Prostate cancer

Prostate cancer - Illnesses & conditions | NHS inform Home Illnesses and conditions Symptoms and self-help Tests and treatments Healthy living Care, support and rights Scotlands Service Directory 0 Home Illnesses and conditions Cancer Cancer types in adults Prostate cancer Prostate cancer About prostate cancer Symptoms of prostate cancer Causes of prostate cancer Diagnosing prostate cancer Testing for prostate cancer Treating prostate cancer Living with prostate cancer About prostate cancer Prostate cancer is the most common cancer in men and anyone with a prostate in the UK. Prostate cancer usually develops slowly, so there may be no signs you have it for many years. Symptoms often only become apparent when your prostate is large enough to affect the urethra (the tube that carries urine from the bladder to the penis). When this happens, you may notice things like an increased need to urinate, straining while urinating and a feeling that your bladder has not fully emptied. These symptoms shouldnt be ignored, but they do not mean you definitely have prostate cancer. It is more likely that they are caused by something else, such as benign prostatic hyperplasia (also known as BPH or prostate enlargement ). Read more about the symptoms ofprostate cancer What is the prostate? The prostate is a small gland in the pelvis. About the size of a satsuma, its located between the penis and the bladder andsurrounds the urethra. The main function of the prostate is to help in the production of semen. It produces a thick white fluid that is mixed with the sperm produced by the testicles, to create semen. Why does prostate cancer happen? The causes of prostate cancer are largely unknown. However, certain thingscan increase your risk of developing the condition. The chances of developing prostate cancer increase as you get older. Most cases develop in men and anyone with a prostate aged 50 or older. For reasons not yet understood, prostate cancer is more common in men and anyone with a prostate of African-Caribbean African descent. Its less common in men and anyone with a prostate of Asian descent. Men and anyone with a prostate who havefirst-degreemale relatives (such as a father or brother) affected by prostate cancer are also at a slightly increased risk. Read more about the causes of prostate cancer Tests for prostate cancer There is no single test for prostate cancer. All the tests used to help diagnose the condition have benefits and risks, which your doctor should discuss with you. The most commonly used tests for prostate cancer are blood tests , a physical examination of your prostate (known as a digital rectal examination or DRE ) and a biopsy . The blood test, known as aprostate-specific antigen (PSA) test, measures the level of PSA and may help detect early prostate cancer. Men and anyone with a prostate are not routinely offered PSA tests to screen for prostate cancer, as results can be unreliable. This is because the PSA blood test is not specific to prostate cancer. PSA can be raised due to a large non-cancerous growth of the prostate (BPH), a urinary tract infection or inflammation of the prostate, as well as prostate cancer. Raised PSA levels also cannot tell a doctor whether a man has life-threatening prostate cancer or not. This means a raised PSA can lead to unnecessary tests and treatment. However, you can ask to be tested for prostate cancer once the benefits and risks have been explained to you. Read more about diagnosing prostate cancer and PSA screening for prostate cancer How is prostate cancer treated? In many cases,treatment is not immediately necessary. If the cancer is at an early stage andnot causing symptoms, a policy of watchful waiting or active surveillance may be adopted. This involves carefully monitoring your condition. Some cases of prostate cancer can be cured if treated in the early stages. Treatments include surgically removing the prostate, radiotherapy and hormone therapy. Some cases are only diagnosed at a later stage when the cancer has spread. If the cancer spreads to other parts of the body, typically the bones, it cannot be cured and treatment is focused on prolonging life and relieving symptoms. All treatment options carry the risk of significant side effects, including erectile dysfunction and urinary incontinence . For this reason, many people choose to delay treatment until there is a risk the cancer might spread. Newer treatments,such ashigh-intensity focused ultrasound (HIFU)or cryotherapy, aim to reduce these side effects.Some hospitals may offer them as an alternative to surgery, radiotherapy or hormone therapy. However, the long-term effectiveness of these treatments are not yet known. Read more about treating prostate cancer Living with prostate cancer Asprostate cancer usually progresses very slowly, you can live for decades without symptoms or needing treatment. Nevertheless, it can have an effect on your life. As well as causing physical problems such as erectile dysfunction and urinary incontinence , a diagnosis of prostate cancer can understandably make you feel anxious or depressed . You may find it beneficial to talk about the condition with your family, friends, a family doctor and other people with prostate cancer. Financial support is also available if prostate cancer reduces your ability to work. Read more about living with prostate cancer Symptoms of prostate cancer Prostate cancer does not