Management of Urinary Incontinence Following Radical Prostatectomy

Brian McGlynn; Naels Al-Saffar; Helen Begg; Murat Gurun; Graham Hollins; Suzanne McPhee; Robert Meddings; Robert Meddings; Mary Tindall

Disclosures

Urol Nurs. 2004;24(6) 

In This Article

Literature Review

The incidence of UI after radical prostatectomy was examined, along with an assessment of how this symptom can affect a person's quality of life. Computerized searches on Medline, CINAHL, PsycInfo, the British Nursing Index, and the Royal College of Nursing database from 1985 to present were done using the key words: radical prostatectomy, urinary incontinence, prostate cancer, quality of life, and symptom management.

Urinary incontinence is a common problem after radical prostatectomy and is often viewed by patients as the symptom which most disrupts their quality of life (Herr, 1997). According to Maxwell (1993), most patients (90%) regain total urinary control after radical prostatectomy but this can take up to a year to achieve, with a small percentage (2% to 4%) experiencing permanent incontinence. However, incontinence rates postradical prostatectomy vary considerably and appear to depend upon the definition of incontinence used (Moore & Dorey, 1999).

Several physician-reported studies document a low incontinence rate ranging from 2% to 8%. A report by Zincke, Oesterling, and Blute (1994) demonstrated only a 5% incontinence rate, but this rate was defined as using three or more pads per day. Defining incontinence as requiring a pad for strenuous activity, Steiner, Morton, and Walsh (1991) reported an 8% incidence. Using a similar definition, Leandri, Rossignol, Gautier, and Ramon (1992) found only a 5% rate of incontinence. Eastham, Kattan, Rogers, and Scardino (1996) reported a 5% incontinence rate from their series of radical prostatectomy patients over a 5-year period but with yet another definition of incontinence: the leakage of urine with moderate exercise onto two or more pads daily. However, all these analyses are based on review of patients' records and direct physician interview of the patient. This may not accurately reflect the true incidence because of poor physician assessment, inadequate documentation, or patients' reluctance to directly report adverse events to their surgeon (Quinlan, Epstein, Carter, & Walsh, 1991).

In contrast, when patients report their personal experience of UI, the incidence is usually significantly higher. In a detailed survey by Heathcote et al. (1998), patients independently completed a questionnaire to determine the incidence and impact of side effects following surgery. These results showed 20% of patients reported postoperative incontinence. More specifically, 11% required pads at least once a week, 8% requiring one pad daily, with 1% requiring two or more pads daily.

In a study of 1,796 men who were continent before radical prostatectomy, Murphy, Mettlin, and Menck (1994) found that 330 (19%) reported they wore pads on a daily basis, with 4% of the men being totally incontinent after surgery. Fowler, Barry, and Lu-Yao (1993) found that 31% of patients in their study had some degree of wetness after their operation. Similarly, Litwin, Hays, and Fink (1995) observed daily urinary leakage in 40% of men who underwent radical prostatectomy.

From these results, it would appear that there is a significant difference between patient and physician in the assessment and definition of UI. It is also apparent that many early publications have underreported UI incidence postradical prostatectomy, with independent questionnaires detecting a higher incidence of complications (Bates, Wright, & Gillat, 1998). This has significant implications in the advice and counseling given to patients pre-operatively regarding the incidence of incontinence after surgery.

In both the patient and physician-reported studies, there is little reference to the type of pads used, their absorbency, or to the subjectivity of each individual as to how often the pads needed to be changed (Abrahams et al., 2002). When number of pads used is the main guide to assessment of incontinence, these factors must be analyzed more closely and a level of standardization reached.

Ganz (1994) describes quality of life as being the patient's appraisal of, and satisfaction with, his current level of functioning compared to what he perceives to be possible or ideal. In comparison to other similar illnesses such as breast cancer, there has been a more limited number of studies on the effect on quality of life of patients receiving treatment for prostate cancer. Cassileth (1992) suggests that this may be because traditionally men have been reserved in disclosing their emotions. A second reason might be that interest and funding for prostate cancer research generally has been only recently established, as the incidence and impact of the disease was eventually realized (Belldegrun, Kirby, & Oliver, 1998).

It is widely accepted that all options for prostate cancer treatment can have a significant impact on a patient's quality of life, and therefore should not be undertaken lightly (Bates et al., 1998; Kirby & Kirby, 1999). However, a recent study carried out by Moul, Mooneyhan, Kao, McLeod, and Cruess (1998) aimed at predicting morbidity factors for patients with prostate cancer receiving radical surgery concluded that although the side effects were high, the majority of men report the same quality of life pre-operatively and would apparently choose the same treatment again.

These findings agree with Frydenberg (1998) who, in a meta-analysis of quality-of-life studies in men coping with prostate cancer, found that most patients expressed their overall satisfaction with the surgical treatment and would choose to have surgery again. This was despite the higher level of incontinence and sexual dysfunction reported by these patients with radical prostatectomy. This would seem to imply that the overwhelming desire to remove the cancer completely outweighs the side effects of the radical prostatectomy for most patients.

Interestingly, however, Herr (1997) reported that this opinion can waver depending on how long the symptom persists. These results came from his questionnaire study assessing quality of life and coping in men who are incontinent after radical prostatectomy. Herr found that 83% of men who had surgery within 3 years of the study would choose the same treatment again. On the other hand, of those whose surgery was more than 3 years before the study, only 47% would make the same choice. These findings are supported by Waxman (1993) who reported that 5 years after radical prostatectomy, only 53% of patients still experiencing incontinence would choose surgery again, compared with 83% in the first 3 years. These results suggest that persistent incontinence may overshadow a patient's earlier enthusiasm after having a successful operation. For some the price of cure may be later perceived as too high.

Urinary incontinence may be perceived as a natural consequence of aging, but even so, may have a significant impact on a person's emotional and social well-being (Colley, 2003). After radical prostatectomy this may have further impact as men attempt to cope with their diagnosis as well as recover following surgery. Physical and psychological symptoms such as confusion, depression, anger, reduced self-esteem, fatigue, anxiety, and insomnia are common (Kornblith, Herr, Ofman, Scher, & Holland, 1994). Due to feelings of stigmatization, men can become socially reclusive and be uncharacteristically dependent on others. Many men are still employed at the time of their surgery and may be the main family wage earners; there may be an added concern of loss of income and increased need to return to work as early as possible (Braslis, 1995).

The effects of UI after radical prostatectomy on quality of life are also experienced by partners and can have an influence on relationships (Butler et al., 2000). It is reported that incontinence following surgery can have a negative impact on the relationship (McCammon, Kolm, Main, & Schellhammer, 1999). How ever, Butler et al. (2000) reported that the majority of partners perceived the quality of their relationship to be unchanged, and for some it was now much better as a result of their experience. Wives and other family members have a major role to play in supporting men after radical prostatectomy. It is often they who must bear the brunt of, and compensate for, the changes to normal activities (Fan, 2002).

Issues about body image and sexuality may also surface, and can have far greater consequences than anticipated (Of man, 1993). Sexuality in this context does not simply mean sex or sexual concerns; although sexuality is widely discussed as such in much of the literature. Reducing this to erectile function alone creates a superficial definition which fails to address its real meaning and importance in altering quality of life (Helgason et al., 1996). Following radical prostatectomy, men who experience UI may express concerns about visible wetness, urine odor, and the type of clothing that can be comfortably worn (Butler, Downe-Wamboldt, Marsh, Bell, & Jarvi, 2001). More profoundly, an inability to totally control one of his most basic and fundamental bodily functions can seriously threaten a man's identity and masculinity (Ofman, 1993).

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