My Dog Calendar for 2012 Don’t buy it…just click the preview button. I bet you’ll see a dog or two you recognize.
Since my book has been written I see a lot of patients who show up for a second opinion. I get to hear first hand the impressions made by the original urologist. Sometimes it’s good but more often it is bad.
Anyway this week a guy shows up for the second opinion discussion and in about three minutes it was clear that this patient’s biggest concern in the world was continence.
Here’s the thing…no urologist in the world and I even mean Dr. Walsh himself can tell a patient he will not be incontinent if he has his prostate removed. Nobody. It is something we just don’t understand. We can give percentages, but not assure continence. I knew that going in for myself.
So my job was easy. Radiation whether external beam or seeds will not cause incontinence. Maybe urgency and some incontinence as a result of urgency but not just leaking.
“Based on what you’ve told me I think that radiation is a reasonable option and I’d recommend a consultation with a radiation oncologist. I’d ask him very specific questions about the risks and benefits and in particular continence questions.”
When a patient clearly tells you what is most important to him in the decision-making process it is like a slow curve ball that doesn’t curve. I’ll knock it out of the park every time.
Prostate Diaries 
And remember guys, most all prostate surgeons WILL NOT tell you they also cut out and remove the bladder neck sphincter from the bladder and that is THE reason for all the talk about incontinence issues. They cut out your main pee valve along with the prostate. The Doctors can not predict if your secondary sphincter will function holding urine (for which nature never intended it to do). So fellow reader /prostate surgery survivor, were you or were you not told your surgeon cuts your bladder neck sphincter?
Most all surgeons WILL NOT tell you nor give you their running score card of surgical performance/outcomes for all their patients. Just lifetime stats is all. H SO we are left only to judge and chose a surgeon on how nice, intelligent etc. the Doctor seems to us in our 1 or 2 visits while searching for God forsaken help while half drowning in the sea of disaster that is swallowing us called prostate cancer.
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I am just a little over three months from robotic removal. I used four pads (bladder shields) a day at first.I am down to one now. It might not be necessary except for that occasional sneeze or hard coughing episode. I see them as a little bit of a crutch and probably can be done. I, of course worry about any leaking so i will continue for another month. My Dr. did tell me he was going to disturb many things in that area, and this would be the result. I feel I am ahead of schedule in this area. Why did I choose this method? Family history led me down this path. (I simply wanted it out of there entirely)
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To Jeff, Fantastic news! I started at TEN DIAPERS a day and for a long time.
That cost me $7/day which equals $2,555 a year.
Like I can pay the 2 DaVinci roboric surgeons $20,000 plus the hospital $20,000 and still have $2,555 left to buy diapers with? No one talked about that. I peed all the time for no reason even though the doctor called it “stress incontinence” rather lame. It is actually PSSTI. Poor Surgeon Skill Technique Incontinence to pee all the time. Does he really think I was sneezing all day long and coughing? Fantastic that you Jeff are doing so well at 3 months. Hng in there it will get better albeit much slower than we like.
At 14 months (sounds like we are discussing infants huh) I was able to try the switch from diapers to thick mens pads (depends also) and wear real jockey briefs again. Geez diapers are so hot and “wet” when working and especially in the summer. What a relief to be out of diapers.
My surgeon also said “if I want the ‘function preservation’ surgery for erectile function being left intact that they need to use the ROBOT surgery and I must pay an addtiional $1,500 up front (plus they get the insurance amount and my copays and dedcutibles etc). The incontinence issue was only mentioned to me, like you, that it would be very brief and only due to “working in the area and stress to the body from major surgery. Sounded normal and made sense to me. I can handle that going home from the office after the cath was removed while I am off work for 2 more weeks or so.
