What is the risk of urinary incontinence after prostate (prostate gland) removal surgery?

Urinary Incontinence Risk After Prostate Removal Surgery

Most men experience urinary incontinence immediately after prostate removal surgery, but approximately 85-90% achieve continence (defined as not requiring protective pads) within 12 months after surgery. 1

Types and Prevalence of Post-Prostatectomy Incontinence

Urinary incontinence after radical prostatectomy (RP) occurs in several forms:

• Immediate post-operative incontinence: Nearly all men experience some degree of incontinence immediately after catheter removal 1, 2
• Stress urinary incontinence: Most common type, affecting 12-16% of men long-term 1
• Climacturia/orgasm-associated incontinence: Occurs in up to 30% of men following RP 1
• Total urinary incontinence: Continuous passage of urine without control (uncommon) 1

Timeline of Incontinence Resolution

• 0-2 weeks: Most patients experience incontinence after catheter removal 2
• 3 months: Approximately 43% still have significant incontinence (>8g urine loss on 24-hour pad test) 3
• 12 months: About 15% continue to have significant incontinence 3
• Long-term: Cumulative rates of surgical intervention for persistent incontinence are 2.6% at 5 years, 3.8% at 10 years, and 4.8% at 15 years 4

Risk Factors for Post-Prostatectomy Incontinence

Several factors increase the risk of persistent urinary incontinence:

• Advanced patient age: Particularly age >65 years 1, 3, 4
• Larger prostate size 1
• Shorter membranous urethral length (measured by MRI) 1
• Previous transurethral resection of prostate (TURP) 3
• Preoperative incontinence (even if subclinical) 3
• Postoperative radiation therapy (increases risk by 61%) 4
• Low surgeon volume (fewer than 49 prostatectomies per year) 4

Mitigation Strategies

1. Pelvic floor muscle exercises (PFME): Should be offered immediately after catheter removal 1, 5

   • Improves time to achieving continence
   • Accelerates recovery at 3-6 months
   • Long-term continence rates at one year remain similar between those who did and did not perform PFME

2. Bilateral neurovascular bundle preservation: Only surgical technique shown to improve continence recovery 1

3. Surgical interventions: May be considered as early as 6 months if incontinence is not improving despite conservative therapy 1

   • Artificial urinary sphincter
   • Urethral sling

Quality of Life Impact

Urinary incontinence significantly impacts quality of life following prostatectomy 6. However, most patients report improvement in lower urinary tract symptoms by 12 months compared to baseline, with mean IPSS (International Prostate Symptom Score) decreasing from 7.4 preoperatively to 5.4 at 12 months 3.

Special Considerations

• Climacturia risk factors: Time since surgery, prior TURP, shorter functional urethral length, and shorter penile length 1
• Surgical approach comparison: No significant difference in incontinence rates between different surgical approaches (open, laparoscopic, robotic, or perineal) 1
• BMI impact: May affect incontinence in short-term but not significantly at one year 1

Patient Counseling

Patients should be informed that:

1. Incontinence is expected immediately after catheter removal 1
2. Most men achieve continence within 12 months 1, 2
3. Risk factors that may predispose to persistent incontinence
4. Sexual arousal incontinence and climacturia are possible complications 1
5. Regular follow-up is important to monitor recovery and address persistent issues

By understanding these risks and timeline for recovery, patients can have realistic expectations about post-prostatectomy urinary function and appropriate management strategies.