Strategy for Incontinence From Prostate Cancer Surgery

Study Shows Benefits of Behavioral Therapy in Reducing Incontinence Episodes

Medically Reviewed by Laura J. Martin, MD on January 11, 2011
From the WebMD Archives

Jan. 11, 2011 -- Pelvic-floor-muscle exercises along with other bladder control strategies, such as keeping a diary and monitoring your daily fluid intake, can help halve weekly incontinence episodes among men with prostate cancer who have had surgery to remove their prostate gland (radical prostatectomy), a study shows.

The new findings appear in the Jan. 12 issue of The Journal of the American Medical Association.

Incontinence is a known risk of prostate removal surgery, and as many as 65% of men will still have some degree of incontinence up to five years after the surgery. Other options to treat incontinence after radical prostatectomy include follow-up surgeries.

“Behavioral therapy should be offered to men with persistent post-prostatectomy incontinence because it can yield significant, durable improvements in incontinence and quality of life, even years after radical prostacatetomy,” conclude researchers who were led by Patricia Goode, MD, a professor in the division of gerontology, geriatrics, and palliative care at the University of Alabama, Birmingham.

Decrease in Incontinence Episodes

In the new study involving 208 men aged 51 to 84 with incontinence from one year up to 17 years after their prostate removal surgery, those who took part in an eight-week behavioral therapy showed a 55% decrease in weekly incontinence episodes (from 28 episodes to 13 episodes per week), compared to men who were placed in a delayed treatment comparison group.

The behavioral intervention consisted of four visits scheduled two weeks apart. Men received education on their pelvic floor anatomy and learned how to do the pelvic-floor-muscle exercises. Homework included three pelvic floor exercise sessions per day done lying down, sitting, and standing. Each session encompassed 15 reps of 2- to 10- second contraction and release exercises. Men were also advised to hold their urine stream during voiding once a day for two weeks, keep a bladder diary, avoid caffeine, and to distribute their fluid throughout the day.

Biofeedback and electrical stimulation did not seem to increase the effectiveness of the behavioral therapy, the study shows. Study participants who used biofeedback and electrical stimulation of their pelvic muscles to augment the behavioral interventions showed a 51% decrease in incontinence episodes per week, compared with men in the delayed treatment comparison group, the study shows.

By the end of the eight-week study, almost 16% of men in the behavioral therapy group were completely dry, as were 17.1% in the group that also added biofeedback and electrical stimulation along with behavioral therapy and 5.9% of men in the comparison group.

Ninety percent of men in the behavior therapy group and 91% of men in the behavior therapy with biofeedback and electrical stimulation group said their leakage was “better” or “much better” when compared with 10% of men in the comparison group, the study shows.

Overall, 47% of men in the treatment groups said they were satisfied with the level of improvement.

Second Opinion

David F. Pearson, MD, MPH, the director of the Center for Surgical Quality & Outcomes Research, and a professor of urologic surgery at Vanderbilt University Medical Center in Nashville, Tenn, says that behavioral therapy is as good as it gets when it comes to a nonsurgical way of treating incontinence after prostate cancer surgery, but he is not sure it is good enough for many men. Pearson wrote an editorial that accompanied the new study.

When it comes to the behavioral intervention outlined in the study, “there is no downside,” he says. “No harm, no foul.”

In terms of improvement, “the surgical options such as placement of sphincter or a male sling are better than this, but for a noninvasive treatment probably is at good as it gets,” he says.

“In the end, patients have to realize there is a chance of bothersome symptoms that will require another aggressive intervention down the road,” he says.

When a man is diagnosed with prostate cancer and considering surgery, it can be hard to appreciate how side effects such as incontinence can affect their quality of life, Pearson says.

“There is no denying the fact that this study shows it has an effect, but people just have to realize that if you want to be totally dry, this isn't going to do that,” he says.

“Are you OK going from four leaks a day to two? Most of my patients will say ‘No. When I walked in I didn’t wear diapers, and I don’t want to wear them now,’” he says.

“A lot of men are suffering from incontinence and there are those who will get treated with surgery to treat prostate cancer and will suffer from incontinence down the road who need a solution,” says Robert A. Smith, PhD, the director of Cancer Screening of the American Cancer Society based in Atlanta.

Behavioral therapy increases the list of options for these men, he says.

“In a small percentage of men, behavioral therapy eliminates incontinence entirely, but for most of them, it just reduces the number of events per week,” he says.

His advice? “If it did work, good, and if it didn’t work to your satisfaction, then you can consider surgery to treat the incontinence,” he says.

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Goode, P.S. The Journal of the American Medical Association, January 2011; vol 395: pp 151-159.

Pearson, D.F.  The Journal of the American Medical Association, January 2011; vol 395: pp 197-198.

David F. Pearson, MD, MPH, director, Center for Surgical Quality & Outcomes Research, Vanderbilt University Medical Center, Nashville, Tenn.

Robert A. Smith, PhD, director, Cancer Screening, American Cancer Society, Atlanta.

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