Penile pain/urethral discomfort after radical prostatectomy

It comes as no surprise that there is some urethral “discomfort” experienced by patients with an indwelling urethral catheter after a radical prostatectomy (regardless of the type of surgery), and that for some patients there can be a degree of significant penile pain until the catheter is removed (usually within about 8 to 10 days).

The seriousness of the urethral discomfort and the penile pain seem to vary considerably from patient to patient, but neither of these are issues that we hear about often from patients (by comparison with the general irritations associated with having to deal with an indwelling catheter and the attached urine collection bag).

Weinberg et al. have now reported data from a small, randomized, double-blind trial designed to see whether they could alleviate this urethral catheter-association pain with a single injection of a drug known as bupivacaine, which acts as a dorsal penile nerve blocker.

Between 2012 and 2013, Weinberg and his colleagues enrolled a total of 140 patients as participants in this trial. All patients had been diagnosed with localized prostate cancer and were scheduled to undergo a robot-assisted laparoscopic radical prostatectomy (RALP) at the Columbia University Medical Center in New York. All the procedures were carried out by the same surgeon. The patients were randomized to receive a single intrapenile injection of bupivacaine or a single injection of a placebo (a simple saline solution) at the completion of their surgical procedure (while they were still under anesthesia).

Patients were asked to complete validated pain rating questionnaires while hospitalized post-surgery and for 9 days post-operatively, until the catheter was removed. Primary study end-points included catheter-related discomfort, abdominal (incisional) pain, and bladder spasm-related discomfort.

Here are the key study findings reported by Weinberg et al.:

  • Of the 140 patients initially enrolled in the trial
    • 120 were actually randomized to receive either bupivacaine or a placebo.
    • 116/120 provided data appropriate for evaluation.
    • 56/116 (48 percent) evaluable patients were randomized to receive a bupivacaine injection.
    • 60/116 (52 percent) evaluable patients were randomized to receive an injection of the placebo.
  • The evaluable patients in the two arms of the trial did not differ in terms of their preoperative characteristics, the perioperative outcomes (what happened during their surgery), or the subsequent pathologic findings.
  • At 6 hours post-surgery, there was a slightly lower level of abdominal pain among patients randomized to the bupivacaine arm of the trial (compared to those randomized to the placebo)
  • There was no difference in abdominal pain between men in the two arms of the trial at any other time point.
  • There were no differences in catheter-related discomfort or bladder spasm-associated discomfort at any of the measured time points.
  • There was no difference in narcotic utilization between the men in the two arms of the trial.

The authors conclude that their results do not justify “the routine use of a dorsal penile nerve block with bupivacaine” following a RALP.

Of course it may well be that for some patients, with relatively unusual, individual, anatomical or clinical characteristics, some form of penile nerve blockade may be appropriate to prevent penile pain post-surgery. But Weinberg et al. seem to have been able to show that such nerve blockade is of no significant value for the majority of “routine” patients.

15 Responses

  1. I had mine taken out at 7 days. After 3 days I was itchy and everything down there was irritated. Desitin and powder and frequent washing had some relieving effect but not much. On the morning of the 7th day I was about to rip the damn thing out. Good thing I didn’t. I had no idea that there was this small inflated balloon in there that prevented the catheter from falling out. No idea at all. Thank God I didn’t just pull harder.

  2. Dear GW:

    Trust me. If you’d pulled harder you would very quickly have stopped because of the pain!

  3. Mike, I was just told that one of the reasons for robotic surgery side effects is because they surgeon must move then reattach the nerve bundle during the surgery. Is that right?

  4. Jim:

    When one carries out any nerve-sparing procedure, the process of separating and lifting the nerve bundles on each side away from the prostate itself is a critical and delicate part of the operation, and it is far from easy to do well. Over the years, different surgeons have developed all sorts of technical tricks that they use to help them do this as well as they can. However, as far as I know there is no requirement to “re-attach” the nerve bundle to anything after the procedure.

    While different tricks to do this particular maneuver may be possible using robot-assisted and “open” (non-robot-assisted) forms of surgery, I am also not aware that the general principles are affected by whether surgery is carried out with or without a robot.

    I think there are probably 1,000 different videos available on Youtube now showing slightly different techniques for the conduct of a neve-sparing radical prostatectomy. Most of these videos (frankly) are meaningless to anyone but another prostate cancer surgeon.

  5. Good nursing care makes all the difference in living with an in-dwelling catheter. Information originating in Australia is by far the best. Chuck Maack has made a very helpful pdf.

  6. I read some these results from a so-called specialist. I can tell you I had my catheter in for 4 weeks along with the drain for 2 weeks. I had pain in my lower abdomen for months after my robotic radical surgery. I am 2 years after my surgery and I still get abdominal pain on my right side, heavy leakage with max absorbence Depends and now I I have been given a penis clamp.

    So, all you men out there, stay away from robotic surgery. My surgery was 12 hours and added many new risks!

  7. A common symptom of prostatitis is pain referred to the tip of the penis. It seems logical that if the proximal urethra, which has just been resected and reattached would be extremely sensitive to the presence of the catheter, with pain being referred to the more distal urethra. Hence nerve block of the dorsal penile nerve would not be expected to reduce the pain.

  8. Three years after radical prostatectomy and radiation I feel discomfort, itching, burning urethra. Urge to urinate especially at night. What can I use to cure the above problems

  9. Dear Ferdinand

    That is a question you are going to have to ask your urologist about because there could be all sorts of possible reasons for these symptoms. It may not be possible to “cure” these symptoms completely, but it should be possible to alleviate at least some of them to a significant extent.

  10. I did indeed experience shortened penis after my prostatectomy. I was small to begin with but now it seems to pull back almost inside me. I asked my surgeon but he said he didn’t pull it inward to reattach the urethra but that is what it feels like, Yes, at 75, nerves were not reattached.

  11. The worst pain I had post prostetectomy (combined with abdominal hernia repair surgery) was due to the Foley catheter. Three weeks post catheter removal I was still experiencing significant penis tip and some bilateral shaft burning sensation/pain with a hardening of the distal urethra (without UT infection).

  12. I have never been well endowed size-wise and pre-prostatectomy ED didn’t help as it limited erectile expansion. Now, post-prostatectomy (with no ability for erection) my penis appears to be even smaller — whether it actually is … or not.

    Being concerned with penile atrophy (don’t use it you lose it syndrome) I bought a pump and and am using it regularly, twice daily, until I can obtain an implant thus reviving my erectile capability.

  13. Hi I had prostatectomy 9/28/21. Unfortunately I am experiencing pain and burning in my penis during urination and other times also. Anyone else have this and if so what did you do to relieve pain?

  14. John:

    You really need to discuss this with your doctors. One possible reason for this pain and burning sensation is that you have an infection of the urinary tract that has nothing to do with your prostatectomy. However, it is also possible that this is something to do with the outcome of your prostatectomy. There is no way that anyone on this forum could tell you — with accuracy — what you should do to relieve your specific problem based on their experience. The first thing that needs to happen is that the cause of the problem needs to be identified.

  15. I had robot-assisted surgery, which apparently is less invasive [compared to open surgery], After the operation, 10 days with a catheter; when removed (relief) a few leaks and used tenor pads. Five months later, I stopped using pads and had more and more control.

    The one thing you can’t get away from is, hopefully, after removal of the prostate the cancer has gone. I am checked every 12 weeks and my PSA is undetectable. Good luck to all.

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