Physical Therapy Can Help Men Before and After Prostate Cancer Surgery by Sabina K. Weaver, MSPT

What it is:
Prostate cancer is a cancer or uncontrollable growing of cells in the prostate gland, while Prostatitis is inflammation of the prostate gland. The prostate gland is a walnut-sized gland present only in men, found in the pelvis below the bladder. One in seven men will be diagnosed with prostate cancer in his life. Prostate cancer is one of the most common types of cancer that develops in men and is the third leading cause of cancer deaths in American men. Since prostate specific antigen (PSA) screening for prostate cancer became widely used, men are being diagnosed younger and with more limited spread of disease. Last month, the USPSTF upgraded its recommendation for screening men ages 55-69. The task force previously recommended that men not be screened for prostate cancer using (PSA) tests.  Now the recommendation is that men ages 55-69 discuss their risk factors with their doctor and decide if PSA testing would be beneficial on an individual basis. African American men and men with a family history of prostate cancer are at higher risk for prostate cancer and may need closer monitoring. The USPSTF still does not recommend PSA screening for men over the age of 70 because they feel the possible harm outweighs the benefits. One in seven men will be diagnosed with prostate cancer in his lifetime. Will this number be affected by the recent change in the U.S. Preventive Services Task Force’s change in recommendations on screening for prostate cancer? What happens when a man has his prostate removed? Is it possible to predict, prevent, or repair urinary incontinence and erectile dysfunction?
 
 
Signs and symptoms after surgery:
Urinary Control  
One year after surgery, 89-100% of men who had robot assisted laparoscopic prostatectomy are using 0-1 pads for incontinence.   Of men who had open radical retropubic prostatectomy, 80-97% are using 0-1 pads for incontinence. Risk for incontinence increases when the man is over 70 years old or has detrusor overactivity (overactive bladder) before surgery and if the surgeon uses certain surgical techniques or does not have a lot of experience. The prostate surrounds the urethra and supports it to help control urination. After prostatectomy, the pelvic floor muscles have to work overtime to make up for the loss of support. If they are not up for the challenge, urine can leak. Coughing, laughing, sneezing, jumping, or getting up from a chair can be especially challenging for the muscles to control. If leaks only occur during these activities, it is called stress urinary incontinence. Pelvic floor PT before and after surgery can help train the pelvic floor muscles to reduce incontinence. ³ The body is asking the muscles to do something they have never had to do before, so average muscles need conditioning to bulk them up (think bodybuilder’s bulky muscles) and support the urethra.  Strength, endurance, and coordination training for the pelvic floor help prevent leaks. MRI images comparing pelvic muscles before and after recovering from incontinence showed that pelvic muscles were thicker and the bladder neck was moved higher and forward after they regained continence. ³

Ejaculation  
The prostate, along with the testicles and seminal vesicles, create secretions for ejaculation. After prostatectomy, the prostate and seminal vesicles are not there to create fluid, so these men have dry orgasms.  
 
  
Pelvic Floor PT:
Additionally, about 50% of the men who have prostate cancer have some kind of pelvic muscle dysfunction or weakness. Men’s pelvic floor muscles are shaped like a hammock that attach to the front, side, and back of the pelvic bone and sacrum. These muscles that support the bladder, prostate, and rectum can become weak or subject to spasm due to surgery, trauma, or disease. Pelvic floor rehabilitation offers an alternative treatment for prostatitis/chronic pelvic pain syndrome. Physical Therapists can work with men who are experiencing pain in their pelvic region, penis, or testicles. Pelvic floor rehabilitation for prostatitis or post-prostatectomy can be useful for men that are also experiencing urinary urgency and frequency, urinary incontinence and erectile dysfunction.
 
What we do/interventions:
Physical Therapy and pelvic floor rehabilitation for post-prostatectomy and prostatitis can have a big impact and target different areas depending on the problem. To better evaluate a patient and figure out a specific plan, most therapists will perform a manual pelvic floor exam and a biofeedback testing using surface EMG pads which helps men learn how to properly contract and lift their pelvic floor. Included is a good exam of hip and lower back and core flexibility and strength assessment. These assessments can tell a therapist about the patient’s pelvic floor muscle dysfunction and recommend specific treatment to fit that patient’s needs. Treatments may vary from patients to patient, but some may include biofeedback, myofascial release, trigger point release therapy, postural exercises, manual therapy, relaxation exercises, stress management techniques, and cognitive behavioral therapy for bladder and bowel training.  Different treatments target different areas such as muscle tension, muscle strengthening, pain, inflammation, and blood flow.
 
 
Case report
 
Eli was a 69 yo male who came to pelvic floor PT three months after radical laparoscopic prostatectomy with urinary incontinence and erectile dysfunction. He presented with moderate pelvic floor strength and endurance, and was not sexually active. Surgery led to lack of urethral support and control, weakness in the abdominal wall, and nerve injury resulting in urinary incontinence and erectile dysfunction. His goals were to decrease the amount of urine leaking and possibly regain an erection. We taught him various exercises for his pelvic floor and proper core stabilization exercises to make them perfectly strong and bulky enough to support the urethra, which helped decrease his incontinence. We also did training on bladder and gut health and reviewed his bladder diary and taught him proper dietary concerns which helped his bladder retrain to gain more bladder control. We also helped him with correcting his posture and teaching proper body mechanics which helped him to do simple activities such as sit to stand without leakage and sneeze cough or lift without leakage.  He later joined a prostate support group.  
 
After beginning physical therapy and with about 4 visits he was only using one Depends per day, which was not very wet, instead of three completely soaked Depends. His strength and endurance were perfect. He ranked his improvement as eight out of ten. He had a satisfying sex life even though his erection did not come back. After about 6 sessions, he was able to do ADLS and enjoy other activities without the use of the pad and was very happy with his outcomes.
 
Prostate cancer affects the body and mind in different ways.  Physical therapy is useful after prostatectomy to improve urinary continence and erectile dysfunction. If you have been through treatment for prostate cancer and have urinary incontinence and/or erectile dysfunction, find a pelvic floor physical therapist who is comfortable and trained with working with this population. Not all pelvic floor PT’s are trained to work with men.
 
 
References:

Clavell-Hernandez J and Wang R. The controversy surrounding penile rehabilitation after radical prostatectomy. Transl Androl Urol 2017;6(1):2-11.doi: 10.21037/tau.2016.08.14.
Mangir N and Turkeri L. Stem cell therapies in post-prostatectomy erectile dysfunction: a critical review.Can J Urol 2017;24(1):8609-8619.
Pacik D and Fedorko M. Literature review of factors affecting continence after radical prostatectomy. Saudi Med J 2-17;38(1):9-17. Doi: 10.15537/smj.2017.1.15293.
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
Glickman C and Emirzian A. The Ultimate Guide to Prostate Pleasure. Berkeley:Cleis Press, 2013.
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