you prefer, you can calculate the pad weights at home using a sensitive digital weighing scale which can take measurements in grams.
Alternatively, you could weigh the pads at home and e-mail us the measurements at xxxxxxx.
What treatment options will I be offered?
If your leakage is related to OAB, you will be offered the treatments for OAB. If your leakage is related to stress incontinence, you could be offered any of the following options depending on how much leakage you have and how bothered you are by it. Sometimes, you may need a combination of treatments for OAB and stress incontinence.
this includes looking at your fluid intake and output to see if any changes can be made to what, how much and when you are drinking to improve your symptoms. You will also be asked to perform pelvic floor exercises link
Medication: duloxetine is a selective serotonin (5-HT) reuptake inhibitor which works by increasing the tone of the sphincter in the urethra (waterpipe). Whilst it is often used in the early stages of incontinence following prostatectomy, it has a significant side-effect profile with up to 40% of men stopping the medication due to one or more of the following side-effects: fatigue, light-headedness, insomnia, nausea and dry mouth. If taken, it cannot be stopped suddenly and the dose must be reduced gradually. It is not a recommended long-term treatment for urinary leakage following prostate surgery in men who are fit for surgery.
Urethral bulking agents
this treatment involves injection of an agent (e.g. collagen, silicone or autologous fat) into the join between the bladder and waterpipe (urethra) under local or general anaesthetic. The effect is to increase the resistance to the passage of urine and thereby reduce unwanted leakage. Whilst this treatment is minimally invasive, the impact is short-lived and up to 50% of men will require repeated treatments to see a significant improvement in symptoms. It is therefore only recommended in a limited number of men with post-prostatectomy incontinence.
Male urethral slings: link
this is a minimally invasive treatment which can be performed under a local or general anaesthetic. It is reported to provide improvement in symptoms in 80% of patients with OAB. It is not a permanent treatment and if is successful it needs to be repeated every six to nine months. Whilst a very successful treatment, it does carry some risks, including but not limited to urinary tract infections (20%) and incomplete bladder emptying requiring clean intermittent self-catheterisation (10%).
Artificial urinary sphincter (AUS) link
this operation is currently considered the gold standard treatment for urinary leakage related to a weak sphiuncter following prostate surgery. The device is a prosthetic device which consists of a cuff that is placed around the urethra (waterpipe), a pump which is placed in the scrotum and a reservoir which is placed underneath the abdominal fat and muscle. The whole device is fluid-filled.
When you have a full bladder and the desire to pass urine, the pump in the scrotum is pressed manually which makes the cuff deflate and urine is able to be passed. The cuff reinflates spontaneously after 1 to 2 minutes, providing continence.
The surgery involves an incision in the perineum (the space between the scrotum and anus) and in the abdominal wall, in a similar position to appendix/hernia surgery. Success rates (which means being dry or requiring 1 thin pad per day) of upto 92% have been have been reported from this surgery.
Whilst this surgery is highly successful, risks include (but are not limited to): device infection or erosion requiring it to be removed (upto 5% per year) and mechanical failure requiring device replacement. The lifespan of the device is considered to be 10-15 years.