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ORIGINAL ARTICLE
Year : 2023 | Volume
: 34
| Issue : 1 | Page : 39-45
Effects of early pelvic floor muscle training on early recovery of urinary incontinence after prostate surgery
Yi-Hsuan Chen1, Yung-Shun Juan2, Wei-Chi Wei1, Jiun-Hung Geng3, Kuang-Shun Chueh4, Hsiang-Ying Lee2
1 Department of Urology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
2 Department of Urology, Kaohsiung Municipal Ta-Tung Hospital; Department of Urology, Kaohsiung Medical University Hospital; Department of Urology, School of Medicine, College of Medicine, Kaohsiung Medical University; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
3 Department of Urology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
4 Department of Urology, Kaohsiung Municipal Ta-Tung Hospital; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
Correspondence Address:
Dr. Hsiang-Ying Lee
No. 100, Shih-Chuan 1st Road, Sanmin District, Kaohsiung 80708
Taiwan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/UROS.UROS_59_22
Purpose: Postprostate surgeries urinary incontinence (UI) is one of the common bothersome complications of prostate surgery. Pelvic floor muscle exercises (PFME) have been reported to have benefits in shortening postoperative recovery time of UI. The aim of our study is to evaluate the efficacy of intensive schedule of PFME and pelvic muscle electrical stimulation in improving the recovery of postoperative UI. Materials and Methods: We prospectively enrolled 72 patients (63 Benign prostate hyperplasia [BPH] and 9 prostate cancer [PC]) who received transurethral resection of the prostate (TURP), anatomical endoscopic enucleation of the prostate (AEEP), Radical prostatectomy (RP) from January 2019 to December 2020. Twenty-seven patients who are unable to remove Foley catheter before discharge or loss follow-up were excluded. Finally, we enrolled 44 patients (35 BPH and 9 PC). All patients were assessed using the pad test, International Prostate Symptom Score, and Overactive Bladder Symptom Score. Abdominal ultrasonography or transrectal ultrasound of prostate was used to measure prostate volume and the postvoid residual urine volume. Results: The rate of UI was 60% and 88.9% immediately after removing the Foley catheter in TURP/AEEP and RP groups respectively. The incontinence rates in TURP/AEEP were 34.2%, 20%, and 3% after 2 weeks, 1 month, and 3 months' postoperation. In the RP group, the incontinence rate was 55.6%, 44.4% after 2 weeks, and 1 month postoperation. The pad amount was 63.11 ± 52.9 g, 37.89 ± 52.99 g, and 13.22 ± 18.48 g after 2 weeks, 1 month, and 3 months' postoperation. Conclusion: We demonstrated early intensive PFME program can shorten the recovery time of UI after prostate surgery.
Keywords: Electric stimulation therapy, exercise therapy, prostate cancer, prostatic hyperplasia, transurethral resection of the prostate, urinary incontinence
Elderly men commonly develop benign prostate hyperplasia (BPH), which can be surgically treated by transurethral resection of the prostate (TURP) or anatomical endoscopic enucleation of the prostate (AEEP), and Prostate cancer (PC), which is noncutaneous and was the fifth leading cause of cancer death in 2020 in Taiwan. Radical prostatectomy (RP) is the standard treatment for clinically localized stages.[1],[2] However, postoperative urinary incontinence (UI) is one of the common bothersome complications, with an incidence of 8.5%–42.7% and 1%–87% after holmium laser enucleation of the prostate (HoLEP) and RP, respectively, due to differences in definition, surgical technique, basic patient characteristics, and evaluation tools.[3],[4] While most patients spontaneously recover from postoperative transient UI after 3–6 months, this complication still affects the patient's quality of life (QoL).[5]
Risk factors affecting the incidence of postoperative UI after prostate surgery include age, body mass index (BMI), prostatic size, operation duration, comorbidities, sphincter injury, neurovascular bundle preservation, and bleeding extent.[6],[7] Clinically, compared with RP, the surgical treatment of BPH may cause more sensitive problems in the case of postoperative UI due to a higher requirement of patient satisfaction. Therefore, meticulous preoperative evaluation and intraoperative improvement of surgical techniques are important to reduce the incidence of UI.[3],[8]
Pelvic floor muscle exercises (PFME) can shorten the postoperative recovery time of patients with UI.[9] Anan et al.[10] demonstrated that preoperative PFME can improve UI earlier after HoLEP. In the present study, patients who underwent TURP, AEEP, and RP received early and intensive intervention with pelvic muscle electrical stimulation (ES) and PFME immediately after surgery as scheduled. The aim of our study is to evaluate the effectiveness of an intensive schedule of PFME and ES in improving recovery from postoperative UI.
Materials and MethodsThis study was approved by our Institutional Review Board (KMUHIRB-F[I]-20190092). We prospectively enrolled 72 patients (63 BPH and 9 PC) who received TURP, AEEP, or RP in our hospital between January 2019 and December 2020. Of them, we excluded 27 patients who were unable to have the Foley catheter removed before discharge or who were lost to follow-up. Finally, we included 44 patients (35 BPH and 9 PC) and assessed them using the pad test, International Prostate Symptom Score (IPSS), and Overactive Bladder Symptom Score (OABSS). We used abdominal ultrasonography or transrectal ultrasound of the prostate to measure the prostate volume and the postvoid residual (PVR) urine volume. We performed uroflowmetry to check the urine flow rate. We evaluated all parameters at 1 week, 2 weeks, 1 month, and 3 months postoperatively.
