Urinary incontinence, or an inability to control urination, is a common side effect of prostate cancer surgery or radiation therapy. There are four types or categories of incontinence:

• Urge incontinence: This condition is sometimes called an “overactive bladder.” Men with urge incontinence experience a sudden need to urinate and cannot control that urge long enough to reach a toilet.
• Overflow incontinence: Men with overflow incontinence have difficulty emptying their bladders, so urine leaks out when their bladders are full. This condition is frequently caused by the obstruction of the bladder or by weak bladder muscles.
• Stress incontinence: A man with stress incontinence will experience urine leakage when he exerts himself, say by coughing or lifting something heavy. This condition can be caused by damage to the urethral sphincter, the name for the group of muscles that can close off the bladder and control urination.
• Continuous incontinence: Men with this very rare condition lose all ability to control their urine.

Why can prostate cancer treatment cause incontinence?
Simply put, the answer to this question is that, to cure prostate cancer, we need to remove or destroy prostate tissue. And the prostate surrounds the urethra, the tube that connects to the bladder and runs through the penis, allowing for the excretion of urine from the body. Prostate surgery, for example, removes the internal sphincter, which is contained within the neck of the bladder and the upper part of the urethra surrounded by the prostate. This removal makes the control of urination more dependent on the external sphincter---the muscle close to the pelvic floor that men can voluntarily contract to stop their urine flow. Consequently, stress incontinence is more likely. Another risk with prostate surgery is that scar tissue may form at the neck of the bladder where the bladder and urethra have been sewn back together after the removal of the prostate, causing overflow incontinence because of an obstruction. Radiation carries risk too, as it can decrease the capacity of the bladder and cause spasms that force urine out.

How common is it?
This question is difficult to answer because of the various degrees and types of incontinence. Also, some loss of bladder control occurs naturally as we age because our muscles lose their tone and flexibility. The Vancouver Prostate Centre reports the following:

• Surgery (radical prostatectomy):  Most men recover significant bladder control in about 12 weeks, although this control continues to improve over 1 to 2 years. Over 90 per cent achieve excellent urinary control and require no pads. Some men will continue to suffer mild stress incontinence, which does not appear to affect their quality of life, although some choose to wear pads for protection. About 1 to 2 per cent will have persistent, problematic incontinence.
• Brachytherapy: About 50 per cent of men will have moderate urinary obstruction or irritation, but, by 12 months, 90 per cent of men return to their pre-treatment state.
• External Beam Radiation: In about 90 per cent of men, the urge to urinate frequently or urinary incontinence clears up in about 6 weeks. The remaining 10 per cent will have more long-term or even permanent side effects, but these are mostly minor. Less than 1 per cent of men experience permanent and severe urinary incontinence because of external beam radiation.

What treatments are available?
Treatments depend on the type of incontinence and its severity.

Stress incontinence is usually managed quite conservatively, at least initially. Your doctor may recommend that you wear protective pads or garments, make lifestyle and behavioural changes, and do pelvic floor exercises, commonly known as Kegel exercises.

• Lifestyle or behavioural changes can help reduce stress incontinence. These include drinking fewer fluids, while ensuring that you do not become dehydrated; avoiding alcohol, caffeine, and spices; quitting smoking; urinating at regular intervals (or timed voiding) so as to keep the bladder fairly empty; or bladder training, which involves gradually training your bladder to hold more urine by resisting the urge to urinate. Losing weight may also help.
•  Pelvic floor exercises or Kegels work to strengthen the muscles that support the external urinary sphincter.  These are the muscles you would contract so as to stop urinating in midstream. Often, getting a doctor or nurse to help you learn the proper technique is wise. And men sometimes combine Kegel exercise training with a biofeedback program. (For information on how to do Kegel exercises, consult the PCCN article Recover Control Earlier with Exercise  or download the excellent article Pelvic Muscle Exercises—Kegel Exercises from the Canadian Continence Foundation.)

Urge incontinence is frequently treated with medications called anitmuscarinics or anticholinergics or with bladder training:

• Anticholinergics, such as oxybutynin (Ditropan, Ditropan XL, Uromax, Oxytrol), tolterodine (Detrol, Detrol LA), solifenacine (Vesicare), darifenacine (Enablex), and trospium chloride (Trosec), work by blocking the action of nerves that are not under conscious control. So they can help prevent the contractions of the bladder that cause urge incontinence. By relaxing the bladder, they also increase its capacity; so they reduce urinary frequency as well as urgency.
• Bladder training involves resisting the urge to urinate, for an ever-increasing number of minutes, so as to train your bladder to hold more urine.

Slightly more bothersome stress and urge incontinence can be treated with the following:

• Biofeedback instruction offered by health care professionals: This process uses mechanical or electronic equipment to give you feedback regarding how well you are using your pelvic floor muscles.
• Electrical stimulation: This process involves stimulating the nerves that control the bladder so that they contract and you learn how to operate these muscles correctly on your own.

For those men bothered by persistent or severe incontinence, more aggressive treatments are available, for example, the artificial sphincter, the male sling, injections, and balloons.

• An artificial urinary sphincter (AUS) is the “gold standard” treatment for men with persistent and bothersome urinary stress incontinence. Usually, the AUS is made of three parts: a pump inserted into the scrotum, a cuff that surrounds the urinary canal, and a balloon reservoir placed behind the pubic bone. The entire system is filled with fluid and is implanted in the body. (No parts are visible after the surgery to implant the AUS.)  When a man wants to urinate, he squeezes the pump, which is underneath the skin of the scrotum, and this moves fluid out of the cuff and into the balloon reservoir---thus opening the cuff and allowing urine through. The cuff then fills back up naturally, restoring urinary control. According to the Canadian Continence Foundation, approximately 80 per cent of the men who have received this treatment for incontinence are satisfied with the results. For more information, consult an article by PCCN member Doug Scott about his experiences with an AUS: A Device to Restore Urinary Continence after Prostate Cancer Treatment.
• The male sling is usually made of a mesh material, which is surgically implanted under the middle part of the urethra. The sling reinforces the urethra and, when downward force is applied, say because of a laugh, it provides support beneath the urethra that helps it contract and stop leakage. Because the sling is placed loosely, when there is no downward pressure, it doesn’t obstruct the urine flow. Slings may not be available in all areas, and there is less long-term data on the male sling than on the AUS. Also, for men who have had radiotherapy, the sling may be less effective than the artificial sphincter.
• Injection therapy involves injecting material (often collagen) just under the lining of the urethra to “bulk” it up and cause it to close inward on itself, creating a sort of seal in the process. This therapy is not usually a good option for men after prostate cancer treatment. Scar tissue may make the selection of appropriate injection sites tricky, and the benefits are often short-lived because the injected material can be reabsorbed into the body.
• Adjustable continence therapy, which uses balloon implants, is a relatively new therapy for stress incontinence, and it may not be available in all areas. Balloon implants are positioned at the neck of the bladder, and, after they are in place, the amount of fluid in them can be adjusted through injecting or withdrawing fluid via small ports just under the skin of the scrotum. (These ports are connected by tubing to the balloon implants.) The balloons act as a sort of valve, reinforcing the neck of the bladder and helping men to establish urinary control.

For more information, consult the Canadian Continence Foundation website. Especially useful, are these sections of the website:

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