The Stages of Incontinence After Prostatectomy

Older man walking along nature path

Before we get into the details about incontinence after prostatectomy, we must discuss Prostate Specific Antigen (PSA) and how we have modified our diagnostic process and, ultimately, treatment of prostate cancer over the years. You may have read elsewhere on our website that we once used to aggressively treat prostate cancer at the first signs of PSA rising above 4. As we have learned over the years, prostate cancer is often very slow-growing, and a single high PSA reading does not necessarily warrant a biopsy or treatment. Similarly, the presence of prostate cancer with a biopsy does not necessarily mean an immediate prostatectomy. The restraint we have shown with this newer knowledge of prostate cancer has reduced the number of prostatectomies we’ve had to perform and ultimately helped some patients avoid the consequences of such surgery, including incontinence and erectile dysfunction.

Why Incontinence?

For those that require a prostatectomy, incontinence and some degree of erectile dysfunction are a virtual guarantee even with “nerve-sparing” prostatectomy. Regarding incontinence, one of the two valves or sphincters used to limit urine flow is removed along with the prostate. While an additional valve remains, we cannot predict if it can immediately regulate the urine flow. That said, only about 2% of all prostatectomy patients have long-term incontinence. In other words, approximately 98% of patients will regain continence within a year or so.

It’s important to know that the return to continence is not linear. Some patients may regain some continence within days, while others may take weeks or months. Similarly, the amount of urinary leakage may be small for some, while it can be significant for others. None of this is predictable nor representative of the likelihood that you will regain continence longer-term. Many patients who leak after three or four months can become discouraged. But rather than look at this as a failure, it’s essential to understand that it is a progressive recovery. The stages of the return to continence after prostatectomy are generally as follows.

  • First, patients may find they can get through the night and remain dry. They may leak once they wake up, unable to get to the bathroom quickly.
  • The second stage is staying dry through the night, needing to urinate in the morning, and calmly getting to the bathroom to void. They will still leak during the day.
  • The third stage is getting through the night dry, voiding it in the morning, and making it through the entire morning without leakage.
  • Then, patients in the fourth stage will typically be able to hold their urine throughout the day until midafternoon and then may have some minor leakage as they get tired.
  • Finally, some patients in the final stage of returning to continence will only leak when exerting themselves but otherwise stay dry throughout the day.

Eventually, when patients are down to one pad throughout the day and manage to keep it dry, we will discuss its continued use. This last pad is known as a confidence pad, and many patients tend to wear this pad indefinitely to assure themselves that they will not leak, avoiding embarrassment. However, this may be the very time to eliminate it. The patient may leak at some point during the day, but more often than not, they do not need the pad and regain confidence in holding their urine until they can get to the bathroom.

Moving on from this last pad is also essential for discipline, ensuring that every time urination is needed, the patient thinks strategically about their bathroom needs. This may include voiding right before or after dinner or before or after an event at which they know using the bathroom may be challenging.

Ultimately, we are looking for progress, and patients should be encouraged even if they find that their progression through these stages is measured and not immediate. On the other hand, if, after a year, the patient still has not achieved their desired level of continence, there are solutions to return it to them, including an artificial urinary sphincter or a male sling. These procedures are minimally invasive, highly effective, and can offer long-term freedom for most patients.

Of course, the first and most important idea is realizing that help is available. Getting help early and understanding your options is the best way to get appropriate treatment and early relief. We encourage you to contact Dr. Kapadia to learn more about the recovery process after a prostatectomy, including understanding the stages of continence after surgery.