Physiotherapy for Urinary Incontinence following surgical prostate gland removal.

Evidence shows that physiotherapy-guided pelvic floor retraining and exercise helps men regain continence significantly faster and more effectively than men not receiving treatment.

Urinary incontinence, or bladder weakness or leakage, is an unfortunate but very common result for men who undergo surgical removal of their prostate gland as treatment for prostate cancer. Rates of incontinence for men post-surgery vary greatly across the literature but can be as much a 70% in the short term. This number decreases with time post-surgery, however up to 5% of men may require surgery to help them recover their continence. It is estimated that 1 in 7 men will be affected by prostate cancer in their lifetime.

anatomy

 

The cause of urinary incontinence following surgical prostate removal is the disruption of two muscles acting like valves, called urinary sphincters. One is around the bladder neck, the other is around the urethra and is part of the pelvic floor. These muscles act together to control the flow of urine by opening and closing the bladder ‘door’ on automatic command from your brain. The prostate is a walnut-sized male reproductive organ located at the base of the bladder and alongside the urethra. If the sphincters or pelvic floor are damaged or weakened during removal of the prostate gland then urinary incontinence can result. As well as these surgical side-effects, radiotherapy treatment can cause irritation, inflammation and swelling to the bladder, prostate, urethra and rectum and this may cause urinary issues, although this is much less common.

There are two main forms of urinary incontinence. Stress urinary incontinence (SUI) occurs on an action or movement that causes stress to the pelvic floor such as coughing, sneezing, laughing, lifting or jumping. This is due to an increase in abdominal pressure on these activities. Urge urinary incontinence (UUI) can occur when the person feels unable to hold their urine once they decide they need to seek out the toilet/on a full bladder ie a sudden strong urge with the inability to delay it. Individuals may experience one or many of the following:

  • Urgency (as per UUI)
  • Frequency (needing to urinate every two hours or less)
  • Pain (any discomfort such as burning, stinging or pain while urinating)
  • Nocturia (need to urinate overnight)
  • Intermittency (a stop/start urinary stream)
  • Dribbling (slight urinary leakage after urinating is completed)
  • Straining (having to push or strain to begin your urinary stream)
  • weak urinary stream (slow flow with minimal force).

The other unfortunate side effect of pelvic floor damage or weakness following prostate surgery is erectile dysfunction as this control involves the same muscles and nerves. Men may experience problems in this area following surgery.

Many men find that their symptoms can resolve or minimise within 12 months after surgery but research has proven that early pelvic floor retraining involving education and strengthening exercises can significantly shorten the time period for full recovery. This is where physiotherapy comes in and is recommended by the Prostate Cancer Foundation of Australia.

The pelvic floor is a sling of muscles and connective tissue that spans the area at the base of your pelvis. It provides support to our organs including bladder and intestines (and uterus in females). It helps control our bladder, as discussed above, as well as our rectum. It also works in conjunction with our abdominal muscles to form our ‘core.’

Our pelvic floor muscles can be trained and strengthened like any other muscle in our body. If we want strong biceps what are we going to do? Bicep curls! Want strong quads? We’re going to squat. So if we want stronger pelvic floor muscles, we need to exercise them. The trick is learning how to activate them correctly, as for many men it’s not something they’ve ever had to do or think about before. If we are doing the contractions incorrectly or imperfectly then the desired results will not be forthcoming. One of our professionally trained physiotherapists will be able to work with you to teach you the appropriate cues and techniques for your individual case to ensure correct activation of the pelvic floor muscles and monitor your progress with the goal of normalising function to allow you to return to regular daily activities and your favourite exercise or leisure activities.

In our clinic the assessment of your pelvic floor activation and the subsequent education and practice is done in a completely non-invasive manner, where the physiotherapist may simply palpate your tummy muscles, which also contract when we correctly activate our pelvic floor. Once the physiotherapist ascertains that you are able to engage the right muscles with the correct technique, they will then provide you with a personalised strengthening exercise program for you to continue at home. We will then follow you up regularly to check that progress is being made and to ensure correct technique is maintained. At these times we will also progress the difficulty of your exercises as you improve, and guide you through returning to any more demanding sports, exercise and leisure activities you may be eager to get back to.

Physiotherapy and pelvic floor strengthening exercises can be very beneficial prior to prostate removal surgery for those men who have some warning and preparation time between diagnosis and potential surgery. In this instance we would perform the same assessments and provide strengthening exercises to do to help strengthen your pelvic floor in the lead up to surgery with the idea of minimising weakness post-surgery. This is very similar to what we do with a lot of clients in the lead up to their total hip or knee replacements, strengthening the quadricep and gluteal muscles to provide a good base strength for their post-surgical recovery.

If you or someone you know are dealing with a prostate cancer diagnosis and are facing prostate gland removal, please consider seeking physiotherapy treatment in the lead up. If you have undergone prostate removal and are experiencing any adverse side effects please don’t suffer in silence, we are here to help.

Written by: Laura Black

Prostate Cancer and Physiotherapy

References

  1. Cornel, E. B., de Wit, R., & Witjes, J. A. (2005). Evaluation of early pelvic floor physiotherapy on the duration and degree of urinary incontinence after radical retropubic prostatectomy in a non-teaching hospital . World Journal of Urology , 23(5), 353-355.
  2. https://www.pelvicpainrehab.com/male-pelvic-pain/4630/what-does-physical-therapy-do-for-men-following-prostatectomy/
  3. https://www.continence.org.au/pages/continence-management-following-prostate-surgery.html
  4. http://prostate.org.au/media/743467/physiotherapy-before-and-after-prostate-cancer-surgery.pdf
  5. Santos NA et al. Assessment of physical therapy strategies for recovery of urinary continence after prostatectomy. Asain Pac J Cancer Prev 2017;18(1):81-86. doi:10.22034/APJCP.2017.18.1.81
  6. https://www.continence.org.au/pages/continence-management-following-prostate-surgery.html
  7. Wolin, K., Luly, J., Sutcliffe, S., Andriole, G. & Kibel, A. (2010) Risk of Urinary Incontinence Following Prostatectomy: The Role of Physical Activity and Obesity. J Urol, 183(2): 629–633.
  8. http://www.prostate.org.au/ (Prostate Cancer Foundation of Australia)
  9. http://www.prostate.org.au/media/468680/understanding-urinary-problems.pdf