Pelvic Muscle Rehabilitation after Radical Prostatectomy - Diane Newman
December 9, 2024
Diane Newman delivers a presentation on pelvic floor muscle rehabilitation following radical prostatectomy, highlighting the prevalence and impact of post-surgical urinary incontinence. She explains that while incontinence affects 2-90% of patients initially, most improve within 2-3 months, though 5-20% may continue experiencing symptoms beyond two years. The discussion emphasizes the effectiveness of pelvic floor muscle training, both preDiane Newman delivered an insightful presentation on pelvic floor muscle rehabilitation following radical prostatectomy, underscoring the significant prevalence and impact of post-surgical urinary incontinence. She highlighted that while incontinence affects 2% to 90% of patients initially, the encouraging news is that most individuals experience improvement within 2 to 3 months. However, it's important to acknowledge that 5% to 20% may continue battling symptoms beyond two years.
The discussion emphasized the powerful role of pelvic floor muscle training, both preoperatively and postoperatively, detailing specific exercises that effectively target both fast-twitch and slow-twitch muscle fibers. Dr. Newman skillfully demonstrated how biofeedback-assisted training can empower patients to visualize and enhance their muscle contractions, bolstered by compelling evidence from clinical studies showcasing its benefits.
In conclusion, the presentation offered a wealth of resources, including educational materials and downloadable audio exercises, designed to support patients throughout their rehabilitation journey. This comprehensive approach ensures that individuals have the tools they need to regain their quality of life after surgery.
**Biographies:**
**Diane K. Newman, DNP, ANP-BC, FAAN, FAUNA, BCB-PMD**
Medical Director, Digital Science Press
Adjunct Professor of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
**Related Content:**
- Pelvic Floor Muscle Rehabilitation Audio Resources
- Unlocking the Power of Pelvic Floor Muscles - Diane Newman
- Pelvic Floor Muscle Training for Urinary Incontinence After Radical Prostatectomy: A Narrative Review.
**Read the Full Video Transcript**
Diane Newman: Welcome. I'm Diane Newman. I'm a urology nurse practitioner. I've been practicing for many years. I'm also President of Digital Science Press and Medical Director of UroToday. I was at the University of Pennsylvania for three years as an adjunct professor of surgery.
And at that time, I saw many men who underwent prostate surgery, either for BPH or for cancer. And I thought that this presentation would be very helpful. So I'm going to talk about pelvic muscle rehabilitation after prostatectomy.
So let's start with some definitions. Urinary incontinence is the involuntary loss of urine. Sometimes, people call this bladder leaks or accidental urine loss. There are usually two types that we see in patients and in men who may have post-prostate cancer or prostate surgery—stress urinary incontinence, which is incontinence on effort or exertion after physical activity. And a lot of times, this is small episodic incontinence, which means it could be in drops that may occur.
Like I hear men tell me when they swing a golf swing, that type of thing, or cough or laugh. Urgency urinary incontinence is usually due to bladder overactivity when the entire bladder contents will leak out, and usually, it's preceded by bladder urgency.
Now, when we look at post-prostatectomy urinary incontinence, prevalence ranges from 2 to 90%. Initially after the surgery, it is transient and usually improves within two to three months. However, incontinence is a very feared complication, and it is an independent predictor of quality of life.
It does decrease over time, and up to one year after surgery, continence—which means no incontinence, you're dry—can range from 60 to 97% in 12 months. So it does get significantly better, but 5% to 20% will continue to have some degree of incontinence one to two years after surgery.
Now, men—there's a really good study that came out in JAMA several years ago. And in the read on this slide, I show you who they looked at, men who were under active surveillance, who had nerve-sparing prostatectomy, external beam radiation therapy, low-dose-rate brachytherapy, or men with favorable disease that were treated with prostatectomy or external beam with ADT therapy if they had unfavorable-risk disease.
And some of the key things from this study is that men who underwent prostate cancer surgery reported clinically meaningful worse incontinence through five years compared with other options. And men undergoing prostatectomy for unfavorable disease reported worse sexual function in five years compared to men who underwent radiation with ADT.
And the other thing that we should think about, though, too, that men will report is at least a third will develop bladder overactivity and that may be accompanied, of course, with urgency incontinence. And this is a predominant cause of incontinence in about 6% out of 83% of men. Additional symptoms we also see is bladder urgency and frequency. Now, this is probably due to low urethral compliance, which is noted in 30.1% of cases and usually associated with scarring. And what's important to know is that we have changed now to robotic prostatectomies, but we haven't really seen the incontinence rates change.
I want to emphasize here is pelvic floor muscle training or pelvic rehabilitation. And on this slide, I show you the different references that really support the fact that this can be very helpful. We also have recommendations from the International Consultation on Incontinence that came out in 2023, and it's on adult conservative management committee.
And basically, they gave a very good grade rating for this recommendation. And that is that we should instruct men in preoperative pelvic floor muscle training that it can maybe help them with recovery of continence. Also, early post-operative pelvic floor muscle training can also reduce the time to continence after surgery. And the biofeedback may be considered for a subsection of a subgroup of men, and I'll show you some biofeedback that I had used in my practice. Long-term side effects, though, are there in erectile dysfunction.
