For the majority of patients who have recently been diagnosed with prostate cancer and who are, quite naturally, overwhelmed, post-surgery urinary incontinence and andrology issues may seem a small price to pay for being cancer free. However, once the wounds have healed and PSA values are undetectable, not having full control of their bladder function and/or not being able to achieve a full erection can have a significant impact on patients' general sense of wellbeing (Donovan et al, 2016).
In the short term, it is estimated that between 8% and 87% of patients experience urinary incontinence following surgery (Donovan et al, 2016; Arroyo et al, 2019; Hodges et al, 2020; Huynh et al, 2021). This wide variance may result from differing definitions of incontinence and durations from surgery. In a British study, 46% of patients were using at least one incontinence pad per day at 6 months, and this figure fell to around 30% at 12 months (Donovan et al, 2016). Only 20% of men who were able to sustain an erection firm enough for intercourse prior to surgery were able to do so at 6 months post-surgery, and two-thirds of men were still affected at 6 years post-surgery.
National Institute for Health and Care Excellence (NICE) guidance recommends that all patients who have had a prostatectomy receive specialist advice on continence and sexual function (NICE, 2021); however, this does not happen in all areas.
Specialist urology continence nurses at the Norfolk and Norwich University Hospitals NHS Foundation Trust have created a care pathway that formalises pre- and post-surgical support for patients undergoing a prostatectomy. The impact of the pathway was recently audited to assess its potential for wider use.
Background
A radical prostatectomy may be conducted using open surgery or a minimally invasive technique, which may be a robotic procedure (NICE, 2021). In either case, the prostatic segment of the urethra and internal sphincter are (inevitably) removed (Figure 1) (Marchioni et al, 2020; Clark et al, 2021). Depending on the extent of surgery, there is also risk of damage to the striated urethral sphincter, the smooth muscle neck of the bladder, the nerves that activate these muscles and the nerves implicated in penile erections (Pacik and Fedorka, 2017; Arroya et al, 2019). This reduces the patient's facility to control urination (especially during exertion or during coughing or sneezing) and, in some cases, to have erections (Albisinni et al, 2019; Rahnama'i et al, 2021).
A surgical catheter is placed as part of the procedure; however, once this is removed (1–2 weeks after surgery, depending on the type and extent of surgery), all patients experience at least some degree of ongoing urinary incontinence (Pacik and Fedorka, 2017). They may also experience difficulty in achieving and/or maintaining an erection (Fode et al, 2012).
Patients are recommended to do pelvic floor exercises to help them regain muscular tone, which will improve continence (Wu et al, 2019; Marchioni et al, 2020; Rahnama'i et al, 2021). These should be tailored to the male anatomy and be commenced prior to surgery, if possible (Goonewardene et al, 2018; Hodges et al, 2020; Mungovan et al, 2021). Patients are advised to do these exercises for 5 minutes per day. Patients should continue these exercises for at least 3 months (NICE, 2015). Work is ongoing to determine the impact of continuing the exercises for 12 months (Hodges et al, 2019; 2020). After surgery, most patients will, at least initially, need a urine-containment device (NICE, 2015). The most popular of these are pads and external catheters/urinary sheaths. Patients may use one or both options (Macaulay et al, 2015; Murphy et al, 2020).
Pads are available in a range of absorbencies to best suit the patients' needs. Bulkiness is a major concern that is best addressed by using pads specifically designed for the male anatomy. Pads designed for women are bulky if worn in a way to maximise absorption. Women's pads will not provide adequate protection against leaks for men as they are designed for the female anatomy.
Sheaths are perceived as more discreet than pads and are very popular with patients who experience large-volume leakage, especially when travelling (Macaulay et al, 2015). They are similar to a condom in appearance but have a hole at the end that connects to a tube and bag that act as a drain for leaked urine. Sheaths are not suitable for men with a small or retracted penis (Macaulay et al, 2015).
