Physiotherapy Treatment After Prostate Cancer

Original Editor - Mandy Roscher Top Contributors - Mandy Roscher, Vidya Acharya, Tarina van der Stockt and Kim Jackson

Introduction

Physiotherapy intervention after Prostate Cancer (PCa) treatment is not always widely implemented. However, appropriate physiotherapy management can have a significant positive impact on a man’s quality of life. The three main goals of Physiotherapy for PCa patients are education, rehabilitation, and referral.

Clinical Reasoning after Assessment

The assessment performed is the most important part of a Physiotherapists interaction with their patient. The specific clinical picture with their symptoms and disabilities and experiences thereof will guide your treatment. Every person’s clinical picture is unique, and a comprehensive assessment is the only way to ensure that they can receive effective management.

Education

Education is based on assessment but usually depends on the type of PCa Rx they had. Every patient is different, but never assume that a patient cannot learn anything new. Your patient may be on top of issues relating to incontinence and erectile dysfunction, or they may be entirely in the dark. Never assume anything.

General Management of Incontinence

Incontinence Pads

Unlike women, men are most likely unfamiliar with sanitary pads. There are specific pads made for incontinence and also more specifically for men. For radical prostatectomy patients, who will most likely have initial incontinence after surgery, it can be helpful to preoperatively prepare them for the use of pads after his catheter is removed postoperatively. [1] It can be beneficial to show them the basics of how they work, how the sticky side sticks onto their underpants, the fact they will need to wear underpants and not boxers to use the pads, and which side should go at the front and back. It can also be helpful to show how they should dispose of them and also prepare them to take a bag and extra packets with them if they go out as men’s public toilets often do not have rubbish bins in the stalls. Men have generally not used sanitary pads before and depending on the openness of the women in their household, they may never have seen them being used before.

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Clothing

Simple advice such as wearing darker coloured shorts or long pants that may not show fluid can also be helpful in case of an accident of leakage of urine. [1]

What to drink/what not to

Certain fluids and foods can attribute to the worsening of symptoms. Coffee, green tea, and beer are examples of fluids that may increase symptoms of incontinence.

General Sexual Rehabilitation

The rehabilitation of a man’s sexual dysfunction requires a multi-disciplinary approach. It is a complex process involving pharmacological, physical and behavioural treatments and needs to be undertaken by appropriately trained professionals.[3][4]. Penile health relies on regular erections (a man will normally have between 5-8 nocturnal erection every night). The blood flows into the penis during an erection encourages oxygenation into the cavernosal sinuses as well as mobility of the connective tissue and smooth muscle of the penis.[5]

Use of medication to attain an erection

Erection enhancing medications are encouraged during and after the rehabilitative phases, especially as it promotes good circulation and tissue health in the penis.[5] There are a variety of erection-enhancing medications, each with their own mechanism of action. Intracavernosal injections to promote an erection can also be used. The description and prescription of medication and injections do not fall into the scope of this page.

Vacuum Erection Device (VED)

A vacuum erection device is a device used to create an erection manually. It consists of a cylinder with a pump that fits over the entire penis, and a constrictive band that fits around the base of the penis. The pump creates a vacuum effect that allows the penis to become engorged and the constrictive band maintains this.

The use of a VED may be the key to maintaining penile tissue length during the rehabilitative phase. It encourages blood flow to the penis and maintains the connective tissue extensibility as well as smooth muscle integrity. Using a VED may also enable a patient to obtain an erection with enough rigidity to achieve penetration and promote a healthy return to sexual function.[5] More research in this field is required.[5]

Psychological Counselling

A diagnosis of cancer is in itself, a significant cause of psychological distress. Pair that with disabling side effects of incontinence and sexual dysfunction from the treatment for cancer and the need for psychological support and counselling is essential in a holistic approach to treatment.[5] While physiotherapy interventions may help a significant amount of men, it is also important to remember that recovery is very dependent on the severity of cancer as well as the treatment they received. Treatment to cure a very severe cancer can often leave a man with severe side effects of sexual dysfunction and incontinence from which they are unable to recover. A lot of men are grateful that their life has been spared and can learn to deal with their disability, but in other men, it can result in depression and other mental health conditions.

