The Frequency of Post-Radical Prostatectomy Incontinence
November is Movember -- Men’s Health Awareness Month. This article focuses on male urinary incontinence and erectile dysfunction following a radical prostatectomy, two diagnoses that incorporate pelvic floor physical therapy as part of the care team.
The incidence rate of post-radical prostatectomy incontinence can range from 2.5–90% depending on the definition for urinary continence. While some studies define continence by using 0-1 incontinence pads per day, others define it as 0 incontinence pads used per day, for a full week. On average, after robotic-assisted radical prostatectomy, rates of incontinence at a 12-month follow-up are 20.2% (where incontinence is defined as 0-1 pad per day)1.
What causes Post-Radical Prostatectomy Incontinence?
Continence is controlled by the connective tissue, pudendal nerves, and muscles of the pelvic floor. The main muscles in charge of maintaining continence are the urethral sphincters (internal and external), puborectalis (of the levator ani muscle group), and suspensory ligaments. After radical prostatectomy, a portion of the internal urethral sphincter muscles, as well as the suspensory ligaments, are removed. This means that continence relies more heavily on the external urethral sphincter and other pelvic floor muscles to compensate for the loss of sphincter muscle mass and the prostate, which also aids in maintaining continence. It is also possible for the pudendal nerve fibers which innervate the urethral sphincters to be damaged during surgery or from cancer, which may impact their functionality1.
Possible Types of Urinary Incontinence after Radical Prostatectomy
Post-radical prostatectomy incontinence is broken into three types of urinary incontinence:
stress urinary incontinence (intrinsic urethral sphincter deficiency, also known as SUI), detrusor overactivity and/or reduced bladder compliance (urge urinary incontinence, also known as UUI), or a combination of stress and urge urinary incontinence (mixed urinary incontinence also known as MUI).
- stress urinary incontinence (SUI)
- urge urinary incontinence (UUI)
- mixed urinary incontinence (MUI), a combination of SUI & UUI
Stress urinary incontinence happens with exertion such as lifting a weighted object, standing up, coughing/ sneezing, but can even occur while lying down. Urge urinary incontinence happens when the bladder muscle (detrusor) contracts too soon or is not able to stretch enough to accommodate a normal volume of urine during bladder filling. When this happens, the force of the bladder squeezing overcomes the ability of the pelvic floor muscles to constrict (close) the urethra to maintain continence.
Pre- and Post-operative Physical Therapy and Treatment Options for Radical Prostatectomy:
What to Expect and Effectiveness
A structured, targeted and coordinated prehabilitation [prior to radical prostatectomy] exercise program can result in beneficial adaptations at the individual muscle level and across the cardiovascular, respiratory, musculoskeletal, neurological, metabolic, and endocrine systems, as well as improve stress and anxiety levels, and decrease disability and time away from work.” -Mungovan SF
At your initial session and post-operatively, your licensed and specially trained pelvic floor physical therapist will inquire about your symptoms, medical history, discuss your goals and current functioning, check your baseline pelvic floor muscle coordination, strength, and endurance as well as the strength of your core, and hip musculature.
Researchers have found that people with urinary incontinence have higher rates of weakness in the hips, abdominals, and/or leg muscles. Improving the strength, coordination, and endurance of your pelvic floor muscles and the areas surrounding the pelvis can positively impact your functioning. A meta-analysis showed that postoperative pelvic floor muscle training with a skilled and licensed practitioner comprising at least 3 sets of 10 repetitions per set daily improved urinary incontinence risk in both the short term and the long term when compared with controls2,3.
Meta-analysis results showing improved urinary incontinence from post-op pelvic floor muscle training:
- short term Relative Risk (RR) 2.16, 95% CI 1.79–2.60 at 3 months, P < 0.001)
- long term (Relative Risk (RR) 1.23, 95% CI 1.04–1.47 at 12 months, P = 0.019)2,3
Erectile Dysfunction After Radical Prostatectomy
Risk factors for ED post-radical prostatectomy
Erectile dysfunction post-radical prostatectomy is associated with these risk factors: older age, diabetes, obesity, alcohol use, current smoking (nicotine), chronic kidney disease, cardiovascular (high blood pressure, high cholesterol), and neurological conditions2-4.