The AUA/SUFU guideline actually came out with an addendum to their main guideline that came out several years ago, and they do also have recommendations, and they follow the International Consultation on Incontinence. And, as you can see, they're recommending pelvic floor muscle exercises and training prior to radical prostatectomy. And then we should be informing patients about these options, and they should also offer exercises in the immediate post-operative period if the patient is seeking treatment—if the man's seeking treatment after radical prostatectomy, we should offer them. But, as far as mixed urinary incontinence or urgency, frequency, and urgency incontinence, they refer us to the overactive bladder AUA guideline.
This is a picture that shows you the anatomy of that internal urethral sphincter, the proximal prostatic urethra, and the striated muscles that contribute to urinary incontinence. And you can see the arrows that whenever you contract the pelvic floor, how that muscle pulls everything forward so that it really supports the internal and the external urinary sphincter that prevents us from leaking urine. So you can see where the prostate is, and with a prostate surgery, we can see some damage that can occur in that area.
Now, this is a very simple picture of pelvic floor muscles. I showed this in my practice to all my patients, and basically, you can see that the muscle starts in the front at the pelvic bone and slings around. So it goes around the prostate, the urethra, and comes back around the other side. It also surrounds the rectum. And if you train this muscle, it can improve function, tone, strength, and endurance.
It's important to realize that the pelvic floor muscle has voluntary, striated skeletal muscles. And the information on this slide is very important because we have two different types—slow twitch and fast twitch muscle fibers.
So these fibers can stimulate the muscle fiber size so they can hypertrophy. That way, they can get stronger to prevent incontinence. By exercising these different fibers, you can build muscle bulk. And that early improvements in strength can be neuro adaptation, so there may be more motor unit firing. So actually, you can really develop strength there.
Now, what is pelvic floor muscle training? Well, the goal is to improve urethral resistance and urinary control through active exercise of the pelvic floor muscles, as I showed you on that previous picture. And there are three components—you want to identify the proper identification of the muscle, you want to coordinate the muscle contraction, so you have to have equal amounts of time of muscle contractions, or squeezing, and relaxation. You want to do these exercises daily, so you have to plan them.
And then I'll show you about something called a KNACK, which is the use of the muscle prior to the event that may be triggering that incontinence. And that's what this is. And some people call it a stress strategy or the KNACK of doing something. And this is an intentional, strong, fast muscle contraction. You can use it before and after the activity that causes a leakage.
So the concept here is you would like to contract the pelvic floor muscle prior to maybe a cough. I tell men before a golf swing, maybe from going from sitting to standing, if that's when you leak. So if you identify what causes that leak, what triggers it, then you want to contract this muscle.
Timing is key. You want to squeeze before that activity. And if you keep on doing that, it almost becomes a reflex. Your body knows to contract and pull in that muscle.
Now, you can use biofeedback, and there's something called biofeedback-assisted pelvic floor muscle training, and this helps a person find the muscles and shows them if they're squeezing the muscles correctly. And I'll show you some pictures. This is usually using equipment, and it's visual, and it uses a computer screen that records muscle activity, and a monitor so that you can see it.
And here are just some pictures. And this was equipment that I used in my practice at the University of Pennsylvania. This is the Prometheus Group's biofeedback system. I used external skin surface electrodes, and you can see them here around the anus at 10:00 and 4:00.
And then you put a grounder on, and then this is a picture of the patient viewing this muscle contraction. You can see that. And I'll show you some better pictures here.
Here is those type II. These are the fast twitch muscle fibers, so these are quick contractions. We call them quick flicks. They're usually about two seconds in length. And this is his first baseline visit. And then this is four weeks later.
Here, you see someone doing what we call long holds or slow-twitch muscle fiber contractions. And these are like around—we're trying to get him to do 10 seconds. And you can see it starts out good and may fall off a little bit here, but this is the baseline. And look how four weeks later, he's really built that strength in that muscle. So this is kind of visualization you see with biofeedback-assisted pelvic floor muscle training.
Now, to be effective, though, with a training program, you want to be able to isolate the pelvic floor muscle. So you want to be able to—in men, it's really around the anus that they should feel closure around their rectal anus as they contract the pelvic floor muscle. They may move their scrotum or penis. But again, the goal is specific to the patient's ability, and you want to build strength and avoid fatigue.
Now, this is a very old study, and this was done many years ago by Kathy Burgio and Patty Gude. And this was looking at 125 men. And what they did is they just did a single session of biofeedback at least one week pre-op. And you can see that they tested whether they had muscle control, they did daily exercises, and they followed them for six weeks, three months, and six months.
And what they showed here—and you can see this—the first graph, you can see the control with—those are men that did not do any exercises, were not taught to do them pre-op. And then this is the intervention. And you can see that after the catheter was removed, you can see that the intervention group. And then six weeks, and this is the degree of urine leakage.
And, as you can see, as they kept doing the exercises over that period of six months, starting at six weeks, and these were taught pre-surgery, you can see that incontinence in that intervention group just really went down significantly. So that's really, really positive as far as these muscles and what they can do, so that's really good.
Now, there are other options too that also can. For urine leakage, I use the cat in the hat because there are products and devices known to help men if they have leakage. And I've used all these products in my practice. Some are better than others, but there are ways to contain that urine leakage so that you can have a good quality of life and go out and do the activity that you want to do.