There are some patients for whom standard continence measures are insufficient. For example, patients who develop an overactive bladder may benefit from a course of an anti-muscarinic drug, such as oxybutynin, tolterodine and solifenacin, or the beta-3 agonist mirabegron (Marchioni et al, 2020; Rahnama'i et al, 2021).
Patients who are not able regain full urinary continence (for example, those whose bladder neck and/or sphincter was unavoidably damaged during surgery, perhaps due to the large size and/or position of the tumour (Schifano et al, 2021), and who have severe urinary incontinence) may be offered further surgery to fit an artificial sphincter or a male sling (NICE, 2015; Rahnama'i et al, 2021; Schifano et al, 2021).
Pre- and post-operative support
Awareness sessions
The advice given about the reasons for, and management of, urinary incontinence and andrology issues prior to surgery is essentially the same for all patients.
In 2014, the specialist urology continence nurses at Norfolk and Norwich University Hospitals (NNUH) NHS Foundation Trust had the idea to deliver this information in group sessions, rather than at individual appointments. This proved to be a more efficient use of clinic time, providing time to explain urinary continence issues and their management in more detail. In 2019, oncology nurses and physiotherapists treating patients with prostate cancer also began to contribute to the sessions, which then became full awareness days. Awareness days are typically held 2–4 weeks before the scheduled date for surgery.
Previous experience among the continence team at NNUH provided useful insights into patient behaviour that have informed the format of these awareness days. Patients attend the sessions without their partners, because this can allow them to speak frankly and ask questions they may not have raised if their partner was present.
From the patient's point of view, the awareness days mean that they are better prepared not only for surgery but also for what happens afterwards. The sessions help patients to understand that urinary incontinence is something that happens to everyone undergoing a prostatectomy. It also helps them appreciate that it is (hopefully) only a temporary part of their life: it can be addressed and, with work, improved with time.
An important aim of the awareness day is that patients go home with the understanding that they do not need to be wet, because products exist that can be tailored to their needs and deal effectively and discreetly with urine leaks. Patients will know who to contact and when and how to contact them if they are having continence problems. Importantly, they appreciate that even severe urine leaks are not medical emergencies requiring attendance at the emergency department or an appointment with the GP, and they can go straight to the specialist urinary continence nurse.
Awareness days also provide an opportunity for patients to meet others undergoing the same procedure, possibly at the same time, which can lead to the formation of informal support/friendship groups that can be helpful as they continue their treatment.
The Norfolk and Norwich urological post-surgical pathway
Recognition of the benefits of awareness days led to the development of a urological post-surgical pathway (Figure 2). Accordingly, the urology assistant practitioners see the patients for removal of the surgical catheter and conduct a full continence assessment. This aims to ensure that each patient gets the right product (sheaths and/or pads of the most appropriate absorbency) for their needs. Patients are then reassessed at 6 weeks and 6 months.
The NNUH Trust provides all patients with incontinence pads of appropriate absorbency following catheter removal. Such provision is not universal in the UK: although this Trust is not the only one to supply all its patients' needs, in some other areas, patients must provide all of their own pads or may only have access to a limited (in terms of number, size and absorbency) supply. NNUH has a contract with Essity UK (Dunstable, Bedfordshire) to exclusively supply the full range of TENA Men pads for use in hospitals and in the community, but there are other manufacturers of similar products.
In 2021, Essity asked the specialist urology continence nurses at NNUH to audit the impact of their care pathway on patients, with a view to recommending its roll-out in other areas.
Method
Audit design
The audit was based on an anonymous mixed-method (though primarily qualitative) survey devised by Essity. This survey included multiple-choice questions on the following areas:
- History (n=6), including interactions with continence specialist nurses; extent and impact of incontinence following catheter removal; and extent of incontinence—stratified by self-selection as ‘Heavy (full emptying of your bladder)’, ‘Moderate incontinence’ or ‘Slight dribble’
- Satisfaction (n=5) with the service and the product they had been supplied with, including fit and comfort (yes, no or not sure)
- Support (n=5), assessing any potential need for additional sources of support (yes, no or not sure)
- Confidence (n=9), focusing on the impact that using prescribed continence products had on quality of life (very satisfied, satisfied, unsatisfied or not sure).
