Urinary Incontinence After Prostate Surgery: Causes & Treatment

How common is incontinence after prostate surgery?

Urinary incontinence is a common side effect of radical prostatectomy. Most men recover continence within 6-12 months, but some have long-term leakage.

• 0-3 months: 50-80% use pads (normal – early recovery)
• 6 months: 20-30% use pads (usually 1 pad/day for minor leakage)
• 12 months: 5-10% use pads (1-2 pads/day)
• 24 months: <5% use pads (most have achieved continence)

Robotic surgery has slightly better continence rates than open surgery, but the difference is small (5-10% absolute improvement at 12 months).

Types of incontinence – stress, urge, mixed, overflow

Four types of incontinence can occur after prostate surgery:

• Stress incontinence (most common – 80%): Leakage with coughing, sneezing, laughing, lifting, or standing up. Caused by weak urethral sphincter.
• Urge incontinence (10-15%): Leakage with sudden, intense urge to urinate. Caused by overactive bladder (OAB).
• Mixed incontinence (5-10%): Combination of stress and urge incontinence.
• Overflow incontinence (rare): Constant dribbling from a full bladder. Caused by bladder outlet obstruction or underactive bladder.

Why does prostate surgery cause incontinence?

Incontinence occurs due to damage to the urinary sphincter or bladder dysfunction:

• External urethral sphincter damage: The sphincter (muscle that keeps urine in) is located just below the prostate. During surgery, it can be stretched, compressed, or partially damaged. This causes stress incontinence.
• Loss of urethral support: The prostate provides structural support to the urethra. After removal, the urethra may be less stable.
• Bladder dysfunction (overactive bladder): Pre-existing OAB may worsen after surgery. Also, chronic obstruction (from BPH) can cause bladder changes that persist after surgery.
• Denervation: Nerves to the bladder and sphincter may be affected during surgery.

Recovery timeline – first year and beyond

Continence recovery is gradual. Do not expect immediate results.

Timeline after surgery:

• 0-2 weeks: Catheter in place (no continence)
• 2-4 weeks (catheter removed): Some men have no control; others have good control. Use pads.
• 1-3 months: Gradual improvement. Most men still need pads (1-3 per day).
• 3-6 months: Significant improvement. Many men need only 1 pad/day (for security).
• 6-12 months: Most men achieve social continence (0-1 pad/day).
• 12-24 months: Little further improvement expected.

Factors that improve recovery:

• Younger age (<60 years)
• Robotic surgery (slightly better than open)
• No prior TURP (prostate surgery)
• Pelvic floor exercises (pre-operative and post-operative)
• Normal weight (not obese)

Conservative treatment – pelvic floor exercises (Kegels), bladder training

Pelvic floor exercises (Kegels):

Kegel exercises strengthen the pelvic floor muscles, which support the urethra. They are the first-line treatment for stress incontinence.

How to perform Kegels correctly:

1. Identify the correct muscles: Try to stop urine flow midstream (do this only once to identify muscles – not as an exercise)
2. Squeeze and lift the pelvic floor muscles (as if stopping gas and urine)
3. Hold for 5-10 seconds
4. Relax completely for 5-10 seconds
5. Repeat 10-15 times, 3 times per day

Protocol:

• Pre-operative: Start 4-6 weeks before surgery (improves outcomes)
• Post-operative: Start as soon as catheter is removed
• Duration: Continue for 6-12 months

Bladder training (for urge incontinence):

• Timed voiding: Urinate every 2-3 hours on a schedule (not waiting for urgency)
• Delayed voiding: When you feel urgency, try to wait 5-10 minutes to train bladder capacity
• Double voiding: Urinate, wait 30 seconds, then try again to empty completely

Lifestyle modifications:

• Avoid caffeine, alcohol, carbonated drinks (bladder irritants)
• Avoid constipation (straining worsens incontinence)
• Maintain healthy weight (obesity worsens incontinence)

Surgical treatment – male sling, artificial urinary sphincter (AUS)

For men with persistent incontinence at 12 months (still using 2+ pads/day), surgical options are highly effective.

Male sling (Advance, Virtue, AdVanceXP):

• How it works: A mesh sling is placed under the urethra to provide compression and support.
• Indications: Mild to moderate stress incontinence (1-3 pads/day)
• Success rate: 70-85% reduction in pad use; 50-60% become pad-free
• Procedure: Outpatient or 23-hour stay; 1-2 hour surgery
• Recovery: Catheter 1-2 days; return to activities in 2-4 weeks
• Complications: Erosion (2-5%), infection, persistent pain

Artificial urinary sphincter (AUS) (AMS 800):

• How it works: A cuff surrounds the urethra, connected to a pump in the scrotum and a reservoir in the abdomen. The patient pumps to open the cuff and urinate.
• Indications: Moderate to severe stress incontinence (3+ pads/day) or failed sling
• Success rate: 80-90% reduction in pad use; 60-70% become pad-free
• Procedure: Overnight hospital stay; 1-2 hour surgery
• Recovery: Catheter 1-2 days; device activated at 6 weeks
• Complications: Erosion (5-10%), infection, mechanical failure (5-10% at 5 years)

Choosing between sling and AUS:

• Sling: For mild to moderate incontinence, no prior pelvic radiation
• AUS: For severe incontinence, prior radiation, failed sling

When to seek help – persistent incontinence at 12 months

See a urologist if:

• You are still using 2+ pads per day at 12 months
• Incontinence affects your quality of life (social isolation, avoiding activities)
• You have recurrent UTIs (from pad use or incomplete emptying)
• You have skin irritation or rash from pads

Evaluation for surgical candidates:

• Urodynamics – to confirm stress incontinence and rule out bladder dysfunction
• Cystoscopy – to assess urethral stricture or bladder pathology
• Pad test – to quantify leakage

Interactive FAQ – Urinary incontinence after prostate surgery

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Disclaimer: This information is for educational purposes. Incontinence after prostate surgery is common but treatable. Consult a urologist at Vivekananda Hospital for personalised management.