Now, what I want to reinforce in this presentation is the fact that we have a lot of resources on UroToday.com, and here's just some of them. I've done quite a bit of education, interviews of individuals who have done, who have practices in this area. There's a lot of patient education, but there are videos and there's also case studies that you can do in these different areas. And I hope that you view access UroToday to get more information. I think my teaching tools are really helpful to really explain more about how to do these exercises.
Also, we do have some information on different research that I've been as far as teaching about urinary incontinence and bladder control strategies, and you can download these resources. I also put up some audio education files. When I was in practice, what I would do after I taught men how to do these exercises, I would actually have them download an MP3 file on their iPhone or on their Android, and actually they could practice the exercises by following an exercise session, and this can be extremely helpful. So I really recommend that you go and download these.
And I actually, on this next slide, give you the URL to download these MP3 audio files because they provide five-minute muscle training. They're very short, but it walks you through a pelvic floor muscle training. So I think these can be very helpful. I'll leave this on for a little bit if you want to just put your phone up and download this QR code because it takes you directly to where you can download these files.
So thank you for listening to this. This was a very short review of pelvic floor muscle rehabilitation—how to work your pelvic floor muscles. UroToday is a great resource for this, so I hope that you do access the website. A lot of good information, a lot of the research in this area on prostate cancer, as well as what to do if you develop any problems after any type of treatment for your prostate. Thank you very much.operatively and post-operatively, detailing specific exercise techniques that target fast and slow-twitch muscle fibers. Dr. Newman demonstrates how biofeedback-assisted training can help patients visualize and improve muscle contractions, sharing evidence of its benefits through clinical studies. The presentation concludes by highlighting various resources including educational materials and downloadable audio exercises, to support patients in their rehabilitation journey.
Biographies:
Diane K. Newman, DNP, ANP-BC, FAAN, FAUNA, BCB-PMD, Medical Director, Digital Science Press, Adjunct Professor of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
And at that time, I saw many men who underwent prostate surgery, either for BPH or for cancer. And I thought that this presentation would be very helpful. So I'm going to talk about pelvic muscle rehabilitation after prostatectomy.
So let's start with some definitions. Urinary incontinence is the involuntary loss of urine. Sometimes, people call this bladder leaks or accidental urine loss. There are usually two types that we see in patients and in men who may have post-prostate cancer or prostate surgery—stress urinary incontinence, which is incontinence on effort or exertion after physical activity. And a lot of times, this is small episodic incontinence, which means it could be in drops that may occur.
Like I hear men tell me when they swing a golf swing, that type of thing, or cough or laugh. Urgency urinary incontinence is usually due to bladder overactivity when the entire bladder contents will leak out, and usually, it's preceded by bladder urgency.
Now, when we look at post-prostatectomy urinary incontinence, prevalence ranges from 2 to 90%. Initially after the surgery, it is transient and usually improves within two to three months. However, incontinence is a very feared complication, and it is an independent predictor of quality of life.
It does decrease over time, and up to one year after surgery, continence—which means no incontinence, you're dry—can range from 60 to 97% in 12 months. So it does get significantly better, but 5% to 20% will continue to have some degree of incontinence one to two years after surgery.
Now, men—there's a really good study that came out in JAMA several years ago. And in the read on this slide, I show you who they looked at, men who were under active surveillance, who had nerve-sparing prostatectomy, external beam radiation therapy, low-dose-rate brachytherapy, or men with favorable disease that were treated with prostatectomy or external beam with ADT therapy if they had unfavorable-risk disease.
And some of the key things from this study is that men who underwent prostate cancer surgery reported clinically meaningful worse incontinence through five years compared with other options. And men undergoing prostatectomy for unfavorable disease reported worse sexual function in five years compared to men who underwent radiation with ADT.
And the other thing that we should think about, though, too, that men will report is at least a third will develop bladder overactivity and that may be accompanied, of course, with urgency incontinence. And this is a predominant cause of incontinence in about 6% out of 83% of men. Additional symptoms we also see is bladder urgency and frequency. Now, this is probably due to low urethral compliance, which is noted in 30.1% of cases and usually associated with scarring. And what's important to know is that we have changed now to robotic prostatectomies, but we haven't really seen the incontinence rates change.
I want to emphasize here is pelvic floor muscle training or pelvic rehabilitation. And on this slide, I show you the different references that really support the fact that this can be very helpful. We also have recommendations from the International Consultation on Incontinence that came out in 2023, and it's on adult conservative management committee.
And basically, they gave a very good grade rating for this recommendation. And that is that we should instruct men in preoperative pelvic floor muscle training that it can maybe help them with recovery of continence. Also, early post-operative pelvic floor muscle training can also reduce the time to continence after surgery. And the biofeedback may be considered for a subsection of a subgroup of men, and I'll show you some biofeedback that I had used in my practice. Long-term side effects, though, are there in erectile dysfunction.
The AUA/SUFU guideline actually came out with an addendum to their main guideline that came out several years ago, and they do also have recommendations, and they follow the International Consultation on Incontinence. And, as you can see, they're recommending pelvic floor muscle exercises and training prior to radical prostatectomy. And then we should be informing patients about these options, and they should also offer exercises in the immediate post-operative period if the patient is seeking treatment—if the man's seeking treatment after radical prostatectomy, we should offer them. But, as far as mixed urinary incontinence or urgency, frequency, and urgency incontinence, they refer us to the overactive bladder AUA guideline.
