How's your plumbing?
When Fiona and I travel around giving talks about prostate cancer and men’s health, we often meet men who are dealing with incontinence. They tend to be men who have already had treatment for prostate cancer – sometimes quite some time ago. Clearly, ongoing “plumbing problems” are an issue out there in the community.
This article aims to explain what happens to your “plumbing” when you have prostate surgery, and what you might expect afterwards. It also includes some helpful information and resources for those of you who might be finding it tough to get your leaks under control.
Before treatment (prehab)
Prior to surgery, men are often referred to a continence physiotherapist to learn techniques to control their pelvic floor muscles (PFM). They may continue to see their continence physio after treatment to make sure that they work on those muscles and regain continence.
You’ve heard of rehabilitation (rehab), but there’s also prehabilitation or “prehab”.
Prehab aims to get you to a better place physically before an operation or other medical treatment.
Actually, prehab is really important, and that’s why you are likely to get that continence physio referral. The better prepared you are before surgery, the more likely you’ll bounce back afterwards with fewer problems.
What is a urinary sphincter?
Urinary sphincters are muscles that act like valves. Before prostate removal, a man has two of these little flow control devices. The diagram below shows what a man’s anatomy looks like before his prostate is removed.
You can see the internal urethral sphincter where the bladder and urethra join, called the bladder neck. The external urethral sphincter sits below the prostate near the pelvic floor.
By opening and closing around the bladder neck and urethra, these two sphincters act together to control urine. When the brain signals them to release urine, the sphincters relax to let the bladder empty. At the same time, the muscles in the bladder tighten and squeeze urine out of the bladder. When you’ve finished, the sphincters contract and close, while the bladder relaxes.
Your pelvic floor muscles also play a part in bladder control. The floor of your pelvis is made up of muscle layers and tissues. The layers stretch like a hammock from your tail-bone at the back to your pubic bone in front. Your pelvic floor muscles support both your bladder and bowel. The urethra (urine tube) and rectum (back passage) pass through the pelvic floor muscles.
When your prostate is removed, unfortunately you will also lose your internal urethral sphincter. The surgeon will rejoin the urethra to the bladder, leaving the external urethral sphincter to do all the flow control work. Your great team of two sphincters is now a lonely single fellow, coping as well as possible under the circumstances!
What happens after surgery?
After prostate surgery, a catheter is inserted up the penis.
We found the helpful diagram below to show where the catheter tubing goes. Luckily, improved techniques and devices mean that there is usually no pain involved when the catheter is removed, roughly ten days or so after surgery.
For most men, there will be some level of incontinence after that catheter comes out. Some men will regain full bladder control within six weeks or so after that, the lucky buggers.
Your continence physio will want you to focus on the area of pelvic floor muscles (PFM) involving your poor old mate, the external urethral sphincter. Now you are in the rehab phase of PFM training. It’s so important that you retrain the muscles, so you can regain control of your bladder.
Most continence physiotherapists say that the two year post-surgery mark is when most men will have reached a plateau with their level of continence. What is important is that you do your PFM exercises daily to make sure you get a level of control over your PFM and urethra.
Why do I still have dribbles or leaks?
Of course, there will be men who never reach a level of control that they are happy with. They will end up using pads every day, which can be costly, frustrating, and interfere with travel. They may also experience leaking when they get an erection, or during orgasm or arousal – this is called climacturia.
Our colleague, Victoria Cullen, has a great website and YouTube channel. For those men who experience climacturia, she has interviewed Dr Jo Milios on the subject and you may find that video helpful.
When you find yourself getting up more than once a night for a pee, that is called nocturia. If you rule out other potential causes, such as drinking too much late at night, including coffee and alcohol, this may mean that you have a problem with your bladder.
The opposite from this is that some men may become continent very soon after surgery, which may include not going that often to empty their bladder. In fact, they may have urine retention problems. So it’s important to consult either your continence physiotherapist or a urology nurse to make sure that there aren’t any bladder issues.
My own experience
I will say that, nine years after surgery, I’m about 99 per cent continent. I do my PFM exercises most days, but still have the occasional leak, for whatever reason. I still need to get up most nights for a trip to the toilet. Again, there are several things which will contribute to that, like how tired I am, how much fluid I’ve had after dinner, and whether I have done my PFM exercises.
I still see a continence physio, when I need to get anything checked out. My pelvic floor muscles occasionally get too tight (in other words, I need to work on relaxing them properly) – this means that the muscles can tire and just give way later in the day, leading to dribbles.
What to do if you are still leaking?
Of course, anybody can experience incontinence (bladder and bowel), for any number of reasons, but there is a lot of information available about how to deal with this, along with products and surgery, if all else fails.
You do not have to put up with incontinence – there is help available!
