Understanding Urinary Problems

To understand your urinary problems, it is important to know how the prostate and bladder are connected, and how your prostate cancer treatment affects them both.

• The prostate gland is normally the size of a walnut but may enlarge as you age. It is located between the bladder and the penis and sits in front of the rectum.
• The main function of the prostate gland is to produce fluid that nourishes and protects sperm. During ejaculation, the prostate squeezes this fluid into the urethra (urine tube) and it is expelled with the sperm as semen.
• The urethra is the thin tube that runs through the centre of the prostate from the bladder to the penis. It is the passage used for urine and semen.

BLADDER AND PROSTATE

Urinary incontinence is the accidental leaking of urine and a possible side effect in men who have had surgery or radiotherapy for treating their prostate cancer. The amount of leakage can vary from a drop to total emptying of the bladder.

For some men, urinary problems may not occur or are quickly resolved. For other men, they can be more problematic, requiring further support and help from members of their healthcare team who specialise in prostate cancer and urinary problems. It is important to talk to your healthcare team about any urinary problems you are experiencing because they understand your individual situation, and are able to give you the most relevant advice.

There are different types of urinary incontinence.

• Stress urinary incontinence is the loss or leaking of urine when there is an increase in abdominal pressure. For example, when you cough, laugh, sneeze, change position or are physically active.
• Urge urinary incontinence is the sudden intense need to urinate without the ability to delay, resulting in the loss or leaking of urine before you reach the toilet. Urgency or urge incontinence occurs when your bladder is overactive or contracting without you wanting it to.

• Mixed incontinence is a combination of urinary problems related to both stress and urge urinary incontinence.
• Overflow incontinence is when your bladder never completely empties, causing urine to leak. This can occur in men with prostate enlargement, scarring of the urethra caused by treatment or at the neck of the bladder due to injury or infection.

SURGERY

When your prostate gland is removed entirely by surgery, a procedure called radical prostatectomy (open, laparoscopic or robotic), two things occur during the surgery that can cause urinary side effects.

• A gap is created between the bladder and urethra, which is then surgically reconnected.
• The bladder neck (where the bladder and urethra join) can be affected and this can cause urinary problems. Also, the external sphincter may be weakened, or very rarely, damaged during surgery, and this can cause urinary problems as well. This is why pelvic floor exercises before your surgery, and after removal of your catheter, which can strengthen the external sphincter, can help with managing possible urinary problems after surgery. (Note: do not perform pelvic floor exercises while the catheter is in place, this allows the surgical area time to recover).

Some urinary side effects that you might experience following surgery include:

• incontinence (accidental leaking of urine)
• incomplete emptying (a feeling of not fully emptying your bladder)
• hesitancy (difficulty beginning your urinary stream)
• intermittency (a stop/start urinary stream)
• dribbling (slight urinary leakage after urinating is completed)
• weak urinary stream (slow flow with minimal force)
• straining (having to push or strain to begin your urinary stream)
• frequency (needing to urinate every two hours or less)
• urgency (strong sudden urge to urinate and inability to delay it)
• nocturia (need to urinate overnight)
• pain (any discomfort, such as burning, stinging or pain while urinating).

Stress urinary incontinence is the most common urinary side effect following prostate cancer surgery.

For some men, these side effects start improving soon after the catheter is removed, while for others it can take 6 to 12 months after surgery for normal bladder function to fully return and urinary side effects resolve. A small percentage of men will experience permanent incontinence. There are treatment options available for permanent incontinence. Discuss your situation with your healthcare team if it applies to you.

Many factors can affect continence following surgery such as your weight, the stage of your cancer, the surgical technique required for your individual situation, or if you were experiencing any urinary problems before your surgery. For older men (over 70 years old), it may be slower initially for them to regain their continence, but there is some evidence that by 3-6 months, there is no difference between younger and older men in terms of urine control after surgery.

Very rarely, the bladder neck (where the bladder joins the remainder of the urethra) can develop a narrowing known as bladder neck stenosis (or stricture).