The survey also included free-text questions (n=7), some of which added detail to particular the multiple-choice answers.
The survey was only open to patients who underwent a radical prostatectomy at NNUH between 27 April and 9 November 2021 and required continence pads. All qualifying patients were invited to participate in the survey when they attended clinic for the removal of their surgical catheter and were given instructions for accessing the online survey. There was no timeline for completion of the questionnaire.
Ethics
Permission to conduct the audit was granted by the Joint Research Governance Committee at NNUH. Full ethics committee approval was not required, because no patient identifiable data were collected. All patients gave informed consent to participation in the survey.
Data collection and treatment
Essity was responsible for collecting the information submitted by participants. Each participant's responses (including free-text entries) were entered into an Excel spreadsheet. The numbers of participants selecting a particular response to a question was converted to a simple percentage of all participants answering that question. No statistical treatment was attempted. Free-text answers were used to create word clouds to display the most prominent or frequent words in participants' responses.
Results
In total, 28 people provided at least one response to the survey. Seven patients responded within 14 days of surgery, 10 patients responded 15–21 days post-surgery, five at 22–28 days and four 29 or more days post-surgery. The earliest response was at 13 days post-surgery, and the latest response was at 37 days.
The maximum number of responses to a question was 26, and the minimum was four. Most participants (71%) responded to all 28 multiple choice questions, with fewer (7–68%) providing free text responses.
Clinical history
Of the respondents, 20 (71%) reported experiencing incontinence after their surgical catheter was removed. Of these, two reported heavy flow (equivalent to full bladder emptying), with the others split evenly between ‘moderate’ and ‘slight’. A sizeable minority (8/20; 40%) reported that their mental wellbeing had suffered because of their incontinence.
With respect to contact with the continence service, ten respondents with incontinence were satisfied with the number of pads they had been prescribed based on an individual assessment made in clinic, but a quarter felt that they needed more. The latter included one with heavy flow and three with moderate flow (Figure 3). The other respondent with heavy flow was not sure if the number of prescribed pads was adequate. Only two respondents had had more than two appointments since surgery, one of whom had developed an infection.
Most respondents (25/28; 89%) were satisfied with the advice that they had been given prior to surgery (Figure 4): one was not sure that the advice had been sufficient, and two were dissatisfied with the level of advice (one of these had heavy incontinence and said that the information given was ‘not very specific or detailed’).
Confidence in and satisfaction with continence solutions
Among the 19 respondents to these questions, 16 were confident that the pads they had been prescribed were helping them to manage urinary leakage, and 16 were confident or very confident that they could manage their incontinence themselves (Figure 5). The five respondents who reported being very confident had the least severe incontinence. Overall, less than a quarter of respondents were ‘very confident’ about going out, meeting people or exercising at the time of participating in the survey.
Patients' responses and comments on their experience with their incontinence pads indicate that, generally, respondents were confident that their overall and mental health had improved, and most were confident or very confident that they had less anxiety.
No respondent sought additional help from their GP or from any other source. Six patients were unsure about whether they might need additional clinical or emotional support in the future. There was no pattern in terms of severity of incontinence or satisfaction with the service delivery among this group.
Both respondents who reported heavy flow had experienced leaks, and one of these reported having to change pads frequently. Neither was confident about going out and socialising, and they were unsure about the effects of incontinence on their general and mental health. However, they did not feel that they needed additional support to manage their condition, and neither had had more than two appointments with the specialist urinary continence nurses.
Most respondents in this section (16/19; 68.4%) had not needed to purchase additional pads. Of the three patients who had purchased additional pads, two had moderate incontinence and one reported slight incontinence.
Opinion of the continence pads supplied
All respondents to this survey were prescribed TENA Men pads. All but one found them easy to fit, and most (13/19; 68%) reported that they were easy to use. A word cloud was generated showing the 10 most frequently used words in free-text explanations of what respondents most liked about TENA Men, including ‘easy’, ‘discreet’, ‘comfortable’ and ‘unobtrusive’ (Figure 6). Six respondents (32%) specifically mentioned that they found them discreet/unobtrusive.
