Leaking after prostate surgery is expected
Almost every man leaks after a radical prostatectomy. Not some men. Almost all of them, at least at the start, and often heavily in the days after the catheter comes out.
That is the sentence most men tell me nobody gave them. They were told the cancer was the problem and the surgery was the fix. Then they stood up out of a chair at home, lost the lot, and had no idea whether that was ordinary or a disaster.
So here it is plainly. The leaking is not the thing that has gone wrong. Not being warned about it is. If you are reading this a fortnight after your catheter came out, you are not the man it failed for. You are the man it happens to, which is nearly all of them.
Why it happens
Continence in men is a job shared between two systems, and surgery removes one of them.
The prostate sits directly beneath the bladder, wrapped around the top of the urethra, and the internal sphincter sits in that same small piece of anatomy. That is the involuntary ring at the bladder neck that holds urine in without you ever thinking about it. When the gland comes out, that mechanism is disturbed or goes with it. Not a complication. The operation.
What is left is the external sphincter and the pelvic floor muscles around it. Those are the ones you can consciously squeeze. Before surgery they were the backup. Now they are the whole system, working in swollen, healing tissue.
Which is why leaking is worst when pressure spikes. Standing up out of a chair. Coughing. The first few steps out of bed. It is mechanical, it is expected, and it is not evidence your surgeon made a mistake.
What to expect, week by week and month by month
This is what I wish every man got before his operation rather than after. Not a promise of dryness. The honest shape of it.
The catheter usually stays in about seven to ten days, sometimes up to a fortnight, until your surgeon is satisfied the join has healed.
The first couple of days after it comes out. Your bladder and urethra are weak straight after removal, and this is usually the heaviest leaking you will do. Take the day off and have more absorbency on hand than you think you need.
The first two weeks. Still heavy and mostly outside your control. Standing, walking and coughing all set it off. This is where men quietly conclude it has failed. Two weeks is too early to judge anything.
Weeks two to six. Slow going, and the wins are small. A dry stretch on the couch. A morning where the first pad lasts longer than last week. The hardest part, because the effort is high and the reward is low.
Six weeks to three months. Usually where the real change happens. In my experience the steepest gains come after the first six weeks rather than during them, and the trajectory in the best Australian trial of pelvic floor training follows that shape. No paper states "the first six weeks are the worst" as a formal finding, so take it as my clinical observation rather than a fact.
Three to twelve months. The Prostate Cancer Foundation of Australia expects most men to be dry three to six months after surgery. Continence Health Australia (formerly the Continence Foundation of Australia) says most regain bladder control within six to twelve months, and the AUA guideline puts the ceiling at about a year.
Recovery is not a straight line, and men who expect one get demoralised. You will be drier in the morning than the evening, worse when you are tired, worse after a long day, worse for a few days after being unwell or lifting something you should not have. A good day followed by a bad day is not a relapse. It is what the graph looks like close up.
And a minority of men do not get all the way back. At a year, Australian and New Zealand registry data show most men are no longer using pads while around one in four still use at least one a day. A few men never regain full control. If that turns out to be you, it is a problem with options, further down this page.
You will also find wildly different figures online for how many men leak, because researchers define "dry" differently. Measure yourself against last month, not against them.
Before surgery: why we always recommend a pre-operative physiotherapy consultation
If you have already had your operation, skip ahead. If you are booked in, read this part.
In clinic we always recommend a pelvic floor physiotherapy consultation before prostate surgery, and PCFA recommends a minimum of one specialist visit pre-surgery too. What I want a man to have before he goes in is four things.
- The skill already in his hands - finding and holding the right contraction is a fiddly motor skill, far easier to learn while you are well and dry than while leaking, sore and frightened.
- Confirmation rather than guesswork - most men who think they are squeezing the pelvic floor are bracing the abdomen, gripping the buttocks or holding their breath. Getting it checked means you are not repeating the wrong movement a hundred times a day and calling it rehabilitation.
- A plan for the day the catheter comes out - what to do, how much, and what is normal that week. Not worked out alone on a Thursday afternoon.
- Someone to ring - which matters more than any exercise. Most of what frightens men in the first fortnight is uncertainty, and that is fixed by one phone call to someone who knows your case.
Men rarely know this beforehand: a pelvic health physiotherapist does not only work on the leaking. Bladder, bowel and erectile function all sit in the same system, and all three are part of what we rehabilitate after this operation. That is what the profession covers, not a claim that physiotherapy is proven to restore erections or settle bowels. It also means nobody has to decide alone which problems he is allowed to raise.