Problems caused by a stenosis may include:

• a weak urinary stream
• hesitancy
• a feeling of incomplete emptying of your bladder
• spraying of urine when urinating
• urinary retention.

BEFORE SURGERY

AFTER SURGERY

RADIOTHERAPY

There are two main types of radiotherapy – external beam radiotherapy (EBRT) and brachytherapy. The difference is whether the treatment is applied from outside the body (EBRT) or delivered from within the prostate (brachytherapy).

External beam radiotherapy

External beam radiotherapy (EBRT) uses high energy X-ray beams that are directed at the prostate from the outside to destroy cancer cells.

Urinary side effects following EBRT can be described as ‘early’ or ‘late’. Early side effects are those that occur during or shortly after radiotherapy treatment, and usually settle a few weeks after treatment finishes. Late side effects are those that take months or years to develop, and can be permanent. These side effects can vary from mild to more severe forms and be age-related rather than due to the treatment. However, most men experience mild forms of these side effects and many have none.

If you are already experiencing urinary problems before starting EBRT, these problems may get worse. Please talk to members of your healthcare team about concerns you have about existing or possible urinary problems following treatment.

Possible early urinary side effects of EBRT include:

• urgency (strong sudden urge to urinate and inability to delay it)
• frequency (needing to urinate every two hours or less)
• pain (any discomfort such as burning, stinging or pain while urinating)
• nocturia (need to urinate overnight)
• intermittency (a stop/start urinary stream)
• dribbling (slight urinary leakage after urinating is completed)
• straining (having to push or strain to begin your urinary stream).

Possible late urinary side effects of EBRT include:

• weak urinary stream (slow flow with minimal force)
• nocturia (need to urinate overnight)
• urgency (strong sudden urge to urinate and inability to delay it)
• intermittency (a stop/start urinary stream)
• dribbling (slight urinary leakage after urinating is completed)
• straining (having to push or strain to begin your urinary stream)
• urinary stricture (narrowing of the urethra due to scarring that can cause side effects already mentioned).

While urinary incontinence may occur after radiotherapy, this side effect is less common than after surgery. Pelvic floor exercises can help. Talk to members of your healthcare team for information (e.g. Continence nurse).

Brachytherapy

Brachytherapy is when radioactive material is given directly into the prostate at either a low dose rate (LDR) or high dose rate (HDR). LDR and HDR relate to the speed with which the dose is delivered, not the actual dose itself.

• Low Dose Rate: It is given by implanting permanent radioactive seeds directly into the prostate. The seeds give off a focused amount of radiation to the prostate with the aim of destroying the cancer cells.
• High Dose Rate: It is also given by inserting radioactive material directly into the prostate but, unlike LDR seeds, the placement of the material is temporary and for shorter periods – usually for a day or two at a time.

Urinary side effects following brachytherapy may occur due to the effect this treatment can have on surrounding areas such as the bladder and urethra. Similar to EBRT, urinary side effects following brachytherapy can be described as ‘early’ or ‘late’.

The early and late side effects of brachytherapy are the same as those listed in the EBRT section.

Most men will experience urinary side effects following LDR. These may be minimal or mild, and usually peak at approximately 6 to 8 weeks, after which side effects then gradually ease and resolve. A small percentage of men still may experience urinary side effects 6 months or longer following implantation. For men who had HDR, urinary side effects usually peak between 1 to 3 weeks and improve at approximately 4 to 6 weeks following treatment.

A small number of men may experience urinary retention (the inability to urinate) due to the swelling of the prostate following brachytherapy. You may be given medication to assist with this immediately following your treatment. The swelling can cause obstruction to your urinary flow from the bladder. Occasionally, a urinary catheter is required to continuously drain your bladder for a short period until the swelling resolves.

Blood in the urine can occur both immediately after brachytherapy or long term after all forms of radiotherapy. As a result of the brachytherapy procedure, some bleeding may occur. This should settle within 24 to 48 hours after the procedure. Blood in the urine that occurs more than 6 months after all forms of radiotherapy could be a new problem as it may not be related to the treatment, and should be discussed with your healthcare team.

