Management of Post-Prostatectomy
Incontinence (PPI)
Primary Care Conference
2/25/04
MARY JO WILLIS, MS, APRN-BC
CLINICAL ASSOCIATE PROFESSOR
NURSE PRACTITIONER, USIM
OBJECTIVES

Discuss the incidence of incontinence in males
post radical prostatectomy for Prostate cancer

Address the common causes of the
incontinence post prostatectomy

Describe which conservative treatments offer
benefit

Describe the surgical options for treatment
CONFLICTS OF INTEREST

I have not received compensation for this
presentation

I have a personal interest in understanding
what options for treatment exist and what
works.

I wish to thank Dr Wade Bushman for his
assistance with this presentation
CASE STUDY

Patient is a 69 y/o w/m who underwent
retropubic radical prostatectomy for prostate
cancer 4/02.
– Prostate cancer was a moderately aggressive
Gleason 7 found on biopsy after patient had
increased problem with nocturia, frequency
and inability to completely empty bladder. No
incontinence
– PSA history 4.4 in 10/2000, 4.5 in 10/2001,
and 5.0 at the time of diagnosis 4/02
RISKS OF RADICAL
PROSTATECTOMY COMPLICATIONS

Multi-center study of over 1069 men provided
self reported incidence of incontinence,
impotence, and bladder neck contracture
/stricture revealed the following results:
– Incontinence=65%
– Impotence=88.4%
– Bladder neck contracture/stricture=20.5%
– Even though complications of post radical
prostatectomy are common and affects overall
quality of life, most patients would elect the
same treatment again.
Journal of Urology 163,858-864, March 2000
GENERAL MALE POPULATION
URINARY INCONTINENCE

Community population rate on incontinence in
persons over 60 is 15-30%; 10-15% in women;
50% in institutionalized elderly

Prevalence rate on incontinence in men >60 in
Michigan study in 1998 was 19% with
– 34.9% had urge incontinence
– 7.9% had stress incontinence
– 28.9 had mixed
– 28.3% had other
–
Ostomy/Wound Management 44(6), 54-59, (1998)
GENERAL MALE POPULATION
URINARY INCONTINENCE

Study conducted by questionnaire in one county
in Minnesota assessing UI in men >50 in
previous 12 months found a prevalence rate of
23% with:
– 24.9% with stress and urge incontinence
– 40.8% had only urge incontinence
– 30.88% had neither stress or urge
incontinence
– 77.8% rated it as mild and 22.2% moderate to
severe
RISKS FOR PPI

Age

Size and configuration of the prostate

Size and location of tumor

Presence and degree of bladder outlet obstruction
and detrusor muscle dysfunction preoperatively

Surgical technique and skill of surgeon: resection of
neurovascular bundles, bladder neck
preservation/reconstruction

Other studies found no association based upon the
above variables nor cancer stage, tumor grade
CAUSES OF PPI
Injury to bladder
– Bladder instability
– Trigonal denervation (reduced sensitivity in the
trigone with altered voiding sensation)
– Bladder wall damage from longstanding
outlet obstruction or decreased bladder wall
compliance
– Bladder outlet obstruction (BOO) causing
overflow incontinence is rare
CAUSES OF PPI
Injury to the sphincter with
– Difficulty emptying the urethra leading to
post void dribble
– Intrinsic sphincter deficiency/weakness is
most common cause
Sphinter injury, pudendal nerve injury
Ischemia and immobilization by scar,
atrophy
Shortening of the urethra below critical
functional length of 2.8 cm
ANATOMY



There are 2 separate continence zones:
Proximal urethral sphincter (PUS) includes
– The bladder neck, prostate and prostatic urethra to veru
montanum
Distal urethral sphincter –DUS extending from the veru
montanum to the bulbar urethra
– Includes slow twitch intrinsic rhabdosphincter fibers that
sustain urethral lumen tone
– Fast twitch fibers of the periurethral extrinsic skeletal muscle
layer that supplement the activity of slow twitch fibers
– Intrinsic smooth muscle layer that is a continuation of the
superficial layer of the detrusor muscle lining the posterior
prostatic urethra
POINTS OF DAMAGE POST OP






