… It’s Not as Easy as What You Got at Age Two:
(draft) 2015, Davd
Did anybody yet warn you, that if you get radiation to the pelvic region—as most prostate cancer patients do—you have to go through Special Toilet Training? That “not going in your underwear”, which has been “good enough” ever since you were two years old, is no longer good enough?
Nobody told me, when i was first told to expect pelvic radiation beam therapy, that it would include an exacting, difficult bowel and bladder discipline. Perhaps someone should have, and perhaps there should be a “toilet training course” for men scheduled to receive radiation beams to the pelvic area1. We’re better able to learn than we were at age two; but this special toilet training is more difficult than the toddler version.
Basic toilet training has one principal purpose: Don’t mess your underwear (or any other clothing). That’s not good enough for pelvic radiation therapy. When you’re flat on your back on that strange plastic table, getting zapped—you won’t be wearing underpants (and no, they don’t welcome soiling the table!)—but the important new purpose of Special Toilet Training, is to put you on that table every appointment, with empty bowels and a full bladder.
The radiation beams [X-rays] can damage any tissue, though i read somewhere that they damage cancer cells more than normal cells. If the bladder is full it “stands up away” from the prostate; if the bowels are empty they sag down away from the prostate. Less radiation hits a full bladder or an empty bowel; that’s why the protocol demands you arrive with empty bowels and a full bladder—which combination, unfortunately, is unnatural.
Basic Toilet Training taught you (and other little boys) to go ahead and empty the both of them, every time you sat on the toilet—and to sit rather than stand, if in doubt, so you could empty them both. If you’ve ever tried to do only one while “holding” the other, you probably found it was very difficult—maybe impossible.
So while Basic Toilet Training works with nature to that extent, and amounts to knowing when you “have to go” and getting to a toilet to “go in”; Special Toilet Training works somewhat against nature: Empty bowels, full bladder, at the same time (but not, unless you are lucky, the same time of day each day2) goes against the natural tendency to empty both at once. Empty your bowels, and the bladder will naturally empty also; don’t empty your bladder, and the bowels might be too full and at risk of more radiation damage.
Being told to arrive at every appointment, with empty bowels and a full bladder, then, is not enough—no more than telling you to start doing it only in the potty, would have been enough for most two year olds. Toddlers don’t naturally take their excretory urges to the nearest potty: Toddler toilet training amounts to showing the child how to “do it only in the potty” (but accepts that if both bladder and bowels are ready to be emptied, it’s completely O.K. to empty both at one sitting.) You are being told to do something unnatural for radiation treatment, but unlike when you were two, not really shown how… and the directions arrive later than some fellow patients and their next of kin, believed they should.
One woman sitting in one of those waiting rooms, said quite sincerely that she believes you should begin practicing bladder control at least a month before your first radiation treatment. I don’t know if she was referring to her own experience or that of a male patient she knew, but that “month before” is consistent with technicians finding many patients arriving for treatments early in the series with bladders not full enough, (and a significant number with bowels not empty enough.)
The blue half page handout i received gives some general directions which are helpful but not enough to guarantee “empty bowels and a comfortably full bladder” every time:
‣ Take a laxative [“Milk of Magnesia”] every night at bedtime;
‣ Sit down and “have a bowel movement” at least one hour before the scheduled treatment;
‣ empty your bladder exactly one hour before the scheduled treatment;
‣ Quickly drink one half litre of water immediately after emptying your bladder.
‣ Do not empty your bladder again until treatment is over (and there may be times when treatment begins late.)
Easier said than done: Taking the laxative is easy enough, but as the handout itself admits, the amount to take isn’t the same for everyone. “Having a bowel movement” 1-3 hours before appointments that aren’t even the same time each day2, can be difficult or impossible. Exercise before sitting on the toilet can help, but it’s not certain to work for every man. The tendency, from limited comments i heard and my own experience, is to aim for “softer movements” than one would want otherwise. Maybe there’s a better way—but how many men will find it in a few weeks of 5-daily radiation treatments?
Emptying your bladder exactly one hour before treatment is not that difficult to do—unless perhaps you go to treatment by bus and have to head to the bus stop more than an hour before that treatment time. (Go ahead, have a laugh—imagine emptying your bladder on a bus—but i doubt many readers will actually do that.)
