Incontinence after RP or RT: Consider preventive measures first

Gwendolyn Hooper, PhD, APRNNew study data on the side effects of three treatment modalities for localized prostate cancer have important implications for nurses and other providers managing post-treatment urinary incontinence, according to Gwendolyn Hooper, PhD, APRN, president of the Society of Urologic Nurses and Associates. In this interview with Urology Times Content Channel Director Richard R. Kerr, Dr. Hooper discusses practical tips for prevention and management of incontinence in this patient population.

A recent study by Barocas et al, presented at the 2017 AUA annual meeting and reported in Urology Times, examined the side effects of various treatments for localized prostate cancer. For the purposes of this interview, let’s discuss post-treatment urinary incontinence specifically and the role of the nurse or other nonphysician provider. What do you think are the key take-aways from this study in this regard?

First, a short overview of the study. This was a prospective population-based cohort study of 2,550 men undertaken to compare functional outcomes and adverse effects associated with three prostate cancer treatments: radical prostatectomy, external beam radiation therapy, and active surveillance. Men were ages 60-80 years, had been diagnosed with clinical stage cT1 T2 (localized) prostate cancer, and their PSA levels were <50 ng/mL.

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Patients were within 6 months of diagnosis and had received treatment within 1 year. The study took place over 36 months, which may be a limitation of the study. 

Regarding the study’s findings on incontinence only, with baseline domain scores being similar across all three groups, postoperative radical prostatectomy (RP) patients reported significantly greater urinary incontinence than did those patients treated with external beam radiation therapy (EBRT) or active surveillance.

To answer your question, nurses and other providers should utilize the results of this and other similar studies to counsel and inform their patients during the shared decision-making process. Keep in mind that men often base their treatment decisions on the potential side effects of the proposed treatment.

Next: How common is incontinence in men who undergo RP and those who undergo RT?

How common is incontinence in men who undergo radical prostatectomy and those who undergo radiation therapy?

Most men undergoing RP see a rapid improvement in continence over the first several months after the catheter is removed and continue to regain their bladder control over time. They are usually considered to have reached their full recovery within 6 to 12 months after surgery. With RP, two types of incontinence can occur: urge urinary incontinence due to changes in the bladder after surgery and stress urinary incontinence, usually attributed to damage to the external sphincter muscle. Men usually experience some type of stress incontinence immediately after the catheter is removed.

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In men undergoing RP, long-term incontinence rates can vary depending on the study, ranging anywhere from 2% to 80% (J Urol 1998; 160:1317–20). These numbers are dependent on the definition of urinary incontinence used and the methodology used in collecting the data.

There are several patient factors that can contribute to urinary incontinence after surgery. These include the age of the patient at the time of surgery and his weight (BMI). We know that in larger studies, increasing age leads to higher rates of male urinary incontinence. Additional patient factors include whether or not the patient had prior surgery on the bladder or prostate, the presence of an enlarged prostate, and the strength of the patient’s pelvic floor muscles.

Another factor is the skill, experience, and technique of the surgeon, which can significantly contribute to incontinence outcomes. The aggressiveness of the cancer itself is an additional factor.

In men undergoing EBRT or brachytherapy (not considered in this study), incidence of urinary incontinence can range from 10% to 30% in some studies. Again, this is dependent on whether the incontinence reports are from the patient or the provider.

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Urinary incontinence in these men can develop months to years after radiation therapy. The other patient factors we discussed with RP also can contribute to incontinence following radiation therapy.

Next: Key considerations for nurses and other allied health professionals

What are the key considerations for nurses and other allied health professionals when managing men who present with urinary incontinence after prostate surgery or radiation?

Prior to surgery, it is important not only to discuss incontinence as a side effect of surgery or radiation, but to discuss opportunities for prevention such as weight loss, decreasing caffeine, discontinuing smoking and other poor lifestyle habits, as well as managing diabetes and other medical problems, all of which can contribute to decreasing incontinence and improving overall good health.

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Also important is instruction in preoperative (Kegel) pelvic floor exercises. Kegel exercises can strengthen pelvic floor muscles prior to surgery; after surgery they help patients improve and regain their bladder control.

What are the primary treatments for post-prostatectomy incontinence in these men?

Depending on the degree and bother of the incontinence to the patient, management can be conservative, as discussed previously: limiting caffeine, alcohol, and other bladder irritants; preventing constipation; and performing Kegel exercises. Continence pads are also an option for management. For men with urge incontinence, medical therapy with an anticholinergic or beta-3 agonist is an option. For those with severe stress incontinence, treatment options include surgical implant of an artificial urinary sphincter or a urethral sling procedure.

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