Urinary Symptoms Post-Prostatectomy Case Study - Diane Newman
May 23, 2020
Diane K. Newman, DNP FAAN BCB-PMD, Urologic Nurse Practitioner, Adjunct Professor of Urology in Surgery Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania
View: Treating Post Prostatectomy Incontinence - Diane Newman
Read: Prostate Cancer Treatment Outcomes: What Men Need to Know
Read: ICS 2018: Biofeedback Assisted Pelvic Floor Muscle Training in Adults and Children-Case Presentations
Download or View: Presentation Slides: Urinary Symptoms Post-Prostatectomy Case Study
Diane Newman: Welcome. I'm Diane Newman. I'm a continence nurse practitioner and a biofeedback-certified specialist. I'm also the Editor of the Bladder Health Center of Excellence on UroToday. I'm going to present to you a case study of a male patient who was referred to me for urinary symptoms following prostate cancer surgery. There's another recording that you can access on biofeedback-assisted pelvic floor muscle training, and this accompanies that because I do use biofeedback for pelvic floor muscle training, and I thought it might be helpful to walk through a case study of a patient who I see almost every day in my practice, so he's really a model for what you can do with these individuals.
Most of these men present with stress urinary incontinence, and what I question is the characteristics of their urine leakage. Quantity is how much leaks. Snd patients don't walk around with a little bottle underneath their penis measuring it, but what I tell them is I'm trying to determine whether they're slight, moderate, or severe. How I figure out how the severity of the incontinence is the number of pads they're using, and I do ask what type of pad. I'll show you that in a minute. Actually, I think that's the next slide.
So they'll say to me, "I use Depends®," and then I actually have a picture like this in my exam room and I'll say, "Point to me which one," because if they tell me that they're using a male guard pad, that's a small perineal pad versus a protective underwear. If they say, "I wear four protective underwear per day and they're very saturated," there that's getting them more into the severe amount of leakage. If they say, "Oh, I wear three male pads and now they may be about 50% wet," then that's more moderate to slight. So it helps me to know what type of pad they're using and what type of product they are.
I find out when it occurs. Does it occur during the day or nighttime? Incontinence will increase in the evening hours because of the pelvic floor muscles fatigue, the sphincter fatigues because they're usually upright all day. Usually, the first symptom that resolves is any nighttime urine leakage, and most men I see tell me that they're able to get through the night without incontinence.
What triggers it? Is it an event? Laughing, coughing, sneezing, bending over when they're exercising, golfing? Whatever is triggering it, I will document that. And then do they void? This is a really important assessment to ask because if they're not voiding at all and all that urine is leaking out, that's telling you that that sphincter is not being supportive of the urethra and that muscle needs to get stronger because as soon as they bend over any kind of pressure from above, they're leaking urine. So it does help to tell me if they're voiding. What initially patients will tell me is that "I get up and urinate at night, but during the day I can't make it there." So I try to determine how much bladder control they actually have. Like I said, I do show pictures of products.
So let's talk about my case study here. And this is a 68-year-old male patient I saw last year. Now a year ago. He had long-term urinary symptoms before he was diagnosed with prostate cancer. He'd been treated for many years by other suburban urologists for BPH. Then he came to Penn Urology and he was found to have prostate cancer. He actually had a robotic-assisted radical prostatectomy in the fall of 2018. So when he presented to me, it was almost about five months later when he came in to see me.
Sometimes they will see me early in the postop period. Some men, the catheter comes out, they're leaking and they already calling, "Can I be seen?" I like to see them about one month after surgery or maybe six weeks, but I do see them in all periods of time. Sometimes I see them up to years after their surgery. He had been experiencing postoperative stress incontinence on that initial visit. He reports a significant amount. He was doing the Kegel exercises religiously. So he told me he didn't come in earlier because he was doing those Kegels. He does them by moving his penis, which tells me is he really isolating? I'm not sure. He's able to maybe hold it for three seconds. Urine leakage with sneezing, lifting, coughing, bending over. He had very little daytime voiding as most of the urine leaks out.
He awakens at least two to three times at night, and he will occasionally have some nocturnal enuresis. I do AUA symptom score. The highest score for impact on the quality of life, which means worsening quality of life is 35. He was level 25 out of 35. He reports that, in relation to quality of life, his urinary symptoms are terrible. You can see this is what I document in my records.