This is a picture that shows you the anatomy of that internal urethral sphincter, the proximal prostatic urethra, and the striated muscles that contribute to urinary incontinence. And you can see the arrows that whenever you contract the pelvic floor, how that muscle pulls everything forward so that it really supports the internal and the external urinary sphincter that prevents us from leaking urine. So you can see where the prostate is, and with a prostate surgery, we can see some damage that can occur in that area.
Now, this is a very simple picture of pelvic floor muscles. I showed this in my practice to all my patients, and basically, you can see that the muscle starts in the front at the pelvic bone and slings around. So it goes around the prostate, the urethra, and comes back around the other side. It also surrounds the rectum. And if you train this muscle, it can improve function, tone, strength, and endurance.
It's important to realize that the pelvic floor muscle has voluntary, striated skeletal muscles. And the information on this slide is very important because we have two different types—slow twitch and fast twitch muscle fibers.
So these fibers can stimulate the muscle fiber size so they can hypertrophy. That way, they can get stronger to prevent incontinence. By exercising these different fibers, you can build muscle bulk. And that early improvements in strength can be neuro adaptation, so there may be more motor unit firing. So actually, you can really develop strength there.
Now, what is pelvic floor muscle training? Well, the goal is to improve urethral resistance and urinary control through active exercise of the pelvic floor muscles, as I showed you on that previous picture. And there are three components—you want to identify the proper identification of the muscle, you want to coordinate the muscle contraction, so you have to have equal amounts of time of muscle contractions, or squeezing, and relaxation. You want to do these exercises daily, so you have to plan them.
And then I'll show you about something called a KNACK, which is the use of the muscle prior to the event that may be triggering that incontinence. And that's what this is. And some people call it a stress strategy or the KNACK of doing something. And this is an intentional, strong, fast muscle contraction. You can use it before and after the activity that causes a leakage.
So the concept here is you would like to contract the pelvic floor muscle prior to maybe a cough. I tell men before a golf swing, maybe from going from sitting to standing, if that's when you leak. So if you identify what causes that leak, what triggers it, then you want to contract this muscle.
Timing is key. You want to squeeze before that activity. And if you keep on doing that, it almost becomes a reflex. Your body knows to contract and pull in that muscle.
Now, you can use biofeedback, and there's something called biofeedback-assisted pelvic floor muscle training, and this helps a person find the muscles and shows them if they're squeezing the muscles correctly. And I'll show you some pictures. This is usually using equipment, and it's visual, and it uses a computer screen that records muscle activity, and a monitor so that you can see it.
And here are just some pictures. And this was equipment that I used in my practice at the University of Pennsylvania. This is the Prometheus Group's biofeedback system. I used external skin surface electrodes, and you can see them here around the anus at 10:00 and 4:00.
And then you put a grounder on, and then this is a picture of the patient viewing this muscle contraction. You can see that. And I'll show you some better pictures here.
Here is those type II. These are the fast twitch muscle fibers, so these are quick contractions. We call them quick flicks. They're usually about two seconds in length. And this is his first baseline visit. And then this is four weeks later.
Here, you see someone doing what we call long holds or slow-twitch muscle fiber contractions. And these are like around—we're trying to get him to do 10 seconds. And you can see it starts out good and may fall off a little bit here, but this is the baseline. And look how four weeks later, he's really built that strength in that muscle. So this is kind of visualization you see with biofeedback-assisted pelvic floor muscle training.
Now, to be effective, though, with a training program, you want to be able to isolate the pelvic floor muscle. So you want to be able to—in men, it's really around the anus that they should feel closure around their rectal anus as they contract the pelvic floor muscle. They may move their scrotum or penis. But again, the goal is specific to the patient's ability, and you want to build strength and avoid fatigue.
Now, this is a very old study, and this was done many years ago by Kathy Burgio and Patty Gude. And this was looking at 125 men. And what they did is they just did a single session of biofeedback at least one week pre-op. And you can see that they tested whether they had muscle control, they did daily exercises, and they followed them for six weeks, three months, and six months.
And what they showed here—and you can see this—the first graph, you can see the control with—those are men that did not do any exercises, were not taught to do them pre-op. And then this is the intervention. And you can see that after the catheter was removed, you can see that the intervention group. And then six weeks, and this is the degree of urine leakage.
And, as you can see, as they kept doing the exercises over that period of six months, starting at six weeks, and these were taught pre-surgery, you can see that incontinence in that intervention group just really went down significantly. So that's really, really positive as far as these muscles and what they can do, so that's really good.
Now, there are other options too that also can. For urine leakage, I use the cat in the hat because there are products and devices known to help men if they have leakage. And I've used all these products in my practice. Some are better than others, but there are ways to contain that urine leakage so that you can have a good quality of life and go out and do the activity that you want to do.
Now, what I want to reinforce in this presentation is the fact that we have a lot of resources on UroToday.com, and here's just some of them. I've done quite a bit of education, interviews of individuals who have done, who have practices in this area. There's a lot of patient education, but there are videos and there's also case studies that you can do in these different areas. And I hope that you view access UroToday to get more information. I think my teaching tools are really helpful to really explain more about how to do these exercises.
