29 March 2020: Bladder control after radical prostatectomy is difficult and confusing – and I am lucky mine is relatively good. Being away from the city reduces fear of being “caught short” by urine leaks. It gives me time to understand why it is so confusing. Why have the most simple automatic bodily functions stopped working like they used to?

It is so weird as a grown man to be perfectly fine one minute, not more than an hour since I last emptied my bladder. The next minute there is a wet patch in my pants. It feels as if the wiring from my brain to my bladder control got stolen by electric cable thieves, and whoever replaced the wires didn’t connect things up quite right.

Less shame, more play

While we are away from the city, I put myself out to play on the lawn just like we did with our kids when they were graduating from nappies. Wear light undies and if you have an accident it causes no harm and dries easily! I am also reminded of the one benefit of prostate surgery – it opens up older men’s urine streams to flow like it did when we were young.

Why bladder control is difficult after prostatectomy

Before surgery, men have two sphincters (muscular valves) to control urine flow from their bladders. The upper one (A in the diagram) is built into the prostate and the “bladder mouth” which is where the urethra connects onto the bottom of the bladder. Removing the prostate takes out that built-in sphincter and often damages the bladder mouth as well. This system is the part that normally controls urine flow for men, and is completely automatic – known as “smooth muscle.”

Comparing bladder control before and after radical prostatectomy

Edited from source: Sanjeev Sabhlok

There’s also a lower sphincter (B in the diagram) which hopefully remains after your prostate is removed. Its normal function is to open to emit sexual fluids during orgasm (while the upper one holds back urine). After surgery, all the sexual fluids have been taken out of the equation. Now this lower sphincter (B) has to stay closed as the last and only form of bladder control. It is a type of muscle that is not normally fully automated (“striated muscle”). It’s no wonder that it is so difficult to rebuild continence after radical prostatectomy surgery.

What I am busy with this month, is building up a new automatic control on that lower sphincter. I also have to retrain my brain to hold shut what used to open during sex. No wonder I am confused. No wonder I feel as if somebody rewired my valves without the proper wiring diagram.

Factors affecting recovery

Given that this is all about muscle control, I am wondering why my surgeon didn’t hook me up with a physiotherapist as a matter of routine – even though I asked him to. Ed. note: Here’s what I found out later about the huge value of pelvic floor physiotherapy.

On the other hand, he did a great surgical job – which he said was helped by my overall fitness and relatively not-so-big prostate. This made it easier to minimise damage to the bladder mouth and also to the remaining sphincter (B in the diagram above).

I am lucky get away with just a few unwanted dribbles

Many men I have spoken to are literally awash with unwanted urine for months after surgery. It is a deeply unpleasant experience to be stuck back into nappies in your 50s or 60s. I am hugely grateful that I have escaped with occasional unwanted dribbles and wet patches rather than floods. And I am lucky out here in the wilds on this retreat, where I can play like a potty-training kid on the lawn. My brain has time to rewire without being doused in shame. My body has time to adjust without nappies.

[Editor’s note: Update 6 months later]