Dr. Alicia Morgans and Dr. Martin Kathrins discuss common urinary side effects after prostate cancer treatment, including incontinence, urgency, and frequent nighttime urination, and emphasize that many effective treatment options are available. They highlight the importance of seeking help, as interventions ranging from pelvic floor therapy and lifestyle changes to medications and surgical procedures can significantly improve quality of life and restore confidence.
Dr. Alisha Morgans:
Well, let's shift gears a little bit and talk about incontinence. It's interesting, we talked to Adam Kiebel at some point and he said, "Men think before surgery all about erectile function, and after surgery, they're thinking all about incontinence." And I'm thinking about incontinence on the front end when I'm counseling these patients, because I know what it can do to their social wellbeing. And sometimes, people have a lot of distress about, "Can I go to work if I'm going to potentially leak? Can I go on a trip? Can I take a long drive?" And these are things that can be really limiting, and people feel phobic and stay home. How do you have the initial conversation with somebody about incontinence, and then we'll talk about what you do.
Dr. Martin Kathrins:
Sure. Yeah. And so as you observed, I mean, bothersome urinary leakage is certainly less common than erectile function, but boy, when it's there, it is really totally front of mind for that man. And these are certainly the most satisfying clinical interactions I have in my job, to help a man regain his continence and help him think about treatments for his urinary continence.
I mean, the first thing that needs to be presented to a man is what can he expect from a timeframe perspective? And so urinary leakage tends to be more of an issue after a man has his prostate removed, although it's the minority of patients, and this tends to get better over the first six months, the first 12 months, and it's a pretty rapid improvement. And there are even things that the man can do that are non-invasive, like working with a pelvic floor physical therapist that he may not have thought about before that you really have to encourage, sometimes even push patients to do it, because it's such an effective therapy.
But if you're in that 10% or so of men who are at a year out and still really struggling with urinary incontinence, I totally agree, it's totally debilitating for some of my patients. And that's really when I would be involved, can do diagnostic testing, can talk about non-surgical options. Medical therapies are pretty few and far between, although they do exist for this kind of leakage, all the way up to surgical therapies, which is a big part of my practice. Yeah.
Dr. Alisha Morgans:
Okay. Well, let's talk first about some bothersome urinary symptoms, because I knew there are some medical therapies that can be a little more effective there, and then we'll get into frank incontinence.
Dr. Martin Kathrins:
Okay.
Dr. Alisha Morgans:
So what do you say to a man who may no longer have his prostate anymore, but he's still waking up multiple times at night to urinate. These guys come into my clinic, and I have to try and think of what to do. Tell me, Martin.
Dr. Martin Kathrins:
So this is the medical jargon. It's called nocturia. And so this is also a medical problem that's near and dear to my heart. I've always been very interested in this problem. And so nocturia, which is getting up to pee overnight, gets a bad rap. It gets piled in with prostate problems and bladder problems when, on average, it's really not related to either often or not. It tends to be related more to how much urine a man or a woman makes in the overnight hours.
And so I agree, even when I do prostate surgeries outside of the cancer realm and I would tell a man beforehand, "You may still get up overnight because it's a different issue." So these require careful evaluations, urinary diaries, checking kidney function, sodium levels, creatinine function. And there are some medications that can be offered to patients that somebody like myself would prescribe them. And there are also some lifestyle modifications that are pretty low-hanging fruit and pretty easy to do, evening fluid restriction, avoiding certain bladder irritants, evaluating the man for a sleep disorder that can help him. But I mean, boy, when you hit the nail on the head, I mean, the patients are so grateful. They can get some sleep and be rested. But yeah, as you observed, it may follow them after their prostate's removed. So, yeah.
Dr. Alisha Morgans:
So important for patients to know that. Just because your prostate's out does not mean you necessarily are going to get better, so you should talk-
Dr. Martin Kathrins:
Not always.
Dr. Alisha Morgans:
... to somebody-
Dr. Martin Kathrins:
Not always. Yes. I would encourage them-
Dr. Alisha Morgans:
... and bring it up.
Dr. Martin Kathrins:
... to reach out. Yeah, because we do have therapies.
Dr. Alisha Morgans:
Absolutely.
Dr. Martin Kathrins:
Yeah.
Dr. Alisha Morgans:
What about things like feeling like when you got to go, you got to go? Radiation is pretty notorious for that one.
Dr. Martin Kathrins:
So, yeah. So as you observed, radiation can affect your bladder function, which prostate removal, in and of itself, tends to do a bit less. And so that can make the cutoff point at which a man feels his bladder full to drop a little bit. And so this is hard. I mean, there are some also lifestyle modifications that can be worked on, things that we can just talk through in clinic that the man can start doing day one after I see him to try to employ, to try to limit those overactive bladder symptoms. We want to do some testing and make sure that we're not missing anything concerning in the bladder itself so we don't take it as a given like, oh, it's just a symptom from radiation. We want to make sure we're not missing anything.
