After prostate cancer surgery

Survivorship is a treatable problem, not a consolation prize

Prostate cancer treatment has become steadily more successful, which means far more men are living for decades afterwards with the functional consequences of that treatment. Urinary leakage and erectile dysfunction are the two dominant issues, and both are frequently under-treated — sometimes because men are told to be grateful they are cancer-free, sometimes because nobody has explained that effective treatments exist.

They do. Most men can achieve substantial improvement in both, and the earlier structured help begins, the better the result tends to be.

Urinary incontinence after prostatectomy

Removal of the prostate disturbs one of the two mechanisms that keep men continent, so leakage in the early weeks is expected. Most men improve substantially over the first six to twelve months. A minority have persistent leakage beyond that point.

Assessment establishes how much you leak and why — stress leakage on coughing and lifting behaves quite differently from urgency, and the two often coexist. Investigation may include a bladder diary, pad weighing, flow rate and residual measurement, flexible cystoscopy to check for a bladder neck stricture, and urodynamic testing where surgery is being considered.

Treatment options include specialist pelvic floor physiotherapy, which should be the starting point and is far more effective when properly supervised; treatment of any overactive bladder component; management of a bladder neck contracture where present; and, for persistent stress incontinence, surgery — a male sling for mild to moderate leakage, or an artificial urinary sphincter, which remains the most reliable option for more significant leakage.

Erectile dysfunction after prostatectomy

The nerves that control erections run immediately alongside the prostate. Even with nerve-sparing surgery, they are stretched and bruised, and recovery is slow — it can continue for up to two years. Radiotherapy causes a different pattern, with function often declining gradually over the years after treatment rather than immediately.

Penile rehabilitation aims to maintain the health of the erectile tissue while the nerves recover, since erectile tissue that receives no blood flow for a prolonged period develops fibrosis and loses length. Strategies include regular PDE5 inhibitors, vacuum erection devices, and intracavernosal injection therapy, which works even when the nerves have not yet recovered. Where recovery does not occur, a penile prosthesis is a highly effective option with high satisfaction rates in this group. See also erectile dysfunction.

Other issues that deserve attention

• Loss of penile length, which is common and distressing, and is reduced by early rehabilitation
• Climacturia — leakage of urine at orgasm, which is common, rarely mentioned and readily managed
• Changes in orgasm, including altered sensation and the absence of ejaculate
• Peyronie's disease, which occurs more frequently after prostatectomy
• Bladder neck contracture, causing a slow stream after surgery
• Fertility, since ejaculation is lost after prostatectomy — sperm banking beforehand matters for younger men
• The psychological impact on you and on your relationship, which is as legitimate a reason for referral as any physical symptom

The Post Prostatectomy Service

I co-founded the Guy's Hospital Post Prostatectomy Service with my consultant urologist colleague Arun Sahai in 2019. We developed it to redefine optimised care after prostate cancer surgery — to understand the factors involved in helping patients achieve the best functional outcomes, and to help men return to a normal life after prostate cancer surgery.

The clinic and service have won nine awards, including a Guy's and St Thomas' Care Award in 2023. With industry partner Nexus Digital Technologies we developed a new post-prostatectomy app for patients, which won a UK Business Award as Best Clinical Management System in 2023.