After attending the Asia-Pacific Prostate Cancer Conference 2018-19 I was excited about the research evidence emerging that supports what I and many of my colleagues have been saying about the importance of pre and post prostatectomy pelvic floor physiotherapy for many years.
In my clinical experience the men who have pre-operative physiotherapy have far less incontinence post operatively and stop needing pads a lot earlier. They are also better prepared for the changes that accompany major surgery such as a prostatectomy and therefore not as stressed as their counterparts who did not see me pre-operatively. Stress is a major barrier to learning new skills, which can slow the recovery of the post-op guys even more. It is my experience that regaining continence has a lot more to do skills training of the pelvic floor than strength training and this has been my approach for some time now.
Unfortunately, until recently the research evidence for pre-operative physiotherapy has been inconclusive. Some studies reported a reduction in the time it took to regain continence, while other showed no benefit. The quality of the studies varied considerably as did the actual instructions and exercises given. Closer scrutiny of these studies indicated that the success of the program is related to the instruction given. It seems that the results are specific to which parts of the pelvic floor muscles are activated during the exercise.
2 researchers at the conference gave us the very latest finding in the field. The first was Professor Paul Hodges, who has been using real time ultrasound imaging and other sensors to measure what muscles are involved in stopping urine leakage and what verbal instructions are needed to get the right muscles working. He was able to show that in addition to the pelvic floor muscle, an even smaller muscle called the external or striated urinary sphincter, works with the pelvic floor to stop the urine flow. He also found that men who leaked more were using the muscles around their tummy, and this actually pushes down on the bladder increasing the leakage. Essentially those who were trying too hard, leaked more than those who were able to focus on perfecting their technique.
The second researcher was Mr Ryan Stafford. He presented some preliminary finding on a trial on whether Pelvic Floor Muscle training is effective. They are comparing the now old-fashioned approach of “squeeze your back passage and pelvic floor muscle as hard as you can” ; the even older approach of “just read a brochure and let time heal” and the newer approach of “gently squeeze the muscles that stop the flow of urine”. They are using the ultrasound imaging, similar to the one we have in our clinic, to show guys which muscles are working and helping them focus on perfecting their technique. The focus is on acquiring the skill to use the pelvic floor muscle and striated sphincter only as much and when needed to stop the urine leaks. The early results are very much in favour of the new approach.
So my take home messages are:
1) Harder is not always faster.
2) Effective Pelvic Floor muscle training is all about perfecting the skill.
3) It’s easier to learn a new skill when we are not stressed, so perfect your skills before having surgery.
Therese (Terry) Wesselink is a registered physiotherapist with post graduate qualifications in Pelvic Floor Physiotherapy. She is one of the continence clinicians and manager at the Victorian Continence Resource Centre and a sought-after speaker at community and professional events. She is also the author of our renowned Reclaim Your Core booklets which are available from our online shop.
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