Gytis Makarevičius 1
Faculty of Medicine, Vilnius University, Vilnius, Lithuania
Abstract
Both, urinary incontinence (UI) and erectile dysfunction (ED) reduce person’s quality of life. Current research shows, that pelvic floor muscle training (PFMT) might lessen pelvic dysfunction symptoms.
Aim: To present the current epidemiology of pelvic floor muscle dysfunction in radical prostatectomy (RP) patients and examine the current literature concerning PFMT in alleviating UI and ED in RP patients.
Materials and methods: Cochrane, Google Scholar and PubMed were searched for articles using the terms “pelvic floor dysfunction”, “urinary incontinence”, “erectile dysfunction” in combination with “prevalence”, “epidemiology”, “statistics”, “burden” and “pelvic floor muscle training” „conservative treatment“ in combination with “radical prostatectomy”, “erectile dysfunction”, “urinary incontinence”, “pelvic floor dysfunction” and included studies from 2010 to February of 2022. Only full text articles were included. Paediatric studies were excluded.
Results: The prevalence of UI among patients who underwent RP varies from 2 to 66%. The prevalence of ED ranges from 10 to 46 % 12 months post RP. Pelvic floor rehabilitation after radical prostatectomy is recommended by the European Association of Urology as a method for UI management for patients after RP. Supervised, high-volume and biofeedback incorporating PFMT seems to be useful in reducing post prostatectomy UI. PFMT is also showed to be beneficial for the treatment of ED.
Conclusions: UI and ED after RP are common. Research on the effectiveness of PFMT for UI and ED raises hope, however, data is highly inconsistent due to methodological disparities.
Keywords: radical prostatectomy, pelvic floor dysfunction, urinary incontinence, erectile dysfunction, pelvic floor muscle training.
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Medical Sciences 2022 Vol. 10 (3), p. 2-10, https://doi.org/10.53453/ms.2022.07.1
Pelvic floor muscle training for conservative treatment of urinary
incontinence and erectile dysfunction after radical
prostatectomy: a review of literature
Gytis Makarevičius
1
Faculty of Medicine, Vilnius University, Vilnius, Lithuania
Abstract
Both, urinary incontinence (UI) and erectile dysfunction (ED) reduce person’s quality of life. Current research
shows, that pelvic floor muscle training (PFMT) might lessen pelvic dysfunction symptoms.
Aim: To present the current epidemiology of pelvic floor muscle dysfunction in radical prostatectomy (RP)
patients and examine the current literature concerning PFMT in alleviating UI and ED in RP patients.
Materials and methods: Cochrane, Google Scholar and PubMed were searched for articles using the terms
“pelvic floor dysfunction”, “urinary incontinence”, “erectile dysfunction” in combination with “prevalence”,
“epidemiology”, “statistics”, “burden” and “pelvic floor muscle training” „conservative treatment“ in
combination with “radical prostatectomy”, “erectile dysfunction”, “urinary incontinence”, “pelvic floor
dysfunction” and included studies from 2010 to February of 2022. Only full text articles were included.
Paediatric studies were excluded.
Results: The prevalence of UI among patients who underwent RP varies from 2 to 66%. The prevalence of ED
ranges from 10 to 46 % 12 months post RP. Pelvic floor rehabilitation after radical prostatectomy is
recommended by the European Association of Urology as a method for UI management for patients after RP.
Supervised, high-volume and biofeedback incorporating PFMT seems to be useful in reducing post
prostatectomy UI. PFMT is also showed to be beneficial for the treatment of ED.
Conclusions: UI and ED after RP are common. Research on the effectiveness of PFMT for UI and ED
raises hope, however, data is highly inconsistent due to methodological disparities.
Keywords: radical prostatectomy, pelvic floor dysfunction, urinary incontinence, erectile dysfunction, pelvic
floor muscle training.