Excellent website for info & free helpline
The Continence Foundation of Australia, which has been around for decades, is an outstanding resource for anyone having continence problems. They offer free information on bladder and bowel health on their website and, if you’d rather talk to someone, they run a National Continence Helpline:
The National Continence Helpline is a free telephone advisory service staffed by a team of continence nurse advisors who provide information, education and advice to callers with bladder and or bowel problems which may include incontinence, constipation, failure of bladder to empty or help for those who are caring for someone with such conditions.
The Helpline also provides information and advice to health professionals.
The Helpline is funded by the Australian Government Department of Health and available to anyone living in Australia. It operates 8am-8pm (AEST) Monday to Friday.
The Helpline number is 1800 33 00 66.
The Foundation runs resource centres in NSW, SA, VIC, and WA. They also produce a regular magazine called Bridge, which you can read online or get a free hard copy posted to you. Their information covers men, women, children and those with disabilities.
Continence products in Australia
Firstly, if you are about to have surgery to remove your prostate, you will wake up with a catheter, as explained above.
When you are about to have your catheter taken out, make sure you have a continence pad to wear inside your jocks. In most cases when the catheter is removed, you won’t even realise that you’re leaking, so it’s really important to have the pads with you. Some clinics may supply you with a pad when your catheter comes out, but it’s best to be prepared.
The major brands of men’s continence pads (and women’s) are sold in most supermarkets, Chemist Warehouse and at pharmacies. Prices will vary and you may find some on special.
If you feel embarrassed about buying them in person, you can order directly from the following websites:
Independence Australia has offices in each state or you can contact them on 1300 788 855. They sell a range of pads and related continence products, with deliveries to your home. You can also order a sample pack, with a maximum of three different pad types (two pads per pad type).
If you are a Veteran and are covered by the Department of Veterans’ Affairs for prostate cancer, they will cover the costs for these products, but you will require a script from your GP, urologist or urology nurse.
Independence Australia has an extensive listing of products, including swimwear and different schemes to assist with the purchase of products and these are all listed on the website. They are also involved with the Federal Government’s CAPS (Continence Aids Payment Scheme), if you have permanent and severe incontinence. There are also the various State Government schemes that you can access, usually via their Department of Health or Human Services.
DependCare has a range of continence products for men and women, with insert pads and men’s pull-up type briefs with a built-in pad liner. Their free call number is 1800 028 334. You can obtain samples of their pads for men as well.
BrightSky is a company with a large range of pads and supporting products for dealing with incontinence. They offer pads, pull-ups or an all-in-one product. You can order their product guide by calling 1300 886 602.
Modibodi is an Australian company that has recently brought out a men’s brief and a boxer style with a built-in pad. These are washable and will hold approximately a couple of teaspoons of urine. So, if you’re travelling and you don’t want to carry lots of pads, these can be an alternative.
Pjama is a Swedish brand which has recently launched in Australia. Their bedwetting pjama “looks like an ordinary pyjama, but it has the ability to absorb the urine after an accident. The bed will be kept dry so there is no need for protective sheets or changing bed linen in the middle of the night. The urine stays in the pants/shorts, so you can feel calm and safe. Pjama is easily washed and is an eco-friendly alternative to the many disposable products that are available on the market today.”
Recent feedback that they received from a customer in Broken Hill was that “they were brilliant, for adults absolutely waterproof, no leakage at all”.
Tena Healthcare carries a large range of products. It’s worthwhile looking around their consumer website as it has lots of useful information, including help for carers coping with incontinence. Discreet delivery to your home is available, if you don’t want to buy from a shop. Their freecall number (within Australia) is 1800 623 347.
Conni is another Australian company that sells a range of products, including men’s washable and re-useable underwear, either briefs or boxer styles. Their contact number is 1300 721 170.
Just want your leaking to stop?
According to Continence Foundation of Australia:
Men with prostate problems can experience straining or pushing to urinate, a weakened urinary stream and other urinary symptoms such as frequency and urgency. Bladder weakness is also common after prostate surgery.
If it’s 12 months or more since your treatment and you are still leaking up to 250mls of urine most days, and PFM exercises have not managed to improve your continence, it may be time to consider surgery.
You can talk to your urologist about fitting a device, either surgically or externally. There are clamps that can be used externally – they are applied to your penis, and you release them when you feel the urge to have a pee.
There are different devices that can be surgically fitted inside you. The following information is from the website of a local reconstructive urologist (who specialises in addressing continence problems):
Surgery is an option for stress or overflow incontinence. There are surgical options for mild to moderate incontinence, and heavy incontinence.
These include a male ‘sling’, a device surgically inserted to support the bladder and urethra. There is also an “artificial urinary sphincter” which is a device designed to act like your own natural urethral sphincter. It controls the exit of urine from your bladder to your urethra using a pump located in the scrotum.
Deciding on the right way to resolve your particular continence problems will require a discussion with either your existing urologist or one that specialises in the fitting of these devices. It will usually be determined by the degree of leakage you are experiencing, as well as other health factors.
We hope that you’ve found this article helpful and, if you have, please do pass it on to anyone you know who might also find it of use.
If you have any questions, please don’t hesitate to contact us.
