Rick is a 75-year-old male who was recently diagnosed with prostate cancer and is scheduled for a radical prostatectomy. According to his urologist, a radical prostatectomy involves removal of the prostate and seminal vesicles. The urologist briefly mentioned the possible side effects of surgery, specifically urinary incontinence (leakage) and erectile dysfunction, which has Rick worried and wondering what he can do to lower these awful possible consequences. He loves to play golf during the week and is worried that urine leakage will make it very hard to go out with his buddies for hours without smelling like urine or needing to use depends. Rick’s confided in a good friend who just had the same procedure two years ago and learned that he did pelvic floor physical therapy (PFPT) before and after surgery which allowed him to prevent urine incontinence and erectile dysfunction after the surgery. Rick’s surgeon did not mention pelvic floor physical therapy as an option to help reduce these risks so he isn’t sure if he should be going to PFPT before surgery, after surgery, or at all.
Prostate cancer is the second most frequent cancer diagnosis for men greater than 65 years old. African American men have increased incidence rates and more aggressive types than white males. Fortunately, most prostate cancer cases are detected when it is still confined to the prostate resulting in a 98% 5-year survival rate in the United States.
A common surgical approach to prostate cancer is a radical prostatectomy, which refers to the full removal of the prostate. This surgery can have side effects like urinary incontinence (leakage) and erectile dysfunction. Urinary incontinence can have a large impact on a person’s quality of life and ability to return to functional activities, like playing golf or simple things such as bending and lifting. Most would argue that they want the quickest, most effective route to return to normal life with as little hinderance as possible.
A study looked at 333 men that underwent a radical prostatectomy and found that there was a decreased number of urine pads per day needed in those who went to PFPT prior to surgery as compared to those who did not; although the difference was not statistically significant. At 3 months post-operation, there was a statistically significant (meaningful difference) decrease in pads used per day in the group that attended PFPT before surgery versus the group of men who did not. This means men who went to PFPT before prostate surgery got to live life with less urine leakage after!
The idea is that men who attend physical therapy prior to surgery will have an opportunity to begin exercises and learn to be effective with them before undergoing a radical prostatectomy as compared to those who must learn new exercises and movement techniques while recovering from surgery.2 Having a stronger muscle is always protective after an injury. Surgery is an injury to the tissues. So, men who have a stronger pelvic floor muscle prior to a prostatectomy will be in a better protective state afterwards and rehab the muscles easier compared to men with a weak pelvic floor and poor control over the muscle.
I always tell my patients that even though we cognitively understand the difference between a surgery to fix something and an injury, the body responds the same way to each. This means that the body is still going to respond with an increased inflammatory response, including increased blood flow and immune cells, to the area that has been operated on. There is also an effect on our body’s ability to create full muscle activation following surgery as the nerves are inhibited, or not turned on all the way, which results in less communication and reduced force production of the pelvic floor muscles. This is supported by research that indicates a significant worsening of pelvic floor muscle strength and urinary incontinence in the months following surgery, as well as a significant impact on quality of life. Luckily, pelvic floor strength, urinary incontinence, and quality of life improve around 6 months following surgery.
Additionally, a 2021 study of 144 men found that prostate volume and pelvic floor endurance were significant predictors of continence 3 months following radical prostatectomy. 75% of men with good pelvic floor endurance were continent (did not leak) at 3 months post-surgery while only 50% of men were continence who started with poor pelvic floor endurance (strength). The study concluded that a pre-operative assessment of pelvic floor endurance may allow a more accurate prediction of early continence following a radial prostatectomy.
There is also evidence that an individualized approach to the therapy is significantly beneficial. A 2020 study found that an individualized PFPT program significantly reduced pad usage per day, decreased pelvic pain, and increased pelvic floor strength following prostatectomy. Traditionally, rehabilitation of urinary incontinence following prostatectomy has mainly emphasized strengthening exercises (kegels) only. However, this study looked at whether each individual who was experiencing urinary incontinence had an underactive (think low muscle tone and weak muscles), overactive (think high tone and tight muscles), or mixed pelvic floor dysfunction. Of the 136 patients, 25 had underactive pelvic floor dysfunction and were treated with strengthening. Thirteen had overactive pelvic floor dysfunction and were treated with relaxation techniques (not kegels), and 98 had mixed and were treated with a relaxation and strengthening combination. This means the majority did not just need kegels! All groups demonstrated improvement including those who received primarily pelvic floor relaxation training. This supports the idea that each person’s PFPT should be individualized to reduce urinary incontinence and pelvic pain. It is not just a one size fits all, just do some kegels approach that actually helps decrease urinary incontinence after a prostatectomy.
This also explains why some men religiously perform pelvic floor contractions, or kegels, and may not see improvement in their incontinence symptoms. In fact, sometimes a person can be doing too many kegels or their muscles are already so tight that they are not able to strengthen beyond the already limited range of motion. Its as if you are working on grip strength but instead of relaxing your hand before squeezing a stress ball you are keeping your hand clenched and then trying to further squeeze the ball. You can only go so far! Plus, it’s not long before your hand starts to cramp or become so exhausted it can no longer provide the same forceful contraction.
A question that is often asked by male pelvic patients who have undergone a prostatectomy is “can I get better if I had my surgery over a year ago?” and the answer is yes! A study looked at 208 men aged 58-84 years old who continued to experience incontinence 1-17 years following radical prostatectomy who were divided into three groups: Behavioral Therapy (pelvic floor muscle training and bladder control strategies), Behavioral Therapy Plus EMG biofeedback and daily home pelvic floor electrical stimulation, or Delayed-treatment meaning they were not provided with treatment. There was a 55% reduction in weekly incontinence episodes in those who received Behavioral Therapy alone and a 51% reduction in those who received Behavioral Therapy Plus. There was only a 24% reduction observed in the Delayed-treatment group. The key is to continue with your rehabilitation even after being discharged from physical therapy. There was an 81-91% adherence to exercises and bladder control strategies at 12 months following their course of treatment. Research has shown that individuals who work with a skilled pelvic floor PT maintain long term results significantly better than when individuals try to do their own self guided pelvic floor strength training program (kegels).
Overall, there is a benefit to attending PFPT prior to your radical prostatectomy. This will allow the physical therapist to determine your pre-surgical baseline of pelvic floor strength, coordination, endurance, and muscle tone. It will also allow you to begin implementing appropriate strategies, such as pelvic floor muscle strengthening and relaxation and intra-abdominal pressure management, prior to your post-surgical recovery. Do not be discouraged if you experience an increase in incontinence during the first month after surgery – this is normal while your body is healing! By month 3-6, you should begin to see improvements in incontinence and quality of life as you return to activities you enjoy or perform on a daily basis. Also, you should feel that your physical therapist is creating an individualized rehab program, which may or may not include pelvic floor strengthening! Your therapist should be able to explain why they are having you perform certain treatment interventions in a way that is easily understood.
Last but not least, even if you did not receive PFPT prior to your surgery or if it has been years since your surgery, you still have the ability to improve your strength and reduce urinary incontinence and/or erectile dysfunction concerns. Reach out to a local and highly skilled pelvic floor PT in your area and start the journey to a better quality of life!
Written by Jordan Schmidt, PT, DPT
Edited by Molly Hart, PT, DPT