Prostate Cancer touches one in eight men and many opt for surgery to the remove the prostate (radical prostatectomy). Other treatments include hormone therapy, radiotherapy and in some instances chemotherapy, largely depending on the stage and grade of cancer. Radical surgery has a 15 year survival rate of almost 90%. However, this life saving surgery can often leave a man suffereing incontinence and erectile dysfunction.
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. Erectile dysfunction can take anywhere between 6 months and 24 months to recover with range of 16% to 80% for recovery rates.
Stress or 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. The prostate serves to function as a valve between the bladder and seminal vesicle preventing semen in the urine and urine in semen. After a radical prostatectomy the removal of the prostate means that the nerves are no longer present and there is no valve to initiate the bladder sphincter to close. As a result there is uncontrolled leakage. Laying down is often the only place where leakage is absent. The mere stress of gravity cn often be enough to initiate leakage.
A complication of prostate surgery is the loss of erections. 3-4 nocturnal erections are common in men and are associated with normal sleeping patterns. The function of this is to ensure the muscles are well perfused with blood and oxygen ensuring continued functionality. Men vary in the number of erections they have in a day depending on levels of arousal and environment. The penis goes through a number of different states depending on circumstances and these are essential for maintaining erectile function. Removal of the prostate also removes the normal stimulus and feedback mechanism for erections. Phosphodiesterase (PDE%) inhibitors can be prescribed by the surgeon or GP. These inhibitors cause the vessels of the erectile tissue to relax, PDE5 is an enzyme normally causing the vessels to contract. In long periods of functional loss the erectile tissue would undergo atrophy and further loss in function. Therefore, maximising blood flow is essential. Not all men respond to inhibitors and a vacuum pump should be offered immediately to ensure no damage to muscles occurs. A physiotherapist can help with identifying the right solution and the patient must engage with the apparatus to ensure maximal recovery. Such solutions can be found with https://www.imedicare.co.uk/en/
Research clearly supports the use of pelvic floor exercises before radical prostatectomy and should be continued after. A phase of 6 weeks pre-operative rehabilitation has been shown to enhance the outcome of patients undergoing surgery. Reduced times for recovery of urine incontinence and erectile dysfunction have been shown.
After surgery pelvic floor muscle rehab should be the mainstay of rehabilitation and patients are taught to become masters of these exercises to control incontinence and also enhance the chances of erectile dysfunction recovery.
The therapist coaches the patient and can use a number of different tools to aid in recovery. At Core Body Clinic we use dynamic ultrasound, palpation and pressure bio-feedback devices. The patient must be taught the correct technique of 'Kegal' where the pelvic floor is lifted and tensed. It is often a frustrating phase for the patient and will take anywhere between 2-8 weeks to master even the basics. Research has been conducted that shows pre-operative exercises to improve the outcome of post-prostatectomy rehabilitation success: click here and here
Below we can see the pelvic floor muscles contract and relax as the patient is taken through the Kegal and Reverse Kegal. This tool is a gold standard in prostate and pelvic pain rehabilitation.
The Ultrasound ensures you are able to control and perform the contraction correctly and is often preferred to more invaisive stimulation tools. Quite often men find it difficult to feel and sense the muscles contracting, even when using stimulators. Ultrasound has the advantage of providing real-time imagery of the pelvic floor muscles so feedback is accurate and tangible.
Exercises can be progressed and more difficult and normal funcitoning exercises can be mastered. The patient will be encouraged to do cardio-vascular exercise to encourage normal pelvic floor activation and weight lifting to expose the pelvis and bladder to stress and strain.
Coaching and psychological support should be offered to ensure the patients stay motivated to perform these often very difficult tasks.