Either the PUS or DUS must be intact to maintain continence
After prostatectomy the PUS is destroyed and continence relies
totally upon an intact DUS
During a radical prostatectomy, the proximal portion of the DUS is
also removed
Continence therefore is dependent on an intact distal sphincter as
well as normal bladder function (capacity and compliance without
detrusor instability)
Any bladder dysfunction resulting in an intravesical pressure that
exceeds that of the distal urethral spincter resistence leads to PPI
Urodynamically based studies point out that sphincter weakness
with secondary detrusor weakness based upon reduced maximum
urethral closure pressure, low leak point pressure and shortened
urethral length lead to incontinence
ANATOMY
PROBLEMS DEFINING
INCONTINENCE RATES



Krane(2000) and Parekh(2003) found incidence post
op to range from2.5-87 % depending on definition,
method and time of data collection
Centers of excellence research indicate overall rates
from 6-20%;70-90% were dry at 1 year
Reported incontinence rates were influenced by the
– Lack of consensus of definition
– Optimal time to assess continence
– Methodology
– Inclusion of pts incontinent prior to surgery
– Variations of operative technique
PPI

Multicenter study: 1990-97
– Immediately after surgery: 81.5%
– 6 months post op status=65.6%)
–53.9% <15ml
–23.2% notice leakage once or less daily
–44% used protection with 27% using pads
–Most commonly used Rx was pelvic exercise
(34%)
PPI


Study by Gomha and Boone(2003) found
– 100% of patients with stress incontinence
– 48% with urgency and urge incontinence
– 42% had delayed first sensation
Study by Chao and Mayo (1995) found
– 57% reported sphincter weakness
– 39% had detrusor dysfunction
– 50% had combined causes
PPI

Findings of Eastham et. al. from Baylor College of
Medicine and The Methodist Hospital
– Continence returned at a median of 1.5 months in pts
treated since 1990 and 95% eventually regained
control
– Patient’s age (less than 70) and technical features of
the surgery significantly improved recovery of
continence (e.g wide resection of 1 bundle substantially
decreased recovery), and increase in functional length
of the urethra improved continence
– Incontinence was largely refractory to conservative
measures
CONSERVATIVE TREATMENT

Urodynamic Testing

Role of Pelvic Floor Exercises
– Commonly recommended
– May be effective when employed in an intensive,
supervised program
– Improved continence at 3 mo (88% vs 56%).
Difference diminished at 1 year (14%).
[Van Kampen et al., Lancet 2000 355(9198):98-102]
– Benefit of office based instruction is questionable
– Sueppel et.al (2001) found that starting PFM exercises
prior to surgery improved outcomes
CONSERVATIVE TREATMENT
INSTRUCTIONS: DIETARY IRRITANTS TO THE URINARY
TRACT
If your bladder symptoms are related to dietary factors,
strict adherence to a diet which eliminates certain food
products should bring significant relief in 10 days.
The proof is resuming your old dietary habits followed by
the return of your symptom complex. Once you are
feeling better, you can begin to add these things back into
your diet, one item at the time. This way, if something
really does cause you symptoms, you will be able to
identify what it is. When you do begin to add foods back
into your diet, it is crucial that you maintain a significant
water intake. Water should be the majority of what you
drink everyday (approximately 1-2 quarts a day). Mayo
Clinic Urology Clinic 11/02
CONSERVATIVE TREATMENT
FOODS TO BE AVOIDED:
**All alcoholic beverages
*Chocolate
*Apples, apple juice
Grapes
*NutraSweet
Guava
Cantaloupe
*Carbonated beverages
*Chiles/spicy foods
**Coffee, tea, (incl decaf)
Vitamin E if powered
Peaches, pineapple, plums
*Citrus foods incl lemons
Tomatoes
Strawberries, cranberries
Onions
Vinegar
Vitamin B complex(B6 okay)
CONSERVATIVE TREATMENT
DAILY DIET SUBSTITUTIONS:
1.
2.







