Watch: Urologist and Continence NZ President, Dr Anna Lawrence, is joined by Prostate Cancer Foundation of New Zealand CEO Graeme Woodside for a chat about the prostate and urinary incontinence.

Continence management following surgery for prostate cancer

Bladder weakness, or urinary incontinence, is experienced by many men following surgery for prostate cancer. This is a common problem, however many men find this the biggest challenge they have to cope with during the recovery process.

Most men regain their bladder control over time and are fully recovered within 6 to 12 months. But it is important to get professional advice to help cope with bladder weakness during this time. This page will provide you with helpful ways to improve and manage your incontinence following prostate surgery.

What is incontinence?

Incontinence refers to the accidental leaking of urine, which often happens during physical activity. The volume of urine leaking can vary from a small to a large amount. Understandably, most men find it highly embarrassing and difficult to talk about, even with their partners.

Many men think that they must manage their incontinence by themselves and feel frustrated and alone in trying to deal with the problem. Men are also often anxious about others knowing about their condition and may avoid social activities in case they risk being 'found out'.

If incontinence is causing you any problems or getting you down, you should talk to your doctor or contact the Continence NZ Helpline on 0800 650 659.

Continence NZ can advise you about the most appropriate health professional to see and put you in touch with a local continence service who can help.

Why does it happen?

The prostate gland is a male reproductive organ. It is about the size of a walnut and sits at the base of the bladder. The thin tube (urethra) that carries urine and semen out of the penis runs through the centre of the prostate gland. At the point where the bladder and urethra join, there is a ring of muscles, known as the bladder neck sphincter, which opens and closes like a camera shutter. The bladder neck sphincter is closed most of the time to prevent urine leaking out but when it gets permission from the brain, it opens to allow urine to be passed.

Another (external) sphincter is part of another set of muscles below the prostate called the pelvic floor. These muscles are also involved in bladder control. If the bladder neck sphincter is damaged during prostate cancer surgery, the pelvic floor muscles are now relied on to control the bladder more often. If the pelvic floor is weak you may experience urinary incontinence.

What are the symptoms?

Urinary incontinence usually occurs when you undertake activities that increase the pressure inside the abdomen and push down on the bladder. If the pelvic floor muscles (external sphincter) are not working well, urine will leak out. This is known as 'stress incontinence'. Typical activities that can cause leakage are coughing, sneezing, shouting, laughing, lifting, walking, bending, pushing, pulling and moving from lying to sitting or sitting to standing positions. Leakage can also occur with everyday activities such as gardening, sport and exercise.

Will it go away by itself?

Incontinence will usually improve with time but by learning how to control the pelvic floor muscles, you can speed up the recovery process and reduce the leakage faster. If you don't strengthen these muscles, the leakage may persist.

What are the pelvic floor muscles?

The floor of the pelvis is made up of layers of muscles which stretch like a hammock from the tail bone at the back to the pubic bone at the front. Pelvic floor muscles play an important role in bladder and bowel control. A man's pelvic floor supports the bladder and the bowel. The urethra and rectum (back passage) pass through these muscles to the outside. By doing pelvic floor exercises, you can strengthen these muscles and improve bladder and bowel control.

Regaining control

There are several things you can do to help regain control over your bladder:

Exercise your pelvic floor muscles

Performing pelvic floor muscle exercises after prostate surgery is vital to your recovery as it is these muscles that help you control your bladder. It is recommended that you seek help from a continence physiotherapist, continence nurse advisor or urology nurse to learn the correct technique.

Identifying your pelvic floor muscles

The first step in performing pelvic floor muscle exercises is to identify the correct muscles. There are several ways to identify them.

• When you go to the toilet, try to stop or slow the flow of urine midway through emptying your bladder. If you are able to do this you are squeezing the correct muscles. Do not do this repetitively. This is not an exercise, but a way to identify the correct muscles. In the early stages after prostate surgery, this will be easiest during the night when the flow is likely to be strongest.
• You can do the exercise lying down, sitting, or standing with your legs apart, but make sure your thighs, bottom and stomach muscles are relaxed.
• Stand in front of the mirror (with no clothes on) and tighten your pelvic floor muscles. If you are tightening the right muscles, you should see the base of the penis draw in and scrotum lift up. The back passage will tighten too but it is not the focus of the exercise. When you relax your muscles you should feel a sensation of 'letting go'.