Also, we do have some information on different research that I've been as far as teaching about urinary incontinence and bladder control strategies, and you can download these resources. I also put up some audio education files. When I was in practice, what I would do after I taught men how to do these exercises, I would actually have them download an MP3 file on their iPhone or on their Android, and actually they could practice the exercises by following an exercise session, and this can be extremely helpful. So I really recommend that you go and download these.
And I actually, on this next slide, give you the URL to download these MP3 audio files because they provide five-minute muscle training. They're very short, but it walks you through a pelvic floor muscle training. So I think these can be very helpful. I'll leave this on for a little bit if you want to just put your phone up and download this QR code because it takes you directly to where you can download these files.
So thank you for listening to this. This was a very short review of pelvic floor muscle rehabilitation—how to work your pelvic floor muscles. UroToday is a great resource for this, so I hope that you do access the website. A lot of good information, a lot of the research in this area on prostate cancer, as well as what to do if you develop any problems after any type of treatment for your prostate. Thank you very much.operatively and post-operatively, detailing specific exercise techniques that target fast and slow-twitch muscle fibers. Dr. Newman demonstrates how biofeedback-assisted training can help patients visualize and improve muscle contractions, sharing evidence of its benefits through clinical studies. The presentation concludes by highlighting various resources including educational materials and downloadable audio exercises, to support patients in their rehabilitation journey.
Biographies:
Diane K. Newman, DNP, ANP-BC, FAAN, FAUNA, BCB-PMD, Medical Director, Digital Science Press, Adjunct Professor of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
Read the Full Video Transcript
Diane Newman: Welcome. I'm Diane Newman. I'm a urology nurse practitioner. I've been practicing for many years. I'm also President of Digital Science Press and Medical Director of UroToday. I was at the University of Pennsylvania for three years as an adjunct professor of surgery.
And at that time, I saw many men who underwent prostate surgery, either for BPH or for cancer. And I thought that this presentation would be very helpful. So I'm going to talk about pelvic muscle rehabilitation after prostatectomy.
So let's start with some definitions. Urinary incontinence is the involuntary loss of urine. Sometimes, people call this bladder leaks or accidental urine loss. There are usually two types that we see in patients and in men who may have post-prostate cancer or prostate surgery—stress urinary incontinence, which is incontinence on effort or exertion after physical activity. And a lot of times, this is small episodic incontinence, which means it could be in drops that may occur.
Like I hear men tell me when they swing a golf swing, that type of thing, or cough or laugh. Urgency urinary incontinence is usually due to bladder overactivity when the entire bladder contents will leak out, and usually, it's preceded by bladder urgency.
Now, when we look at post-prostatectomy urinary incontinence, prevalence ranges from 2 to 90%. Initially after the surgery, it is transient and usually improves within two to three months. However, incontinence is a very feared complication, and it is an independent predictor of quality of life.
It does decrease over time, and up to one year after surgery, continence—which means no incontinence, you're dry—can range from 60 to 97% in 12 months. So it does get significantly better, but 5% to 20% will continue to have some degree of incontinence one to two years after surgery.
Now, men—there's a really good study that came out in JAMA several years ago. And in the read on this slide, I show you who they looked at, men who were under active surveillance, who had nerve-sparing prostatectomy, external beam radiation therapy, low-dose-rate brachytherapy, or men with favorable disease that were treated with prostatectomy or external beam with ADT therapy if they had unfavorable-risk disease.
And some of the key things from this study is that men who underwent prostate cancer surgery reported clinically meaningful worse incontinence through five years compared with other options. And men undergoing prostatectomy for unfavorable disease reported worse sexual function in five years compared to men who underwent radiation with ADT.
And the other thing that we should think about, though, too, that men will report is at least a third will develop bladder overactivity and that may be accompanied, of course, with urgency incontinence. And this is a predominant cause of incontinence in about 6% out of 83% of men. Additional symptoms we also see is bladder urgency and frequency. Now, this is probably due to low urethral compliance, which is noted in 30.1% of cases and usually associated with scarring. And what's important to know is that we have changed now to robotic prostatectomies, but we haven't really seen the incontinence rates change.
I want to emphasize here is pelvic floor muscle training or pelvic rehabilitation. And on this slide, I show you the different references that really support the fact that this can be very helpful. We also have recommendations from the International Consultation on Incontinence that came out in 2023, and it's on adult conservative management committee.
And basically, they gave a very good grade rating for this recommendation. And that is that we should instruct men in preoperative pelvic floor muscle training that it can maybe help them with recovery of continence. Also, early post-operative pelvic floor muscle training can also reduce the time to continence after surgery. And the biofeedback may be considered for a subsection of a subgroup of men, and I'll show you some biofeedback that I had used in my practice. Long-term side effects, though, are there in erectile dysfunction.
The AUA/SUFU guideline actually came out with an addendum to their main guideline that came out several years ago, and they do also have recommendations, and they follow the International Consultation on Incontinence. And, as you can see, they're recommending pelvic floor muscle exercises and training prior to radical prostatectomy. And then we should be informing patients about these options, and they should also offer exercises in the immediate post-operative period if the patient is seeking treatment—if the man's seeking treatment after radical prostatectomy, we should offer them. But, as far as mixed urinary incontinence or urgency, frequency, and urgency incontinence, they refer us to the overactive bladder AUA guideline.