Drinking half a litre of water may take more than a minute or two, but within ten minutes you can probably comply with that demand. Trouble is, an hour may be too long, especially if you drink a lot of water, juice, tea … if you are normally “well hydrated.” For years, maybe decades, i’ve normally had 2-4 litres each day mostly of mild tea with Vitamin C and orange peel, but also including water, coffee, juice, sometimes even beer,. That meant that my bladder would fill in more like a half hour than a whole hour, if i drank that half litre of water. 3
The fact that i like coffee with my breakfast might also have been an influence. Coffee probably did make it easier for me to arrive at treatment “with empty bowels.”
I’m only one man, and i don’t know how men generally “feel the fullness of their bladders.” The feeling and the words used for it—among those few men who even talk about the fullness of their bladders before being told they must pay special attention—probably vary from man to man, and plausibly, even more between men and women4. (I found that in the early weeks, if my bladder was uncomfortably full, the technicians were happier with its condition, than if i had only a slight “urge to go.”) That woman who said we should allow a month to learn to perform, not merely into the potty but so as to arrive with empty bowels and a full bladder, might have been right about how long it takes, or might take.
I’m not so proud as to think i can design and describe a good Special Toilet Training course in a day or even in a month. What i’ll do here, is list some things that might help you without that course, to help your bladder and bowels flee to safety before the X-rays come; and might even be parts of the Special Toilet Training course that is designed too late for this Movember:
‣ Starting 3-4 weeks before your “CT Simulation appointment”, practice holding your bladder, full, until you’re getting worried you’ll wet your pants. Notice how that feels (and with luck, learn how to hold that “urethral sphincter” shut longer and more easily. I don’t know what to tell you to expect, and i don’t need to; you get to figure it out yourself because it may not be the same as the next man’s.
‣ Drink 2-3 litres of water or weak tea each day “so your body is normally well hydrated”.
‣ Starting a week or so before the “CT Simulation appointment”, practice emptying your bladder , quickly drinking one half litre of water immediately after, and setting a timer for one hour5. Note how full your bladder feels and how easily you can “hold it” as the hour passes.
‣ Note when you have had coffee, and how much, relative to these practice sessions.
Yes, this does take a lot of time and attention. .. and i have only given you some general ideas how to proceed, not a course outline.
Back when i was in my late teens, as i mentioned in two earlier posts, a friend of my father’s was diagnosed with prostate cancer—and castrated. He died not long afterward despite the castration. In his time, there was no “Prostate Specific Antigen” test to detect prostate cancer early; no testosterone suppression drugs to substitute for castration, and radiation treatments were cruder. In my case, those recently developed techniques give me a serious chance to die of something else, and years later than if the cancer were diagnosed as late as in his time, and treated in those ways.
One of the next steps forward might be, not another sophisticated new technology, but a superior way to learn Special Toilet Training. Being zapped with empty bowels and a full bladder, means less damage to those vital organs, and less risk that they will get secondary cancer from the radiation. All i can provide here is a general indication of the Special Toilet Training you should have, to make pelvic radiation safer, and a little advice that might help you prepare while it isn’t available as a short course. It ought to be possible to make that training more complete and more specific to specific patients’ natures and needs, than the blue handout; but one man can’t do that alone.
Finally, my apologies to any men who find the language of this blog “prissy.” The Webmaster specifies “PG-13” limits to rude words, and using the ruder words i would normally use talking among men, probably wouldn’t read well either… given that it’s a public site and the subject is hospital treatment. As many of you may have noticed, hospitals expect us to use very nice, polite language, to the point that it can be a chore for some men to translate from “the way the guys say it.”
Maybe that’s why some guys found M.A.S.H. such a fun read.
1. Any women reading this, please remember it was published on a men’s website during Movember. The principal focus is on prostate cancer, which is exclusively male and normally treated by radiation beamed into the pelvic area. (Tumors which are managed by “watchful waiting” are “benign” and usually not called “cancers.”) Women do get radiation beam treatments to the pelvic area, but the prostate is not what’s involved, your anatomy is [duuuuuuuhhh] different from ours, and plausibly your Special Toilet Training should be somewhat different also.
2. My treatment times ranged from 8:15 AM to 3:36 PM.
3. One technician said that an hour is too long an interval for many patients, and that the bladder of a well hydrated man can refill well enough for safe treatment in 30-40 minutes.
4. i’m writing that “in the analysis of variance sense”, in case you reader are schooled in probability and statistics.
5. Most relatively new mobile phones have timer software, and provide a convenient way to time this business. Only a little subtraction arithmetic is required.