Bill Landry BScPT, BScH, MCPA, CAFCI blandry@fpclondon.com Family Physiotherapy Centre of London
Objectives To describe the scope of post-prostatectomy incontinence To describe what s been done To provide details of pelvic floor physiotherapy for PPI To give insights into research in the field.
Physiotherapy for Men after RP Education Functional Exercises based on anatomy, physiology and focus on mechanisms to compensate on what has been removed. Confirm patients are performing the exercises correctly using: Real time ultrasound trans-abdominal Use of Biofeedback in severe cases RTUS Rectal probe EMG
The incidence of Urinary Incontinence after prostate surgery is a grossly under reported problem, with a significant variation between reports. According to Haab F et al (1996) the incidence ranges from 2.5% to 87%. Majoros A et al (2006) found 84.1% of men had some incontinence immediately after RP. Glazener et al (2011) found 691 / 740 (93%) of men had incontinence at 6 weeks after RP.
Pathophysiology of UI after RP Multifactorial Age Anatomic Physiologic Pre-existing function (detrusor overactivity, obstructive prostate)
Pathophysiology of UI after RP Removal of internal urinary sphincter after RP (Bladder neck resection) Bladder neck reconstruction Nerve sparing or not Controversial External sphincter injury Urethral length Found to be significant in a number of studies
Male Anatomy
Male Anatomy http://www.myoptumhealth.com
Male Anatomy Changes Bauer et al. Eur Urol 2008
Physiology of the RhabdoSphincter The striated muscle fibers of the rhabdosphincter enclose the urethra ventrally and laterally. Dorsally, a strong connective tissue anchors the rhabdosphincter in the perineal body. The striated fibers of the rhabdosphincter are slow twitch (type I) fibers. (Hannes S, 2011) The rhabdosphincter is capable of maintaining tone over prolonged time periods without fatigue. (Hannes S, 2011)
Pelvic Floor Contraction A correct pelvic floor muscle contraction has been described as an inward lift and squeeze around the urethra with resultant urethral closure, stabilization and resistance to downward movement, Bo K et al (2001) Baessler K & Junginger B (2011) found that: 25% of a maximal pelvic floor contraction in healthy women significantly elevates the bladder neck. A maximal pelvic floor contraction does not further elevate the bladder neck after 50% of effort in pelvic floor of healthy women. There is a considerable increase in intra-abdominal pressure with maximal PFM contraction. Maximal pelvic floor muscle contractions are not necessary to elevate and support the bladder neck and have the disadvantage of increasing the intra-abdominal pressure undesirably due to cocontractions of the superficial abdominal muscles.
Types of Incontinence Seen After Radical Prostatectomy Stress Involuntary urinary leakage on effort or exertion, sneezing, or coughing Urge Involuntary leakage accompanied by or immediately preceded by urgency Mixed Involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing Overflow Leakage owing to bladder outflow obstruction of any cause resulting in large post-void residual volume
Treatment for Urge Incontinence Patient education Lifestyle modifications Type and timing of fluids Diet Smoking Haidinger et al 2000 Patient specific pelvic floor muscle exercise Urge suppression techniques Anticholinergics if severe
Urge Suppression Techniques Keep calm Relax abdominal muscles Stand still or sit down Wait 1 minute until urge disappears. Perform Kegel exercises 10 second hold and relax for the minute. NEVER RUSH TO TOILET MID-URGE Visit toilet or continue activities
Typical Program at Our Facility Usually start treatment within the first 2 weeks after catheter removal Treatment after radiation Treatment years after RP There is no conclusive evidence that starting pelvic floor exercises before surgery has any more benefit then after surgery research is still needed
Subjective Assessment Personal details Medical, Surgical history, Pre-surgical Continence Hx Duration and severity of symptoms Amount and frequency of leakage Number of pads used per day/night Neurological problems Bowel activity Sexual dysfunction Motivation and functional factors
Typical Program at Our Facility Education on physiology and anatomy of the male pelvic region. Internal urinary sphincter Urethra External urinary sphincter (rhabdosphincter) Slow twitch muscle fibres Fast twitch muscle fibres Smooth muscle fibres
Typical Program at Our Facility Discuss common issues with incontinence after RP Minimal leakage at night when sleeping gravity Leakage worse in the early evening muscle fatigue Leaks when the client gets up out of a chair, bed etc. gravity and increased intra-abdominal pressure. Leaks more with more activity especially carrying, lifting and walking as above Discuss fluid intake advice
Typical Program at Our Facility Discuss 4 exercises that focus on 1. Increasing tone and endurance 2. Motor control and Motor learning 3. Strength and Power Use Real time ultrasound to teach the patient a proper pelvic floor contraction and teach them how to perform the 4 exercises. Discuss using a 24 hour pad test to objectively monitor the amount of leakage over time.
Typical Program at Our Facility We usually will see the patients in 4-6 weeks for a follow up. At the follow up session, we discuss The 24 hour pad test result taken at baseline and at 4 weeks. How their exercises have been going. Use the RTUS to see how they are performing their exercises. We re-iterate that they need to perform sub-maximal pelvic floor contractions before and during activities that cause leakage.