As noted earlier, while uncommon, radiotherapy for prostate cancer may cause urinary stricture. Men who had brachytherapy (high dose rate) are at higher risk of a stricture. Problems caused by a stricture may include:

• a weak urinary stream
• hesitancy
• a feeling of incomplete emptying of your bladder
• spraying of urine when urinating
• urinary retention.

It’s important for you to learn about the possible urinary side effects from prostate cancer treatment because occasionally they may require urgent medical attention. Please talk to members of your healthcare team for more information.

Possible urinary side effects that require immediate attention include:

• a urinary tract infection (symptoms include fever, pain, burning, stinging while urinating, pain into the kidney area, feeling unwell, smelly or cloudy urine)
• blood in the urine
• inability to urinate.

Your general practitioner

Your GP can help coordinate your care and provide you and your family with support and information to help you make informed choices about treatment. Your GP can help you and those close to you manage your physical and emotional health needs throughout the cancer journey, including help with managing your urinary problems.

Your healthcare team

Generally, there is a member of the healthcare team who will be your main contact person. This person might change during your cancer journey. If you’re unsure who this person is, ask one of the health professionals you’re seeing. Your contact person can talk with other health professionals on your behalf and can make sure all your health care needs are met.

The benefits to you in having a healthcare team include:

• improved communication, coordination and decision making between health professionals about your care
• improved treatment planning because all treatment types and options are considered by a range of health professionals
• improved coordination of services
• improved delivery of services
• improved quality of life.

When working with your healthcare team, you may see the following health professionals:

• GP: Your first port of call who can provide referrals to other specialists and who will monitor your health
• Urologist*: A specialist in treating diseases of the urinary tract system and male reproductive organs
• Radiation Oncologist*: A specialist in the treatment of cancer using radiation therapy
• Medical Oncologist*: A specialist doctor who uses different drugs to treat cancer (such as chemotherapy)
• Endocrinologist*: A doctor who specialises in hormones, body chemistry and bone density

*These health professionals also use hormone therapy, also known as androgen deprivation therapy (ADT), as part of their treatment.

• Pathologist: Conducts tests to assess the stage and aggressiveness of cancer
• Radiologist: A specialist doctor who examines scans, X-ray and other imaging results
• Nurse (also known as Urology or Prostate Care Nurse): Provides treatment, support and assistance through all treatment stages
• Cancer Nurse Coordinator: Guides you, your family and the person you are caring for through cancer treatments and liaises with other care providers
• Continence Nurse: Helps you manage any problems related to continence (urinary or bowel) care after treatment
• Pharmacist: Dispenses medications and offers medication advice
• Dietitian: Recommends the best eating plan while in treatment and recovery
• Physiotherapist: Specialises in movement and function of the body, advises on resuming normal physical activities
• Exercise Physiologist: Specialises in the benefits of exercises to help people get fitter for overall health or help people with a medical condition through exercise
• Occupational Therapist: Helps with the physical side of daily life by providing rehabilitation exercises
• Social Worker: Advises on support, practical and legal matters, and provides strategies to cope with emotional, social and spiritual challenges
• Psychologist, Psychiatrist or Counsellor: Provides strategies with decision making, problem solving, and dealing with psychosocial issues; including providing emotional and practical support, and managing anxiety and depression
• Palliative Care Specialist: Expert in pain and symptom control who works closely with the treatment team
• Sex Therapist: Helps with sexuality issues by identifying the level of sexual functioning available, and enhancing sexual and relationship functioning
• Fertility Counsellor: Specialises in helping people with fertility concerns and issues, and can advise on fertility preservation options before starting treatments.

Health professionals who can help to manage urinary problems

‘I needed more information on dedicated physiotherapy interventions to control incontinence.’

There are specialist healthcare professionals who can assist with urinary problems you may be experiencing.

It can be helpful for you to talk with your urologist about your urinary side effects from prostate cancer treatment. There are medical treatments, including surgery, to help manage continence (e.g. artificial urinary sphincters and male sling surgery).