And then we have a dizzying array of different medical therapies, even therapies with minor invasiveness to help a man, not so much with leakage, but just with like running the bathroom all the time, overactive bladder symptoms. So it's a big part of our practice inside the cancer survivorship realm and definitely outside of it as well. So I'd like to think we're pretty good at this out here.
Dr. Alisha Morgans:
I'm sure you are. And that one should probably get better over time, too. If they finish their radiation, does it, in some cases, get better?
Dr. Martin Kathrins:
Yeah. So it can. I mean, so sometimes, the thing with radiation is some of these symptoms take some time to kick in actually. So you may not see this problem arise for maybe even a few months after. Radiation itself is its own impact. But yeah, I mean, these symptoms can wax and wane. I have as much patience as the patient has, but we also want to play referee and say, "Okay, we've tried waiting. You're not better. Let's talk about moving to the next stage and talk about medical therapy." So I'm happy to stay with non-medical therapies as long as the patients are willing to or wants to.
Dr. Alisha Morgans:
Well, let's talk then about the other elephant in the room that we've already mentioned - incontinence - and there are options that range from ... Well, you mentioned some medical, but I think more of them are there's physical ones, clamps and things, and then all the way up to surgeries. Tell us a little about those.
Dr. Martin Kathrins:
So for this thing called stress incontinence where the sphincter muscle that sits under the bladder, it's just weakened by some of the therapies, and when the man exerts himself that he's just leaking urine, when he's in the yard, when he's lifting up something heavy, when he coughs, he sneezes.
So there are some things that you do at the bedside that you can just provide a man for. For men with higher degrees of leakage, we use external clamps, which sound kind of horrible, but they're actually better tolerated than I think some patients might think, and it's something pretty quick and pretty easy that the man can employ to regain some social continence. Other things I have had less success with, although some patients can do well with them, things like condom catheters to catch the urine.
But then for some men that have higher degrees of leakage that want a more permanent solution, there are surgeries. And so there are two classes of operations that I do more frequently. One is called a urethral sling, which is a little piece of mesh that gets placed surgically under the urethra to move some of the urethra closer to the sphincter muscle, so the sphincter can grab onto more and help him be drier. It's an attractive surgery in so far as you hope it's a set-it-and-forget-it operation, he doesn't need to do anything else. Of course, there are risks to this. It doesn't always work out exactly the way we want, and so patient counseling is super important.
The other operation I do and we do a little bit more frequently is something called an artificial urinary sphincter, which is a little difficult for most patients to wrap their brain around. They're like, "This thing exists?" And we have them in clinic. We show patients these devices. So similar to the penile prosthesis, this is totally inside of the patient's body, and it's like an internal clamp for the urethra tube, and it acts as kind of a dam, so the urine can't get out, and the man can deactivate it anytime his bladder fills and he wants to go pee, and these are just amazing.
When I turn on these devices for a man that's using, the rare man that has really high leakage, and I turn it on, which is quick at the bedside, it's one of those eye-opening events and just incredibly gratifying and satisfying for me as a surgeon, as a physician to do that. They're also not perfect. They don't last forever, not unlike an inflatable penile prosthesis, but they can be absolutely life-changing operations for some patients.
Dr. Alisha Morgans:
Wonderful. So one of the things I think about with that in particular is, is that something that's okay for a patient with maybe some cognitive impairment or dementia? Because I just worry if they can't remember to open that clamp, then they could get kidney damage. And so I'm always a little cautious sending people with dementia for that particular intervention.
Dr. Martin Kathrins:
I share your concern. I worry about that, too. And as a surgeon, just because I can doesn't mean I should in a lot of scenarios. So yeah, I mean, so patient selection is really important. So yeah, if I have a patient that's facing a diagnosis of some form of dementia, has some memory problems or has significant dexterity problems such that he really can't operate the thing, no, I agree with you that's not something we'd want to do, and we want to be aggressive about finding other ways that he can regain continence and not saying, "Well, that's it" type thing. Just maybe that this thing in particular is not for you or just not maybe ... It may cause more problems than good, I think, is how I present. So I totally agree.
For urinary leakage, I have such empathy for patients that are dealing with this, and I'm just incredibly motivated, really motivated to try to do what I can to help them regain continence and that sense of normalcy that, let's be honest, some patients think they've lost. And it's a privilege to see men after their prostate cancer therapies, and it gets me in the office every day.