Journal Articles

Key Points

Urinary tract dysfunction following definitive management for localised prostate cancer has diminished in frequency and severity as curative modalities have been refined, but problems can occur.
• Pre-operative counselling before radical prostatectomy should include instruction from a continence physiotherapist in the technique of pelvic floor training.
• For men with significant sphincter weakness incontinence post radical prostatectomy, which is not responsive to pelvic floor training, surgical intervention is indicated.
• Radiation cystitis can develop a number of years after prostatic radiotherapy has been administered.
• Men who suffer radiation cystitis with haematuria must initially be evaluated carefully for other causes of haematuria, such as kidney or bladder cancer.
• The management of radiofibrosis with stricturing includes urethral dilatation and in some cases the placement of a urethral stent.
• It is critically important that appropriate genito-urinary rehabilitation occurs following definitive prostate cancer treatment, in order that the patient may return to a high quality of life.

Treatment options for localised prostate cancer include watchful waiting, radical prostatectomy, external beam radiotherapy or prostatic brachytherapy (either with iodine seed implantation or high dose rate iridium wire insertion). The treatment chosen must be appropriate to the man’s age, potential longevity and clinical stage and grade of his prostate cancer. When practised by experienced clinicians, brachytherapy and radical prostatectomy are low-morbidity procedures with an excellent outcome of longterm cure in a large number of cases.

Radical prostatectomy can be performed via retro-pubic, trans-peroneal or robot-assisted laparoscopic technique. There is no significant advantage of one technique over another; it really depends on surgeon training and preference. In Australia, the average age of men undergoing radical prostatectomy is 64 years. A very significant number of these men suffer with benign prostatic obstruction with seco ndary detrusor instability, resulting in complaints of frequency, urgency and voiding at night. By removing the obstructing prostate gland, radical prostatectomy surgery may improve bladder function for a significant number of these men. Pre-operative counselling should include instruction from a continence physiotherapist in the technique of pelvic floor training. Men frequently have trouble identifying their pelvic floor muscles and tend to strain rather than contract. Intra-operative technique is critical to good long-term continence preservation. The apical preservation should be done as carefully and as atraumatically as possible. Preservation of striated muscle fibres situated anterior to the prostato-membranous junction is an important part of the apical dissection. The prostato-membranous junction should not be subject to diathermy trauma or traction during division.

Most men undergoing radical prostatectomy will have some degree of urinary incontinence following surgery. Symptoms may include stress incontinence, frequency, urgency, urge incontinence, post-micturition dribble, nocturia and nocturnal enuresis. It is useful for men undergoing prostate surg e ry to learn how to perform a pelvic floor muscle contraction correctly. This will help them to improve the strength, endurance and quality of the contraction. It is easier for patients to learn how to contract their pelvic floor muscles prior to surgery, when they are without pain or discomfort. Strong muscles will help post-operatively as the patient will know how to use these muscles effectively, thereby reducing or even preventing incontinence. Following the surgery, a urinary catheter is left in situ for between one and two weeks, depending on surgeon preference. Pelvic floor training should not be performed while the catheter is in situ. Once the catheter has been removed, the patient should be encouraged to perform daily pelvic floor training. After removal of the catheter, the severity of the incontinence may vary from very little bladder control, to only some minor leaking for a few days. Strengthening the pelvic floor muscles and learning to use them functionally can definitely help these patients gain bladder control sooner.

The pelvic floor muscles extend from the pubic bone anteriorly to the coccyx posteriorly and to the ischial tuberosities laterally. These skeletal muscles are made up of type I slow-twitch and type II fast-twitch muscle fibres. Puborectalis arises from the pubic bone anteriorly; it lies medially to pubococcygeus and wraps around the anus posteriorly. Pubococcygeus arises from the pubic bone anteriorly and inserts into the coccyx posterio rly. Pubococcygeus, iliococcygeus and ischiococcygeus form the levator ani muscles, and are supplied by the pudendal nerve (S2, S3, S4). Recent research has found a strong link between transverse abdominis, the internal obliques and pelvic floor muscles. These muscles co-activate and so, by strengthening the lower abdominal muscles, one can improve the strength and quality of contraction of the pelvic floor muscles.

