Post-Prostatectomy

Did you know prostate cancer is the most common type of cancer in men? In some cases of prostate cancer, the treatment of choice is a prostatectomy, which is a removal of the prostate. The term “radical prostatectomy” refers to removal of the entire prostate gland and surrounding tissues. There are a variety of surgical procedures to remove the prostate, but no matter which is performed, they all share some side effects.

Anatomical Changes Post-Prostatectomy

During a radical prostatectomy, the prostate, ligaments, and part of the urethra are resected. The bladder neck (where the urethra attaches to the bladder) and the internal urethral sphincter (the main sphincter muscle that helps achieve continence of the bladder) are altered. Therefore, the mechanics by which the body achieves urinary continence after a radical prostatectomy change and oftentimes the body has to learn how to work efficiently again.

In particular, because the internal urethral sphincter is removed, which plays a significant role in continence the body must learn to use and rely on the remaining external urethral sphincter, as well as the rest of the pelvic floor muscles. This is where pelvic physiotherapy both prior to and after surgery can greatly affect one’s post-prostatectomy experience.

Symptoms Post-Prostatectomy

Post-surgical symptoms may include:

• Soreness/infection around the incision site, whether suprapubic (above the pubic bone) or perineal (between the base of the penis and the anal opening).
• Bladder incontinence.
• Erectile dysfunction.
• Retrograde ejaculation:

Semen enters the bladder instead of being expelled through the urethra due to injury to the bladder sphincter. This condition is often managed with pharmaceuticals.

• Abdominal tension or pain.
• Bowel issues.
  

Post-Prostatectomy Incontinence

Incidence and Cause

The frequency of post-prostatectomy urinary incontinence (PPI) is estimated to be experienced by 2-85% of men. Though that number indicates a wide range, PPI is a very common symptom post-prostatectomy. As a result of prostate removal and the fact that the internal urethral sphincter (the main continence muscle) is removed, the likelihood of incontinence is great. Additionally, the external urethral sphincter may have had a period of weakening due to disuse before surgery, when the urethra was compressed by the enlarged prostate (achieving passive continence).

Physiotherapy Treatment

(See “Treatment” section for comprehensive list of physiotherapy treatments)

The good news is that the remaining external sphincter (the assistant to the main sphincter), as well as the pelvic floor muscles as a whole, can be taught and trained to provide more support and closure to the urethra such that urinary leakage is reduced and abolished. This is a main focus of post-prostatectomy pelvic health physiotherapy. Your physiotherapist will assess the strength, tone, and function of your muscles, help you to correct anything that puts them at a disadvantage to optimal function, and then develop an individualized pelvic floor muscle training program for you. Sometimes this involves strengthening, sometimes it involves lengthening/relaxing certain muscles, and most often it involves a combination of both types of exercise.

Additionally, your physiotherapist will discuss appropriate pads to use during the rehabilitation process, as well as different tools on the market to aid in the management of incontinence such as penile clamps and removable clamps that clip around the penis to compress the urethra and stop urinary leakage. Tips to manage things like post-void dribble, where a small amount of urine leaks out immediately after voiding, may be discussed as well.

Pharmaceutical Treatment

In addition to pelvic floor muscle training, sometimes pharmaceuticals are useful in achieving continence. There are a wide variety that a physician/pharmacist may prescribe. Some of them include:

• Anticholinergics:

Increase the amount of urine that the bladder can hold.

Decrease the sensation of pressure experienced with the urge to urinate.

• Antimuscarinic:

Useful for symptoms of overactive bladder (sudden, uncontrollable urge to urinate).

• Tricyclic Antidepressant:

Relaxes the bladder muscle (decreases urinary urgency) while simultaneously contracting the smooth muscles at the bladder neck (promotes continence).

Medical/Surgical Treatment

By 12-24 months post-surgery, the large majority of males will have achieved satisfactory urinary continence. However, for those who have not, other treatment options may be considered. These can include a variety of additional surgical interventions including an insertion of a sling to provide compression of the urethra and prevent urinary leakage or an insertion of an artificial sphincter that provides closure to the urethra that has to be manually deflated in order to void the bladder. These options are used as last resorts if the natural healing process combined with rehabilitation have not provided satisfactory results. 

Erectile dysfunction

Incidence

Along with incontinence, erectile dysfunction (ED) post-prostatectomy is a common side effect. It is estimated that 50% of men may experience prolonged or permanent ED and virtually all experience ED immediately post-surgery.

Physiotherapy Treatment

(See “Treatment” section for comprehensive list of physiotherapy treatments)

Similar to the assessment and treatment of incontinence, your physiotherapist will assess the state of your pelvic floor tissue and muscles, will educate you on proper muscle activation and relaxation, and will develop a program for you to follow to ensure the muscles that help you achieve and maintain an erection are flexible, strong, and pain-free. The first of the three layers of pelvic floor muscles is of particular importance in sexual function, so that will likely be a focus of one’s treatment sessions. Additionally, aids available on the market including vacuum penile pumps, which help a male to achieve and maintain an erection, may be discussed.

Pharmaceutical Treatment

In addition to pelvic floor muscle training, your physician/pharmacist may prescribe pharmaceuticals to aid in the ability to achieve and maintain an erection.

Physiotherapy Treatment Post-Prostatectomy

Pelvic health physiotherapy can positively affect your unwanted symptoms post-prostatectomy, whether you experience pain, urinary incontinence, erectile dysfunction or other symptoms. If possible, see a pelvic floor physiotherapist prior to your surgery date. Attending physiotherapy both prior to and after surgery is ideal. Treatment may include:

• Breathing techniques
• Education on movement:
  Transfers/transitional movements.
  Posture/positioning.
  Mobility/walking.
• Scar treatment:
  Myofascial mobility.
  Decrease sensitivity.

• Bowel and bladder education.
• Toileting/evacuation positioning and techniques.
• Diet modification:
  Adequate water and fiber intake.
• Therapeutic exercise:
  Whole body reconditioning.
• External myofascial techniques.
• Internal myofascial techniques.
• Pelvic floor muscle training:
  Proprioceptive training.
  Strengthening muscles.
  Urinary incontinence.
  Erectile dysfunction.
  Lengthening/relaxing muscles.
  Urinary incontinence.
  Pelvic pain.
• Tips for intimacy:
  Vacuum devices for erectile dysfunction.
• Tips for urinary incontinence:
  Penile clamps.
  Discussion around pharmaceutical, medical, and surgical interventions for continued incontinence.
• Mindfulness/meditation:
  Pain.
  Anxiety/stress/depression.
  Relaxation.
• Lymphedema treatment.
• Visceral mobilization.
• Prioritizing/goal setting:
  Especially important for cancer-related fatigue.
• Pain education.
• Treatment of the nervous system.

Post-prostatectomy rehabilitation requires a whole-person approach, from the way a person moves to how they breathe, to how they think about their body, surgical experience, and symptoms. By addressing the treatment areas listed above, one is sure to regain confidence and improve their everyday quality of life.