Truth is the ability to retain urine for the normal human male is due to the bladder neck sphincter, (aka proximal sphincter, internal sphincter) and it only makes/lets you pee when it gets to a fullness level that it triggers nerve signals to the brain and the brain sends back signals. That is the “hmm i need to pee soon” signal. Those signals and responses get more intense and eventually you have to go and can wait no longer. Your brain opens the internal sphincter, your bladder wall muscles contract, all done involuntarily, and then you intentionally relax your EXTERNAL sphincter (the same muscles that make the sausage dance when you want it to), You can start and stop the urine flow with the EXTERNAL sphincter for fun and exercise but only as long as your brain keeps the INTERNAL sphincter open. Once your all done you CAN NOT pee any more. Not even a drop because your brain has your bladder necks INTERNAL sphincter tightly closed. We all know that feeling, you get to the urinal and just ‘relax’ and let your insides take over. before you make it to the urinal you were actually tightening muscles to keep your pee in and not let your brain push it out and embarrass you before you get to the bathroom. You can also squeeze other stomach muscles to speed things up but now you are using the involuntary muscle group and your voluntary muscle group. Important distinction to understand your future functionality after prostatectomy!
After prostate removal and bladder neck sphincter removal you can pretty much tighten your muscles and pee out drops or squirts any time you wish. This is because you now only have the EXTERNAL sphincter holding back all the pee and that EXTERNAL sphincter is always under your voluntary control.
You will still get the sensations of “mmm i need to pee” however you may only have one ounce in you to pee out. Things and people vary. Chart your own course remember you really know more answers than your doctor does about you. Your doctor only knows after the fact info from patients on how things go for the patients. As patients we live it, we know. Your doctor can only tell you if “that happens to other men”. Some men, a few men, many men get some degree of control and it varies. I still say there is no reason for any doctor hiding the bladderneck sphincter removed at time of prostate removal from prospective patients. I still say all doctors should be required to publish and hand to every new prostatectomy patient the “surgical outcome report” chart for all his patients. A running score card to date. Then You and I can see the history of actual results and can use that in our decision making process, if we want. This keeps ALL the info and ALL control in the patients hands.
Go have fun Jeffery and best of luck.
Jim
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Careful, Dr. McHugh, lets not be too critical of our colleagues. “I get to hear first hand the impressions made by the original urologist. Sometimes it’s good but more often it is bad.” What is bad? I strongly doubt the job these other urologists did was bad in the sense of ‘bad medicine.” What was undoubtedly bad was the biopsy or lab report they had to convey to their patient, who was, without doubt, worried sick just waiting for the report in the first place. I am a surgeon myself, and in my experience far too many patients are so shaken when bad news is presented they rarely remember the most important details of what is said on that day. When they return for further consultation, or a “second opinion,” more or less hoping I have better news for them the second time around, I always encourage them to bring in family members as well as a recording device to fully understand the detailed discussions that will outline the management of their disease. Even so, it is human nature to deny bad news and hope another doctor can come up with a more pleasant diagnosis or approach to what initially strikes the patient as a catastrophe. So, second and third opinions are here to stay, and for the most part do help patients clarify the course they will follow. What I am driving at is that the second opinion consultation is far easier for us as physicians because the patient is now more educated, “tuned in” and focused on what he wants done than on the ugly day he received the bad path report and was told he had cancer. By the time of their second opinion consultation most patients have accepted what they cannot change, and, when there are options as in prostate cancer, are able to clearly express their true desires for going forward. Which is why, when doing second opinions, we may often feel we’ve hit it out of the park with the patient in question, but know in our own heart that the original physician would have probably done exactly the same if given the opportunity. Am I correct?
Thanks again for this wonderful blog,
Jack Brown
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No, you are exactly correct and sorry for the miscommunication. I guess what I meant to say is that the “second opinion patient” is skewed to having a less than perfect relationship with his urologist, or is indeed that patient of which you refer.
I have said a thousand times to patients that the second opinion doctor is at an advantage and am very careful not to be critical of another doctor who made decisions and recommendations ,as we used to say in residency, “the heat of battle.” I agree with you wholeheartedly and fully understand that when one points a finger at someone there are three pointing back. Thanks for your comments.
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Erectile dysfunction or erectile function always seems to take precedence over incontinence. Perhaps this is because the statistics show a 10% problem with incontinence as compared to 75% or greater problems with erectile function. However, there are ways around having orgasms without an erection or ejaculation but dealing with incontinence is a challenging task.
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