Is the internal sphincter important to post prostatectomy continence in the treatment prostate cancer?


don't call me sweet pea call me pee pee....cause i'm urine

What is the internal sphincter in regards to the male bladder, post prostatectomy incontinence and the external sphincter?” Hmmmmmmmmmm? If the internal sphincter is so important to continence then why don’t men leak after a TURP?

Dr. Catalon’s explanation of post prostatectomy anatomy and continence.

There  was  a comment about the internal sphincter and a patient being disappointed that the urologist did not tell him that it would be removed at the time of a prostatectomy. The patient has incontinence and is concerned that if the internal sphincter had not been removed he would not be leaking urine.  Here are my thoughts and my understanding of continence after the prostate is removed..

But first….Walsh’s take on this matter…on in which I am in full agreement.

  • The external sphincter is a defined muscle that one can contract and stop and start the urinary stream.
  • It is the primary sphincter for the control of continence after the prostate is removed.
  • It is at the distal aspect of the prostate (furthest away from the bladder) and in normal circumstances is not disturbed by removing the prostate.
  • It can be strengthened by doing Kegel maneuvers.
  • The internal sphincter is not a well defined muscle but rather the confluence of muscles at the very tip of the bladder and blends into the urethra.
  • The IS is responsible for antegrade ejaculation. It closes and propels the sperm forward.
  • The IS, the prostate, and the external sphincter are all responsible for continence before a prostate is removed…only the external sphincter is available for continence after the prostate is removed.
  • Often times if the dissection allows, the internal sphincter can be spared at the time of a prostatectomy (after removing the prostate the surgeon can see the bladder neck as a small opening that has tone and closes. The reason some surgeons might not want to try to preserve the bladder neck area is that there is the possibility that one leaves some prostate (not taking enough bladder neck above the prostate to assure that all the prostate and cancer are removed) in the area that abuts the bladder. In the original descriptions of Walsh nerve sparing prostatectomy surgeons purposefully took a wide area of the bladder neck so large that it would have be closed before reattaching the bladder to the urethra. This did not prove to be detrimental to continence.
  • When urologists do a TURP we purposefully remove prostate tissue to open the prostatic urethra and trim the bladder neck area as well and in turn trim away the internal sphincter. A TURP rarely results in incontinence but almost always results  in retrograde ejaculation.
  • The fact that some men leak urine after the prostate has been removed has less to do with internal sphincter being removed than the surgical technique as it applies to the urethra and the external sphincter. As Walsh says, some men have a perfect surgery and still leak and this is something we don’t understand.

What do I tell people considering a prostatectomy? First of all I don’t always specifically mention the internal sphincter. I don’t think discussion of that is the critical point. I do however say this:

  • The likelihood of leaking urine all the time is a real possibility but it occurs less than 1% of the time.
  • Stress incontinence is common.
  • It will take anywhere from 2 weeks to a year to reach your baseline continence level.
  • It is not uncommon for patients not to leak at all after removal of the catether…but you can tell who will be which.
  • The surgery could go badly and a patient not leak.
  • The surgery could go very well and he leaks.
  • If your primary concern is leaking urine…I’d recommend radiation. You will not have stress incontinence or total incontinence but you may very well have frequency or urgency incontinence.

Choose your poison.

 

 

5 Replies to “Is the internal sphincter important to post prostatectomy continence in the treatment prostate cancer?”

  1. As a post prostatectomy (davinci robot) patient living with results of poor surgeon choice or that important information was witheld from me about what this surgery does in will say again from the patient perspective.
    Every thing I read in medical articles says (paraphrasing) “the internal sphincter (bladder neck sphincter), is indeed the main continence mechanism in men, it is held tightly shut and it is under involuntary nervous system control, there is an interplay of signals of being full sent from the bladder to the brain that tell the detrusor muscle (bladder wall) to contract and tells the internal sphincter (IS) to relax and open, you can voluntarily close your external sphincter (urethral sphincter) to stop and re-start the flow of urine during that process while the internal sphincter is told to stay open, but once the brain signals the internal sphincter to close, you’re done, you can squeez and squeeze your external sphincter and your gut, your tummy or whatever you want but you will not get one more drop of urine out of you. The system is turned off, internal sphincter commanded to be tightly shut, urine kept inside bladder before it touches the prostate. If during orgasm as things are pumping out seman the internal spincter opens slightly then semen would flow into bladder rather than out the penis tip. That is a problem unto itself and is not at all the norm for most all men. After prostatectomy there is no continence mechanism other then the last thing in the original system the external sphincter.”
    Given the facts of how men urinate, I have a completely different view of what is important to a patient than, apparantley some/many/all doctors have.
    I will say again all doctors should tell you that “Mr Patient, you will pee out, you will drip pee, you can squeeze an ounce of pee out of you at any time you whsh, you will squirt pee lots of different times without the knowledge that are about to do so, you will only know about it after it happens. Now some men, statistics (me your doctor however does not maintain nor hand out to you Mr Patient any of the result/records of how my patients did after my surgery so you cant judge my outcomes) vary widely. 50% are incontinent, 31%are incontinent, 3% are incontinent, 62%were safety pads but think they are continent but never know when there might be that moment that they squirt. Definitions of what continent means vary also Mr Patient.
    Absolutely should be more explanation of what is removed, that bladder neck sphincter is the same as the front faucet on your house, you cut that out and connect your now shortened garden hose (urethra) directly to the water pipe (bladder) and lets see if your old nozzle out there on the end can hold back the water with no drips.
    Point is I think medical personell are caught up in what they think must be done and what they think is important to tell a patient based on what the medical personell think the patient should do. Yes I know, Doctors always say “it’s your decision Mr Patient” But I based my decision on the information you told me. I just get the sense that men do not know the whole story before prostatectomy. I suspect that the real number of men that never ever ever needed any pad or liner or diaper before prostatectomy and who now after prostatectomy have need for a pad or liner or diaper is 60% but it could be 77%. No one has the real data and they won’t keep it and they don’t want it.
    Every Doctor should furnish his patients the running score card if his work as a contractor for prospective customers to view. That would mean rate the outcome @ 1month, 3 months, 6months, 12 months, 18 months, 2 years, 3years, 4 years, and so on. The info returned would be ?do you wear any pad?, liner? or diaper?, yes/no. How many per day on average?
    Now if that info was maintained then the real numbers of outcomes would be known. Info could be broken down by ages, stages, severity, etc .
    Should also keep score card of erections, fairly simply too.
    ?Are your erections the same as before prostatectomy?
    Can you get partial erections? Do you need pills for erections at any time? Must you use injections instead? Did you need the implant? Can you have sex as often as you did before prostatectomy?
    Somehow there is an easy way to ask for the information that reveals the true numbers on outcomes for that subject too.
    Again, I am just a patient that lived it all starting July 19, 2010.

    Like

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