A prostatectomy is the surgical removal of all or part of the prostate gland. The prostate gland is located just under the bladder and has the urethra traveling thru it. The urethra is a tube like structure that carries urine from the bladder to the penile opening. When the prostate gland becomes enlarged, there is increased “squeeze” pressure around the urethra which restricts the normal flow of urine, causing discomfort and difficulty voiding.
There are three types of prostatectomy’s: 1) transurethral resection of the prostate (TURP), primarily performed to treat benign prostatic hyperplasia (BPH); 2) open prostatectomy which allows manual manipulation and open visualization through the incision; and 3) radical prostatectomy, the removal of the entire prostate gland along with some surrounding tissue in order to remove the entire cancer.
Robotic prostatectomy is a state-of-the-art procedure that has recently become the most common form of prostate removal. With the latest technology, greater accuracy is gained, smaller incisions are made, shorter recovery period occurs and post surgical pain is lessened.
A prostatectomy, like any surgery, has possible complications and side effects. Due to the prostate’s location and anatomical components, incontinence and erectile dysfunction are possible side effects. While it is common for men to experience some leaking for a few weeks post surgery while tissues heal, some men can experience symptoms for many months post op.
When the prostate is surgically excised damage to the cells/tissues that provide continence may occur. The pelvic floor muscles must take the lead to maintain continence. The pelvic floor muscles (PFM) are a group of muscles located the base of the pelvis that help control sexual, urinary and bowel function. The PFM could present as either very weak, too tight or be uncoordinated, resulting in pelvic floor dysfunction. If the PFM are weak, they cannot squeeze tightly, or contract fast enough around the urethra during a sudden sneeze, resulting in leaking. Some men may experience leaking only with coughing, laughing or lifting weight. Other men may experience constant dribbling throughout the day with increased leakage during physical activity. If the PFM are too tense or restricted, both leaking and erectile dysfunction can occur as well.
A successful treatment option for men experiencing pelvic floor dysfunction following prostatectomy is physical therapy. The PT, who is specially trained in the pelvic floor, first evaluates the function of the PFM. Flexibility, mobility and strength are measured via manual intrarectal exam (PFM are located approx one inch intrarectally). Biofeedback assessment of resting tone, strength and endurance of the PFM are performed. A study published from the World Journal of Urology titled “Evaluation of early pelvic floor physiotherapy on the duration and degree of urinary incontinence after radical retropubic prostatectomy in a non-teaching hospital” reviewed the effects that early pelvic floor re-education had on the degree and duration of incontinence. This study concluded that the time period towards continence after a prostatectomy procedure can be shortened significantly if pelvic floor re-education is started early in recovery.
Physical therapy treatment for incontinence and erectile dysfunction consists of manual therapy, neuromuscular re education (biofeedback), strengthening and coordination training. Manual therapy improves extensibility of the PFM, enhancing endorphin production and blood flow. Soft tissue work is a key component for many patients post prostatectomy. Men may subconsciously tighten their PFM all day, thinking this prevents leaking. However, constant tension causes the PFM to become tight and restricted resulting in further weakness/dysfunction.
Once the PFM are free of tension, manual quick stretch techniques are performed to promote strength, recruiting muscle fibers that may be inactive. Biofeedback, which is first used to assess the PFM can also be incorporated into the treatment process. The biofeedback hand held units read the electrical activity of the PFM, giving both the physical therapist and the patient quantitative information about the state of the muscles. Are the muscles too weak, too tight, have poor endurance? Biofeedback training educates patient how to locate their PFM, lower the muscle tension and strengthen weakened muscles. A tailored home exercise program is taught to help men improve their PFM awareness during home/work/sport and empowers men to improve PFM function.
While working with one of the staff DPT (Doctor of Physical Therapy) at EMH Physical Therapy and under the guidance of Evelyn Hecht, PT, ATC the first to offer pelvic floor rehabilitation in NYC 16 years ago, most men with symptoms of incontinence post prostatectomy can regain full continence in 2 to 3 months.
Cornel, E. B., de Wit, R., & Witjes, J. A. (2005). Evaluation of early pelvic floor physiotherapy on the duration and degree of urinary incontinence after radical retropubic prostatectomy in a non-teaching hospital . World Journal of Urology , 23(5), 353-355.