24 Hour Pad Test This is an objective way of measuring the amount of leakage: 1. Weigh an empty pad in a zip lock bag (using kitchen scale). Measure in grams. 2. Use same type of pad and when you need to change pad, place in zip lock bag. Seal the bag. When able, weigh this pad and bag using a kitchen scale. 3. Subtract the Full pad from the empty pad, this is the amount of leakage in grams that has occurred. 4. Repeat this process over the 24 hour period to come up with the total leakage weight over 24 hours. 5. Record Date, weight in grams leaked, and any activities performed throughout the day, record amount of fluid intake.
24 Hour Pad Test There are no consistent standards in regards to severity at this time but it is generally excepted that in men: A score of > 450 g over 24 hours is considered Severely incontinent A score of < 20 g is considered mildly incontinent A score of < 2 g is considered fully continent. Once a patient is consistently getting less then 20g of leakage, we discuss starting the day with no pad and putting one on after a few hours. The patient is to slowly increase this pad free time
Exercise Program - Focus Sub-maximal contractions & Endurance Motor control and motor learning Power and strength Functional exercises
Exercise 1 Contract pelvic floor 50% for 5 seconds then Contract pelvic floor to 100% for 5 seconds then Slowly relax to the 50% range for a further 5 seconds Rest for 5 seconds. Repeat 10-15 times, three times per day. If you leak during this exercise, try keeping a slight contraction while resting. 5 sec 100% 5 sec 5 sec 50% 5 sec * 10 Threshold
Exercise 2 Quickly, as fast and as hard as you can, squeeze your pelvic floor muscles 100% for 3 full seconds... Relax slowly.do NOT REST..Quickly squeeze back to 100% for another 3 seconds. Repeat this 10 times, rest 30 seconds and repeat 4 times. Perform this exercise at least 2 times per day. 3 sec 3 sec * 10 100% 50% Threshold
Exercise 3 Squeeze your pelvic floor 10-20% of maximum. Hold this for 1/2 an hour while going for a walk. Perform this once per day. If you feel you lost the contraction, slightly squeeze your pelvic floor and continue. 100% 30 minutes 10-20% Threshold
Exercise 4 Functional When getting up from lying or sitting slightly tighten your pelvic floor then perform your activity. Keep a slight contraction to avoid any leakage. When you are going to cough or sneeze, slightly tighten your pelvic floor After urinating, perform 4 quick 100% contractions (1-2 second holds) to prevent post micturation dribble. If you are leaking, it is because your pelvic floor s tone is too low.
Real-Time Ultrasound Ultrasound gives direct visualization of pelvic floor muscle contraction and can be used as an adjunct to standard physiotherapy to assess pelvic floor elevation. U/S provides direct visualization of pelvic floor muscle contraction to both the therapist and patient. Thompson JA et al (2005) Showed that RTUS was reliable for measuring pelvic floor movement during a pelvic floor muscle contraction. Sherburn M et al (2005)found Transabdominal U/S a non-invasive method for imaging and assessing pelvic floor muscle activity and movement
Ultrasound for biofeedback 3.5 Mhz curved array transducer is used in our facility. We use transabdominal ultrasound (sagittal and transverse plane) Advantages include: Imaging of pelvic floor function Imaging of the body that is not normally visable Application possible in different patient positions: lying, sitting, standing Ability to teach and educate proper techniques Patient has a clearer idea of what is asked of him
Real Time Ultrasound - Example Exercise # 1: Partial contraction 5 seconds then full contraction..
Real Time Ultrasound - Example Exercise # 2: Fast contract/partial relaxation 1 second holds
Real Time Ultrasound - Example Improper pelvic floor contraction, over activation of abdominals
Further Research Required There remains no clear support that conservative management of any type of postprostatectomy UI is either helpful or harmful, whether delivered as treatment to men who are incontinent or as a prevention to all men undergoing surgery, (The Cochrane collaboration Hunter, KF, Moore KN, Glazener CMA, 2009) The Cochrane review stated that Well-Designed clinical trials are needed to clarify the role of these therapies.
Future Research A Comparison of Continence Outcomes for Men with and without Pelvic Floor Rehabilitation Following Robot Assisted Laparoscopic Radical Prostatectomy Randomized Controlled Trial New Exercise Protocol Real Time Ultrasound
Future Research Outcome Measures used in at our clinic include: The 24 hour pad test taken 3 days in a row (averaged) at baseline (day of catheter removal), 1 month, 1 month + 2 days, 3 months, 6 months and at 1 year. International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ- SF) International Consultation on Incontinence Questionnaire Male Lower Urinary Tract Symptoms Module (ICIQ-MLUTS)
Take Home Message Pelvic floor control more important then power Men often are contracting their abdominals as well as their pelvic floor The external urinary sphincter (rhabdosphincter) and pelvic floor musculature are mainly composed of slow twitch muscle fibres. Well designed RCT s are needed. Remember this phrase..less IS MORE