Pelvic Floor
PHYSIOTHERAPY
following
prostatectomy
By:
Danielle Bell
BSc(Hons)Physiotherapy,
Director, Principal Physiotherapist Active Physiotherapy Mackay
Member of the Continence and Women’s Health Group,
Australian Physiotherapy Association, CFA, IUGA
Today’s Purpose
• What would you like to know?
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What does a Continence Physio do?
Is it effective?
Is it invasive?
What does it feel like to isolate PF?
How can my patients access treatment?
- APM only Senior Continence PT, mentor team
- Pensioner EPC no gap
- Private $140 60 min initial
- expert objective assessment
- individualized advice
- ongoing support
Myth Busting time
• The Pelvic Floor is a muscle that squeezes
closed the urethra, anus (vagina)
• Levator Ani fixes UI in M&F
• Continence physiotherapy =
pelvic floor exercises
What is the Pelvic Floor?
A group of muscles and connective tissues which create
a supportive sling underneath the
bladder and bowel for men
Normal continence mechanisms
Urethral closing pressure
maintained by prostate, IUS
Smooth mm invol
Filling phase –
IUS contract lumbar plexus
sympathetic
Voiding phase –
(detrusor contract)
IUS relax
Parasympathetic
Hypogastric nerve
Men rarely aware EUS
Striated mm
Voluntary control
Pudendal nerve
Anticipatory control cough Stafford 2014
http://med.uc.edu/labmanual
IUS
Urinary Incontinence
Post Prostatectomy
99% Glina 2009, 1 year occasional 90% Peterson 2012
Stress incontinence
Urge Incontinence
Passive Incontinence
Frequency/low capacity
Nocturia
Post void retention
Post void dribble 80% Milios
Climacturia 70% Milios
unpublished
Post –prostatectomy incontinence
Why do men leak after prostatectomy?
1. Nerves need to be stretches around prostate, pierced, minor damage inevitable
2. These nerve supply the sphincter
3. The prostate provided closing pressure urethra
(esp if enlarged)
4. Not had to use pelvic floor muscles before
- out of practice or
-not well mapped in brain
What are the odds? 98% UI post op
The time to continence was classified as:
early (0–3 mo) 70%,
midterm (4–12 mo) 18%,
late continence (13–24 mo) 3%.
A cutoff point of more than 15% of urine loss ratio
(pad weight) indicates a high risk of incontinence
(when catheter removed)
ULR predicts the time to continence and may be used to
select patients for specific rehabilitation
#2006 European Association of Urology.
Pre-habilitation / rehabilitation
• 4 weeks pre-operative training
• reduces likely episode incontinence to 6 weeks post operative
• Needs to be physio guided individualized objective v verbal
instruction only Yao 2012
• No pre-hab = 6 months average duration incontinence
What is prehab?
• Practicing exercises without swelling or nerve damage,
learning to cortical voluntary control, speed, hypertrophy,
endurance pre-operatively
• Education on expected post operative symptoms, healthy
habits and lifestyle modification
Post prostatectomy
Pelvic Floor Physiotherapy
• PF rehab = 80% clients are dry in 8 weeks Dorey 1997
How?
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EUS striated mm ability to produce UCP
Reconnect / connect correct motor pattern
for cortical voluntary control EUS
Strengthen EUS to contract more forcefully /
withhold more load Stafford 2013
Condition EUS to function for longer periods
Hypertrophy also passive assistance,
not just during voluntary control Bo 2010
EUS Is a modifiable factor
unlike time and nerve regeneration
Specific PF retraining
• Objective measurement RTUS (hold time, 10 reps)
• Highly specific as per golf swing instructor
• Technique “not how hard hit ball”
• Not Levator Ani Stafford 2014
-opposite to Female
- vectors
- lift bladder
- not UCP
- loud voice in room
- No DRE!
(DRE based research poor results Glazener 2010)
Specific pelvic floor activation
Increasing urethral angle
Pincher action
Bulbocavernosus and
striated urethral sphincter
Transperineal RTUS
Jocks on, testes to the side
Stafford 2014 not yet published
Ready to try it?
Before we start…….
• Posture, posture, posture
• RELAX outer tummy and
buttock muscles
• No outer body movmt
• Natural diaphragmatic
breath
Let’s give it a go……
1 SQUEEZE around
the anus- close, lift,
forwards
DON’T DO THIS
AGAIN. LOUD VOICE
IN ROOM
(normal to feel lowest
TrvAb mild tighten)
Let’s give it a go……
2 LIFT the testes
Quiet voice in room
Let’s give it a go……
3 indrawing or
retraction of penis
Quiet voice in room
Putting it together:
1 Relax anus
2 Lift testes
3 Indraw penis
4 Keep breathing
5 Then….
deliberately Let go
How long and how many?
• To strengthen a muscle you need to find
the isolated muscle then gradually fatigue
a muscle
• Must be individualised:
- How long can YOU hold for?
- How many can YOU do?
- How fast- time 10 quick lifts
- At the righ time- c/sn/lift bucket
Pelvic Floor “The Knack”
(Bracing Techniques)
Brace with your pelvic floor
and deep abdominal
muscles when you cough,
sneeze, lift or exercise
Need to master in controlled
environment, cortical
before anticipatory
subconscious
Gadgets and Gizmos
Tibial nerve TENS
Rectal e- stim
Perineal e-stim
EMG biofeedback
Anal perinometry
Sacral TENS
neuromodulation
www.pelvicfloorfirst.org
MODIFIED GENERAL EXERCISE
10 step guide to pelvic floor safe exercise
1. Avoid heavy lifting
2. Use your pelvic floor muscles
3. Lift with good posture
4. Exhale with every effort
5. Choose supported positions
6. Keep your feet close together
7. Strengthen gradually
8. Take care when fatigued or injured
9. Rest between sets
10. Avoid aggravating exercises and machines
(leaking, bulging, pain, breath holding)
Good Bladder Habits
 Drink 6-8 cups of fluid a day (light yellow wee)
 Limit caffeine and alcohol intake
 Avoid straining to empty bladder
 Double void to reduce retention
 Sit if difficult to relax standing
 Do not hover
 Evaluate your urinary urge
Good Bowel Habits
 Optimal stool consistencyEnsure Adequate Fluids,
movicol v metamucil
 Eat sufficient Fibre **
 Light pressure to initiate
evacuation
 Perineum drops, puborectalis
relax, EAS open
 Use Optimum Defecation
Position- stool, knees
 Very high priority for all pelvic
floor conditions
 KISS – balloon expulsion
Myth Busting time
• The Pelvic Floor is a GROUP of muscles AND CONNECTIVE
TISSUE. Each muscle has a different cue/feeling/function
• Levator Ani muscle strengthening aids STRESS continence in
women, BUT NOT MEN. SUS strengthening aids UI in men. There
are many other conditions such as obturator hypertonicity made
worse by strengthening.
• Continence physiotherapy = pelvic floor exercises + MUCH WIDER
SCOPE OF PRACTICE pain/dyspareunia, constipation/FI, POP,
pessaries, Peyronie’s, ED , UTI, lifestyle counselling, safe exercise,
healthy habits
More Information?
www.pelvicfloorfirst.org.au
www.continence.org.au
Helpline: 1800 33 00 66
www.prostate.org.au
Phone 49533557