By Leeanna Maher, Reg. PT

According to the Canadian Cancer Society, 21 300 men will be diagnosed with prostate cancer in 2017 (1). This represents 21% of all new cancer cases in men. Thankfully, due to advancements in early detection and treatment methods, cure rates are very high. Conversely, this also means that men are living longer with the commonly reported symptoms of urinary incontinence and erectile dysfunction post prostate surgery. Reports of post prostatectomy urinary incontinence ranges from 1-90% and almost 60% of men who have prostate surgery will report some form of erectile dysfunction 18 months later (2,3).

During prostatectomy surgery, the internal urethral sphincter is removed along with the prostate. The internal urethral sphincter (involuntary control) and the external urethral sphincter (voluntary control) act to provide a “double stop” system to close the urethra and prevent unwanted leakage of urine. The pelvic floor muscles are required to compensate for the loss of function of the internal urethral sphincter. If the pelvic floor muscles are weak, urine can leak during activities such as coughing,  laughing and sneezing. This is referred to as stress urinary incontinence. Pelvic floor physiotherapy focuses on strength, endurance, and optimizing coordination of the pelvic floor muscles to help meet the new demand that has been placed on them. In fact, research suggests there is a great benefit in initiating pelvic floor physiotherapy prior to prostatectomy surgery to help reduce the duration and severity of early urinary incontinence (4,5,6).

Prostate surgery attempts to spare and preserve the nerves that supply the penis and pelvic floor muscles but nerves may still be manipulated and be damaged. This can contribute to a decrease in erection quality. Nerves are slow to recover and require a lot of oxygen for optimal healing. Pelvic floor physiotherapy focuses on optimizing the flexibility and contractility of the pelvic floor muscles, thereby increasing oxygen rich blood and nutrient exchange to the injured muscles and nerves. The most superficial layer of the pelvic floor includes the bulbospongiosus and ischiocavernosus muscles. The ischiocavernosus muscle helps maintain rigidity of the penis while the bulbospongiosus muscle contributes to contractions during orgasm and assists in emptying the urethra of urine or semen. Together these muscles aid in the initiation and maintenance of erections. Pelvic floor physiotherapy provides guidance on how to increase the strength and endurance of these specific muscles. Pelvic floor muscle training can improve erectile function and reduce climacturia (urine leakage during orgasm) post-surgery (7,8).

The goals of pre and post-surgical pelvic floor physiotherapy include the following:

• Restore and/or increase the strength, endurance, and flexibility of the pelvic floor muscles.

• Ensure the pelvic floor muscles are properly coordinated with other core muscles during dynamic movements (getting out of bed, getting up from a chair, coughing, sneezing)

• Assess and address pelvic alignment and postural symmetry

• Address possible constipation and/or voiding issues by providing education on optimal toileting positions and defecation dynamics to decrease pressure on the pelvic floor.

There are many resources that suggest men perform “kegels” to resolve urinary incontinence and erectile dysfunction. While these exercises are beneficial for some, for others they may be detrimental and lead to a worsening of symptoms. This is why, it is of the utmost importance to be assessed by a trained pelvic floor physiotherapist. The therapist will be able to determine whether the pelvic floor muscles are appropriate for “kegels” or whether they may be to shortened/tight and therefore, excessive contracting of these muscles will simply create more dysfunction. In this case, therapy will focus on providing guidance on how to relax and lengthen the pelvic floor muscles thereby establishing a much more functional resting tone.

Pelvic floor physiotherapy improves urinary incontinence and erectile function after prostatectomy. If you will be undergoing prostate surgery, book an appointment with a pelvic health physiotherapist to help you on your journey to health and recovery.

References:

1) http://www.cancer.ca/en/cancer-information/cancer-type/prostate/statistics/?region=sk
2) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908931
3) https://www.fredhutch.org/en/news/releases/2000/01/JAMAprostatectomy.html
4) http://www.ncbi.nlm.nih.gov/pubmed/18448233
5) http://www.ncbi.nlm.nih.gov/pubmed/26610857
6) http://www.ncbi.nlm.nih.gov/pubmed/21915042
7) http://onlinelibrary.wiley.com/doi/10.1111/iju.12099/full
8) http://www.nature.com/ijir/journal/v28/n1/full/ijir201524.html