AND URINARY INCONTINENCE
B.J. Reid Czarapata, MSN, ANP-BC, CUNP
Pelvic Floor Center, Medical Faculty Associates
George Washington University Hospital
(A summary of a presentation to the WRAMC Us TOO Chapter on August 6, 2008)
Article in "WRAMC Us TOO Newsletter" - November 2008 *
Why do men who have had primary treatment for prostate cancer have a higher risk of urinary incontinence? The answer is obvious and well-known to those of you here tonight. The primary therapies for prostate cancer - surgery, radiotherapy, and cryotherapy - involve delicate procedures affecting the urinary process. Despite the improvements in technique and technology over the years, the primary therapies will affect patient continence to some degree. Various studies citing the incontinence rates associated with the prostate cancer therapies may cite better or worse incontinence outcomes, but few men will be unaffected by their treatment. (Note: Ms. Czarapata then displayed and explained a slide showing the anatomical relationships of the male urinary system and its relationship to the prostate gland.)
Letís define our topic at the outset. Urinary incontinence is a condition in which involuntary loss of urine is a social or hygienic problem and it is objectively demonstrable.
All types of incontinence involve the pressure in the bladder becoming greater than the closing pressure of the urethra. We prefer to help men deal with urinary incontinence by the least invasive process, and thatís where I come in. Tonight I want to discuss urinary incontinence as treated by the nurse practitioner who employs various techniques to help men overcome urinary incontinence or at least manage its effect on their lives.
EVALUATING THE PATIENT
When a patient comes in and says he is leaking, I donít take anything for granted. For example, I take a thorough history to help assess the cause of the patientís condition. He is often surprised by the detail I seek. He is probably thinking, "Why is she asking me all these questions," that to him seem unrelated to his problem. For example, the patient who underwent a radical prostatectomy often assumes his incontinence is related solely to his surgery. Perhaps it is, but I simply canít rely on his assumption. There are other systemic conditions that, if not the immediate cause, could be aggravating factors.
These are the other factors I take into consideration in my evaluation of the patient: other genito-urinary complaints; sexual problems; gastrointestinal complaints; back pain; lower extremities; appetite; sleep habits; bowel function; mobility and dexterity; recent life style changes; environmental issues; and social factors.
On examination, Iím going to evaluate anal sphincter tone. Is the sphincter in good shape? Is there evidence of retained stool that might be irritating the bladder? There are two reflexes called the "anal wink" and the bulbocavernosus reflex that show whether the nerves to the bladder coordinating the voiding function are working. They create the possibility that one can detect a "need to go" and thereby control it.
We also perform a bladder scan using an ultrasound machine to detect urinary retention in the bladder. Urinary retention is often found in men who had a radical prostatectomy. The reconnection of the bladder and urethra after removal of the prostate can result in scar tissue, restricting urine flow. If this is the case, there are urologic procedures to correct the condition.
STRESS URINARY INCONTINENCE
Letís start with stress urinary incontinence. It is the most common type of incontinence. Urinary leakage occurs with increased abdominal pressure. A cough, a sneeze, rising from a chair, bending over, picking up heavy objectsóall these activities will likely result in leakage for persons with stress urinary incontinence. In dealing with stress urinary incontinence, we focus on the development of the lower pelvic musculature. The key here is the Kegel exercise, correctly performed. Too often I see varying descriptions of the Kegel, so itís no wonder that some men become confused and disillusioned with the resultsóso they quit doing them! Here is my practical description of the correct Kegel. Just imagine that last night your wife found a new recipe for baked beans. She used it, and the results were so good that you had three servings. Now you are sitting among friends and the accumulated gas is about to wreak havoc on the social environment! Of course, you are going to try and hold back the gas. To do so, you squeeze the anus to retain the gas. Hold it for about one second and then relax. There, you have done a Kegel correctly! I usually have my patients perform the Kegel for ten repetitions-three times a day (thirty times). We recommend you start and hold the squeeze for one or two seconds, then you work up until you can hold the squeeze for ten seconds and relax it for ten seconds. The goal is to over-exercise the muscles to bulk them up so they can better control urine flow. (As an aside, when I gave my description of a correct Kegel to a group of urologists, one of them said in jest," Why would you want to hold back the gas?" I responded that only a man would fail to do so!)
