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Query about anatomy of incontinence

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Posted 12/29/2018 8:09 AM (GMT -5)
I am 9 months post-RALP and doing well except for the incontinence. I figure I am about 50/50 in that I don’t leak when lying down or sitting and can generally make it to the bathroom after doing so but standing/walking/running are a problem. Running is the biggest issue since a heavy duty pad is only good for about 5 miles and I usually go longer than that and changing one isn’t always convenient depending on where I am.

I am currently seeing a PT with a specialty in pelvic floor issues and am on a workout regimen but am wondering what the difference is, anatomically, between those of us RALP people who leak and those who do not. The PT showed me some diagrams and it looks like it comes down to how those muscles are configured around the urethra.

Does anyone have any ideas on this?
Posted 12/29/2018 10:36 AM (GMT -5)
Prior to surgery you had two sphincter to close the urinary tract.

One is now gone and you're just using one. All the cutting from surgery weakens the structures and it can take months for that to heal. In some cases these muscles never heal and without the prostate the whole system is weakened.
Posted 12/29/2018 12:03 PM (GMT -5)
Vince, I was looking for a simplified diagram, and can't find one. However--how it works is something like this:

Urine is created by your kidneys, and they drain through the ureters into the bladder. At the base of the bladder is a circular muscle, the urinary sphincter, which opens to allow urine to flow. Inside the prostate is another structure that also closes off the urine from the bladder so that ejaculate can flow through the urethra when you're sexually stimulated. There are also the pelvic floor muscles (pubo-coccygeal muscle) which forms a figure 8 structure around the end of the urethra and the anus.

When the prostate is removed, the internal sphincter is gone, and the urethra is stitched together where the prostate was--and this is what we sometimes notice as the shortening of the penis after surgery--an inch or so of the urethra was removed, and everything was pulled together to reconnect.

The RP surgery can also damage the main urinary sphincter at the base of the bladder, damage the nerve structure that operates it, and/or weaken the whole thing. Ultimately, after surgery, we have the same urinary system of valves and muscles that the women of the world have--and ours is weaker because we've always counted on the 3-way valve inside the prostate to keep things under control.
Posted 12/30/2018 4:07 PM (GMT -5)
Vince

I am 5 years post RALP. It took over three years for my bladder function to get to where I am now. I can now sleep through the night. I do have minor stress incontinence but never need more than a light pad. PT, Kegel's, and time should improve things. Hang in there.
Posted 12/30/2018 10:23 PM (GMT -5)

halbert said...
Vince, I was looking for a simplified diagram, and can't find one. However--how it works is something like this:

Urine is created by your kidneys, and they drain through the ureters into the bladder. At the base of the bladder is a circular muscle, the urinary sphincter, which opens to allow urine to flow. Inside the prostate is another structure that also closes off the urine from the bladder so that ejaculate can flow through the urethra when you're sexually stimulated. There are also the pelvic floor muscles (pubo-coccygeal muscle) which forms a figure 8 structure around the end of the urethra and the anus.

When the prostate is removed, the internal sphincter is gone, and the urethra is stitched together where the prostate was--and this is what we sometimes notice as the shortening of the penis after surgery--an inch or so of the urethra was removed, and everything was pulled together to reconnect.

The RP surgery can also damage the main urinary sphincter at the base of the bladder, damage the nerve structure that operates it, and/or weaken the whole thing. Ultimately, after surgery, we have the same urinary system of valves and muscles that the women of the world have--and ours is weaker because we've always counted on the 3-way valve inside the prostate to keep things under control.


http://www.ivyroses.com/humanbody/urinary/urinary_bladder_urethra_male.php
Posted 12/30/2018 10:36 PM (GMT -5)
""When a surgeon cuts out the prostate, a gap is created between the bladder and the urethra. The bladder must be pulled down and the urethra pulled up so that the two can be surgically reconnected," Dr. Catalona explained.
"Frequent urination is normal after a radical prostatectomy."

The larger the prostate the bigger the gap and sometimes the more difficult to reconnect the bladder and the urethra. In addition, the internal sphincter muscle, the muscle that involuntarily controls bladder output, is removed with the prostate.

After the operation, men who had three layers for holding back urine – the internal sphincter muscle, the prostate lobes pressing against each other, and an external sphincter muscle – have only one, the external sphincter.

"The external sphincter can do all the necessary work to hold in the urine, but it has to be strong. That's why the Kegel exercises, both before and after surgery, are so important," Dr. Catalona said.

He explained why procedures during the surgical removal of the prostate cause temporary incontinence and how time and the healing process usually fix the situation.

The bladder and the urethra must be connected to each other but if they were just sewn together, postoperative swelling of the tisues would close the opening for the urine to pass through. Temporarily, they need a stent to preserve the opening, and that stent is the catheter.

The bladder is always being emptied by the catheter. The bladder isn't holding urine and therefore doesn't expand as long as the catheter is in place. When the catheter is removed, the bladder is a shrunken version of itself.

"Over weeks and months, the bladder expands again and, most often, returns to normal size and normal function," Dr. Catalona said.................."
http://www.drcatalona.com/quest/quest_spring03_2.htm
Posted 12/30/2018 11:21 PM (GMT -5)
Thanks for all your feedback on this.

Halbert said "The RP surgery can also damage the main urinary sphincter at the base of the bladder, damage the nerve structure that operates it, and/or weaken the whole thing. Ultimately, after surgery, we have the same urinary system of valves and muscles that the women of the world have...."

However, when looking at both the male (http://www.ivyroses.com/humanbody/urinary/urinary_bladder_urethra_male.php) and female (http://www.ivyroses.com/HumanBody/Urinary/Urinary_Bladder_Urethra_Female.php) systems, the female version shows both the urethral sphincter (at the bladder neck) and the external urethral sphincter (in the urogenital diaphragm).

That leads me to understand that the female version has two valves and for males after RALP there is only the one.

Maybe related or not, it took a long time for my anastomosis to heal. I was walking, easily, after the surgery and, because I am a runner and wanted to get back to it, I picked up my walking pace to a 20 minute mile at 6-weeks post -op. I passed LOTS of blood as a result. The urologist told me that could be normal and to back off and try again in a week. I did and had the same problem and this continued until about the 3-month point.
Posted 12/31/2018 12:27 AM (GMT -5)
I was nearly dry 9 months after RP. But then I had a penile prosthetic installed. After that I started to leak again. This discussion has given me a clue why I leak now. The implant is stretching out the eureathra an inch and disturbing the valve which will have to relearn its job.
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