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3
Introduction
Ever since A.H Kegel has published his work on
pelvic floor exercises for women in 1948 there has
been a rise in research, concerning the benefits of
pelvic floor exercises for women (1). However,
pelvic floor exercises historically have been as
important to men as they are to women during
modern times. The muscles which comprise the
pelvic floor can be divided into three layers. The
superficial layer is comprised of bulbospongiosus,
ischiocavernosus, superficial transverse perineal
and external anal sphincter. This layer is important
for healthy ejaculation and urinary and faecal
continence. The second layer is mostly responsible
for ensuring stress continence (eg. when coughing
and sneezing) and is comprised of deep transverse
perineals, the sphincter urethrae and the
compressor urethrae. The third and the deepest
layer is the pelvic diaphragm. It is made up of
pubococcygeus, puborectalis, pubourethralis,
iliococcygeus and ischiococcygeus (2). The correct
form and execution of pelvic floor exercises are
voluntary contractions of the pelvic floor muscles,
that allows the general upwards lift of all muscles
and contraction of sphincters, which in turn stops
the urine stream or passing of gas (3). Hippocrates
and Galen spoke of pelvic exercises performed in
bathhouses, there are records of “deer exercises”
specifically catered to men, to preserve their
vitality and health from 6000 years ago in ancient
China (4). The burden of urinary incontinence (UI)
and erectile dysfunction (ED) post radical
prostatectomy (RP) is significant and often
unavoidable (5). Because of greatly successful
utilization of pelvic floor muscle training (PFMT)
for UI in female populations, pelvic floor
physiotherapy has received a lot of attention from
physicians and researchers as a possible treatment
for UI and ED in patients post RP.
Materials and methods
The searches in Cochrane, Google Scholar and
PubMed have been conducted. The searches were
performed using the terms “pelvic floor
dysfunction”, “urinary incontinence”, “erectile
dysfunction”, “” in combination with “prevalence”,
“epidemiology”, “statistics”, “burden” and “pelvic
floor muscle training” „conservative treatment“ in
combination with “radical prostatectomy”,
“erectile dysfunction”, “urinary incontinence”,
“pelvic floor dysfunction” and included studies
from 2010 to the February of 2022. The articles
were included in the review if they were written in
English, if full text version was available and if
they were published in peer-reviewed journals.
Paediatric studies were excluded. There were 37
articles identified in our search and included in our
review.
Results
After literature search 53 papers were selected to
acquire and conduct full text review, out of those
53 papers 29 met inclusion criteria and were
included in this article. Conducted review allowed
to determine the most common types of pelvic floor
physiotherapy for men, currently used in clinical
practice to treat UI and ED: PFMT, PFMT guided
by a physiotherapist, PFMT with biofeedback,
PFMT with transcutaneous electrostimulation,
extracorporeal magnetic innervation.
1. PFMT is considered to be the most basic
form of pelvic floor physiotherapy and is
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4
described as voluntary pelvic floor muscle
contraction that causes an upward lift of
pelvic floor muscles and contraction of
anal and urethral sphincters, which causes
stop of urine stream and/or passage of
gas/faeces (3).
2. PFMT guided by a physiotherapist is a
PFMT regimen that is taught and
supervised by a professional. This can be
achieved by introducing regular check-
ups in an outpatient clinic or a
physiotherapist office during which a
digital examination could be performed to
assess the strength and technique of pelvic
floor exercises. These visits can be
scheduled in many ways, meaning
weekly, biweekly or monthly schedule
and can be held more or less often,
depending on individual results (6).
3. PFMT with biofeedback is more popular
among women, than men. However, there
are biofeedback devices who are made
specifically for men. Usually, such
devices are made to be safely inserted
inside the body, to measure the strength of
muscle contractions, while performing the
exercises they can be connected to an app
on a person’s phone, where an algorithm
measures the efficacy of exercises, gives
tips on how to improve, shows results
from usage over time. It is important to
note, that there are biofeedback devices
for men who are made to be sat on and do
not require insertion (7).
4. PFMT with transcutaneous
electrostimulation is different from
methods mentioned earlier because it is a
primarily passive way to train pelvic floor
muscles. This means, that a person who is
undergoing such treatment will contract
muscles involuntarily. This type of PFMT
is beneficial for patients who have very
weak pelvic floor muscles and are
incapable of inducing effective voluntary
contractions (8).
5. Extra‐corporeal magnetic innervation is a
passive method and is applied by using a
magnetic chair to surround pelvic floor
muscles in a magnetic field, which in turn
should induce involuntary muscle
contractions, much like electrostimulation
this method is most used for patients who
are incapable of inducing effective
voluntary contractions (8).
Usually these training methods are performed
sitting or lying, however there are some studies that
offer to train while standing up (6). All of the
mentioned methods aim to train all of the pelvic
floor muscles, which are: bulbospongiosus,
ischiocavernosus, superficial transverse perineal
and external anal sphincter, deep transverse
perineal, the sphincter urethrae and the compressor
urethrae, pubococcygeus, puborectalis,
pubourethralis, iliococcygeus and ischiococcygeus
(2).
