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

Methodology

Convenience sampling was used for both aspects of the study which were audited separately. Regarding the nurse-led histology clinic, all those who were approached about the study participated; a total of 106 patients took part. All patients who had undergone a radical prostatectomy within the sampling period were contacted.

Under the new nurse-led histology program, all patients diagnosed with urologic cancer now receive their diagnosis directly from the Specialist Urology Oncology Nurse (see Figure 1). Following surgery or biopsy, patients are routinely given a half-hour appointment to see the specialist nurse, during which they receive and discuss their histology results. Ap pointments are made under exactly the same criteria as per urology clinic: when a cancer is diagnosed, the specialist nurse coordinates the further staging investigations and schedules a return appointment for the results. All patients are offered detailed written and verbal information about their diagnosis and provisional treatment options. Information is staged as appropriate for each individual case to minimize information overload and maximize patient understanding. A contact number for the specialist nurse is given for more immediate access to further information or clarification. Subsequently, the patient attends the urology clinic already aware of his diagnosis and the results of the staging investigations, making the consultation more productive and meaningful for both patient and clinician.

Diagnosis.

Patients who are diagnosed with prostate cancer and are provisionally suitable for radical prostatectomy receive a specific booklet on the surgery. This information is reviewed at two, and sometimes three, visits with the specialist nurse (again with a half-hour appointment each time) to discuss the implications of the diagnosis and to assist in deciding choice of treatment. Incontinence is discussed in detail during these visits; patients are made aware of the risk of incomplete urinary control following radical prostatectomy surgery. This risk varies in the literature, depending on the definition of incontinence, and ranges from as little as 2% to as much as 31%, and implies a range of intensity of treatment required postoperatively to improve it (Eastham et al., 1996; Heathcote et al., 1998; Leandri et al., 1992; Moore & Dorey, 1999; Murphy et al., 1994; Steiner et al., 1991).

It is also emphasized to operative candidates that although radical prostatectomy has generally become the first-line treatment for younger, fitter men diagnosed with localized prostate cancer, there is no conclusive evidence that surgical treatment is definitely superior to any other in terms of long-term survival (Lu-Yao & Yao, 1997). Within the study site, the age of men having a radical prostatectomy performed ranged from 41 to 71 years, with a mean age of 62 years.

If he finally opts for surgery, the patient is referred by the urology oncology nurse for a pre-operative assessment by the continence and physiotherapy team as per the guidelines developed. At this visit, after establishing their current continence status, a best and worst-case scenario is given regarding continence after surgery, along with realistic targets relating to expected duration until recovery of continence. This is extremely important in order to create realistic expectations for their recovery after surgery and minimize the sense of despair when reality prevails (Fan, 2002).

Patients are taught how to tighten their pelvic floor muscles prior to standing, coughing, and sneezing. Stress incontinence, experienced by most patients after radical prostatectomy, and caused by the decrease of the urethral sphincter capability following surgery, will improve with pelvic floor exercises (Dorey, 2001). Several studies assessing the effect of pelvic floor exercises have recommended them as a curative intervention for incontinence post radical prostatectomy (Moore & Dorey, 1999; Van Kampen et al., 2000; Wille, Sobottka, Heidenreich, & Hofmann, 2003), although it is accepted that further research is needed to evaluate their optimum benefit for these patients (Moore & Dorey, 1999). Advice is also given regarding avoidance of stimulant fluids (such as tea, coffee, and carbonated drinks) in order to reduce intravesicle irritation and the resultant frequency and urgency (Bryant, Dowell, & Fairbrother, 2002). This, in combination with correctly performed pelvic floor exercises, allows for retraining of the bladder to store urine for longer periods following the removal of the catheter (Fantl, 1998).

Removal of the urethral catheter post prostatectomy can be the most traumatic time for patients as it is then that they often experience incontinence for the first time (Fan, 2002). Although they may have been warned to expect poor control, actually experiencing it can be extremely stressful. Usually at this time patients not only require physical assistance in the form of pads or further teaching of pelvic floor exercises, but also may need psychological support in coming to terms with what is now the reality of urinary incontinence (Herr, 1997). For this reason, patients' admission for removal of catheter is coordinated with an appointment for the same day with the continence and physiotherapy team, with the urology oncology nurse available if needed. This ensures specialist intervention when required, and because patients are always seen by the same team members, it promotes a continuity of care which is extremely important (NICE, 2002).

Depending upon their progress, patients are then regularly reviewed by the multidisciplinary team during the same visit. This allows for good communication among team members and for discussion of any issues which may arise to be discussed at one clinic visit, thus avoiding unnecessary visits and limiting delays (NICE, 2002). For example, patients may be continually wet without the expected improvement, thus requiring more intense physiotherapy input (Dorey, 2001). Another problem may be that although continence has returned, patients may be experiencing poor urinary flow pressure and could have significant post void bladder residual volumes. This might indicate an anastamotic stricture which requires prompt intervention by the continence nurse who can refer to the patient's urologist that same day for assessment (Surya, Provet, Johansen, & Brown, 1990). Similarly, patients may have new or ongoing concerns regarding their cancer generally, which the urology oncology nurse can discuss, and communicate with the urologist as appropriate (Ofman, 1993). In addition, the urology oncology and continence nurses have 24-hour helplines which patients can access.

To evaluate the effect on patients' physical and psychological status under the new collaborative approach, an audit was carried out and results compared with that of the previous practice. On both occasions a telephone survey was performed by the continence nurse and physiotherapist, with each patient using a validated continence severity index questionnaire (Sandvik et al., 1993) (see Figure 2) and quality of life questions from the International Prostate Symptom Score Questionnaire (Cockett et al., 1994) (see Figure 3). The telephone audit, on both occasions, was carried out at 1 year following surgery, as by this time the optimum level of continence should have been achieved.

Severity Index.

International Prostate Symptom Score (I-PSS).

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