1. Val Ward Caroline Grimes Clinical Nurse Specialist: Rochester

2. Many types SUI Urge incontinence Mixed incontinence Overflow Climacturia

3. Incidence Varies 2.5-87% Differences in definition & reporting

4. Factors Patient Age Stage of disease Co-morbidities Previous TURP Previous radiation Pre op continence status Surgery Technique Surgeon experience Nerve sparing RRP Bladder neck sparing/reconstruction

5. RRP v Lap RP Continence after 3 months 80% RRP 62% LRP RRP provided better functional results in terms of recovery of continence & potency Porpiglia F et al 2012

6. Why does it happen? Damaged small nerves alongside prostate resulting in failure of urinary sphincter Stretching of urinary sphincter as prostate removed Loss of supports Over activity of bladder Obstructions/Stricture Co-mobidities Pelvic floor tone Post prostatectomy incontinence Bladder dysfunction Obstruction Sphincter dysfunction

7. Subjective v Objective Self reporting Leakage measurement Pad weight Number of pads used Physicians – 5-10% pad use Patients- 74% report pad use

8. QOL Study of post RRP patients Need to wear pads = greater problem than loss of sexual function Fowler Jr FJ, Barry MJ, Lu-Yao G et al 1995 Age of retirement Child care Sick pay 60 is new 40 Patient expectations of outcome

9. “Before my prostatectomy, I had high energy levels & would describe myself as a motivated person who was actively engaged with life. With the coming of incontinence, I am a different person. Frequently, I feel dogged by depression & I’m in the middle of ‘existential agnst’ that weakens my enthusiasm for life. Instead of taking action & initiating things, I feel more passive. Some of that comes from knowing that when I move about, I will leak more. The sense of not being able to control one of my basic bodily functions makes me very sad. My family & a few close friends know of my situation but everyone else is unaware. Sometimes the pressure to continue to appear normal is tough”

10. Treatment Options: PFE Behavioural modification Pelvic floor physio Pre/post prostatectomy Evidence shows effectiveness G Dorey BJN 2013 11 radomised trials McDonald et al 2007 Over 1000 men Early recovery of continence in PFET No difference at 6 months

11. Medication Anti Cholinergics for urgency Duloxetine (SRI)

12. Surgical Options Symptoms persist beyond a year Artificial urinary sphincter Male slings Injectables

13. Artificial Sphincter Gold standard for moderate to severe incontinence High satisfaction rates 90-96% 88 -91% continent at 3-10 years

14. Male Sling 62 men at 28 mths 65% pad free, 23% improved Oliveira et al BJU 2009 40 men at mean 3 years 55% cured, 32% same or worse 73% short term perineal pain 12.5% sling removed for infection Gilberti J Urol 2009

15. Injectables 322 men, av 4.37 injections Complete continence 17% Duration 6.3 months Wesney et al, J Urol 2005

16. Conservative Management Pads Sheaths Briefs/Appliances

17. Pads Advantages Easy to use Readily available/easily purchased Variety of sizes & absorbencies Disadvantages Disposal- environment Cost Bulky Hot Skin integrity Limited availability from local continence services Self management

18. Sheaths Advantages Easy to use Readily available on FP10 Variety of sizes & styles Material- silicone & latex Self confidence Improved QOL Disadvantages Application problems Large abdomen Retraction Cognitive impairment Skin integrity Physicians view Nurses ability & view

19. Briefs/Appliances Advantages Easy to use DIY Readily available on FP10 Variety of sizes & styles Self confidence Improved QOL Disadvantages Large abdomen Retraction Cognitive impairment Expensive £24-70 Nurses ability & knowledge Latex

20. Choosing your Surgeon

23. Choosing your Patient