• Squeeze the muscles around the anus and try to lift the anus towards his head, as he would if he were trying to stop himself from passing flatus
• Be able to see and feel the anus contracting and lifting • Try to lift the scrotum and draw up both testicles; this can also be felt and seen • Imagine stopping the flow of urine mid-stream
• Feel and observe that the area around the base of the penis
dips in towards the abdomen • Be aware of the tightening of the lower abdominal muscles during a pelvic floor contraction. When performing a strong pelvic floor contraction, the above a reas should be contracting together. The pelvis should not move or tilt and there should be no active contraction of the gluteal or adductor muscles. A pelvic floor exercise and bladder control program should include the following:
• Strong maximal contractions (up to 10 repetitions), which are held at this intensity for 5-10 seconds.
• Fast contractions, which work on speed and strength.
• Sustained sub-maximal contractions where the lower abdominals and the pelvic floor muscles are contracted to between 25% and 50% of their maximum intensity for long periods of time, e.g. while walking.
• Functional muscle contractions, where both the pelvic floor and the lower abdominals are contracted strongly with any rise in intra-abdominal pressure, e.g. coughing, sneezing etc.
• Specific exercises for transverse abdominis and the internal oblique muscles.
• Urge control techniques, with which the patient learns to suppress the urge to void by strongly contracting the pelvic floor muscles and using a number of distraction techniques. Together with bladder training, these cont rol techniques will help the bladder return to normal capacity and decrease nocturia.
• Postural awareness and cont rol. For example, patients need to be aware that their pelvic floor muscles work more effectively when sitting upright. A slouching or slumping position makes it more difficult to engage the muscles effectively. A physiotherapist, working in the area of incontinence, will be able to provide an individualised program for each patient, depending on his presenting symptoms.

Continence preservation has improved significantly during the past 20 years of experience with contemporary radical prostatectomy surgery. In experienced hands, there is now only a 2% risk of long-term sphincter weakness urinary incontinence. Many men are socially continent within days of the catheter being removed, and the majority have excellent continence by six weeks post-operatively. However, the re t u rn of sphincteric function is variable, and it is very important to support those men whose continence return is more prolonged. The surgeon and continence physiotherapist should see them regularly for the purposes of providing support, reassurance and encouragement. Sphincteric function can continue to improve for up to 18 months following the operation.

In men with significant bladder neck obstruction pre-operatively, and secondary detrusor instability, irritative urinary symptoms may persist for six months. Anticholinergic medication in the form of oxybutynin should be trialled if irritative symptoms persist. For men with poor bladder control six months post-operatively, a urodynamic study should be performed. This computerised x-ray study is the gold-standard diagnostic test for determining the cause of urinary incontinence. The urodynamic study will determine whether significant detrusor instability is present and will identify significant sphincter weakness incontinence. For men with significant sphincter weakness incontinence not responding to pelvic floor training, surgical intervention is indicated. Three interventions are currently in practice: transurethral or transvesical injection of bulking agents such as macroplastique or collagen; the insertion of a male sling; or the implantation of an artificial urinary sphincter. Bulking agents are seldom successful. Long-term experience with the sling is limited, but initial results are promising. The definitive management of sphincter weakness incontinence following radical prostatectomy surgery is the implantation of an artificial urinary sphincter.

This is a hydraulic device inserted via a trans-scrotal incision. The patient is hospitalised for 24 hours; the device is deactivated for six weeks, to allow healing to take place, and thereafter activated in the office situation. The artificial urinary sphincter is comprised of a reservoir of n o rmal saline situated within the abdomen, while a cuff is placed around the bulbar urethra and a control valve is situated within the scrotum. The cuff is continually filled with fluid and as a result compresses the bulbar urethra and maintains continence (see Figure 2). When the bladder is full, the patient experiences a norm a l sensation of fullness. The patient then pumps the control valve within the scrotum two to three times. This transfers the fluid from the cuff into the abdominal reservoir and allows normal bladder contractions to occur, resulting in bladder emptying. The cuff refills spontaneously over a two to three-minute period, once again restoring urinary control. For most men, the artificial urinary sphincter is an excellent means of restoring normal bladder function. Occasionally an additional cuff needs to be added in men in whom the urethra is less compliant. Prosthetic infection rates are low, and revisional surgery is possible should urethral atrophy occur over a number of years and continence diminish.