I know how this lands. You have just had a life-changing cancer diagnosis, you are still catching up with the word itself, and here is a physiotherapist adding bladder, bowels and erections to the list. It is completely overwhelming and I will not pretend the timing is kind. I still want you informed, because there is nothing worse than going in blind.
I want to be straight about the evidence, because it is not as tidy as I would like. Two meta-analyses of pre-operative training found an advantage at three months that had faded by six, and a third found no advantage at any time point. The AUA, GURS and SUFU guideline reflects that split: clinicians may offer pelvic floor training before surgery, a conditional recommendation rather than a strong one.
In Perth, Jo Milios and colleagues randomised 97 men who had all begun pelvic floor training five weeks before surgery, comparing a supervised programme of 120 contractions a day, done standing, against the usual advice of 30. In the higher-dose group 14% were dry at two weeks, 32% at six and 74% at twelve, against 4%, 11% and 43% on usual care. Dry meant zero grams on a 24-hour pad weight test, a far harder bar than "no more than one pad a day", which is why they read low. Both arms had pre-operative physiotherapy, so the trial never tested seeing a physiotherapist against not seeing one, and it stopped at twelve weeks. What it shows is that how the training is taught and dosed changes how quickly men get dry. That dose was supervised with fortnightly review, so it belongs in a physiotherapist's hands, not copied off a website.
So what I am offering is clinical reasoning, not proven outcome. I recommend it because a man who walks into surgery already able to contract, already checked, already holding a plan and a phone number, starts on day one instead of week three.
When to start again after surgery
Not straight away. Continence Health Australia is clear for Australian men: after prostate or urological surgery, wait until your surgeon has checked your healing. Ask at the post-operative review. Once cleared, our guide to pelvic floor exercises for men covers the contraction, the dose and how to check you are doing it right.
What pelvic floor physiotherapy does and does not do
Blossom Pelvic Health would rather tell you this than have you find it later and wonder what else we left out.
The largest trial of physiotherapy after prostate surgery did not find a benefit. MAPS recruited more than 400 UK men who were already leaking at six weeks and gave half of them four one-to-one sessions with a continence physiotherapist or nurse, the other half a lifestyle leaflet. A year later the two groups were the same. The authors concluded that where pelvic floor exercise information is already widely available, one-to-one therapy for men already incontinent after prostate surgery is unlikely to be effective or cost-effective.
That is a real result and I am not going to pretend otherwise. What it is not is a verdict on everything a physiotherapist does. MAPS tested four generic sessions offered late, as a rescue treatment, against a structured leaflet in a system where exercise information was easy to find. It did not test preparation before surgery, instruction in the first days after the catheter came out, or dose.
The guideline position is more useful. Clinicians should offer pelvic floor training in the immediate post-operative period, and what that training is understood to do is improve the time to continence rather than overall continence rates at twelve months. In plain English: it may get you there sooner, and it does not appear to make you more likely to end up dry. If a website tells you otherwise it is overselling.
What a physiotherapist adds is verification and dose. Continence Health Australia lists the reasons to be assessed in person: you cannot feel a contraction, cannot slow your stream, the exercises hurt, or nothing has changed after three weeks. Doing the wrong movement a hundred times a day is not a dose.
The part nobody prepares you for
Men are told about the cancer, the operation, the catheter, the PSA schedule. Nobody says the months afterwards can be flattening.
Low mood, anxiety, a loss of confidence, not wanting to see people, quietly rearranging your life around where the toilets are. These are common after prostate cancer treatment and talked about far too little. Men tell me they have not mentioned it to their brother, their best mate, or in some cases their wife, having decided it is not worth making a fuss about.
Finding this hard is not weakness, and it is not a sign your recovery has failed. You have had a cancer diagnosis, an operation, and a change to something private and fundamental, all inside a few months, usually while going to work and telling everyone you are fine. Of course it is heavy. It would be strange if it were not.
It is also worth telling somebody, because this is one of the few problems that gets lighter when it is said out loud. Tell your GP, who can do more than you think. Tell the Prostate Cancer Specialist Nurse if you have one, because they have had this conversation hundreds of times and will not be surprised. Tell the person you live with, even badly, even in one sentence. Tell your treating team, so mood is part of your follow-up rather than something you manage alone between appointments.
Support is available in Australia around the clock if you would rather talk to someone tonight. Lifeline is on 13 11 14 and Beyond Blue on 1300 22 4636, both 24 hours a day.
Getting through the first few months
Pads and products. PCFA's guidance covers absorbent pads shaped for male anatomy in different absorbencies, urinary sheaths draining into a leg bag, and penile clamps for temporary use only. Buy them before the catheter comes out, not on the day. Continence Health Australia also runs BINS4Blokes, putting disposal bins in public men's washrooms.