50% of men suffer from depression 1 year after their prostate surgery[6]. 50% of patients undergoing RT have ED after five years[7]. In the long term, men who have undergone prostatectomy surgery will continue to suffer from Sexual Dysfunction, Depression and Anxiety. Understanding the impact of the anticipated side effects, like erectile dysfunction, and assisting patients with treating erectile dysfunction, is imperative to treatment satisfaction. Healthcare providers can improve care and promote intimacy for the man and his partner by providing comprehensive information about sexual issues throughout and after treatment and providing resources addressing sexual dysfunction and depression and anxiety. [8]

Peyronies Disease

Peyronies disease "is a symptomatic disorder characterised by a variety of penile symptoms including pain, curvature, shortening, narrowing, indentation, hinge deformity, palpable plaque and erectile dysfunction (ED)".[9] There is a development of a plaque within the penis that results in the curvature. Treatment options for this disease have historically been invasive and painful. Joanne Milios, a physiotherapist in Australia, has been researching the use of therapeutic ultrasound for the use of Peyronies disease and the findings from her randomised control trial of 43 men show that the use of therapeutic ultrasound as a treatment for Peyronies disease results in reduced penile pain, improved penile deformity and increased erectile function.[9] At present these results have not been published in a peer-reviewed journal and form part of Milios's Thesis Document.

Pelvic Floor Muscle Rehabilitation

Verbal Cues to contract the Pelvic Floor

Pelvic floor exercises are all about technique. With optimal motor learning of the pelvic floor, there is more potential for improved continence and erectile function.[10] An optimal pelvic floor contraction requires closure and lift of the pelvic floor muscles.

Recent research by Stafford et al. (2016) showed that verbal cues can alter the degree of motion observable in various pelvic floor muscles. The muscles closest to the urethra itself (i.e. bulbocavernosus and striated urethral sphincter muscles) have an optimal mechanical role in developing urethral closure pressure compared to the more distant levator ani muscle.[10]

Commonly used phrases to help elicit pelvic floor contractions in men are “shorten the penis”, “elevate the bladder”, “elevate the scrotum”, “stop the flow of urine” and “tighten the anus” [10]. Stafford et al. conducted a study in asymptomatic participants and in patients suffering from incontinence the cues “shorten the penis” and “stop the flow of urine” were considered the best to target the specific muscles involved in urinary continence. A journal club held in 2015 with Men’s Health Physiotherapists concluded that while those instructions are helpful, everyone is unique and respond differently to the various instructions. It is best to customise your instruction to each patient and try different methods.[11] They also suggested that for men, particularly in the prostatectomy population, where penile shortening is a side effect of treatment, the cue “shorten your penis” may be distressing.[11] A popular colloquial cue rather than “lift your scrotum” that men seem to respond well to is “nuts to gut.” This cue particularly targets the important lifting action of the pelvic floor.
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Preoperative Pelvic Floor Exercises

Strengthening the pelvic floor muscles before a prostatectomy was shown to significantly improve post-prostatectomy urinary continence, post-micturition dribble and erectile function.[13] It would be prudent for all men to exercise their pelvic floor muscles preoperatively to maintain normal pelvic floor function postoperatively. One study reported that 18% of patients who received pre-op pelvic floor muscle rehab before their prostate surgery reported sexual bother at 1 year vs 66 % of men who did NOT receive pre-op pelvic floor muscle rehab.[14] Acquisition of early motor skills are achievable within a clinically reasonable amount of time and are more likely to be successful if conducted before prostate surgery.[15]

Pelvic Floor Muscle Training for Erectile Dysfunction (ED)

Physiotherapy has repeatedly been proved successful in treating ED of various etiologies. It is cost-effective, non-invasive, and straightforward and could be used as a first-line approach[4]. A weak pelvic floor, as well as a pelvic floor in spasm, can both contribute to erectile dysfunction, and it is important to determine the exact cause before giving pelvic floor strengthening. Strengthening exercises given to someone with a pelvic floor in spasm will exacerbate symptoms.[4]

