These are common questions for Marcy Donkle, BSN, RN. As the nursing coordinator for urologist David Miller, MD, in Richmond, Va., Donkle serves as the point person for pre- and post-operative patient education.

Before surgery, Donkle provides the patient with a high-level overview of the cancer itself, the surgical process and potential side effects, including, of course, urinary incontinence. This conversation includes information on Kegel exercises to strengthen pelvic floor muscles, incontinence pads and other common ways to control leakage.

After surgery, Donkle reinforces that urinary incontinence is a common side effect and can be expected for three to six months and sometimes up to a year. She advises patients to avoid caffeinated beverages, as well as strenuous physical activity, which can cause increased leakage. She also discusses the importance of protein as a healing agent.

"My biggest pet peeve is diet," Donkle says. "These patients cannot have anything that stimulates or irritates the bladder. When they do, it adds another variable. Leaking is normal, but you can't gauge leaking if diet is part of the problem."

Lasting Leakage
While Donkle is careful to present information to patients on an as-need basis, to avoid overwhelm and maximize the amount they retain, she says patients often need to be reassured after surgery that some leaking is normal.

"Even though you have explained that they can expect some leaking, it is the first thing they ask about when they call in from home after the operation," she says.

In these cases, Donkle simply reinforces that leaking is normal and that the patient can take measures, as mentioned, to minimize quality-of-life issues.

"Sometimes you have to say it over and over again," she says. "Sometimes you have to hold their hand."

But when a patient reports mild to moderate urinary incontinence--one to four saturated pads per day, what Miller calls "social" incontinence--for more than six months, Donkle introduces new information.

"'We can fix it.' That's the first thing I say," she says.

Then she discusses a male sling system with her patients. Although slings have been widely used for years to improve urinary control in women, they are a relatively new treatment for men. Prior slings were anchored to the pelvis with small bone screws, but that was painful for many patients.

The newer sling, Miller says, is less invasive and yields better results. It involves passage of a thin strip of mesh between pinpoint incisions on the inner thigh, which is then passed beneath the bottom of the urethra to increase support where tissues are weakened, providing additional flow resistance and preventing leakage when abdominal pressure increases.

"The sling is a mesh material, the same type that general surgeons use for hernia repairs," Miller says. "It works by repositioning the urethra, allowing the sphincter to function properly, as it should have prior to surgery."

Miller added he has seen a 90% success rate in patients who were saturating one to two pads per day and an 80% success rate for those using three to four pads per day.

While factors such as past radiation therapy and scar tissue at the bladder neck may negatively affect outcomes of the procedure, Miller says recovery is minimal for patients who do not have these histories: "No heavy lifting for six weeks."

Education & Expectations
Miller and Donkle agree that appropriate education, from the preop class to the point of "problem" incontinence, is the best way to help a patient maintain his quality of life.

"Expectations are so important," Miller says. "You have to make sure they know what to expect postoperatively, about the risk of urinary incontinence and how long it could take to overcome incontinence.

"We want to cure the cancer but maintain quality of life, so they are dry and happy," he continues. "It's important that everyone knows we may have to be patient; it may take time and additional treatment."

Rich Magda is a senior associate editor at ADVANCE.