Although some of these risk factors cannot be changed (we only wish we could reverse our age!), a guided, one-on-one physical therapy program and collaboration with skilled multi-disciplinary teams such as an endocrinologist, urologist, clinical nutritionist, and other appropriate medical practitioners can help you lower your risk factors for erectile dysfunction. Studies show that moderate physical activity for 150 minutes per week can significantly lower your blood pressure, decrease insulin resistance (better control of blood sugar and diabetes), decrease BMI (linked with obesity), and can improve stress, sleep2, and even improve your mental focus. Your physical therapist knows that no two people are alike, and will individualize a program that is realistic and enjoyable for you and your goals.
Below, you will find an explanation of the types of physical therapy treatments to help with both erectile dysfunction and urinary incontinence.
Physical Therapy Treatments for UI & ED
Physical therapy treatments to help with both erectile dysfunction and urinary incontinence after radical prostatectomy:
Therapeutic exercises to strengthen the pelvic floor, which will help with both erectile dysfunction and urinary incontinence.
Biofeedback technology to help the patient correctly isolate and contract the correct pelvic floor muscles imvolved in erection and continence
Photobiomodulation Therapy for pain relief and encouraging cellular healing and desensitization of scar tissue adhesions, tender trigger points, and muscle spasm pain.
Visceral mobilization (gentle massage techniques that loosen internal adhesions and restore movement to the organs including the intestine, kidneys, and bladder) to improve motility and GI organ function
Training in self-treatment techniques so you can start to manage your symptoms at home
Neuromuscular re-education to get your muscles to activate at the right time, with the right amount of force, and autonomic nervous system downregulation to reduce chronic muscle over-activity and improve parasympathetic nervous system function, including pain management and digestion
Patient Education and Empowerment
Lifestyle modifications like sexual positioning, stress reduction, bladder and bowel habits, hygiene, recommendations of supportive tools/ devices
Manual therapy including soft tissue massage, connective tissue manipulation, muscle energy techniques, and myofascial release to treat connective tissue dysfunction and myofascial trigger points
Internal pelvic manual therapy to treat sensitive tissues, muscle spasms, trigger points, and muscle guarding that can cause issues like frequency and urgency of urination, and pain with bowel movements
Commonly used prescription medication for erectile dysfunction post-radical prostatectomy may include phosphodiesterase type 5 inhibitors (PDE5i) medication, which when taken daily post-operatively leads to a significant improvement in erectile function.4
Vacuum erection devices (VED) are another alternative to help you achieve and sustain an erection. They work by creating a vacuum around the penis and drawing blood into corpus cavernosum (a muscle in the shaft of the penis). A constriction ring can be applied at the base of the penis to prevent the blood outflow, therefore sustaining the erection. VEDs are relatively inexpensive and have good results for people with erectile dysfunction.4
Recovery of continence following radical prostatectomy is typically gradual and takes longer than most people initially expect. People report most improvement in symptoms within the first year, continuing up to 2 years after surgery,2 so stick with it!
For men who continue to have urinary incontinence despite pelvic floor physical therapy, there are also off-the-shelf devices that can be purchased, such as these:
Radical Prostatectomy is a life-saving procedure. Working with a skilled pelvic floor physical therapist as part of your pre- and post-operative plan can help maximize your functioning and decrease the severity and occurrence of incontinence and erectile dysfunction post-operatively.
Rahnama'i MS, Marcelissen T, Geavlete B, Tutolo M, Hüsch T. Current Management of Post-radical Prostatectomy Urinary Incontinence. Front Surg. 2021;8:647656. Published 2021 Apr 9. doi:10.3389/fsurg.2021.647656
Mungovan SF, Carlsson SV, Gass GC, et al. Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy. Nat Rev Urol. 2021;18(5):259-281. doi:10.1038/s41585-021-00445-5
Fernández RA, García-Hermoso A, Solera-Martínez M, Correa MT, Morales AF, Martínez-Vizcaíno V. Improvement of continence rate with pelvic floor muscle training post-prostatectomy: a meta-analysis of randomized controlled trials. Urol Int. 2015; 94(2):125-32.
Bratu O, Oprea I, Marcu D, et al. Erectile dysfunction post-radical prostatectomy - a challenge for both patient and physician. J Med Life. 2017;10(1):13-18.