URGE URINARY INCONTINENCE
Urge urinary incontinence is a sudden need to urinate. You leak because your bladder pressure increases due to the contraction of the bladder. The bladder is twitchy or simply contracts and its pressure exceeds the closing pressure of the urethra. Patients with normal sphincter function can often hold back the urine spurt, but if the sphincter is damaged as a result of your primary therapy for prostate cancer, then look out! But if you employ the Kegel technique we just practiced, that will often turn off the urge to urinate. When you sense that urge, relax the abdomen (donít tighten it as many men do) and do three little squeezes. That should do, and hereís why--there is coordination between the bladder and the sphincter so that as the bladder contracts, the sphincter muscles open allowing the urine to come out. But if you sense the bladder contracting and you squeeze the sphincter muscles, the bladder relaxes. That is the process essential to resisting urge incontinence.
Now is the time to tell you my pet peeve. Some urologists tell their patients to perform the Kegel exercise by starting and stopping the urine stream. That is wrong! You do not want to do the Kegel exercise that way because it fouls up the natural coordination between the bladder and the sphincter muscles.
OTHER KINDS OF INCONTINENCE
Mixed incontinence is some combination of stress incontinence and urge incontinence. The majority of patients probably fall in this category. Overflow incontinence is often associated with urine retention caused by scarring at the bladder-urethra reconnection that I mentioned earlier. Your bladder keeps topping off, making you leak small-volume voids periodically. Occasionally there can be a completed emptying of the bladder during sleep. Functional incontinence is not due to urinary tract problems. Rather, it is a situation wherein otherwise continent persons with mobility difficulties or other physical conditions have difficulty coping with the need to urinate.
DEALING WITH INCONTINENCE
The whole process is determined by how much damage has been done to the bladder neck and your sphincter muscles during prostate cancer therapy. The first step is to develop a preliminary individualized continence program involving timed voiding, habit training, prompted voiding, and bowel training.
The treatment process has several aspects: Kegel Exercises properly performed. We used to recommend 300 Kegels a day, but no more. If you over-exercise your pelvic floor muscles, you cause muscle fatigue that could actually worsen incontinence. So we recommend three sets of ten. Obturator Internus Exercises. These two exercises affect the pelvic sling. One exercise involves placing a ball between the knees while seated. The knees are then pressed together for five seconds for several iterations. Then a related exercise involves wrapping an exercise stretch band around your legs while you try to spread your knees. Timed voiding means exactly what it says. The patient keeps a schedule of when he voids, picks "half way" times, and makes an effort to urinate at that interval, relying on Kegels, as necessary, to meet the scheduled time objective. The idea is to urinate "by the clock" without turning your life upside down in the process. Biofeedback and Electrical Stimulation are wellknown procedures, the "big guns," so to speak. (Ms. Czarapata displayed and discussed a slide demonstrating biofeedback.) Electrical stimulators applied to the pelvic floor muscle give it a boost to increase the effort to contract. They may also dull the urge to urinate if it is overactive. Medications like Detrolģ and Ditropanģ help quiet down the bladder. This reduces urinary urgency and may reduce leakage caused by coughing or sneezing. When these treatment processes are inadequate, the patient and his physician may resort to more invasive procedures, such as Collagen injections or the implantation of an Artificial sphincter. Collagen injections may work for some men, but overall, they have not been the success we would hope for. On the other hand, the artificial sphincter has had good success in helping many men cope with incontinence.
Bladder irritants stimulate the bladder to contract. These irritants are well known: caffeine in coffee, chocolate, aspartame, citrus products, alcohol, constipation, and any urinary tract infection or inflammation. I can tell patients about these bladder irritants, but they must commit to dealing with them in any program to reduce or cure incontinence.
Coping with incontinence requires bladder training. Its components are a bladder diary, fluid management, urge control, and bowel training. I have already discussed urge control when we described the Kegel exercise. So letís move on to the others. The bladder diary keeps track of when the person urinates and when leakage occurs.
I recommend the person try timed voiding, that is, an attempt to urinate every hour whether he needs to or not; then try to stay dry in between times. If this is doable, I may increase the target time to an hour and a quarter. Some persons restrict fluid intake in order to reduce leakage. This could lead to overconcentrated urine in the bladder which will only exacerbate bladder irritation. Fluid management helps to ensure that fluid intake is adequate to the bodyís needs.
Bowel training is important because constipation is a bladder irritant. The idea is to have a bowel movement when you can expect it daily. I usually recommend that persons with constipation drink 8oz. of hot water first thing in the morning, then insert a glycerin suppository (non-laxative) to stimulate a bowel movement. Of course, foods high in fiber are very useful. Within fifteen minutes of finishing breakfast, the person should use the bathroom to try and have a bowel movement without straining. If it is not accomplished after fifteen minutes, then try later. The idea is to regularize bowel movements to avoid constipation. Abdominal massage is also useful to stimulate peristalsis.