Continence nurses and continence physiotherapists from your healthcare team can advise you on all matters to do with incontinence. Continence Nurse Advisors can be contacted through your healthcare team or Continence Foundation of Australia has listings of where to find your local advisor (www.continence.org.au).

Continence Nurse Advisors can assist with:

• pelvic floor exercise education
• toileting practices during recovery from treatment
• continence product assistance for managing symptoms
• assistance and education with self-help techniques
• financial assistance advice (you may qualify for local or federal funding schemes)
• information and resources
• homecare matters such as:
• waste disposal, infection control measures such as use of disinfectant hand wash, bathing and hygiene in the home
• advice on fittings and fixtures commodes, rails to assist in toileting and arranging a home care assessment. If you are eligible you may receive assistance with the cost of these home alterations.

Continence Physiotherapists can assist with:

• pelvic floor exercise education
• toileting practices during recovery from treatment, particularly correct posture
• assistance and education with self-help techniques
• development of individual pelvic floor and general exercise programmes.

Questions you could ask Listed below are some questions you might want to ask members of your healthcare team about urinary problems following prostate cancer treatment:

• What can be done about my urinary problems? What would you recommend?
• What are the alternatives to the approach that you’re recommending?
• What are things that I can do to improve urinary problems?
• What are the lifestyle changes I need to make to improve my urinary problems?
• Are there food, drinks or activities I should avoid? What are they? How do they make my urinary problem worse?
• If I chose medical treatment to manage my urinary problems, how quickly do they work? And are there any side effects?
• Who else could I see to help me with my urinary problems?

These are not the only questions to ask. There might be questions you have that are specific to your needs. The important thing to do is to always ask questions that can help you understand what can be done about your urinary problems so you, with support from your healthcare team, can make the best decision for you.

There are a range of things you can do to improve, and help you cope with, your urinary side effects. If you require assistance with any of these self-help measures, contact the health professionals or organisations listed in this section.

• Continence products: There are a range of continence products to help manage urinary incontinence. Pads are an effective first choice. Supermarkets and pharmacies stock ranges specifically designed for men. Pads are to be worn with firm-fitting underwear, not boxer shorts. Ensure you change pads regularly, keeping your skin clean and dry to avoid irritation.

‘There was a continence nurse who explained a lot of the things that were supplied like the incontinence aids... for the five years since I’ve had the operation, I’ve had to find what suits me by experimenting with the products that were available.’

Continence products can be costly. Continence or urology nurses can provide advice about continence products including information on possible financial assistance schemes to assist with costs. The Continence Aids Payment Scheme (CAPS) can provide financial assistance for continence products (see www.bladderbowel.gov.au/caps/capsfaq.htm).

NOTE: Ensure you have a continence pad with you for the day of your catheter removal following radical prostatectomy. It is quite common to experience urinary leakage at this stage.

• Pelvic floor exercises: These are essential and should ideally commence prior to and following prostate cancer treatment. The pelvic floor muscles help control your bladder and strengthening them using the correct technique is vital. If you are unsure of the technique or require further assistance, a continence physiotherapist, continence nurse or urology nurse can assist.

‘I found out about how to do pelvic floor muscles myself, and I found out all that sort of stuff... I did a lot of that work on my own.’

NOTE: Do not perform your pelvic floor exercises while you have a catheter in (e.g. following prostate cancer surgery).