normally cause symptoms until the cancer has grown large enough to put pressure on the urethra. This normally results in problems associated with urination. Symptoms can include: needing to urinate more frequently, often during the night needing to rush to the toilet difficulty in starting to pee (hesitancy) straining or taking a long time while urinating weak flow feeling that your bladder has not emptied fully Your prostate mayget larger as you get older due to a non-cancerous condition known as prostate enlargement or benign prostatic hyperplasia. Symptoms that the cancer may have spread include bone and back pain, a loss of appetite, pain in the testicles and unexplained weight loss. Read further information: Cancer Research UK: prostate cancer symptoms Causes of prostate cancer Its not known exactly what causes prostate cancer, although a number of things can increase your risk of developing the condition. These include: age  riskrises as you get older andmost cases are diagnosed inmen and anyone with a prostate over 50 years of age ethnic group  prostate cancer is more common among men and anyone with a prostate of African-Caribbean and African descent thanin men and anyone with a prostate of Asian descent family history  having a brother or father who developed prostate cancer under the age of 60 seems to increase the risk of you developing it; having a close female relative who developed breast cancer may also increase your risk of developingprostate cancer obesity  there may be a link between obesity and prostate cancer exercise  men and anyone with a prostate who regularly exercises have also been found to be at lower risk of developing prostate cancer diet  research is ongoing into the links between diet and prostate cancer; a diet high in calcium is linked to an increased risk of developing prostate cancer In addition, some research has shown that prostate cancer rates appear to be lower inmen and anyone with a prostate who eat foods containing certain nutrients including lycopene, found in cooked tomatoes and other red fruit, and selenium, found in brazil nuts. However, more research is needed. Read further information: Prostate Cancer UK: who is at risk of prostate cancer Cancer Research UK: prostate cancer risks and causes Diagnosing prostate cancer If you have symptoms that could be caused by prostate cancer, you should visit your GP. There is no single, definitive test for prostate cancer, so your GPwill discuss the pros and cons of the various tests with you to try to avoid unnecessary anxiety. Your doctor is likely to: ask for a urine sample to check for infection take ablood sample to test your level of prostate-specific antigen (PSA) examine your prostate ( digital rectal examination ) In 2015, the National Institute for Health and Care Excellence ( NICE ) published guidelines to help GPs recognise the signs and symptoms of prostate cancer and refer people for the right tests faster. To find out if you should be referred for further tests for suspected prostate cancer, read the NICE 2015 guidelines on Suspected Cancer: Recognition and Referral . PSA testing PSA is a protein produced by the prostate gland. All men and anyone with a prostate have a small amount of PSA in their blood, and it increases with age. Prostate cancer can increase the production of PSA, and so a PSA test looks for raised levels of PSA in the blood that maybe a sign of the conditionin its early stages. However, PSA testing is not a specific test for prostate cancer. Most men and anyone with a prostate who has prostate cancer will not have a raised PSA level. Most peoplewith a raised PSA level will not have cancer, as PSA levels rise in all men and anyone with a prostate as they get older. Read more about PSA screening for prostate cancer Digital rectal examination (DRE) The next step is a DRE, which can be done by your GP. During a DRE, your GP will insert a lubricated and gloved finger into your rectum. The rectum is close to your prostate gland, so your GP can check to feel if the surface of the gland has changed. This will feel a little uncomfortable, but should not be painful. Prostate cancer can make the glandhard and bumpy. However, in most cases, the cancer causes no changes to the gland and a DRE may not be able to detect the cancer. DRE is useful in ruling out prostate enlargement caused by benign prostatic hyperplasia, as this causes the gland to feel firm and smooth. Biopsy Your GP will assess your risk of having prostate cancer based on a number of factors, including your PSA levels, the results of your DRE, and your age, family history and ethnic group. If you are at risk, youshould be referred to hospital to discuss the options of further tests. The most commonly used test is a transrectal ultrasound-guided biopsy (TRUS). A biopsy may also be taken during a cystoscopy examination or through the skin behind the testicles (perineum). During a TRUS biopsy, an ultrasound probe (a machine that uses sound waves to build a picture of the inside of your body) is inserted into your rectum. This allows the doctor or specialist nurse to see exactly where to pass a needle through the wall of your rectum to take small samples of tissue from your prostate. The procedure can be uncomfortable and sometimes painful, so you may be given a local anaesthetic to minimise any discomfort. As with any procedure, there may be complications, including bleeding and infection. Although