This is a picture that shows you the anatomy of that internal urethral sphincter, the proximal prostatic urethra, and the striated muscles that contribute to urinary incontinence. And you can see the arrows that whenever you contract the pelvic floor, how that muscle pulls everything forward so that it really supports the internal and the external urinary sphincter that prevents us from leaking urine. So you can see where the prostate is, and with a prostate surgery, we can see some damage that can occur in that area.
Now, this is a very simple picture of pelvic floor muscles. I showed this in my practice to all my patients, and basically, you can see that the muscle starts in the front at the pelvic bone and slings around. So it goes around the prostate, the urethra, and comes back around the other side. It also surrounds the rectum. And if you train this muscle, it can improve function, tone, strength, and endurance.
It's important to realize that the pelvic floor muscle has voluntary, striated skeletal muscles. And the information on this slide is very important because we have two different types—slow twitch and fast twitch muscle fibers.
So these fibers can stimulate the muscle fiber size so they can hypertrophy. That way, they can get stronger to prevent incontinence. By exercising these different fibers, you can build muscle bulk. And that early improvements in strength can be neuro adaptation, so there may be more motor unit firing. So actually, you can really develop strength there.
Now, what is pelvic floor muscle training? Well, the goal is to improve urethral resistance and urinary control through active exercise of the pelvic floor muscles, as I showed you on that previous picture. And there are three components—you want to identify the proper identification of the muscle, you want to coordinate the muscle contraction, so you have to have equal amounts of time of muscle contractions, or squeezing, and relaxation. You want to do these exercises daily, so you have to plan them.
And then I'll show you about something called a KNACK, which is the use of the muscle prior to the event that may be triggering that incontinence. And that's what this is. And some people call it a stress strategy or the KNACK of doing something. And this is an intentional, strong, fast muscle contraction. You can use it before and after the activity that causes a leakage.
So the concept here is you would like to contract the pelvic floor muscle prior to maybe a cough. I tell men before a golf swing, maybe from going from sitting to standing, if that's when you leak. So if you identify what causes that leak, what triggers it, then you want to contract this muscle.
Timing is key. You want to squeeze before that activity. And if you keep on doing that, it almost becomes a reflex. Your body knows to contract and pull in that muscle.
Now, you can use biofeedback, and there's something called biofeedback-assisted pelvic floor muscle training, and this helps a person find the muscles and shows them if they're squeezing the muscles correctly. And I'll show you some pictures. This is usually using equipment, and it's visual, and it uses a computer screen that records muscle activity, and a monitor so that you can see it.
And here are just some pictures. And this was equipment that I used in my practice at the University of Pennsylvania. This is the Prometheus Group's biofeedback system. I used external skin surface electrodes, and you can see them here around the anus at 10:00 and 4:00.
And then you put a grounder on, and then this is a picture of the patient viewing this muscle contraction. You can see that. And I'll show you some better pictures here.
Here is those type II. These are the fast twitch muscle fibers, so these are quick contractions. We call them quick flicks. They're usually about two seconds in length. And this is his first baseline visit. And then this is four weeks later.
Here, you see someone doing what we call long holds or slow-twitch muscle fiber contractions. And these are like around—we're trying to get him to do 10 seconds. And you can see it starts out good and may fall off a little bit here, but this is the baseline. And look how four weeks later, he's really built that strength in that muscle. So this is kind of visualization you see with biofeedback-assisted pelvic floor muscle training.
Now, to be effective, though, with a training program, you want to be able to isolate the pelvic floor muscle. So you want to be able to—in men, it's really around the anus that they should feel closure around their rectal anus as they contract the pelvic floor muscle. They may move their scrotum or penis. But again, the goal is specific to the patient's ability, and you want to build strength and avoid fatigue.
Now, this is a very old study, and this was done many years ago by Kathy Burgio and Patty Gude. And this was looking at 125 men. And what they did is they just did a single session of biofeedback at least one week pre-op. And you can see that they tested whether they had muscle control, they did daily exercises, and they followed them for six weeks, three months, and six months.
And what they showed here—and you can see this—the first graph, you can see the control with—those are men that did not do any exercises, were not taught to do them pre-op. And then this is the intervention. And you can see that after the catheter was removed, you can see that the intervention group. And then six weeks, and this is the degree of urine leakage.
And, as you can see, as they kept doing the exercises over that period of six months, starting at six weeks, and these were taught pre-surgery, you can see that incontinence in that intervention group just really went down significantly. So that's really, really positive as far as these muscles and what they can do, so that's really good.
Now, there are other options too that also can. For urine leakage, I use the cat in the hat because there are products and devices known to help men if they have leakage. And I've used all these products in my practice. Some are better than others, but there are ways to contain that urine leakage so that you can have a good quality of life and go out and do the activity that you want to do.
Now, what I want to reinforce in this presentation is the fact that we have a lot of resources on UroToday.com, and here's just some of them. I've done quite a bit of education, interviews of individuals who have done, who have practices in this area. There's a lot of patient education, but there are videos and there's also case studies that you can do in these different areas. And I hope that you view access UroToday to get more information. I think my teaching tools are really helpful to really explain more about how to do these exercises.
Also, we do have some information on different research that I've been as far as teaching about urinary incontinence and bladder control strategies, and you can download these resources. I also put up some audio education files. When I was in practice, what I would do after I taught men how to do these exercises, I would actually have them download an MP3 file on their iPhone or on their Android, and actually they could practice the exercises by following an exercise session, and this can be extremely helpful. So I really recommend that you go and download these.
