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Nonsurgical Treatment for PPI

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Non-surgical treatment of urinary incontinence after prostate removal

It has been shown that between 5-90% of patients will develop some degree of incontinence after a radical prostatectomy. Continence status will continue to evolve for up to 1 year after the surgery and in most patients will resolve after this period. Conservative treatment options should be trialled before proceeding to more invasive treatments, particularly in the early postoperative period, and patients should be followed up regularly to monitor treatment progress. Among the most common conservative treatments are behavioural therapies, pelvic floor muscle training with or without biofeedback, electrical simulation, and pharmacotherapy. (1)

Why does it happen?

Male stress urinary incontinence or post prostatectomy incontinence (it’s official name) is usually as a result of various steps in the surgical procedure. It is defined by the complaint of involuntary leakage on effort or exertion such as coughing, sneezing or bending forward. Several mechanisms for how this occurs have been proposed (refer back to previous blog on the anatomy of the prostate and urethra): direct injury to the internal sphincter which lies at the exit of the bladder; direct injury to the external rhabdosphincter (which lies on the under surface of the prostate and surrounding the urethra); shortening of urethra lengthwise; injuries to the supporting structures of the urethra; injury to the nerves that supply the sphincters; or detrusor underactivity (reduced contraction of the muscles within the bladder wall). (2)

Which factors increase the likelihood of it happening (3)?

- Increased age

- Obesity

- Comorbidities (other illness and treatment)

- Bladder function before and after surgery

- Prostate volume or size (larger prostate may increase the risk)

Behavioural modifications

The first step in conservative management is behavioural or lifestyle modifications (for example fluid restriction particularly at night, limiting caffeine and alcohol intake, stopping smoking, timed voiding [having set time points when one urinates], or double voiding [urinating again immediately after one has just urinated], avoiding bladder irritants [spicy foods and certain acidic foods to name a few]). The efficacy of these interventions has yet to be determined despite their recommendation often being the first-line treatment. They be more effective in combination with other conservative measures.

Pelvic floor muscle training/exercises and Biofeedback

The most common conservative treatments include pelvic floor muscle training (PFMT) or exercises (PFME) with or without biofeedback. This should ideally be carried out by a physiotherapist who has specialised knowledge of the male pelvic floor. Physiotherapist-guided PFME (PG-PFME) affects not only correct contraction of the target muscle, but also the persistence of PFME.

How does it work?

PFME activates the pelvic floor muscles, such as the striated urethral rhabdosphincter, the bulbocavernosus (muscle surrounding the bases of the penis and urethra running through it), and the levator ani (part of pelvic floor muscles), which increases the internal urethral pressure, preventing urine leakage. It is an economical and safe treatment that supplements urethral sphincter insufficiency by improving muscle strength and endurance through repetitive pelvic floor muscle contractions.

Because the pelvic floor muscles have a complex anatomical structure, it is hard for a person who undergoes PFME to know whether or not the muscle is contracting correctly. A physiotherapist provides this advice and also ensures that they are avoiding the involvement of other muscles, such as abdominal muscles, which may be incorrect. They provide accurate instructions such as “tighten the anus” or “stop the urine flow” and may utilise a biofeedback device to assist the training. Before performing PG-PFME, the therapist should explain to the patient the anatomical structure and function of the pelvic floor muscles so that the patient can feel the muscle contraction on their own. The person is then trained in PFME performed in several positions and instructed to carry them out daily. It may be helpful to perform the exercise prior to any activity the person knows may result in them leaking. Regular follow-up appointments are essential to provide adjustments to the exercise regimen, encouragement, and motivation to continue exercising (3).

Pre-operative Pelvic Floor physiotherapy

Professor Manish Patel (University of Sydney) and Dr Sean Mungovan (Westmead Hospital) have shown that a physiotherapist-guided pelvic floor muscle training program, commenced 4 weeks prior to surgery, significantly reduces the duration and severity of early urinary incontinence after surgery. At 6 weeks postoperatively, the 24-hour continence pad weight was significantly lower in those who followed an exercise regime compared to those who didn’t (9 g vs 17 g). (4)

How effective is pelvic floor muscle training?