The epidemiology of pelvic floor dysfunction
The male population does not undergo pregnancy
and birth, has a different pelvic anatomy, thus the
prevalence rate of UI is much lower: for example
UI prevalence among the general population is
estimated to be about 8 %, however among women
it is 25-45% (9,10). Usually, pelvic floor
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dysfunction prevalence in male population
increases with age or in case of pelvic cancers, such
as prostate cancer (11). UI and ED are two most
common complications of RP (12). One cross
sectional survey that looked at the prevalence of
pelvic floor dysfunction among men and women
aged 15-95 years old revealed that 4,4% of men
experienced UI (13). The prevalence of UI after
nerve sparing prostatectomy is around 1%,
however this number increases steeply among
patients who underwent RP and varies from 2 to
66% (14). Globally ED prevalence is from 3 to
77% and is closely associated with increasing age
and cardiovascular diseases (15). Among patients
who underwent RP surgery ED increases
significantly compared to general male population
and ranges from 10 to 46 % 12 months post RP (5).
Some researchers assume that disparities in
prevalence of UI and ED after RP might be related
to such factors as: type of RP performed (for
example robotic versus open RP or laparoscopic
versus open RP), stage of prostate cancer at
diagnosis. However, a prospective trial conducted
in 2015 found that UI and ED was almost equally
prevalent in the group that was treated with open
RP and the robot-assisted laparoscopic RP (RALP)
(16). For example, in the 2015 trial 12 months after
surgery UI was found in 21,3% of men who were
treated with RALP and 20,2% among those who
underwent open RP, meanwhile ED was present in
70,4% of those who underwent RALP and in
74,7% of open RP patients (16). Another
prospective observational study from the European
Prostate Centre Innsbruck found that RP
significantly increases the risk of UI and ED as they
found that UI rates increased from 18.8%
preoperatively to 63% 12 months post RP and a
similar trend was observed in ED prevalence as it
increased from 39,6% to 80,1% postoperatively
(17). A large 2021 systemic review and
metanalysis found that larger prostate volume,
older age and shorter membranous urethra length
were prognostic factors of urinary incontinence 12
months postoperatively (18). For example: every 1
mm increase of the membranous urethra length
reduces the chance of postoperative UI by 17%,
every 5 year increase in age adds a 15% increase of
UI risk and every 10 ml increase in prostate volume
adds 5% of risk for UI up to 3 months after surgery
and 4% for every 10 ml 3-12 months after surgery
(18). However, currently there is insufficient data
to claim, that prostate cancer stage and biopsy
Gleason score has any role in predicting UI
prevalence in post RP patients (18). Concerning
ED prevalence after RP, currently there are no
standardised prediction tools routinely used in
clinical practice, however a 2017 systematic
review found two accurate (>70% accuracy)
prediction tools, that could be generalised and used
in clinical practice (14). These tools used patient
dependent variables such as age, race, estimated
prostate volume, Gleason score, body mass index
and more to calculate patient outcome after RP
(14).
Pelvic floor muscle training for urinary
incontinence
Pelvic floor rehabilitation after radical
prostatectomy is recommended by the European
Association of Urology as a method for UI
management for patients after RP (19). There are a
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lot of contradicting studies concerning the efficacy
of PFMT for treatment of UI after prostatectomy.
Some found significant effect of physiotherapy on
physical and quality of life parameters (7,12,20–
22). Others stated that the results of PFMT for UI
treatment after RP are inconclusive (8,23–25).
Among articles that found a positive effect of
PFMT for UI post RP one study found, that at 3
months post RP from the control group 23,3% were
continent and from the comparison group 34,9%
were continent (22). Another randomized trial
found, that the number of continent individuals
increased more than 5 times from 2 weeks after RP
to 12 weeks after RP (14% to 74% respectively) in
the intervention group, while the increase in the
control group was from 4% to 43% (21). A
systemic review and meta-analysis conducted in
2018 found 5 studies of moderate GRADE quality
that revealed a significant increase of continent
men in the PFMT intervention group, than in the
control group, the same meta-analysis found no
statistical difference between PFMT with
biofeedback intervention group and PFMT only
control group (7).