Correct technique is very important when doing pelvic floor muscle exercises. You should feel a 'lift and a squeeze' inside your pelvis. The lower abdomen may flatten slightly, but try to keep everything above the belly button relaxed, and breathe normally. A continence physiotherapist, continence advisor can help if you have trouble identifying your pelvic floor muscles.

Factors that may cause pelvic floor muscle weakness:

• Pelvic surgery
• Obesity
• Smoking
• Heavy lifting
• High impact exercises
• Chronic coughing
• Constipation
• Chronic low back pain

Pelvic floor muscle training

Once you master the art of contracting your pelvic floor muscles, try holding the inward squeeze for longer (up to 10 seconds) before relaxing. If you feel comfortable doing this, repeat it up to 10 times. This can be done three times a day. Make sure you continue to breathe normally while you squeeze in.

Many men find it difficult to remember to do their pelvic floor exercises. Linking the exercises to a regular activity such as mealtimes or brushing your teeth is a good way to incorporate them into your daily routine.

Putting the pelvic floor into action

Every time the pressure in your abdomen increases you are potentially pushing urine out of the bladder. Identify the activities that cause urine to spurt out such as coughing, standing up or lifting, and tighten your muscles first to prevent urine escaping. Practice this control until it is automatic. This is called 'the knack'.

You should also try to use your pelvic floor muscles throughout the day. Some examples of when you could use them are:

• While walking - try lifting your pelvic floor about 50% of the maximum squeeze.
• When you feel the urge to pass urine - squeeze your pelvic floor to hold on until you get to the toilet.
• After you have passed urine - tighten your pelvic floor, which may help prevent the embarrassment of an after-dribble leak of urine as the squeeze expels the last few drops of urine from the urethra.
• After opening your bowels - tighten around your back passage.

When should I start these exercises?

Ideally, you start doing pelvic floor muscle exercises 4 to 6 weeks prior to surgery to get into the habit of incorporating them into routine activities such as exercising. But even one day before surgery is beneficial.

Doing pelvic floor muscle exercises after surgery (while a urinary catheter is in place) can irritate the bladder and cause discomfort. It is therefore recommended that you do not do any exercises during this time. However, once the catheter is removed you may start the pelvic floor exercises straight away. Once you identify your pelvic floor then start working on 'the knack'. Also, identify 2 to 3 regular times in a day when you can concentrate and spend 5-10 minutes working on your muscles. It is important that you give your muscles time to recover when getting back into a regular routine.

Do this by making sure you 'rest' for as long as you 'hold'. For example, if you hold for 5 seconds make sure you rest for 5 seconds. When your muscles get tired, give them a full minute rest.

As doing the exercises gets easier you can try doing them in progressively more challenging positions: from sitting to standing and on to walking. Over time you may only be leaking when you exert yourself.

By identifying the activities that cause you to leak, you can learn to tighten your muscles to try and prevent it using 'the knack'. If it happens during your chosen sport you may need to practice the movement involved so that tightening your pelvic floor muscles becomes automatic.

How long will I need to keep doing the exercises?

Your pelvic floor will remain a weak spot for life. It is therefore important that you keep exercising it for life. If you become sick with the flu and cough a lot you may start leaking again. This does not have to be permanent, however, so revisit a pelvic floor training regimen once you recover.

Drink well to prevent bladder irritability and constipation

It is recommended that you drink 1.5 to 2 litres of fluid each day (about 6-8 drinks) unless otherwise advised by your doctor. Limit caffeine, alcohol and fizzy drinks as they may cause bladder irritation. Remember that water is the best fluid. It is important not to drink too much.

A good guide to whether you are drinking enough is to look at the colour of the urine you are producing. Pale yellow urine and soft, easily passed bowel motions are a good guide to drinking enough. Reducing your fluid intake makes urine more concentrated and you risk getting bladder infections and going to the toilet more often.

Signs of improvement

• Using fewer incontinence pads
• Getting up less than 2 times a night and remaining dry
• Being dry in the early part of the day
• Being dry all-day
• Not leaking when you cough, sneeze, laugh or lift
• Being dry with sport and exercise

Eat a healthy diet rich in dietary fibre

Make sure your diet has an adequate amount of fresh fruit, vegetables, breads and cereals. This will help to prevent constipation and maintain a healthy body weight.