Some concepts of how pelvic floor physiotherapy for ED works

  • Improving the strength of the ischiocavernosus muscle could potentially help increase the intracavernosal pressure to improve the rigidity of the erection.[16].
  • Spasm in the pelvic floor can restrict blood flow to the penis, thereby reducing erectile function. By teaching relaxation of the pelvic floor and possibly performing manual release of the muscles (through internal release) blood flow can improve, thereby improving erectile function.[4][16]
  • This field has not yet been extensively researched, but it has also been proposed that relaxation of the bulbospongiosus and ischiocavernosus could help inhibit the ejaculation reflex to help men with issues of premature ejaculation.[16]

Pelvic Floor Muscle Training for Incontinence

Pelvic Floor Muscle Training Programme

Hodges et al have proposed a specific training programme to optimise pelvic floor function in the treatment of incontinence post-prostatectomy:[17]

Goal 1: Optimise the pattern of pelvic floor muscle contraction[17]

This stage includes making sure the correct muscles are being engaged. This involves using the correct verbal cues, using feedback techniques such as EMG biofeedback, real-time ultrasound, visual analysis or palpation.

Goal 2: [17] control into function[17]

It is very important to progress to functional as soon as they are able to contract and relax their pelvic floor muscle correctly. Pelvic floor muscles need to be exercised in a variety of contexts and specific to the individual's problems. If a man is experiencing leaking when he moves from sitting to standing, it would be prudent to practice pelvic floor muscle contractions during that activity.

Goal 3: Bladder training[17]

Bladder training is important to maintain bladder compliance and volume. Men often restrict fluids to avoid having urine to leak or else they go to the toilet frequently “just in case”. Both these strategies are harmful to bladder health, and a comprehensive bladder training programme should be implemented from early on.

Goal 4: Low-intensity tonic hold training for sustained tasks[17]

For men post-prostatectomy, the striated muscle (external sphincter) has to learn to maintain the low-intensity hold that the internal sphincter was mostly responsible for prior to its removal. This is especially important for later in the day when general fatigue sets in and leakage is often worse. Low load training involving slow and tonic contractions will help train this muscle.

Goal 5: High-level strength and endurance training for high intensity[17]

This stage involves improving the strength of the contraction, endurance of the contraction, as well as the speed of the contraction

Goal 6: High-performance training for demand and unexpected challenges[17]

The final stage is incorporating pelvic floor rehabilitation into high demand activities that involve increased intra-abdominal pressure with whole-body exercise specific to the individual's needs.

Additional considerations to optimise results[17]

  • Pelvic floor rehabilitation is not a passive intervention and to see improvements patients need to adhere to the exercises
  • Any bowel dysfunction must be managed as this negatively impacts the pelvic floor and bladder
  • Any issues of mental health must be addressed
  • General exercise is very important and has been shown to improve outcomes
  • Weight loss is important in overweight men as obesity has been linked to poorer outcomes

Additional Videos and Podcasts

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Webinar Series on Pelvic Floor Rehabilitation for Post Prostatectomy Incontinence