Coffee-acid removed: Kava, cold brewed coffee
Weak or Herbal teas-if free of large amounts of citrus. dunk a
tea bag in water 4 times quickly to color the water. Sun-brewed
tea
3. Carob for chocolate; Ovaltine instead of chocolate drinks
4. Fruit juices: apricot, nectar, pear nectar, papaya, watermelon
5. Late harvest dessert wines
6. Fructose, as in Superose instead of NutraSweet or saccharin
7. Orange or lime peel without white part of rind
8. Pine nuts in place of other types of nuts
9. Consider wheat allergy: breads made of potato, soya, rice flour
10. Vitamins: Vit. C in calcium ascorbate co-buffered with calcium
carbon
CONSERVATIVE TREATMENT

Electomyography (EMG) can be used as an
adjunct when teaching the PFM exercises to
provide visual and audible assessment of the
pelvic floor.
– Low EMG profile is an identifiable risk
factor for incontinence. Can be done
preoperatively to establish risk
CONSERVATIVE TREATMENT

Bladder retraining
– Helpful if detrusor dysfunction is present,
especially with adjunctive anticholinergics
– Useful for urinary urge and frequency
– Patient needs to keep a bladder diary with
information on voiding pattern, frequency
and voided volumes
MEDICAL AND SURGICAL TREATMENT
OPTIONS

Medical: In addition to conservative measures:
– Anticholinergics for detrusor instability

Surgical:
– Bulbourethral Sling
– Artificial Urinary Sphincter
BULBOURETHRAL SLlNG
Northwestern technique – bulbourethral sling
Recent interest in male sling procedures for
post-radical prostatectomy incontinence
 preserve volitional voiding
 quick, simple to perform
PRE-OPERATIVE URODYNAMIC
EVALUATION

Confirm Sphincter deficiency

R/O detrusor instability as cause of
leakage

R/O diminished bladder compliance
BACKGROUND

Northwestern technique (bulbourethral
sling)
– Gore-tex bolsters placed beneath bulbar
urethra, suspended from rectus fascia
– Intraoperative urodynamics
– Goal = analogous procedure to
pubovaginal sling
BACKGROUND
Previous analysis with 12-month follow-up:
 91% cured or improved
 85% 0-2 pads per day
 6% removal rate for infection, erosion
The purpose of this study was to review the long-term
outcomes of the first 95 patients (10/94 to 6/00) who
underwent the bulbourethral sling procedure at
Northwestern.
STUDY MATERIALS AND METHODS

95 patients from 10/94 to 6/00

8 patients deceased at time of questionnaire

71/87 patients completed survey (82% contact
rate)

Mean follow-up interval 4.0 years (0.27-6.55)

Mean age at time of surgery: 69 years (55-81)

Preoperative adjuvant radiation therapy: 9
(13%)
PREOPERATIVE INCONTINENCE
(%)
Complete
20
> 5 pads
40
> 2 pads
98
*Median duration of incontinence: 68 month (range
14-198)
RESULTS AT 4 YEARS
Overall
Sling Intact
Total patients
71
64
Cured (n=25)
35%
39%
Cured/ Improved
73%
81%
(n=52)
0 pads (n=23)
32%
36%
<2 pads per day
62%
69%
(n=44)
POSTOPERATIVE CONTINENCE STATUS:
Non-radiated Patients
12%
U
I
28%
C
38%
Cured (n=22)
Improved (n=28)
Unchanged (n=7)
>2
1-2
50%
30%
0
42%
0 Pads
(n=24)
1-2 Pads
(n=17)
>2 Pads
(n=16)
POSTOPERATIVE CONTINENCE STATUS:
Radiated Patients
14%
14%
C
U
72%
I
14%
Cured (n=1))
Improved (n=1)
Unchanged (n=5)
0
57%
>2
1-2
0 Pads (n=1)
29%
1-2 Pads
(n=2)
>2 Pads
(n=4)
PATIENT SATISFACTION:
Non-radiated Patients
Would you undergo the procedure all
over again?
N
Y
81%
19%
No (n=11)
Yes (n=46)
PATIENT SATISFACTION:
Radiated Patients
Would you undergo the procedure all
over again?
43%
Y
N
57%
No (n=4)
Yes (n=3)
POST-OPERATIVE PAIN
Do you have persistent perineal pain or numbeness?
3%
9%
6%
82%
severe (n=2)
moderate (n=6)
minimal (n=4)
none (n=52)
INCONTINENCE QUALITY OF LIFE
Questionnaire
20%
moderate/severe
impact (n=12)
minimal/mild
impact (n=48)
80%
SLING COMPLICATIONS
no. (%)
Retightening
15 (21)
Sling removal
7 (10)
- infection
6
(8)
-urethral erosion
1
(1)
COMPARISON TO SHORT TERM
Follow-up
Follow-up Duration
12 months
4 years
Cured/Improved
2 or less pads
91%
85%
81%
69%
No perineal numbness/pain
Moderate/severe pain
47.5%
26%
82%
12%
Bolster removal
6%
10%
COMPLICATIONS SUMMARY

