Case Study: Post Prostatectomy Incontinence

Fred was referred to WMHP with significant incontinence after surgical treatment for prostate cancer.  This case study is a fascinating example of the complexity and diverse etiological factors which can contribute to post-prostatectomy incontinence, and explores Fred’s journey on the road to recovery of continence.

 
 
 

Subjective Assessment

  • History:
    • Fred, a 69 year old farmer, was referred to WMHP by a friend for management of post-prostatectomy incontinence, 2 months following a robotic-assisted radical prostatectomy for organ confined prostate cancer.
    • At initial consultation, Fred had significant incontinence, filling 3-4 pull-ups per 24 hours.
    • He reported stress urinary incontinence with typical rises in intra-abdominal pressure such as sit to stand and bending, urgency urinary incontinence with nocturnal voids and first void in am, and also constant insensible urine leakage throughout the day.
    • He was only voiding small volumes 2-3 times per day in the toilet, nocturia of 3-4.
    • He reported no voiding dysfunction, with “much better flow than before”.
  • Pre-operative LUTS: Fred reported episodes of urgency urinary incontinence a few times per week, increased frequency, nocturia of 2-3, and voiding dysfunction with slow stream and incomplete emptying.
  • Bowel function: Fred was prone to constipation and straining, eats a lot of meat and potatoes but “not too keen on veggies”.
  • Erectile function: no current erectile function, pre-operative things had been “slowing down” and his wife was “not that keen”.
  • Social history: married with 2 daughters and 4 grandchildren, manages dairy farm, brother also has prostate cancer. Fred was very embarrassed by his incontinence and was avoiding leaving the house.  His wife reported that he was becoming very irritable and angry.
  • Exercise: increased BMI of 29, no regular exercise program currently or pre-op, but long hours working on the farm which he runs largely by himself. Had been doing pelvic floor exercises that he learnt on the internet but was finding they “weren’t making any difference”.

Objective Assessment

  • Observation: minimal penile retraction and testicular lift with attempted pelvic floor muscle contraction, global response with breath holding and abdominal / gluteal contraction.
  • Real-time 2D transperineal ultrasound (TPUS) examination: poor ability to isolation a pelvic floor muscle contraction, minimal urethral occlusion with mild activation of puborectalis (2mm bladder neck elevation) and bulbocavernosus, urethral sphincter flickering in and out only, unable to sustain.
  • Pad weight diary: leaking 870mls per 24/hrs, including ~150mls overnight. 
  • Bladder diary: diurnal urinary frequency of 2-3 (volumes 30-150mls), nocturia of 3-4 (volumes of 40-150mls), fluid intake 1.2-1.4L inc. 2-3 coffee per day.
  • Bladder scan: no post void residual.
  • Dipstick urinalysis: NAD.

Impression:

Fred is a complex case of post-prostatectomy incontinence.  His incontinence is likely caused by sphincteric weakness following surgery, overactive bladder (evidenced by urgency and urgency incontinence, nocturia, and nocturnal leakage on pad weight diary), and poor function of the pelvic floor and urethral sphincter muscles, and further exacerbated by poor fluid habits, constipation and increased BMI.  
 
It is likely that his pre-existing LUTS contributed to his bladder dysfunction, and his constipation, lifestyle and BMI contributed to poor pelvic floor muscle function. 
 
Recent work by Stafford and colleagues1 demonstrates the importance of the function of the pelvic floor muscles puborectalis, bulbocavernosus, and striated urethral sphincter in the recovery of post-prostatectomy incontinence. Their recent study shows that all 3 muscles are important for recovery of continence, and that the striated urethral sphincter is the most integral.
 
This case study highlights the diverse etiological causes of post-prostatectomy incontinence, and the importance of a thorough subjective and objective assessment.  It also demonstrates the benefit of a pre-operative visit – if Fred had attended pre-op he could have improved the function of his pelvic floor muscles leading into surgery, and his pre-existing LUTS and constipation could have been addressed, which would have likely led to a faster recovery of continence after surgery.
 

Treatment program:

  • TPUS assessment and biofeedback: Fred was educated how to correctly contract his pelvic floor muscles using TPUS for biofeedback, with a focus on the striated urethral sphincter, puborectalis, and bulbocavernosus activation.  TPUS is a very beneficial tool in men with post-prostatectomy incontinence, as it enables the therapist to visualise all the striated muscles involved in continence, including the striated urethral sphincter (which cannot be assessed via rectal examination).  
  • Pelvic floor muscle training program: Fred’s program was focused initially on correct technique of activation, followed by a strengthening program and functional integration into his daily activities which caused leakage such as lifting and bending during farm duties.
  • Fluid modification: it was recommended that Fred minimise his caffeine intake, and aim for around ~1.5L total fluid intake.
  • Behavioural bladder retraining: a bladder retraining program was commenced, focusing on urge suppression, and then urge deferral aiming to increase his functional bladder capacity.
  • Referral to surgeon for opinion on medical management for OAB: Fred was reviewed by his surgeon and commenced on Betmiga. 
  • Weight loss advice: Fred was educated about the impact of increased BMI on incontinence and the benefit of dietary changes and increasing general exercise for weight loss.
  • Treat constipation: Fred was educated in dietary changes for stool softening and taught how to empty his bowels without straining.
  • Psychological: Fred was offered referral to a psychologist (which he declined), however his physio had many discussions with him about the importance of re-engaging in social and leisure activities to reduce his social isolation and improve his recovery.

Outcome

After 6 weeks of treatment, Fred’s pad weights had reduced by ~50% to ~400mls per day.  TPUS examination showed improved function of the striated urethral sphincter, puborectalis and bulbocavernosus, he was now able to get reasonable urethral occlusion and hold it for 8 seconds.  He was voiding 5-6 times per day in the toilet, nocturia of 2-3, and no longer had urgency urinary incontinence, but had ongoing stress urinary incontinence with physical exertion such as walking and farm work.
 
At 11 months post-surgery, with excellent adherence to an advanced functional pelvic floor muscle training program, Fred’s incontinence had made a near-full recovery.  He was wearing 1 liner per day for occasional leaks with heavy farm work, and had successfully weaned off Betmiga.  He was feeling much happier, and was confidently enjoying his social activities again, especially fishing and enjoying a few beers with friends. 
 
 
References 
1Stafford, van den Hoorn, Coughlin, Hodges. (2017). Post prostatectomy incontinence is related to pelvic floor displacements observed with transperineal ultrasound imaging. Neurourology and Urodynamics, 1-8.