And I actually, on this next slide, give you the URL to download these MP3 audio files because they provide five-minute muscle training. They're very short, but it walks you through a pelvic floor muscle training. So I think these can be very helpful. I'll leave this on for a little bit if you want to just put your phone up and download this QR code because it takes you directly to where you can download these files.
So thank you for listening to this. This was a very short review of pelvic floor muscle rehabilitation—how to work your pelvic floor muscles. UroToday is a great resource for this, so I hope that you do access the website. A lot of good information, a lot of the research in this area on prostate cancer, as well as what to do if you develop any problems after any type of treatment for your prostate. Thank you very much.
Diane Newman: Welcome. I'm Diane Newman. I'm a urology nurse practitioner. I've been practicing for many years. I'm also President of Digital Science Press and Medical Director of UroToday. I was at the University of Pennsylvania for three years as an adjunct professor of surgery.
And at that time, I saw many men who underwent prostate surgery, either for BPH or for cancer. And I thought that this presentation would be very helpful. So I'm going to talk about pelvic muscle rehabilitation after prostatectomy.
So let's start with some definitions. Urinary incontinence is the involuntary loss of urine. Sometimes, people call this bladder leaks or accidental urine loss. There are usually two types that we see in patients and in men who may have post-prostate cancer or prostate surgery—stress urinary incontinence, which is incontinence on effort or exertion after physical activity. And a lot of times, this is small episodic incontinence, which means it could be in drops that may occur.
Like I hear men tell me when they swing a golf swing, that type of thing, or cough or laugh. Urgency urinary incontinence is usually due to bladder overactivity when the entire bladder contents will leak out, and usually, it's preceded by bladder urgency.
Now, when we look at post-prostatectomy urinary incontinence, prevalence ranges from 2 to 90%. Initially after the surgery, it is transient and usually improves within two to three months. However, incontinence is a very feared complication, and it is an independent predictor of quality of life.
It does decrease over time, and up to one year after surgery, continence—which means no incontinence, you're dry—can range from 60 to 97% in 12 months. So it does get significantly better, but 5% to 20% will continue to have some degree of incontinence one to two years after surgery.
Now, men—there's a really good study that came out in JAMA several years ago. And in the read on this slide, I show you who they looked at, men who were under active surveillance, who had nerve-sparing prostatectomy, external beam radiation therapy, low-dose-rate brachytherapy, or men with favorable disease that were treated with prostatectomy or external beam with ADT therapy if they had unfavorable-risk disease.
And some of the key things from this study is that men who underwent prostate cancer surgery reported clinically meaningful worse incontinence through five years compared with other options. And men undergoing prostatectomy for unfavorable disease reported worse sexual function in five years compared to men who underwent radiation with ADT.
And the other thing that we should think about, though, too, that men will report is at least a third will develop bladder overactivity and that may be accompanied, of course, with urgency incontinence. And this is a predominant cause of incontinence in about 6% out of 83% of men. Additional symptoms we also see is bladder urgency and frequency. Now, this is probably due to low urethral compliance, which is noted in 30.1% of cases and usually associated with scarring. And what's important to know is that we have changed now to robotic prostatectomies, but we haven't really seen the incontinence rates change.
I want to emphasize here is pelvic floor muscle training or pelvic rehabilitation. And on this slide, I show you the different references that really support the fact that this can be very helpful. We also have recommendations from the International Consultation on Incontinence that came out in 2023, and it's on adult conservative management committee.
And basically, they gave a very good grade rating for this recommendation. And that is that we should instruct men in preoperative pelvic floor muscle training that it can maybe help them with recovery of continence. Also, early post-operative pelvic floor muscle training can also reduce the time to continence after surgery. And the biofeedback may be considered for a subsection of a subgroup of men, and I'll show you some biofeedback that I had used in my practice. Long-term side effects, though, are there in erectile dysfunction.
The AUA/SUFU guideline actually came out with an addendum to their main guideline that came out several years ago, and they do also have recommendations, and they follow the International Consultation on Incontinence. And, as you can see, they're recommending pelvic floor muscle exercises and training prior to radical prostatectomy. And then we should be informing patients about these options, and they should also offer exercises in the immediate post-operative period if the patient is seeking treatment—if the man's seeking treatment after radical prostatectomy, we should offer them. But, as far as mixed urinary incontinence or urgency, frequency, and urgency incontinence, they refer us to the overactive bladder AUA guideline.
This is a picture that shows you the anatomy of that internal urethral sphincter, the proximal prostatic urethra, and the striated muscles that contribute to urinary incontinence. And you can see the arrows that whenever you contract the pelvic floor, how that muscle pulls everything forward so that it really supports the internal and the external urinary sphincter that prevents us from leaking urine. So you can see where the prostate is, and with a prostate surgery, we can see some damage that can occur in that area.
Now, this is a very simple picture of pelvic floor muscles. I showed this in my practice to all my patients, and basically, you can see that the muscle starts in the front at the pelvic bone and slings around. So it goes around the prostate, the urethra, and comes back around the other side. It also surrounds the rectum. And if you train this muscle, it can improve function, tone, strength, and endurance.
It's important to realize that the pelvic floor muscle has voluntary, striated skeletal muscles. And the information on this slide is very important because we have two different types—slow twitch and fast twitch muscle fibers.