Nocturia is the frequent need to get up during the night to urinate. My experience is that patients who have had a radical prostatectomy arenít affected too much by nocturia. Instead, they tend to lay there asleep and donít leak throughout the night. Polyuria, the daily passing of large amounts of urine, is another condition we must consider. There are probably underlying systemic problems, such as diabetes II, that need to be evaluated. Polyuria also affects our ability to concentrate our urine output. The urine output of younger persons is very concentrated and this is good. But as we age, our urine output is less concentrated because the kidneys become less efficient over time. Then there is the mobilization of stored fluid. Hereís how it works. When you have been up all day and on the go, you have stored a lot of fluid in your lower extremities. When you lay down in bed, that fluid all gets back into your system while you are sleeping. To overcome this condition and its effect on the bladder, I encourage patients to do some reclining for about an hour before retiring with the feet elevated to the level of the heart. You do that for about an hour, then sit up vertically or walk around, then urinate before getting in bed. This should help reduce the need to void during the night. Nocturia may also be associated with obstructive sleep apnea. So if you find that you are putting out a lot of urine during the night compared to your daytime volume, then a sleep apnea study may be indicated. Sometimes there are accidents on the way rushing to the bathroom. This is related to the functional incontinence I mentioned earlier. So make sure there is a lighted path towards the bathroom and no loose rugs that you can trip over on the way.
One final point. There are all sorts of diapers and pads available to deal with incontinence. Some men even improvise methods to collect urine leakage. I recently became aware of a new product called BioDermģ. It attaches to the very tip of the penis and channels urine into a soft collection chamber that holds about eight ounces. This device is for someone who is leaking constantly. Properly used, BioDermģ reportedly needs to be changed every three days. In closing, here are some Words of Wisdom for the incontinent--SQUEEZE BEFORE YOU SNEEZE! Now Iím open for your questions. QUESTIONS AND ANSWERS
Question: Do you have hand-outs of your presentation?
Answer: No, but a summary of it will be included in the November issue of the WRAMC Prostate Cancer Support Group newsletter.
Question: I had collagen injections for my incontinence, but the effect wore off after a few months. Subsequent treatments were also unsuccessful. Iím still looking for an effective alternative.
Answer: Unfortunately, your experience with collagen is all too typical. Collagen is injected into the bladder neck. It causes the tissues to enlarge and squeeze together to reduce leakage. Over time, the collagen begins to be absorbed, and when it is, it takes up less room, so it becomes progressively ineffective. The virtue of collagen is that it is a relatively easy-to-do outpatient procedure that can be repeated. You may wish to consider the implantation of an artificial sphincter. Many men have found it very effective. Another surgical procedure is the male sling that is placed under the urethra to create pressure on it. You should consult with your urologist to learn if these surgical procedures are appropriate for you
Question: I understand the importance of doing the Kegels correctly and regularly. How long must a man perform them before they can be declared successful?
Answer: Normally you achieve maximum rehabilitation of a muscle at four months of regular exercise, but many men will note some improvement at the outset. Then usually after about a month or two, we see more substantial improvement. If we donít see improvement by four months, we need to consider another alternative. I actually had one patient call me after hearing my presentation to say he went from 14 pads to one pad per day. So, all of you have the possibility of improved continence just by listening to me! (Laughter)
Question: What about the man who is very active, regular jogging, for example? Leakage control while exercising is my biggest problem.
Speaker: This situation affects both men and women. When jogging, or performing some other type of exercise, you are increasing the pressure in your bladder that exceeds the urethra closure pressure. You may want to consider wearing a condom catheter during your scheduled exercise period.
Question: A friend of mine had a urinary incontinence problem after surgery that lasted almost a year before it cleared up on its own. I imagine that Kegel exercises would probably have helped help clear it up sooner.
Answer: You are absolutely right. Many men experience a natural resumption of continence as the pelvic muscles and tissues heal over time. That is why urologists prefer to wait twelve months or so after primary therapy before addressing a patientís incontinence issues. On the other hand, most men donít want to wait a year to see if natural processes will solve their incontinence problems. They want them solved NOW! The regular and correct performance of the Kegel exercise can speed up those natural healing processes. Thatís the name of the game!
Question: So if a man had a radical prostatectomy six or seven months ago, and he is not satisfied with his progression toward continence, is it too late to begin or resume Kegel exercises?
Answer: Absolutely not! Start or resume now. The regular and correct performance of Kegel exercises can only help the healing process. The saying that "The Lord helps those who help themselves" certainly applies in this situation.
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