Exercise

Exercise regularly to help prevent constipation and maintain a healthy body weight. Walking is a great way to start getting back into exercise, but you should consult your doctor before you return to vigorous sport or exercise.

Practice good toilet habits

Practice good toilet habits to prevent bladder and bowel control problems:

• Go to the toilet when your bladder feels full. Don't get into the habit of going just in case.
• After prostate surgery, you may find that you do not experience the sensation of a full bladder. The sensation of a full bladder will gradually return as you are able to hold on longer. It is important to practice holding on to increase the amount of urine your bladder can hold.
• Take time to empty your bladder and bowel and use the correct sitting position on the toilet to avoid straining. Make sure your knees are higher than your hips - a footstool can be used. Lean forward and put your elbows on your knees. Relax your stomach muscles so that your belly gently bulges out.

Correct toileting position

• Have your knees higher than your hips.
• Lean forward and put your elbows on your knees.
• Bulge out your abdomen.
• Straighten your spine.

How do I manage the incontinence?

You may experience severe incontinence in the first few weeks following surgery. The best way to deal with this is to be prepared for it and learn what you should do to manage it. Incontinence after prostate surgery can take 6 to 12 months to completely resolve. In some cases, there can be an ongoing problem which may require further surgery. You can contact the Continence NZ helpline on 0800 650 659 to learn more or to access free information and education resources.

Continence products for urinary incontinence

Pads

Pads are the first choice in managing urinary incontinence. There are several pads available in supermarkets and pharmacies which are specifically designed for men.

Some pads have an adhesive strip to keep them in place in the underwear. It is important to wear firm fitting jock-type underwear - not boxer shorts. Some pads are like complete pants with an absorbent pad in the crotch.

Pads are designed to lock away urine so that you feel dry and any unwanted odours are contained. A continence nurse advisor, urology nurse or continence physiotherapist can advise you on which pad is best for your level of incontinence.

Note: a pad is a way of managing incontinence, not treating it. It is important to eat well, drink well, exercise, do regular pelvic floor muscle exercises and practice good bladder and bowel habits.

Condom drainage

Condom drainage is useful for men experiencing severe leakage that requires more than 4-6 pads a day. A continence nurse advisor or urology nurse will be able to assess if condom drainage is suitable for you. This system uses a specially adapted condom type device that fits on the penis and is held in place by an adhesive. A drainage bag is attached to the condom to collect leakage from the bladder, similar to using a catheter.

Note: Condom drainage is a way of managing incontinence, not treating it. To improve bladder control, it is important to eat well, drink well, exercise, do regular pelvic floor muscle exercises and practice good bladder and bowel habits.

Skin Care

Skin irritation is commonly associated with incontinence. Here are some simple steps to care for your skin:

• Wash in warm water using a soap-free cleanser or pH-neutral soap.
• Pat dry carefully - do not rub.
• Avoid talcum powder as it can cause skin irritation and may interfere with the absorbency of pads.
• Wear firm fitting cotton underwear - no boxer shorts.
• Avoid plastic pants or sheets that will cause you to sweat.

If your skin becomes irritated, you can use Sorbolene cream to moisturise the area. A barrier cream may also be necessary. Use any cream sparingly as it may interfere with the absorbency of pads. Talk to a continence advisor nurse if your skin irritation does not improve with these simple steps.

Help and advice

There are a number of health professionals who can help you with incontinence following prostate surgery. Continence advisors can give you advice about diet, exercise (including pelvic floor muscle exercises) and products such as pads, catheters and mattress protectors.

Continence physiotherapists specialise in pelvic floor muscle exercises and can develop an individual programme to suit your needs as well as provide advice about pads and general exercise. If your incontinence persists beyond 12 months, talk to your urologist as there are a range of surgical alternatives to help you achieve dryness, for example, an artificial sphincter or sling.

Remember, incontinence can be treated, managed and in many cases cured.

If you are unsure who you need to see, contact the free Continence NZ Helpline on 0800 650 659.

This document has been developed by and remains the property of, the Continence Foundation of Australia

© Continence Foundation of Australia 2015