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References

  1. 1.0 1.1 Milios JE. Therapeutic interventions for patients with prostate cancer undergoing radical prostatectomy: A focus on urinary incontinence, erectile dysfunction and Peyronie’s disease. Thesis Document University of Western Australia. 2019
  2. drummerussProstatectomy guide to incontinence pads Available from https://www.youtube.com/watch?v=NwOIB7pzz-U&feature=emb_logo
  3. Salonia A, Adaikan G, Buvat J, Carrier S, El-Meliegy A, Hatzimouratidis K, McCullough A, Morgentaler A, Torres LO, Khera M. Sexual rehabilitation after treatment for prostate cancer—part 1: recommendations from the Fourth International Consultation for Sexual Medicine (ICSM 2015). The journal of sexual medicine. 2017 Mar 1;14(3):285-96.
  4. 4.0 4.1 4.2 4.3 Rudolph E, Boffard C, Raath C. Pelvic Floor Physical Therapy for Erectile Dysfunction—Fact or Fallacy?. The journal of sexual medicine. 2017 Jun 1;14(6):765-6.
  5. 5.0 5.1 5.2 5.3 5.4 Salonia A, Adaikan G, Buvat J, Carrier S, El-Meliegy A, Hatzimouratidis K, McCullough A, Morgentaler A, Torres LO, Khera M. Sexual rehabilitation after treatment for prostate cancer—part 2: recommendations from the Fourth International Consultation for Sexual Medicine (ICSM 2015). The journal of sexual medicine. 2017 Mar 1;14(3):297-315.
  6. Teloken PE, Mulhall JP. Erectile function following prostate cancer treatment: factors predicting recovery. Sexual medicine reviews. 2013 Jul 1;1(2):91-103.
  7. Gaither TW, Awad MA, Osterberg EC, Murphy GP, Allen IE, Chang A, Rosen RC, Breyer BN. The natural history of erectile dysfunction after prostatic radiotherapy: a systematic review and meta-analysis. The journal of sexual medicine. 2017 Sep 1;14(9):1071-8.
  8. Albaugh JA, Sufrin N, Lapin BR, Petkewicz J, Tenfelde S. Life after prostate cancer treatment: a mixed methods study of the experiences of men with sexual dysfunction and their partners. BMC urology. 2017 Dec;17(1):45.
  9. 9.0 9.1 Milios JE. Therapeutic interventions for patients with prostate cancer undergoing radical prostatectomy: A focus on urinary incontinence, erectile dysfunction and Peyronie’s disease. Thesis Document University of Western Australia. 2019
  10. 10.0 10.1 10.2 Stafford RE, Ashton‐Miller JA, Constantinou C, Coughlin G, Lutton NJ, Hodges PW. Pattern of activation of pelvic floor muscles in men differs with verbal instructions. Neurourology and urodynamics. 2016 Apr;35(4):457-63.
  11. 11.0 11.1 Shelley B et al Summary of Pelvic PT Distance Journal Club - Male Study Group 2015 (Accessed 20 Feb 2020) https://www.bethshelly.com/docs/Summary-of-male-info-11-8-15.pdf
  12. Michelle Kenway How to Kegel for Men - Professional Guide to Effective Kegel Strength Exerciseshttps://www.youtube.com/watch?time_continue=1&v=dSqK4_3YSMI&feature=emb_logo
  13. Goonewardene SS, Gillatt D, Persad R. A systematic review of PFE pre-prostatectomy. Journal of robotic surgery. 2018 Sep 1;12(3):397-400.
  14. Teloken PE, Mulhall JP. Erectile function following prostate cancer treatment: factors predicting recovery. Sexual medicine reviews. 2013 Jul 1;1(2):91-103.
  15. Doorbar-Baptist S, Adams R, Rebbeck T. Ultrasound-based motor control training for the pelvic floor pre-and post-prostatectomy: Scoring reliability and skill acquisition. Physiotherapy theory and practice. 2017 Apr 3;33(4):296-302.
  16. 16.0 16.1 16.2 Cohen D, Gonzalez J, Goldstein I. The role of pelvic floor muscles in male sexual dysfunction and pelvic pain. Sexual medicine reviews. 2016 Jan 1;4(1):53-62.
  17. 17.0 17.1 17.2 17.3 17.4 17.5 17.6 17.7 17.8 Hodges PW, Stafford RE, Hall L, Neumann P, Morrison S, Frawley H, Doorbar-Baptist S, Nahon I, Crow J, Thompson J, Cameron AP. Reconsideration of pelvic floor muscle training to prevent and treat incontinence after radical prostatectomy. InUrologic Oncology: Seminars and Original Investigations 2019 Dec 25. Elsevier.
  18. Continence Foundation of AustraliaProstate Cancer surgery and pelvic floor exercises. Available from https://www.youtube.com/watch?v=E0U7x_oiyO0&feature=emb_logo
  19. ProstateCancerCanada Pelvic Floor Rehabilitation for Post Prostatectomy Incontinence (1/3) with Bill Landry Available fromhttps://www.youtube.com/watch?time_continue=1&v=U10K6V-hAKs&feature=emb_logo
  20. ProstateCancerCanada Pelvic Floor Rehabilitation for Post Prostatectomy Incontinence (2/3) with Bill Landry Available fromhttps://www.youtube.com/watch?v=rPe6eQyaQ4k&feature=emb_logo
  21. ProstateCancerCanadaExpert Angle: Pelvic Floor Rehabilitation for Post Prostatectomy Incontinence (3/3) with Bill Landry. Available fromhttps://www.youtube.com/watch?time_continue=9&v=Ngj7ymhedts&feature=emb_logo