it is more reliable than a PSA test, the TRUS biopsycan haveproblems. It can miss up to 1 in 5 cancers, because the location of the cancer is unknown when it is carried out. The doctors can see the prostate using the ultrasound scan, but not the tumour(s) if they are present. You may need another biopsy if your symptoms persist, or your PSA level continues to rise. Your doctor mayrequest an MRI scan of the prostate before another biopsy. The TRUS biopsy can also find small low-risk cancers that do not need treatment, but may cause you anxiety. Many people often choose to undergo surgery or radiotherapy that may not benefit them but causes side effects, such as incontinence and erectile dysfunction . The samples of tissue from the biopsy are studied in a laboratory. If cancerous cells are found, they can be studied further to see how quickly the cancer will spread. This process is known as staging and grading and helps doctors to decide which treatment is the most appropriate. Read further information: Cancer Research UK: the stages of prostate cancer Macmillan: grading and staging of prostate cancer Further testing If there is a significant chancethe cancer has spread from your prostate to other parts of the body, further tests may be recommended. These include: a magnetic resonance imaging (MRI) or computerised tomography (CT) scan  these scans build a detailed picture of the inside of your body an isotope bone scan  this can tell if the cancer has spread to your bones; a small amount of radiation dye is injected into the vein andcollects in parts of the bone where there are any abnormalities Read further information: Cancer Research UK: prostate cancer tests Testing for prostate cancer There is currently no screening programme for prostate cancer in the UK. This is because it has not been proved that the benefits would outweigh the risks. PSA screening Routinely screening all men and anyone with a prostate to check their prostate-specific antigen (PSA) levels is a controversial subject in the international medical community. There are several reasons for this: PSA tests are unreliable and can suggest prostate cancer when no cancer exists (a false-positive result)  this means that many men often have invasive and sometimes painful biopsies for no reason the PSA test can find aggressive prostate cancer that needs treatment, but it can also find slow-growing cancer that may never cause symptoms or shorten lifesome men and anyone with a prostate may therefore face difficult decisions about treatment treating prostate cancer in its early stages can be beneficial in some cases but theside effects of the various treatments are potentially so serious that men may choose to delay treatment until it is absolutely necessary although screening has been shown to reduce a mans chance of dying from prostate cancer, it would mean many people receive treatment unnecessarily More research is needed to determine whether a screening programme would provide men and anyone with a prostate with more benefit than harm. One European study showed deaths from prostate cancer could be reduced by 20% if there was a screening programme, but this needs to be balanced against the harms of: overdiagnosis people being diagnosed with a cancerthat will never cause symptoms or death during their lifetime overtreatment people being treated unnecessarily for tumours that would beunlikely tobe harmful Improving the test As there are many reasons why PSA levels may be high at any one time, researchers are trying to make the PSA test, or a variation of it, more accurate. This includes looking at how PSA levels change over time and comparing the PSA level to prostate size. Researchers are also looking at whether new imaging tests, such as MRI scans, or other blood and urine tests, can be used to decide which people with an elevated PSA should have a biopsy. Instead of a national screening programme, there is an informed choice programme called prostate cancer risk management for healthy men and anyone with a prostate aged 50 or over who ask their GP about PSA testing. It aims to give men and anyone with a prostate good information on the pros and cons of a PSA test. If youre aged50 or over with a prostate and decide to have your PSA levels tested after talking to your GP, theywill be able to arrange for it to be carried out for free on the NHS. If results show you have araised level of PSA, your GP may suggest further tests. Should I have a PSA test? Because the results of the PSA test are not as reliable as doctors would like, other tests and investigations are needed to diagnose prostate cancer. A PSA test cannot identify prostate cancer on its own, and changes in PSA levels alone are not a good reason to start treatment. If you are thinking about asking for a PSA test, it is important that you first discuss whether it is right for youwith your GP so you understand what the results might mean. The Prostate Cancer Risk Management Programme has information on the risks and benefits of the PSA test to help you decide whether or not to have it. Treating prostate cancer Staging of prostate cancer Doctors will use the results of your prostate examination, biopsy and scans to identify thestage of your prostate cancer (how far the cancer has spread). The stage of the cancer will determine which types of treatments will be necessary. A widely used method of staging isanumber staging system. The stages