I show you this because I think this is interesting. What is he using to contain the urine? He was using multiple products. As the top picture on the left shows, he used a guard pad that you can see there's urine leakage. It's yellow inside. He would wear protective underwear, which is a product over that pad, and when the pad became wet, he would remove the guard pad and throw it away.
He would get away with maybe to protective underwear per day. He then put these shorts, these briefs that he found online that are more of a cloth brief, over the protective underwear. And then he bought vinyl pants online because he was so paranoid about leaking through to his clothes. It's important to find this out because I document all this because this is really showing a guy that's just so worried about embarrassing himself. Then I try to ask him, "Well, what is getting soaked here?" He admitted to me that the protective underwear does not get wet because he removes those pads, his smaller pads, which are guard pads, four to six a day as they became saturated. And over our visits, I would try to get him to get rid of vinyl pants, because especially in Philadelphia in the summer, I worry about incontinence-associated dermatitis or fungal perineal rashes, which I see all the time because of the moisture of the wetness. If you're wearing vinyl, it's going to be even hotter in those products.
This was the first graph of the biofeedback, which shows an underactive pelvic floor muscle. You can see on the top graph that he is trying to contract for two seconds, but very weak muscle. On that bottom one, I was trying to get him to do five-second contractions. I did not do 10-second holds because I knew he couldn't do them. As you can see, it's slightly improved, but again, very weak underactive pelvic floor muscle with quick and long contractions.
By May, which was his second visit, he was maybe a little bit better, but he still had frequency. He was talking to me, the frequency's always been a problem. Remember he had BPH. He may have hypertrophy of that bladder, but it's unchanged. So I asked him, "Did you have urinary frequency before the surgery?" He said, "Yeah, it was not a big problem." He maybe goes every three to four hours. He does have nervous situations. He calls it nervous voiding. He thinks when he's worried about where he is or where the bathroom is, he voids and he thinks those are his nerves. He's nervous about not being able to access the bathroom. He says the incontinence just happens. That leakage just happens with sneezing, coughing, and sometimes he just doesn't know why. But he feels he's holding it better. And again, at night he is improving. So you can see some improvement.
I did ask him also on that visit, how many pads he was using. He, I think was still using all those products. He may be down to maybe only four pads, but he would not stop using the vinyl pant and all those other layers.
So on the third visit in June ... Now I was seeing him every month, mostly because my schedule is so busy. I recommend that you see them every two weeks. This man maybe benefited from it every two weeks. So he was saying at night he doesn't use the vinyl. It's now June in Philadelphia. He gets hot, which I can understand. So he stopped wearing the vinyl pant. He started noticing that he does not need to change that smaller guard pad as often. It may be a little drier. So that's telling me maybe he has less incontinence. He's reporting less product use. And he's been very compliant with doing the exercises. So I review that with him on every visit.
In July, he is only using a thinner pad. A lot of men will tell me, "I use a thin liner. My wife got that for me." So again, he must have less incontinence. He's only using two to three. Remember we started out with a heavier pad, four to six in March, April. He stopped using the vinyl pant. He now only uses one protective underwear per day. He has added a cloth brief because he likes it. Coughing, sneezing causes UI. Urinary frequency is actually improving. "It's not as bad. I have more control." At this point, if someone was having a lot of urgency and frequency, I may add drug therapy, overactive bladder drug, but I didn't feel he needed it. Weak stream. But again, he feels that's been my whole life. That's been it. Look at that AUA symptom score. It's now down to 11, which means that it's not as bad as far as symptomatology. But he still rates them terrible with an impact on the quality of life. He's been again very consistently doing the exercises.
You can see this improvement over time. Look at that baseline how weak it was. But look after by July, he really had increased his strength, his bulk and his endurance in his pelvic floor muscle. I actually give patients handouts of these graphs so they can see the difference. This is such a motivator for them. And they'll ask me, "Diane, show me what I was like when I first came. Am I better?" I show them and they can visualize that improvement.
So that's just a really short case study that shows you the progression. You see I saw him about three to four visits over what, probably about four months. And then I expanded the visits. I probably didn't see him back for two to three months. So I do tell them the goal is to be without pads. I want them continent. And I say to them, "If you're dry, don't come back and see me, but let's get you on the schedule just in case." So I may follow them with extended time visits for maybe up to six months. So I hope that was helpful. Please share with me any of your stories. You can find me on UroToday. Thank you.