Pelvic floor physical therapy helps men after prostatectomy

What would Prostate Cancer Awareness month be without a blog about prostate cancer? 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?

U.S. Preventive Services Task Force’s (USPSTF) Recommendations on Screening for Prostate Cancer

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.

Post-Prostatectomy

Now switching gears, let’s talk about when prostate cancer screenings are positive. Your doctor may say, “It has got to go!” Depending on the cancer, an oncologist may recommend radical prostatectomy, a surgery to remove the whole prostate. Luckily, prostatectomy is very effective at getting rid of many prostate cancers, but let’s look at life without a prostate.

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 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

Sometimes the weakness is also in the middle of the abdominal wall, called diastasis recti. This is common after robotic/laparoscopic surgeries and also during pregnancy; in fact Malinda wrote a blog all about it here. Basically, it is a weakness in the abdominal wall which has been associated with difficulty getting good closure of the urethra. Think of it like stepping on a garden hose to stop the flow.  If the abdominal wall is weak, then it is like stepping on a garden hose on a trampoline; you can’t get good closure. Pelvic PTs also strengthen the abs.

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. 

Erections and Penile Rehab

Erections are a common concern for men after prostate surgery because the nerves responsible for erectile function are often injured during surgery, even if it is a nerve-sparing surgery (meaning the nerve is not cut). Radiation therapy also can decrease quality of erections. Erectile dysfunction (ED) is less prevalent in men that are younger, fully potent before surgery, and healthy. Use of robot assisted, athermal dissection, and nerve-sparing surgical techniques also result in less ED.¹ Nerves are very slow to recover, so men can regain erectile function for up to two years after surgery. Nerves need a lot of oxygen, so the best thing to do for a recovering nerve is to supply it with a lot of oxygenated blood.¹ Can anyone think of a great way to get blood to a penis? You guessed it – have an erection! Does anyone else see a problem here? Men with erectile dysfunction aren’t having erections, so they aren’t getting good blood flow to the nerves, which is not optimal for nerve healing, which does not improve erection quality….To stop this never ending spiral, let’s talk about what is known as, penile rehabilitation. Men can still have arousal and orgasm without erection, and this brings some blood flow to the area, so it’s a good idea to continue sexual activity.  Use it or lose it! Check out my previous blog on sex after prostate cancer. Phosphodiesterase 5 inhibitors (PDE5-Is), such as Viagra, Cialis, and Levitra, relax the smooth muscles of the penis resulting in increased blood flow and possible erection. Studies show that using PDE5-Is on-demand improved erectile function, and daily use also preserved penis length.¹ Research has also found intraurethral alprostadil (IUA) and intracavernosal injection therapy (ICI) to be effective and even more useful when therapy is started soon after surgery.  Vibratory stimulation of the pudendal nerves in the penis can cause a reflexive erection. Vacuum erection devices do not require functioning nerves to create an erection, and can be used to increase oxygenated blood flow to the tissues and prevent fibrosis which leads to ED and shortened penile length.¹ Animal models have also shown success with using stem cell therapy to repair damaged tissue and improve erection quality.² Stay tuned to this blog for the next two weeks to learn more about erectile dysfunction.

Case report

Eli was a 69 yo male who came to PT three months after radical laparoscopic prostatectomy with urinary incontinence and erectile dysfunction. He presented with moderate pelvic floor strength and endurance, a small diastasis recti, 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. I taught him various exercises for his pelvic floor and abs to make them perfectly strong and bulky enough to support the urethra, which helped decrease his incontinence. I also discussed his options for increasing blood flow to the nerves supplying the penis to help recover nerve function and erection. After many months, he spoke to his doctor and tried a vacuum device, a PDE5-I, and injections. He later joined a prostate support group. 

A year after beginning physical therapy, 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. He did have a delayed start to using the vacuum device, PDE5-I, and injections and remember, it can take up to two years for nerves to recover. He will continue to attempt erections regularly to improve blood flow for the next year and then as desired after that.

Pelvic PT

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 physical therapist here.

References:

1. 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.
2. Mangir N and Turkeri L. Stem cell therapies in post-prostatectomy erectile dysfunction: a critical review.Can J Urol 2017;24(1):8609-8619.
3. 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.
4. 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
5. Glickman C and Emirzian A. The Ultimate Guide to Prostate Pleasure. Berkeley:Cleis Press, 2013.