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Stages for Continence Following Prostatectomy

By Dr. Brooke Meinema, PT, DPT, FAFS, PCES

Leaking following prostatectomy should be expected for most individuals undergoing the procedure, but it doesn’t make it any less frustrating. While we hope for improved continence by 3 months, taking 6-12 months to regain continence is not unusual. Likewise, nerve weakness may remain for up to 2 years. Most studies suggest 95-98% of those undergoing proctectomy will regain continence over time. While timing for each person will vary depending on the complexity of the surgery, continence before the procedure, and other health comorbidities, here is a bit of a breakdown of what you can expect when working towards regaining your continence:

  1. Constant dripping/leaking:
    • This is typically an issue early on following prostatectomy resulting in the need for 4-10+ pads per day.
    • Things to work on:
      • Keep track of fluid intake
        • Both how much you are drinking and what type of fluids you are drinking as certain types of fluids can be agitating to your bladder and worsen leakage.
      • Bladder training
        • Improving strength and coordination of your pelvic floor muscles (learning how to properly perform Kegels) as well as the ability of your bladder to hold urine.
          1. In one study, men who performed Kegels had greater continence rates at 3 months and 12 months compared to those who did not (74% v 30% and 98.7% v 88% respectively).
        • Activity modification
          • Avoid strenuous activities at this phase (think lifting heavy objects, high-intensity activities, running/jogging, etc.).
        • Breathing coordination
          • Use your diaphragm to reduce abdominal pressure downward. Before coughing or sneezing, take a deep breath in to allow your diaphragm to take some of the pressure. Exhale on exertion! Do not hold your breath during activity as this increases pressure downward on your pelvic floor.
  1. Dry at night but wet during the day:
    • Individuals in this phase begin to have continence overnight but continue to require 3+ pads during the daytime. This shows autonomic muscular control is intact and functioning at night with difficulty functioning against gravity in upright function during the day.
    • Things to work on:
      • Getting rid of dependence on pads at night.
        • After having 3 dry nights in a row, discard pad usage! This is an important psychological step in developing trust in your pelvic floor.
      • Activity modification. Continuing to avoid excess strain.
      • Increase motor control of pelvic floor muscles as well as intensity and duration of pelvic floor contractions.
  1. Spurt/Spray of leakage:
    • Most individuals at this phase will use 2+ pads a day because the reaction of their pelvic floor muscles is compromised or delayed.
    • Urine is able to clear the sphincter and is past the normal stopping point when a contraction occurs causing the urine to be able to squirt out.
    • Things to work on:
      • Specific demands to improve speed and control of the sphincter.
        • Work on the specific tasks that you would notice this form of leakage the most.
      • Pressure management training (blowing up a balloon during a squat, lunge, etc. to increase downward pressure during activity)
  1. Afternoon leaker:
    • Being able to stay dry during the a.m. hours but leaking during the afternoon (typically 1-2 pads a day) indicates endurance issues with the pelvic floor musculature.
    • For these individuals, 4-6 p.m. tends to be the worst for bladder control.
    • Things to work on:
      • Endurance/sustained holds with Kegels
        • Try working on long holds of Kegels in different positions. Typically, upright activity will be the most difficult making it the hardest to maintain continence, so doing Kegels in an upright position will be the most beneficial.
      • Posture and deep core strength.
  1. Bladder irritant leaking:
    • These individuals usually have a good level of continence but still will require 1 pad or shield due to bladder irritability.
    • Certain foods and drinks can be irritating to the bladder leading to an increased likelihood of leakage (caffeine, carbonation, alcohol, high acidity, etc.).
    • Things to work on:
      • Monitoring diet.
        • Keeping a bladder diary to assess if there are connections between what you eat and drink and leakage following can help narrow down your specific irritants.
  1. Phantom Leak:
    • Random leakage despite being fully continence.
    • This is not always activity related and can just have a small amount of leakage at a seemingly random time.
    • May precede improved erectile function by 1-4 weeks.
  2. Continence = no pads!

 

Additional advice from Jo Milios’ pad weaning protocol:

  1. After 3 nights dry in a row, discard pad use
  2. Delay pad application in the morning
  3. Use a pad if going out, exercising, or at work ONLY
  4. No pad in the mornings or evenings
  5. Shield if going out or consuming alcohol
  6. Shield in pocket
  7. Forget needing them!

 

If you or someone you love is navigating the path to regaining continence after a prostatectomy, remember that patience and the right practices can make a tremendous difference. It’s crucial to recognize that while the journey might be challenging, you’re not alone. Our team of specialized physical therapists is here to provide the support, expertise, and personalized care plan that suits your unique needs. Don’t hesitate to reach out and take the first step towards a more comfortable and confident life. Contact us today to schedule a consultation, and together, we’ll stride towards achieving your continence goals. Remember, progress is possible, and we’re here to guide you every step of the way.

 

*Generalities of this classification system were inspired by Stuart Baptist with further breakdown from Jo Milios

*Filocamo MT, Li Marzi V, Del Popolo G, Cecconi F, Marzocco M, Tosto A, et al. Effectiveness of early pelvic floor rehabilitation treatment for post-prostatectomy incontinence. Eur Urol. 2005;48:734–8.

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