A meta-analysis (a study that combines the results of several clinical trials) found that PFMT leads to an improvement in continence in the short term, but a modest difference between intervention and control groups at 12 months. Biofeedback is used to assist with PFMT but its efficacy remains controversial. One randomized controlled trial (RCT) of 73 men found a benefit to biofeedback with a 96% continence rate for patients treated with biofeedback vs 75% in the control group 1 year after surgery. Biofeedback with PFMT may speed up the immediate recovery of continence postoperatively (1).

Electrical stimulation (ES)

Electrical impulses are produced by a dedicated machine, relayed by a probe or an electrode, and transmitted to the muscles through nerve fibres. This causes the muscles to contract, without the need for a voluntary command provided by the patient’s brain. The practitioner can adjust the electrical parameters of the stimulation (intensity, frequency, recovery time and overall duration of the session). ES uses electrical current to stimulate the muscle fibres which can improve self-perception of the muscular activity. Improving the strength of the pelvic muscles can also lead to a reduction in daily urine leakage. ES may lead to a faster recovery of urinary continence, but no long-term benefit has been demonstrated at 6 months or greater after surgery.

Penile clamp

A well-fitting penile clamp may be a comfortable alternative in those where the above-mentioned measures have failed, and the person prefers not to move on to medical or surgical treatment options. The clamp seals off the penis to prevent urine leakage and can be released when the patient is ready to empty their bladder.

Pharmacologic therapy

In selected people medication may be an option. These drugs include antimuscarinics (relax the muscle in the bladder wall) for those whose bladder muscles are overactive, phosphodiesterase inhibitors (such as sildenafil or tadalafil), and alpha-adrenergic agonists (contract the muscle to close off the exit of the bladder). One study found that participants with 9-month tadalafil treatment after radical prostatectomy had significant improvement compared with placebo.

Detrusor overactivity (overactive bladder) may be a contributing factor to incontinence in some. A trial comparing solifenacin to placebo found a reduction in average change in pads per day, and improvement to quality of life.

Duloxetine, a type of anti-depressant, acts by increasing the stimulus sent to the urethral sphincter sealing it off to prevent urine leakage in those with intrinsic sphincter deficiency.

Overall, pharmacotherapy provides only a mild benefit and is not the definitive treatment of choice, but may augment other treatment modalities.

Conclusion

Incontinence can be very debilitating resulting in unpleasant odour, recurrent urinary tract infections, impact on sexual and ultimately mental health. There is a high correlation between depression and incontinence. For these reasons it must be treated. If conservative management fails, the next choice of treatment that should be considered is surgical treatment (which is addressed in another blog).

Watch a webinar hosted by the PCFA Shine A Light Support group with Special Guest Speaker and Internationally renowned, local functional urologist Professor Vincent Tse. Webinar: Urination troubles and prostate cancer - YouTube

References

1. Radadia KD, Farber NJ, Shiner B, Poltti CF, Milas LJ, Tunuguntla HSGR. Management of postradical prostatectomy urinary incontinence: A review. Urology 2018; 113: 13-19.

2. Rahnama'I MS., Marcelissen T, Geavlete B, Tutolo M, Hüsch T. Current Management of Post-radical Prostatectomy Urinary Incontinence. Frontiers in Surgery 2021; 8.

3. Park JJ, Kwon A, Park JY, Shim SR, Kim JH. Efficacy of pelvic floor exercise for post-prostatectomy incontinence: Systematic review and meta-analysis. Urology 2022.

4. Patel M, Yao J, Hirschhorn AD, Mungovan SF. Preoperative pelvic floor physiotherapy improves continence after radical retropubic prostatectomy. International Journal of Urology 2013; 20(10) 986-992.


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About the Author

Kalli Spencer

MBBCh, FC Urol (SA), MMed (Urol), Dip.Couns (AIPC)

Kalli is an internationally renowned Urological Surgeon, specialising in oncology and robotic surgery. He trained and worked in South Africa, before relocating to Australia where he has worked at Macquarie University Hospital and Westmead Hospital. His passion for what he does extends beyond the operating room, through public health advocacy, education and community awareness of men’s health, cancer and sexuality.

Kalli has been involved with the Prostate Cancer Foundation of Australia for many years, advocating for improved cancer care and facilitating community prostate cancer support groups.


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