Skin. Not from a guideline, from clinic. Change pads promptly instead of stretching them out, dry properly, and ask your pharmacist about a barrier cream early rather than once the skin is raw.
Bowels. Constipation and straining work directly against a healing pelvic floor. Continence Health Australia recommends fibre from fruit, vegetables and whole grains, and straining is best avoided in early recovery.
Fluid. Do not try to leak less by drinking less. Continence Health Australia's advice is to drink enough, and to cut back on caffeine, alcohol and fizzy drinks if they are making your symptoms worse. That caffeine evidence mostly comes from people with overactive bladder rather than men after prostate surgery, so treat it as worth a try rather than a rule. Easing off fluids in the evening helps too, particularly if you are getting up repeatedly overnight.
Know your leak. Most post-operative leaking is stress leakage, the kind that happens when pressure spikes. Plenty of men get urgency as well, and stress leaks and urge leaks are different problems needing different management. If urgency dominates, bladder retraining is the better tool.
A word on clamps and erections
Some men use a compression device during the heaviest weeks, usually for specific activities rather than all day. A penile clamp works by applying slight pressure to the urethra, and peak-body guidance is explicit that clamps are for temporary use only. The Wiesner Penile Clamp is a practical aid some men choose after prostate surgery, sitting alongside pelvic floor rehabilitation rather than replacing it. Fitting, safe wear time and precautions are in our guide to penile clamps for male incontinence.
Continence and erections recover on different clocks. If that is on your mind, erectile rehabilitation after prostate surgery covers it. This post stays on the bladder.
Does the type of surgery change things?
Somewhat, and in a familiar direction. A large review of cohort studies found nerve-sparing surgery improved early continence up to about six months, with no significant difference beyond that. Nerve-sparing and pelvic floor physiotherapy do much the same thing statistically: both get men there sooner without clearly changing where they end up at a year.
Radiotherapy given after prostatectomy can take continence backwards, and continence going into it is the strongest predictor of continence afterwards. A real argument for doing the pelvic floor work properly before radiotherapy starts.
When leaking needs reviewing
Book an appointment if you cannot feel a contraction at all, cannot slow your stream, get pain when you exercise the muscles, see no improvement after three weeks of practice, or things are going backwards.
Contact your surgeon or go to hospital promptly if you cannot pass urine at all, have severe lower abdominal pain when urinating, burning at the tip of the penis beyond three days or getting worse, or blood in your urine that has not cleared after 24 hours of increased fluid.
If you are still leaking at a year
You are not out of options and you are not a failed case.
The AUA guideline says surgical options may be offered at six months if leakage persists despite conservative treatment, and should be offered at twelve months. The two procedures are an artificial urinary sphincter and a male sling.
The sphincter carries a strong recommendation for discussion across mild to severe stress incontinence, and the guideline is equally firm that you must be told it will likely lose effectiveness over time and that reoperations are common, with devices lasting around eight years on average. Male slings suit mild to moderate leakage and are not for severe incontinence. After radiotherapy, the guideline recommends the sphincter.
Have that conversation with your urologist at the twelve-month review, not years later.
Where to get help in Australia
Continence Health Australia runs the National Continence Helpline on 1800 33 00 66, free and confidential, Monday to Friday 8am to 8pm AEST. Nurse continence specialists staff it and can point you to a GP or physiotherapist. If you ring one number after reading this, make it that.
PCFA runs a national network of Prostate Cancer Specialist Nurses with a telenursing service on 1800 22 00 99 for men without a nurse locally, plus support groups in person and online. Men are often reluctant to try one and then glad they did. For a physiotherapist, PCFA points to the Australian Physiotherapy Association's find-a-physio tool. Ask for someone who works with men after prostatectomy, because not every pelvic health physio does.
The Continence Aids Payment Scheme helps with the cost of continence products, information line 1800 239 309, though the eligibility bar is permanent and severe incontinence, so most men in the first year of recovery will not qualify.
The short version
The leaking is expected. It is what the surgery does, and it is not a sign anything failed. Most men improve over three to six months, with the steepest gains after the first six weeks rather than during them, and it is uneven the whole way. Pelvic floor training may get you there sooner. The honest evidence does not support promising more.
If you are still deciding about surgery, book the pre-operative consultation. It is the one thing on this page you can do before anything happens to you. If you need support products meanwhile, our men's pelvic health range is here.
And if you are sitting at home tonight counting pads and feeling like the only man this has happened to, ring the helpline. It is free, they have heard all of it before, and you are further inside normal than you think.