Infection/erosion rate=10%
– AUS 6.8%
– Barrett 2000

Revision rate = 21%
– XRT 66%; no XRT 15 %
– AUS 20-40%
– Light 1989; Barrett 1989; Montague 1992; Webster
1992; Singh 1996; Herschorn 1996; Castro Diaz
1997
CONCLUSIONS

Bulbourethral Sling is effective for post-radical
prostatectomy incontinence

Radiation significantly reduced efficacy

Post-operative discomfort resolved in most
patients
ARTIFICIAL URINARY
SPHINCTER

Gold standard for surgical treatment of PPI

First developed in 1947 by Foley; refined in
the 1970s. AMS 800 developed in 1983

AUS implantation usually delayed for 12
months after RP

Men usually seeking this option have
significant incontinence
ARTIFICIAL URINARY SPHINCTER DATA
Gousse et al1 : mean follow-up 7.7 years
0 pads: 27%
very satisfied:
58%
>3 pads: 25%
satisfied:
19%
16% revision rate
unsatisfied:
23%
Montague et al2: mean follow-up 73 months
0-1 pads: 64%
2+ pads: 35%
12% revision rate
very satisfied:
satisfied:
dissatisfied/
28%
45%
very dissatisfied:
10%
ARTIFICIAL URINARY SPHINCTER
DATA
Elliot and Barrett3: 245 of 271 pts (90%) had functioning AUS at 5 years
Complications: Mean follow-up 68.8 months (narrow-backed cuff data)
17% (31 of 184) required a first re-operation
7 required 2nd re-operation
1 required 3rd operation
7% Infection/erosion rate
7.6% Mechanical failure
Quality of Life: Several recent studies have found patient satisfaction
with the AUS in PPI is 85-95% even in the face of revisions and
complications




1. Gousse, A.E., Madjar S., Lambert, M-M, Fishman: Artificial urinary sphincter for post-radical prostatectomy urinary incontinence: long-term subjective
results. J. Urol 166: 1755, 2001.
2. Montague, D.K, Angermeier, K.W., and Paolone, D.R: Long-term continence and patient satisfaction after artificial sphincter implantation for urinary
incontinence after prostatectomy. J Urol 166: 547, 2001.
3. Elliot, D.S., and Barrett, D.M.: Mayo Clinic long-term analysis of the functional durability of the AMS 800 artificial urinary sphincter: a review of 323 cases
J. Urol 159: 1206, 1998.
4. Tse,Vand Stone,A.R. Incontinence after prostatectomy: the AUS. BJU 92(9),2003.
CONCLUSIONS:

Pelvic floor exercises are not helpful for patients
with established SUI

Medical therapy is of limited value

Urodynamic testing is useful to R/O detrusor
instability or diminished compliance

Artificial Sphincter and BUS show similar efficacy.

Artificial sphincter is preferred in patients with
history of radiation and in post-TUPR
incontinence.
CASE STUDY OUTCOME

Initial reaction to incontinence

Patient uses <2 pads per day
– Stress incontinence continues to limited patient’s
hobbies such as golf, tennis and landscaping
– Has limited social events to avoid embarrassment
– PFM exercises were never really beneficial in fact
it worsened the problem after 6 months
– Will not consider further surgery unless the PPI
gets worse.