So these fibers can stimulate the muscle fiber size so they can hypertrophy. That way, they can get stronger to prevent incontinence. By exercising these different fibers, you can build muscle bulk. And that early improvements in strength can be neuro adaptation, so there may be more motor unit firing. So actually, you can really develop strength there.
Now, what is pelvic floor muscle training? Well, the goal is to improve urethral resistance and urinary control through active exercise of the pelvic floor muscles, as I showed you on that previous picture. And there are three components—you want to identify the proper identification of the muscle, you want to coordinate the muscle contraction, so you have to have equal amounts of time of muscle contractions, or squeezing, and relaxation. You want to do these exercises daily, so you have to plan them.
And then I'll show you about something called a KNACK, which is the use of the muscle prior to the event that may be triggering that incontinence. And that's what this is. And some people call it a stress strategy or the KNACK of doing something. And this is an intentional, strong, fast muscle contraction. You can use it before and after the activity that causes a leakage.
So the concept here is you would like to contract the pelvic floor muscle prior to maybe a cough. I tell men before a golf swing, maybe from going from sitting to standing, if that's when you leak. So if you identify what causes that leak, what triggers it, then you want to contract this muscle.
Timing is key. You want to squeeze before that activity. And if you keep on doing that, it almost becomes a reflex. Your body knows to contract and pull in that muscle.
Now, you can use biofeedback, and there's something called biofeedback-assisted pelvic floor muscle training, and this helps a person find the muscles and shows them if they're squeezing the muscles correctly. And I'll show you some pictures. This is usually using equipment, and it's visual, and it uses a computer screen that records muscle activity, and a monitor so that you can see it.
And here are just some pictures. And this was equipment that I used in my practice at the University of Pennsylvania. This is the Prometheus Group's biofeedback system. I used external skin surface electrodes, and you can see them here around the anus at 10:00 and 4:00.
And then you put a grounder on, and then this is a picture of the patient viewing this muscle contraction. You can see that. And I'll show you some better pictures here.
Here is those type II. These are the fast twitch muscle fibers, so these are quick contractions. We call them quick flicks. They're usually about two seconds in length. And this is his first baseline visit. And then this is four weeks later.
Here, you see someone doing what we call long holds or slow-twitch muscle fiber contractions. And these are like around—we're trying to get him to do 10 seconds. And you can see it starts out good and may fall off a little bit here, but this is the baseline. And look how four weeks later, he's really built that strength in that muscle. So this is kind of visualization you see with biofeedback-assisted pelvic floor muscle training.
Now, to be effective, though, with a training program, you want to be able to isolate the pelvic floor muscle. So you want to be able to—in men, it's really around the anus that they should feel closure around their rectal anus as they contract the pelvic floor muscle. They may move their scrotum or penis. But again, the goal is specific to the patient's ability, and you want to build strength and avoid fatigue.
Now, this is a very old study, and this was done many years ago by Kathy Burgio and Patty Gude. And this was looking at 125 men. And what they did is they just did a single session of biofeedback at least one week pre-op. And you can see that they tested whether they had muscle control, they did daily exercises, and they followed them for six weeks, three months, and six months.
And what they showed here—and you can see this—the first graph, you can see the control with—those are men that did not do any exercises, were not taught to do them pre-op. And then this is the intervention. And you can see that after the catheter was removed, you can see that the intervention group. And then six weeks, and this is the degree of urine leakage.
And, as you can see, as they kept doing the exercises over that period of six months, starting at six weeks, and these were taught pre-surgery, you can see that incontinence in that intervention group just really went down significantly. So that's really, really positive as far as these muscles and what they can do, so that's really good.
Now, there are other options too that also can. For urine leakage, I use the cat in the hat because there are products and devices known to help men if they have leakage. And I've used all these products in my practice. Some are better than others, but there are ways to contain that urine leakage so that you can have a good quality of life and go out and do the activity that you want to do.
Now, what I want to reinforce in this presentation is the fact that we have a lot of resources on UroToday.com, and here's just some of them. I've done quite a bit of education, interviews of individuals who have done, who have practices in this area. There's a lot of patient education, but there are videos and there's also case studies that you can do in these different areas. And I hope that you view access UroToday to get more information. I think my teaching tools are really helpful to really explain more about how to do these exercises.
Also, we do have some information on different research that I've been as far as teaching about urinary incontinence and bladder control strategies, and you can download these resources. I also put up some audio education files. When I was in practice, what I would do after I taught men how to do these exercises, I would actually have them download an MP3 file on their iPhone or on their Android, and actually they could practice the exercises by following an exercise session, and this can be extremely helpful. So I really recommend that you go and download these.
And I actually, on this next slide, give you the URL to download these MP3 audio files because they provide five-minute muscle training. They're very short, but it walks you through a pelvic floor muscle training. So I think these can be very helpful. I'll leave this on for a little bit if you want to just put your phone up and download this QR code because it takes you directly to where you can download these files.
So thank you for listening to this. This was a very short review of pelvic floor muscle rehabilitation—how to work your pelvic floor muscles. UroToday is a great resource for this, so I hope that you do access the website. A lot of good information, a lot of the research in this area on prostate cancer, as well as what to do if you develop any problems after any type of treatment for your prostate. Thank you very much.