are: stage 1  the cancer is very small and completely within the prostate gland stage 2  the cancer is within the prostate gland, but is larger stage 3  the cancer has spread from the prostate and may have grown into the tubes that carry semen stage 4  the cancer has spread into the lymph nodes or another part of the body, including the bladder, rectum or bones; about 20 to 30% of cases are diagnosed at this stage If prostate cancer is diagnosed at an early stage, the chances of survival are generally good. Read further information: Cancer Research UK: the stages of prostate cancer Watchful waiting Watchful waitingis often recommended for older men and anyone with a prostate when it is unlikely that the cancerwill affect your natural life span. If the cancer is in its early stages and not causing symptoms, you may decide to delay treatment, and wait to see if any symptoms of progressive cancer develop. If this happens, pain medication and hormone medication to control prostate cancer are usually used. Watchful waiting may also be recommended for people with a higher risk of prostate cancer if: your general health means you are unable to receiveany form of treatment your life expectancy means you will die with the cancer rather than from it In this case, hormone treatment may be started if there are symptoms caused by the prostate cancer. Active surveillance Active surveillance aims to avoid unnecessary treatment of harmless cancers, while still providing timely treatment for men and anyone with a prostate who needs it. When they are diagnosed, around half to two-thirds of men and anyone with a prostate with low-risk prostate cancer do not needtreatment. Surveillance is a safe strategy that provides a period of observation to gather extra information over time to see whether the disease is changing. Active surveillance involves you having regular PSA tests andoften severalbiopsies to ensureany signs of progression are found as early as possible. Sometimes, MRI scans may also be carried out. If these tests reveal the cancer is changing or progressing,you can then make a decision about further treatment. About 1 in 3 people who undergo surveillance will later have treatment. This does not mean they made the wrong initial decision. Good evidence showsthat active surveillance is safe over an average of 6 years. Men undergoing active surveillancewill have delayed any treatment-related side effects, and those who eventually need treatmentwill be reassuredthat it was necessary. Radical prostatectomy A radical prostatectomy is the surgical removal of your prostate gland. This treatment is an option for curing localised prostate cancer and locally-advanced prostate cancer. Like any operation, this surgery carries some risks, and there may be some side effects: some people have problems with urinary incontinence  t his can range from leaking small drips of urine, to leaking larger amounts but this usually clears up within 3 to 6 months of the operation some men have problems getting an erection ( erectile dysfunction )  t his sometimes improves with time, but around half will have long-term problems in extremely rare cases, problems arising after surgery can be fatal For many men and anyone with a prostate, having a radical prostatectomy will get rid of the cancer cells. However, for around 1 in 3 people, the cancer cells may not be fully removed, and the cancer cells may return sometime after the operation. Radiotherapy after prostate removal surgery may increase the chances of a cure, although research is still being carried out into when it should be used after surgery. After a radical prostatectomy, you will no longer ejaculate during sex. This meansthat you will not be able to have a child through sexual intercourse. You may want to ask your doctors about storing a sperm sample before the operation, soit can be used later for in vitro fertilisation (IVF). Read further information: Macmillan: surgery for early prostate cancer Radiotherapy Radiotherapy involves using radiation to kill cancerous cells. This treatment is an option for curing localised prostate cancer and locally-advanced prostate cancer. Radiotherapy can also be used to slow the progression of metastatic prostate cancer and relieve symptoms. Radiotherapy is normally given as an outpatient at a hospital near you. It is done in short sessions for 5 days a week, for 4 to 8 weeks. There are short-term and long-term side effects associated with radiotherapy. You may receive hormone therapy before undergoing radiotherapy to increase the chance of successful treatment. Hormone therapy may also be recommended after radiotherapy to reduce the chances of cancerous cells returning. Short-term effects of radiotherapy can include: discomfort around the rectum and anus (the opening through which stools pass out of your body) diarrhoea loss of pubic hair tiredness cystitis  an inflammation of the bladder lining, which can cause you to urinate frequently; urination may be painful Possible long-term side effects can include: an inability to obtain an erection urinary incontinence back passage problems (diarrhoea, bleeding, discomfort) As with radical prostatectomy, there is a 1 in3 chance the cancer will return. In these cases, medication is usually used to control the cancer instead of surgery. This is because there is a higher risk of complications from surgery in men and anyone with a prostate who have previously had