Discussion
Questionnaires have previously been shown to be efficient methods for collecting qualitative and quantitative data on aspects of life after a radical prostatectomy (García Cortés et al, 2021; Huynh et al, 2021).
This small survey indicates that the support offered by the NNUH continence team through their awareness days and urological post-surgical pathway had a positive effect on patients who had undergone a radical prostatectomy and also had advantages for the Trust.
Encouragingly, there was a high degree of satisfaction with the information provided prior to surgery. It is interesting to note that no patient needed additional support from their GP, and only a small minority sought additional appointments with the hospital for help with their incontinence, but this study is not geared to assess the overall significance of this for continence services or Trusts. Indeed, the majority felt confident or very confident in managing their incontinence themselves.
As per the pathway, all patients were prescribed anatomically appropriate incontinence pads when their surgical catheter was removed. Patients' needs were assessed, and pads of the appropriate absorbency were prescribed. Of note, the eight patients who did not report incontinence in the survey were assessed as requiring pads when their surgical catheter was removed.
Most patients were satisfied with the number of pads prescribed and confident or very confident that they could return to working, socialising and exercising without worrying about leaks. They found the TENA Men pads easy to use; discreet to wear and to carry; and comfortable to wear.
The awareness days for patients with prostate cancer have potential benefits for patients and staff. For example, staff time is saved by not having to repeat the same information at multiple individual consultations. Patients meet not only the specialist urinary continence nurses and andrology nurses but also the oncology nurses and physiotherapists and get an understanding of how these will help in their recovery. They also meet others in similar circumstances, possibly provoking discussions that help to establish a deeper understanding of the consequences of a radical prostatectomy, as well as establishing informal support networks.
Little is known about how individual continence services address the pre- and post-prostatectomy management of continence. As far as the author is aware, the NNUH is the first hospital to publicly review its approach. Anxieties about being wet can be reduced through management of patient expectations and increased knowledge and understanding of post-operative incontinence achieved through awareness days and the formal care pathway. The authors are confident that this is evidence for the impact of the patient-centred advice and access to prescribed male incontinence pads, because pelvic floor exercises would be unlikely to have had an effect within the timescale of this study.
Limitations
This is a very small, single-centre study. Recruitment took place during the COVID-19 pandemic, when the rate of surgery had slowed, limiting the number of potential participants. Likewise, patients were unable to attend face-to-face group awareness sessions, where they would have had a chance to ask questions, and instead had to rely on pre-recorded information videos, which may have impacted their information intake.
There is no comparator arm containing patients not treated according to the NNUH pathway and no demographic data or data on the type or extent of the surgery and how long after catheter removal the survey was completed. While this limits the interpretation of the data, it would have changed the nature of the study, making it necessary to go through full ethical approval.
Conclusion
This study suggests that awareness days and a tailored clinical pathway help give patients undergoing radical prostatectomy confidence in their ability to manage post-surgery continence issues themselves and could be of value in other hospitals. Easy access to incontinence pads designed for the male anatomy plays an important part in this. There are also potential benefits for hospitals, in particular the saving of clinic time. A larger, controlled trial would help to establish these principles.
The study results also underline the importance of allocating the correct product to a patient, enabling them to manage their own condition more effectively. This more effective self-management can provide patients with a better quality of life and reduce the strain on health services.
KEY POINTS
- Many people who undergo prostatectomy develop urinary incontinence, which they may manage using incontinence pads
- A post-surgical pathway for prostatectomy-related urinary incontinence was linked with greater confidence and self-efficacy and lower anxiety among patients
- Access to incontinence pads specifically designed for the male anatomy can help improve wellbeing among this patient group
- Users value incontinence pads that are easy-to-use, comfortable and discreet
CPD reflective questions
- What are the most significant challenges facing patients after a radical prostatectomy?
- In what ways can a nurse-led pathway support patients after major pelvic surgery?
- What are some of the important features of incontinence pads designed for use by men?