Radical radiotherapy is a commonly utilised treatment modality for localised prostate cancer. It is generally applied to men in their late 60s and 70s. It is also a viable treatment strategy for younger men who, for medical reasons, are not suitable for radical prostatectomy surgery. Radical radiotherapy traditionally has been performed using external beam radiotherapy to a dose of 67 Gy. Newer modalities have been developed and are widely used in clinical practice. These include iodine seed implantation, high dose rate brachytherapy and conformal radiotherapy. The modern forms of radiotherapy target the prostate more accurately and selectively, thereby minimising collateral damage to the rectum and bladder. As a result, urinary toxicity has been diminished when compared with traditional external beam therapy. Nevertheless, urinary complications of radiotherapy and brachytherapy do occur. These complications should be evaluated carefully and appropriate treatments offered.

Men who have been treated with a form of radical radiotherapy for early prostate cancer may still develop benign bladder neck obstruction (BNO). Before treatment is instituted, a diagnostic urodynamic study should be undertaken to document the presence of BNO and to determine whether secondary detrusor instability is present. Alpha-blockers and anticholinergic medication may be used separately or together depending on the urodynamic findings. Transurethral prostatectomy surgery should be avoided in men who have had radical radiotherapy for localised prostate cancer. There is a very significant incidence of sphincter weakness incontinence, and also of urethral stricture disease. If medical management does not prove effective, a conservative bladder neck incision can be performed transurethrally. This is generally effective, with minimum risk of sphincter weakness urinary incontinence.

Radiation cystitis is due to permanent radiation damage to the urothelium of the bladder. It can develop a number of years after prostatic radiotherapy has been administered. Radiation cystitis is characterised by urinary frequency, urgency, urge incontinence and haematuria. The urothelium is atrophic and friable, and bleeding can be heavy with resultant clot retention. Men who suffer radiation cystitis with haematuria must initially be evaluated carefully for other causes of haematuria, such as kidney or bladder cancer. The evaluation includes a CT scan of the kidneys, along with three voided urinary cytology examinations followed by careful cystoscopic examination of the bladder and urethra. The purpose of the cystoscopy is to exclude bladder cancer and, where possible, to laser ablate or diathermy discrete bleeding points. Frequently, the radiation cystitis is a global change affecting the urothelium. As such, it is not amenable to local therapies. Increasingly, hyperbaric oxygen therapy is being used as a management option for recurrent haematuria resulting from radiation damaged bladder urothelium. However, success is variable and the therapy may need to be repeated. For men with recurrent heavy bleeding, bladder irrigation with alum, which is an astringent, may sometimes prove helpful. The patient is admitted to hospital, and a three-way catheter passed. For a 72-hour period, the bladder is irrigated with an alum solution. The catheter is then removed and the patient discharged. This therapy is well tolerated and can be repeated should bleeding recur. Instillation of formalin into the bladder under spinal anaesthesia has also been used. While formalin instillation may control bleeding, it can result in long-term bladder dysfunction. Very rarely, cystectomy with urinary diversion may be necessary for heavy intractable radiation haemorrhagic cystitis. Men may suffer with the irritative symptoms of radiation cystitis without being troubled with haematuria. These symptoms may be managed by the use of anticholinergic medications.

Radiofibrosis can occur in treated men, and can result in stress urinary incontinence or constant dribbling-type urinary incontinence. Pelvic floor training should be trialled, though it is less likely to be successful in view of the presence of radiofibrotic damage to the distal urethral sphincter mechanism. These men are best treated by the implantation of an artificial urinary sphincter. Due to the radiofibrosis and decreased urethral compliance, a double cuff technique should be used to maximise the chance of restoring urinary control.