The most recent 2015 Cochrane review for
conservative management of UI after RP found that
there was no evidence that PFMT with biofeedback
or PFMT is more beneficial for UI treatment after
RP than simply waiting 12 months after surgery
(8). Electrostimulation and extracorporeal
magnetic innervation were found to be beneficial,
as the number of incontinent men was lower than
in control groups 12 months after surgery (8).
Researchers have found, that the main reason for
heterogeneity in the reported efficacy for
management of urinary dysfunction in men could
be the variations between the design of pelvic floor
muscle training programs in different trials: most
programs had different repetition times, had
insufficient descriptions of the exercises or they
were not provided at all (6). For example out of 115
studies who were investigated in the 2018
systematic review: 63 did not specify whether
patients were educated on pelvic floor anatomy
(meaning they knew which muscles needed to be
contracted and which not) before the start of
physiotherapy, 78 studies did not specify the
duration of PFMT sessions (6). Most trials
recommended participants to perform 3 training
sessions a day, each session had to include 9-15
repetitions, however overall daily contractions
differed greatly between trials and ranged from 18
to 240 (6). Another reason in heterogeneity of
results could be a varying definition of UI among
researchers as some define UI relying on quality of
life questionnaires done by the patient, while others
use the “no pad” definition, meaning that a person
is continent only if they require no pads to live their
daily life (18). Furthermore, a 2020 meta-analysis
found study design features, that should be
generalised in all future studies investigating UI
after RP in order to reduce disparity between
results in different trials (26). In the 2020 meta-
analysis usage of biofeedback, instruction to
contract around the urethra, a control group with no
prior education on PFMT, inclusion of all men
despite continence status and continence defined as
no leakage were found to be study design features
important for 3 month study result outcomes (26).
This is further supported in a 2021 meta-analysis,
which showed, that supervised, high-volume (with
higher number of repetitions) and biofeedback
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incorporating pelvic floor muscle exercises are the
most beneficial in reducing post prostatectomy UI
(27).
Pelvic floor muscle training for erectile
dysfunction
The neurovascular bundle containing the erectile
nerve is right by the anterolateral side of the
prostate, because of the anatomical location of the
bundle it is difficult not to damage it during radical
prostatectomy (5). Some researchers claim, that
evaluating the effect of physiotherapy in treating
ED in patients after RP is difficult because a lot of
patients in these studies also have UI, which can
severely affect sexual relationships and sexual
satisfaction (25). Some studies find that
improvement of erectile dysfunction is closely
related to urinary continence, going as far as to say,
that urinary continent males after RP have a 5.4
times higher chance of being potent (28). A
possible reason for impaired sex life could be
climacturia associated incontinence which is more
common in patients after RP and can occur from 22
to 49% of cases (29). One study found that PFMT
with electrical stimulation did not provide better
results than in the control group, both PFMT with
electrical stimulation group and no intervention
group recovered with no significant difference:
muscle strength and urinary continence returned at
the same rate (25).
In the Laurienzo et al. study patients were
randomly assigned to three groups (patient
variables: age, body mass index, severity of ED
were accounted for and groups were homogenous):
first group was control and received no education
on postoperative PFMT, second group was
instructed to perform PFMT exercises 2-3 times a
day for 6 months, third group performed PFMT
exercises and additionally received
electrostimulation therapy two times a week for 7
weeks (14 sessions in total) (25). At 6 months post
RP all three patient groups were examined, no
statistically significant difference in pelvic muscle
strength, continence or erectile function was found
(25).
In the Geraerts et al. study, which examined the
effectiveness of PFMT for the treatment of ED one
year after RP, the treatment group achieved better
results than the control group, but the ability to
orgasm did not differ between the two groups (29).
In this study patients could not use any other aids
to support erectile function and received individual
physician supported PFMT together with
electrostimulation and performed an at home
program that consisted of 2 sessions of exercises,
30 repetitions each (29). At the end of 15 month
treatment, 12/30 patients were able to have
penetrative sexual intercourse, whereas before the
treatment 5/30 could have sexual intercourse (29).
Conclusions
Urinary incontinence and erectile dysfunction are
common complications of radical prostatectomy
that greatly impair the quality of life of the patients
affected. The data on the effectiveness of current
conservative treatment options is inconsistent as
the disparity between different trials studying the
efficacy of these exercises is too great. Supervised,
high-volume and biofeedback incorporating pelvic
floor muscle exercises have been found to be the
most beneficial in reducing post prostatectomy
urinary incontinence. Despite improvement of
erectile properties, pelvic physiotherapy has no
effect on the ability to orgasm.
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