• Avoid constipation: Eating a diet high in fibre such as wholegrain breads and cereal, fresh fruit and vegetables, and drinking 1.5 to 2 litres of water a day will help to prevent constipation. Constipation or hard stools cause you to strain and this can weaken your pelvic floor muscles. The pressure from a full bowel can cause bladder pain or discomfort. It can also affect the amount of urine your bladder can hold and require you to urinate more urgently or frequently.
• Quit smoking: Smoking can affect your bladder in two ways. It acts as an irritant to the bladder, and coughing can weaken the pelvic floor.
• Avoid drinks or food that cause bladder irritation: Caffeine (tea, coffee, cola drinks), alcohol, citrus juices, drinks with artificial sweeteners, citrus fruits, tomatoes and tomato-based products, spicy or acidic foods can cause bladder irritation. Water is the most beneficial drink that you can have. You may need to plan when to drink your fluids, for example, by cutting back fluids in the evening to prevent getting up at night.
• Lose weight if required: Excess body weight puts extra pressure on the bladder, which can increase urgency urinary symptoms.
• Diabetes: If you are diabetic, ensure your blood glucose levels are regulated. Urinary issues can be affected by unstable blood glucose levels.
• Exercise: This assists in maintaining a healthy weight as well as preventing constipation. Regular exercise helps you to sleep well, and is beneficial for your overall wellbeing.
• Rest and relaxation: Rest is as important as exercise, particularly in the early stages following or during treatment. Many men report their urinary side effects are worse at the end of the day when they are tired or fatigued. Regular periods of rest can prevent this.
• Toilet maps: These can be helpful in locating toilet facilities in unfamiliar areas or when planning outings. Maps are available at www.toiletmap.gov.au.
• Prostate cancer support groups: These groups are located all around Australia. Seeking support and advice from men who are in similar situations to you can be valuable in coping with urinary side effects.

MANAGING THE COST OF TREATMENT

The Australian Government subsidises the cost of listed prescription medicine to all residents and eligible overseas visitors through the Pharmaceutical Benefits Scheme (www.pbs.gov.au/info/about-the-pbs). Not everything relating to your cancer treatment may be covered by the scheme so check with your doctor when they prescribe a medication or refer you to a service. If you have private health insurance, check what your policy will cover so that you are prepared for any possible financial outlays.

Talk to a member of your healthcare team (e.g. social worker) about what financial and practical support services are available. Talk to your local Medicare office about the ‘Pharmaceutical Benefits Scheme Safety Net’ and the ‘Medicare Safety Net’ on costs of medications and medical bills (www.humanservices.gov.au/customer/services/medicare/pbs-safety-net and
www.humanservices.gov.au/customer/services/medicare/medicare-safety-net).

WHERE TO GET MORE INFORMATION

Listed below are some of the leading organisations and services that can provide you with accurate information and support about urinary problems following prostate cancer treatment.

• Prostate Cancer Foundation of Australia
  Tel: (02) 9438 7000 / 1800 22 00 99 (local call)
  Website: www.pcfa.org.au
• Cancer Australia
  Website: www.canceraustralia.gov.au
• Continence Foundation of Australia
  Tel: (03) 9347 2522 / 1800 330 066
  (free helpline staffed by continence nurse advisors)
  Website: www.continence.org.au
• Australian Government Bladder and Bowel Website
  Website: www.bladderbowel.gov.au
• Australian Physiotherapy Association
  Tel: (03) 9534 9400
  Website: www.physiotherapy.asn.au
• Cancer Council Helpline
  Tel: 13 11 20
• Urological Society of Australia and New Zealand
  Tel: (02) 9362 8644
  Website: www.usanz.org.au

FURTHER READING

• The Localised Prostate Cancer Pack is a resource for men affected by localised prostate cancer. It provides information on how localised prostate cancer is diagnosed, treatment options, managing side effects and wellbeing.
• The Advanced Prostate Cancer Pack is a resource for men affected by different stages of advanced cancer, including locally advanced disease. It provides information on how advanced prostate cancer is diagnosed, treatment options, managing side effects and wellbeing.
• Allingham, C. (2013). Prostate recovery MAP: Men’s Action Plan. Buderim: Redsok
• Chambers, S. (2013). Facing the Tiger – A Guide for Men with Prostate Cancer and the People who Love Them. Toowong: Australian Academic Press
• Dornan, P. (2003). Conquering Incontinence: A new and physical approach to a freer lifestyle exercise. Crows Nest: Allen & Unwin

Other resources
For more information about prostate cancer and symptom management, PCFA has a number of resources.
Please visit PCFA website
or call: (02) 9438 7000/1800 220 099 (freecall).

Please note: If calling from overseas, the country code for Australia is +61