radiotherapy. Some hospitals now offer new minimally invasive treatments if radiotherapy fails to work, sometimesas part of a clinicaltrial. These new treatments are called high-intensity focused ultrasound (HIFU) and cryotherapy. These treatments have fewer side effects, but the long-term outcomes are not yet known. Read further information: Macmillan: radiotherapy for early prostate cancer Brachytherapy Brachytherapy is a form of radiotherapy where the radiation dose is delivered inside the prostate gland. It is also known as internal or interstitial radiotherapy. The radiation can be delivered using a number of tiny radioactive seeds that are surgically implanted into the tumour. This is called low dose-rate brachytherapy. The radiation can also be delivered through hollow, thin needles placed inside the prostate. This is called high dose-rate brachytherapy. This method has the advantage of delivering a high dose of radiation to the prostate, while minimising damage to other tissues. However, the risk of sexual dysfunction and urinary problems is the same as with radiotherapy, although the risk of bowel problems is slightly lower. Read further information: Cancer Research UK: internal radiotherapy (brachytherapy) for prostate cancer Hormone therapy Hormone therapy is often used in combination with radiotherapy. For example, you may receive hormone therapy before undergoing radiotherapy to increase the chance of a successful treatment. Hormone therapy may also be recommended after radiotherapy to reduce the chances of cancerous cells returning. Hormone therapy alone should not normally be used to treatlocalised prostate cancer inpeople who are fit and willing to receive surgery or radiotherapy. This is because it does not cure the cancer on its own.Hormone therapycan be used to slow the progression of advanced prostate cancer and relieve symptoms. Hormones control the growth of cells in the prostate. In particular, prostate cancer needs the hormone testosterone to grow. The purpose of hormone therapy is to block the effects of testosterone, either by stopping its production or by stopping your body being able to use testosterone. Hormone therapy can be given as: injections to stop your body making testosterone, called luteinising hormone-releasing hormone (LHRH) agonists tablets to block the effects or reduce the production of testosterone, called anti-androgen treatment combined LHRH and anti-androgen treatment The main side effects of hormone treatment are caused by their effects on testosterone. They usually go away when treatment stops. They includeloss of sex drive and erectile dysfunction (this is more common with LHRH agonists than anti-androgens). Other possible side effects include: hot flushes sweating weight gain swelling and tenderness of the breasts An alternative to hormone therapy is to surgically remove the testicles, called orchidectomy. The operation does not cure prostate cancer, but by removing the testosterone, it controls the growth of the cancer and its symptoms. Read further information: Cancer Research UK: hormone therapy for prostate cancer Trans-urethral resection of the prostate (TURP) DuringTURP, athin metal wire with a loop at the end is inserted into your urethra (the tube that carries urine from your bladder to your penis) and pieces of the prostate are removed. This is carried out under general anaesthetic or a spinal anaesthetic (epidural). This is done to relieve pressure from the urethra to treat any problematic symptoms you may have with urination. It does not cure the cancer. Read more information about transurethral resection of the prostate (TURP) . High intensity focused ultrasound (HIFU) HIFU is sometimes used to treat men and anyone with a prostate with localised prostate cancer that has not spread beyond their prostate. An ultrasound probeinserted into the rectum releases high-frequency sound waves through the wall of the rectum. These sound waves kill cancer cells in the prostate gland by heating them to a high temperature. The risk of side effectsfrom HIFUisusually lower than other treatments. However, possible effects can include impotence (in 5 to 10 in every 100) or urinary incontinence (in less than 1 in every 100). Back passage problems are rare. Fistulas (an abnormal channel between the urinary system and rectum) are also rare, affecting less than 1 in every 500. This is because the treatment targets the cancer area only and not the whole prostate. However, HIFU treatment is still going through clinical trials for prostate cancer.In some cases, doctors can carry out HIFU treatment outside of clinical trials. HIFU is not widely available and its long-term effectiveness has not yet been conclusively proven. Read further information: Cancer Research UK: high intensity focused ultrasound (HIFU) for prostate cancer Cryotherapy Cryotherapy is a method of killing cancer cells by freezing them. It is sometimes used to treat men and anyone with a prostate with localised prostate cancer that has not spread beyond their prostate gland. Tiny probes called cryoneedles are inserted into the prostate gland through the wall of the rectum. They freeze the prostate gland and kill the cancer cells, but some normal cells also die. The aim is to kill cancer cells while causing as little damage as possible to healthy cells. The side effects of cryotherapy can include: erectile dysfunction  this can affect between 2 and 9 in every 