Prostate Cancer touches one in eight men and many receive surgery for the removal of the prostate and adjacent cancer cells or radiation treatment. The prostate does go through a process of hypertrophy (increase in size) in pretty much all men and may not develop or show cancer cell presence (the PSA level can be checked by your GP and is usually routine after 50 years of age). A TURP (Transurethral resection of the Prostate) can be performed if it is getting in the way. Because of an increase in size this squeezes the urethra (tube under the bladder) causing problems with having a wee. If this is the case SEE THE GP!
The prostate is a gland and it is a male reproductive organ. The size of a walnut it sits at the base of the bladder. The urethra is a thin tube carrying both semen and urine out of the penis and runs through the centre of the prostate gland. A ring of muscles known as the bladder neck sphincter is situated at the junction between the Urethra and Bladder. It open and shuts, almost like a camera-shutter. The bladder sphincter is prevents the leaking of urine and is therefore closed most of the time. Signals from the brain opens the sphincter neck and allows urine to pass. The pelvic floor muscles also help control the bladder. They are formed by another set of muscles below the prostate and can be through of as an external sphincter.
Prostate surgery (prostatectomy) can be followed by bladder weakness, urinary incontinence and/or erectile dysfunction. These are very common and they can present a huge challenge for men. While the intention of the surgeon is to spare the tightly packed nerves around the prostate there is often unavoidable disruption and damage to the nerves. Nerves supply the muscles and therefore things stop working in an optimal fashion. Most men regain bladder control over time and are often fully recovered within 6 to 12 months. Physiotherapy can really help and it is important to get professional advice to help cope with bladder weakness during this time.
Symptoms of incontinence
Stress of strain to the abdominal and pelvic region increases intra-abdominal pressure. This causes a downward force on the bladder and exerts pressure on the sphincter neck. The inadequacy of the muscles due to loss of nerve function means that they are not able to react and leakage can occur. This is stress incontinence. It may happen with sneezing, coughing, heavy lifting and other activities that cause and increase in bladder/sphincter pressure.
Incontinence can be more profound and sometimes require the wearing of pads or a catheter. However, these are more extreme cases.
Urgency, not emptying and non initiation
When the prostate increases in size it will prevent the flow of urine through the urethra. This means that the bladder may not be able to empty, there may be symptoms of not being able to initiate the passing of urine and ther will be a feeling of not being empty. This can result in several trips to the toilet. The common feeling is of wanting to lean forward to squeeze the urine out but this further restricts flow by kinking the urethra. A simple way to overcome this is to lean backwards and relax, allowing the pelvis to come forwards. This tilts the angle of the urethra and can open up the bladder sphincter. Of course, if you have problems then get it checked 1st!
Increasing the strength of the pelvic floor helps to reduce leakage and this should be a priority for patients undergoing prostate surgery. Looking to strengthen these muscles before your operation can help you identify where the muscles are, increase their strength and therefore nerve activation, and give you a ‘heads up’ on what to expect post-operatively. Most men recover given time but seeing a health professional like a physiotherapist can help greatly.
Physiotherapy should be a matter of course after prostate treatment but some patients still experience symptoms and may also develop non-specific pain syndromes.
Treatment can start BEFORE the operation and emerging evidence suggests that we can get patients back to a more normal functioning situation if ‘pre-habilitation’ is undertaken. It may also reduce the period of physiotherapy post-prostate treatment.
Treatment can include Pelvic floor training
Finding the pelvic floor
Learn how to activate and relax the muscles
General core and hip strengthening
Gym program to engage pelvic floor muscles
General fitness program
Another problem accompanying incontinence is the strain on psychological wellbeing. There is often worry and anxiety about leaking in public, the embarrassment of having wet underwear and the potential smell of urine. Patients can become isolated, loose self esteem and may disengage from engaging in physical activity or social events. This can cause significant emotional stress for the individual and also their partners or family. Appropriate counselling is an essential component in rehabilitation and should be sought to ease concerns. Setting appropriate goals and educating one’s self can help tremendously.
Erectile dysfunction describes a condition where an erection is either not possible or is not sufficient for the desired task of sexual activity. It is a condition that can have multiple causes and therefore you must discuss with the GP. They will look for all medical reasons for this problem and advise you accordingly, conducting tests where necessary. We know that smoking, alcohol, a poor diet and lack of exercise can have an impact (for some) on erectile dysfunction.
Where a pelvic pain condition is deemed to be the cause or prostate treatment has been undertaken there will often be weakness in the pelvic floor with the inability to ‘let go’ or activate the pelvic floor. Stained or inactive muscles reduces blood flow or prevents the appropriate flow of blood to the area. The result is a poor or absent erection. It is important to consider that if there is a pelvic pain component then there is often a need to assess the wider pelvis, lumbar spine and lower groin.
Physiotherapy can help by:
- Removal of aggravating factors
- Consideration of life style: Alcohol, smoking, diet, exercise.
- Manual therapy treatment to your low back and pelvis, getting the joints moving correctly
- Trigger point therapy: Getting the muscles working properly and rid of the overactive parts in both the low back muscles, hip muscles and pelvic floor muscles. You will also be taught how to do this yourself also.
- Pelvic floor exercises to release your pelvic floor
- Specific hip, spine and pelvis exercises to get you and your pelvic floor moving better, think yoga poses and squatting
- Specialised Breathing and relaxation work
- Re-education of the pelvic floor, hip and abdominal musculature
- General exercise
We often recommend involving your partner as this will help with marital or relationship problems and in some cases can greatly expedite your recovery. In some cases we will suggest you see a counsellor as this can be hugely beneficial. Our minds and body are connected and we know about the harms that stress and anxiety can bring.