Bladder Control after a Prostate Operation

Types of operation

Operations to the prostate gland are of two types, each having its own purpose:

1. partial removal of an enlarged prostate gland, to relieve an obstruction to the flow of urine, and
2. total removal, to cure cancer (for more details about this see the relevant part of the Imperial Cancer Research Fund website).

The vast majority of prostate operations are of the first type. The prostate tissue causing a blockage to the flow of urine is removed, usually in a "keyhole" manner through the penis but sometimes by an "open" operation through the abdomen. After the operation your urine should run freely.

When the operation is done for cancer, the whole prostate gland is removed so that if possible all the cancerous tissue is removed and a cure is achieved. There are often few or no symptoms of incontinence before the operation.

After either type of surgery you may have problems of bladder control, perhaps involving involuntary leakage of urine (urinary incontinence), but this is much more likely after the second, more extensive, operation.

Immediately after the Operation

After the operation a tube (a catheter) will have been left in your bladder in order to drain it. This will be removed after a few days, but the final pattern of urine flow and control may well not become established for a number of weeks after the catheter is removed. This is because the urinary system is not entirely under voluntary control and it takes time to adjust to the new situation. This period can extend to three months or even longer. However, even during this early period, useful treatments are available if you have difficulty controlling your bladder: some are described below.

Once you are discharged home after the operation, you should slowly return to your normal pattern of eating and drinking. You may have been asked to increase your fluid intake initially, but you should be able to go back to your normal level pretty quickly. Some drinks, like tea, coffee and cola drinks, as well as strong alcoholic drinks, cause bladder irritation, and should not be drunk in excess.

You can build up your physical activities gently and progressively, including walking, swimming or any regular activity you used to undertake before your operation. You should be able to go back to your normal pattern within three or four weeks.

Avoid constipation. The best way is by having a diet rich in fibre, including wholemeal bread, bran and plenty of fruit and vegetables. If constipation is a problem, consult your doctor or practice nurse, as excessive straining should be avoided.

After a prostatectomy it is usual for men to cease to ejaculate semen from the penis during sexual intercourse. This is because the ejaculate goes backwards into the bladder rather than coming out of the penis, and it may make the urine look cloudy when next passed. This is not harmful in any way but it usually means that the man is infertile and cannot father a baby. (This cannot be guaranteed, however, so if you were using contraception before the operation, it will still be advisable afterwards.)

If you experience burning or pain when you pass urine, or if the urine is cloudy, or if it smells unpleasant, it is possible that you have a urine infection. You should see your doctor, who will usually ask for a urine specimen to be tested, and may prescribe an antibiotic.

It is not unusual to experience some bleeding about ten days to two weeks after prostatectomy. Usually this is of no significance and can be managed by increasing your fluid intake. If it is very marked, however, or you have difficulty passing urine, you should seek nursing of medical advice.

Incontinence as a complication

Urinary incontinence is obviously a serious complication of prostate surgery. It is critical to establish its precise type and severity in order to try to predict its progress and, if need be, to decide on the best treatment.There are five relevant types of incontinence:

1. Passive or persistent incontinence The valve which should keep the urine in the bladder (the urinary sphincter) no longer functions at all. The urine trickles out in a constant and slow stream. The bladder is empty, and there is no remaining ability to control the flow of urine. This type is extremely uncommon after a partial removal, less so after the rarer total removal of the prostate. It may call for a further operation or for permanent management.More details on persistent incontinence.
2. Stress incontinence Urine only leaks when the pressure in your abdomen rises to above a certain level (on coughing, sneezing, lifting, etc). This can be mild, moderate or severe, and will affect you accordingly. Stress incontinence is usually due to a weak, or partially damaged, valve (urinary sphincter) mechanism. For most men it gets better with time following the operation. It may be treated initially (and commonly successfully) by pelvic floor exercises but in rare, severe cases may call for further surgery.More details on stress incontinence
3. Urgency and urge incontinence You feel the need to pass urine suddenly ("urgency") and may not always able to control it ("urge incontinence"). You may well need to pass urine frequently - often in small amounts - and you may be woken at night or may wet the bed while asleep. These symptoms are the result of overactivity by the muscles which squeeze the bladder to empty it. Before the operation, they had to squeeze hard to force the urine past the enlarged prostate gland and they may take time - even several months - to adjust to the removal of the obstruction. (If you had urge incontinence beforehand, it may or may not be cured by the operation.) The problem generally disappears over a period of time, but in the meantime useful treatments include pelvic floor exercises, bladder retraining, and drugs called "anticholinergics" which help control excessive bladder activity More details on urgency and urge incontinence
4. Mixed incontinence This is a combination of stress incontinence and urge incontinence and is treated accordingly.More details on mixed incontinence
5. After-dribble The loss of a small amount of urine almost immediately after the bladder has been emptied is common both before and after prostate operations and tends to increase with age. It may be because your bladder does not quite empty, or because urine becomes trapped in the bladder outlet, where the prostate used to be, and leaks out afterwards. This problem usually improves with time but may be helped if you sit down on the lavatory and lean forwards to pass urine, or else if you push up behind the scrotum and massage gently to expel the last few drops. Pelvic floor exercises may also help men control this problem. More details on after-dribble

Passive or Persistent Incontinence

If your incontinence does not get better, mention it to your urologist at your post-operative visit, or if it is severe ask your doctor to refer you back to your urologist without delay so that it can be discussed and investigated further. There are many reasons why you may be incontinent, and it is clearly important to establish which applies in your case so that the correct treatment can be chosen.

Such treatment may be measures to control bladder overactivity, exercises ors (especially if you have persistent stress incontinence) you may be advised to have further surgery, perhaps to implant an artificial sphincter. This can be very successful, but it is obviously an individual decision whether the problem is causing enough trouble to warrant more surgery.

Occasionally the condition is found to be untreatable or else the treatment available is not suitable for you. There are then many different products which may help you to cope with and disguise your problem, thereby enabling you to lead a full, normal life, despite incontinence. Pads and pants, penile sheaths, body-worn appliances and dribble pouches are available for different needs.You will find details in the products section of this site. Some are available on prescription from your GP, others can be obtained via the district nurse or continence adviser (a specialist, usually a nurse, who advises people about continence problems). Your doctor or nurse should be able to tell you how to contact your local Continence Adviser, as can the Continence Foundation Helpline.

A useful book, Coping Successfully with Prostate Problems, is available through the Continence Foundation Book Service