What if I am incontinent after radical prostatectomy or radiation therapy? What if I have erectile dysfunction after radical prostatectomy or EBRT or brachytherapy?

When seeking treatment for prostate cancer, many men are very concerned about the effects of the treatment on erectile function. Basically, all of the treatment options carry a risk of erectile dysfunction; however, they differ in how soon after treatment the erectile dysfunction occurs and how likely it is to occur. If you are already having trouble with erections, none of the treatments for prostate cancer will improve your erections. The incidence of erectile dysfunction associated with radical prostatectomy varies with patient age, erectile function before surgery, nerve-sparing status, and the surgeon's technical ability to perform a nerve-sparing radical prostatectomy. The incidence of erectile dysfunction after a nerve-sparing radical prostatectomy varies from 16 to 82%. When it occurs with radical prostatectomy, erectile dysfunction is immediate and is related to damage of the pelvic nerves, which travel along the outside edge of the prostate. Men who have undergone nervesparing radical prostatectomies and who are impotent after surgery may experience return of their erectile function over the following 12 months.

The incidence of erectile dysfunction after EBRT ranges from 32 to 67% and is caused by radiation-related damage to the arteries. Unlike with surgery, the erectile dysfunction occurs a year or more after the radiation. The incidence of erectile dysfunction is 15 to 31% in the first year after EBRT and 40 to 62% at 5 years after EBRT.

The incidence of erectile dysfunction after interstitial seed therapy with or without medium-dose EBRT ranges from 6 to 50%. Similar to EBRT, the erectile dysfunction tends to occur later than with radical prostatectomy.

Hormone therapy with the LHRH analogues or orchiectomy also causes erectile dysfunction, as well as loss of interest in sex in most men. This loss of libido is related to the loss of testosterone, but why the loss of testosterone causes troubles with erections is not well known.

Various therapies are available for the treatment of erectile dysfunction, including oral, intraurethral, and injection therapies; the vacuum device; and the penile prosthesis^[1], which is a device that is surgically placed into the penis and allows an impotent individual to have an erection (see Questions 75, 80-100).

In the treatment of post-radical prostatectomy erectile dysfunction, the effectiveness of oral PDE-5 Inhibitors ( Viagra, Cialis, Levitra) varies with nerve-sparing status:

Bilateral nerve sparing: 71% success rate Unilateral nerve sparing: 50% success rate Non-nerve sparing: 15% success rate

In men with EBRT-associated erectile dysfunction, oral PDE-5 Inhibitors work in about 70% of individuals. In men who have erectile dysfunction associated with interstitial seed therapy, PDE-5 Inhibitors have a success rate of approximately 80% (see Question 81 for use of PDE-5 inhibitors).

If oral therapy is not effective or if you have contraindications to oral therapy there are a variety of other medications/devices that may allow you to achieve an adequate erection for satisfactory sexual function. See Questions 84-99.

Urinary incontinence, the uncontrolled loss of urine, is one of the most bothersome risks of prostate cancer treatment. Although it is more commonly associated with radical prostatectomy, it may also occur after interstitial seed therapy, EBRT, and cryotherapy. Urinary incontinence may lead to anxiety, hopelessness, and loss of self-control and self-esteem. Fear of leakage may limit social activities and participation in sex. If you are experiencing these feelings, you should discuss this with your doctor and spouse or significant other.

If you experience persistent urinary incontinence after surgery or radiation therapy, your doctor will want to identify the degree and the type of incontinence. You will be asked questions regarding the number of pads you use per day, what activities precipitate the incontinence, how frequently you urinate, if you have frequency or urgency, how strong your force of urine stream is, if you feel that you are emptying your bladder well, and what types and how much fluid you are drinking. The doctor may check to make sure that you are emptying your bladder well. This is usually done by having you urinate and then scanning your bladder with a small ultrasound probe to determine how much urine is left behind. Normally, less than 30 cc (one tablespoon) remains after urination.

Several different types of urinary incontinence exist, and the different types may coexist. The treatment of urinary incontinence varies with the type, and the types that may be encountered in men being treated for prostate cancer includes stress, overflow, and urge incontinence. Men who have undergone radical prostatectomy typically experience a type of stress incontinence called intrinsic sphincter deficiency. Stress incontinence may also occur after interstitial seed therapy and is much more common if a TURP of the prostate was performed in the past. In men, urinary control is primarily at the bladder outlet by the internal sphincter muscle. This muscle remains closed and opens only during urination. An additional muscle, the external sphincter, is located further away from the bladder and is the back up muscle. The external sphincter is the muscle that you contract when you feel the urge to urinate and there is no bathroom in sight. During a radical prostatectomy, the internal sphincter is often damaged with removal of the prostate because it lies just at the top of the prostate. Continence then depends on the ability of the remaining urethra to close (coapt) and on the external sphincter.

Urge incontinence^[2] is the involuntary loss of urine associated with the urge to urinate and is related to an over-active bladder. Although less common than intrinsic sphincter deficiency in men who have undergone radical prostatectomy, it may be present alone or in conjunction with intrinsic sphincter deficiency. Overactive bladder and decreased bladder capacity are more common in men who have undergone EBRT for prostate cancer. Urge incontinence can be treated with antimuscarinic agents, medications which relax the bladder muscle.

Overflow incontinence^[3] is the involuntary loss of urine related to incomplete emptying of the bladder. After radical prostatectomy, this may occur if significant scarring (a bladder neck contracture) is present at the bladder outlet area. Treatment of the bladder neck contracture often relieves the overflow incontinence. Other symptoms include a weak urine stream and the feeling of incomplete bladder emptying. With overflow incontinence, the bladder scanner would demonstrate a large amount of urine left in the bladder after urinating. Urethral strictures after EBRT may also cause overflow incontinence; dilation of such strictures also improves

the overflow incontinence. Urethral strictures tend to recur, and daily in and out passage of a catheter beyond the site of the stricture helps prevent recurrence of the stricture. Swelling of the prostate after interstitial seed therapy may cause voiding troubles, which if unrecognized, may lead to overflow incontinence. Initial treatment of overflow incontinence after seed therapy is with clean intermittent catheterization, and possibly the addition of an alpha-blocker (Hytrin, Cardura, Flomax, Rapaflo) and a nonsteroidal anti-inflammatory.

Your doctor may wish to perform further studies (see urodynamics in Question 34) to further identify the cause of your incontinence.

• [1] A device that is surgically placed into the penis that allows a man with erectile dysfunction to have an erection.
• [2] Incontinence associated with urgency.
• [3] A condition in which the bladder retains urine after voiding, and as a result, urine leaks out, similar to a full cup under the faucet.