10 incontinence  this affects less than 1 in 20 It is rare for cryotherapy to causerectal problems or fistulas. Cryotherapyis still undergoing clinical trials for prostate cancer. In some cases, doctors can carry out cryotherapy treatment outside of clinical trials.Itis not widely availableand its long-term effectiveness has not yet been conclusively proven. Treating advanced prostate cancer If the cancer has reached an advanced stage, it is no longer possible to cure it. However, it may be possible to slow its progression, prolong your life and relieve symptoms. Treatment options include: radiotherapy hormone treatment chemotherapy If the cancer has spread to your bones, medicines called bisphosphonates may be used. Bisphosphonates help reduce bone pain and bone loss. Chemotherapy Chemotherapy is mainly used to treat prostate cancer that has spread to other parts of the body (metastatic prostate cancer) and which is not responding to hormone therapy. Chemotherapy destroys cancer cells by interfering with the way they multiply. Chemotherapy does not cure prostate cancer, but can keep it under control and reduce symptoms (such as pain) so everyday life is less affected. The main side effects of chemotherapy are caused by their effects on healthy cells, such as immune cells. They include infections, tiredness, hair loss, sore mouth, loss of appetite, nausea and vomiting. Many of these side effects can be prevented or controlled with other medicines, which your doctor can prescribe for you. Steroids Steroid tablets are used when hormone therapy no longer works because the cancer is resistant to it. This is called hormone-refractory cancer. Steroids can be used to try to shrink the tumour and stop it from growing. The most effective steroid treatment is dexamethasone. Other medical treatments There are a number of new medications that could be used if hormones and chemotherapy fail. Your medical teamcan tell you if these are suitable and available for you. NICE has recently issued guidance on medications called abiraterone andenzalutamide. Read the NICE guidelines on: enzalutamide for metastatic hormone-relapsed prostate cancer previously treated with docetaxel abiraterone for castration-resistant metastatic prostate cancer previously treated with a docetaxel-containing regimen Deciding against treatment As many of the treatments above have unpleasant side effects that can affect your quality of life, you may decide against treatment. This may be especially true if you are at an age when you feel that treating the cancer is unlikely to significantly extend your life expectancy. This is entirely your decision, and your MDT will respect it. If you decide not to have treatment, your GP and hospital team will still give you support and pain relief. This is called palliative care . Support is also available for your family and friends. Living with prostate cancer Impact on everyday activities If you have no symptoms, prostate cancer should have little or no effect on your everyday activities. You should be able to work, care for your family, carry on your usual social and leisure activities, and look after yourself. However, you may be understandably worried about your future. This may make you feel anxious or depressed ,and affect your sleep. If your prostate cancer progresses, you may not feel well enough to do all the things you used to. After an operation or other treatment, such as radiotherapy or chemotherapy, you will probably feel tired and need time to recover. If you have advanced prostate cancer that has spread to other parts of your body, you may have symptoms that slow you down and make it difficult to do things. You may have to reduce your working hours or stop working altogether. Whatever stage your prostate cancer has reached, try to give yourself time to do the things you enjoy and spend time with those who care about you. Read further information: Cancer Research UK: coping with prostate cancer Complications of prostate cancer Erection problems If you have erectile dysfunction , speak to your GP. It may be possible to treat you with a type of medicine known as phosphodiesterase type 5 inhibitors (PDE5). PDE5s work by increasing the blood supply to your penis. The most commonly used PDE5 is sildenafil (Viagra). Other PDE5s are available if sildenafil is not effective. Another alternative is a device called a vacuum pump. It is a simple tube connected to a pump. You place your penis in the tube and then pump out all the air. This creates a vacuum, which causes the blood to rush to your penis. You then place a rubber ring around the base of your penis. This keeps the blood in place and allows you to maintain an erection for around 30 minutes. Urinary incontinence If your urinary incontinence is mild, you may be able to control it by learning some simple exercises. Pelvic floor exercises can strengthen your control over your bladder. To carry out pelvic floor exercises: Sit or lie comfortably with your knees slightly apart. Squeeze or lift at the front as if you were trying to stop the passage of urine, then squeeze or lift at the back as if you were trying to stop the passage of wind. Hold this contraction for as long as you can (at least 2 seconds, increasing up to 10 as you improve). Relax for the same amount of time before repeating. If your urinary incontinence is more severe, it may be possible to treat it with surgery. This would involve implanting