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.

URINARY CATHETER

A urinary catheter is a thin plastic tube that runs from your bladder through your penis and drains urine into a bag on the outside of your body. The catheter is held in place by an inflated balloon inside your bladder. Generally a catheter is left in place for 1 week following your surgery but this may vary based on your individual situation.

RESOURCES

PCFA has resources on side effects of treatments for prostate cancer. For further information, please see www.pcfa.org.au.

BEFORE SURGERY

Before Surgery

AFTER 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).

While urinary incontinence may occur after radiotherapy, this side effect is less common than after surgery.

It can be helpful for you to talk with your urologist about your urinary side effects.

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.