We informed patients of the schedule and the process of PFME before the surgery, and patients started intensive biofeedback with ES combined with PFME at the time of Foley catheter removal [Figure 1]. Patients received biofeedback with ES in the hospital twice in 1 week, which lasted for 3 months. Three kinds of exercises were taught to the patients: First was the pelvic tilt, in which the patient lay down with their back on the floor and legs bent, pulled the belly bottom in toward the spine, and held the position for 5 s; this movement was repeated for two sets of 10–15 counts/day. The second was the bridge, in which PFME was performed at home using a pressure ball [Figure 2]. We designed the pressure ball to monitor the pelvis muscle strength when practicing. The patient lay down on their back and bent the knees with the pressure ball between the knees. The buttocks were contracted and lifted several inches off the ground. The position was held for 5–10 s, and this movement was repeated for three sets of 10–20 counts/day. The numbers shown on the scale indicated muscle strength. The third was the squat, in which the patient stood straight with the feet apart and lowered themselves down as if sitting in an invisible chair without knee internal or external rotation; this movement was repeated for two sets of 10–15 counts/day. UI was defined as pad test >1 g.[11] In the pad test, we weighed the pad after coughing 10 times, squatting and standing up 10 times, running in place for 10 s, washing hands with cold water, and climbing 30 stairs under bladder distention.
Figure 2: The pressure gauge connected with the elastic ball, which can reflect the patients' muscle strengthWe performed paired sample t-test analysis to compare the urinary symptoms and strength of the pelvic floor muscle before surgery and after PFME.
ResultsPatient characteristics are listed in [Table 1]. The mean (± standard error) age in the BPH group was 69.36 ± 7.56 years, mean BMI was 25.13 ± 2.51 years, mean prostate volume was 70.97 ± 30.35 g, and mean resected prostate volume was 33.39 ± 23.4 g. The mean (standard error) age in the PC group was 70.67 ± 6.14 years, mean BMI was 24.93 ± 3.23, mean prostate volume was 50.52 ± 22.44 g, and mean resected prostate volume. The incontinence results are shown in [Table 2]. The rate of UI was 60% and 88.9% immediately after Foley catheter removal in the TURP/AEEP and RP groups, respectively. The incontinence rates in the TURP/AEEP group were 34.2%, 20%, and 3% after 2 weeks, 1 month, and 3 months postoperatively. In the RP group, the incontinence rates were 55.6% and 44.4% at 2 weeks and 1 month postoperatively. The pad amount was 63.11 ± 52.9 g, 37.89 ± 52.99 g, and 13.22 ± 18.48 g after 2 weeks, 1 month, and 3 months, respectively.
Table 1: The baseline characteristics between benign prostate hyperplasia and prostate cancer group
Table 2: The recovery status of incontinence between benign prostate hyperplasia and prostate cancer patientsThe IPSS, OABSS, and uroflowmetry results of the TURP/AEEP and RP groups are listed in [Table 3] and [Table 4]. In the BPH group, the preoperative baseline IPSS and the mean IPSS were 17.91 and 13.29 at postoperative 1 week, respectively. After PFME, the scores improved to 9.46, 5.94, and 2.71 at postoperative 2 weeks, 1 month, and 3 months, respectively (P < 0.01; P < 0.01; P < 0.01). For OABSS, the IPSS was 6 and 7.26 for preoperative and postoperative 1 week, respectively, and after PFME, the scores improved to 5.83, 5.26, and 2.51 at postoperative 2 weeks, 1 month, and 3 months, respectively (P = 0.815; P = 0.315; P < 0.01). These results indicate an improved QoL in both groups. The uroflowmetry results showed an increased flow rate and a decreased PVR urine volume. The flow rates were 10.82 ml/s, 18.57 ml/s, 20.65 ml/s, and 21.84 ml/s before surgery and after 2 weeks, 1 month, and 3 months, respectively (P < 0.01; P = 0.012; P = 0.04); PVR urine volume was 99.32 cc, 41.76 cc, 36.82 cc, and 28.29 cc, respectively (P = 0.011; P = 0.121, P = 0.008).
Table 3: The comparison of International Prostate Symptom Score, Overactive Bladder Symptom Score, and uroflowmetry results of benign prostate hyperplasia group before and after surgery
Table 4: The comparison of International Prostate Symptom Score, Overactive Bladder Symptom Score, and uroflowmetry results of prostate cancer group before and after surgeryIn the PC group, the mean IPSS was 14.44 at postoperative 1 week compared with preoperative baseline scores of 13.11. After PFME, the scores improved to 9, 6.44, and 5.78 at postoperative 2 weeks, 1 month, and 3 months, respectively (P = 0.304; P = 0.046; P = 0.012). For OABSS, the scores were 5 and 10.56 for preoperative and postoperative conditions. After PFME, the OABSS scores improved to 8.11, 6.44, and 5.78 at postoperative 2 weeks, 1 month, and 3 months, respectively (P = 0.062; P = 0.344; P = 0.422). These results indicate an improved QoLin both groups. The uroflowmetry results showed an increased flow rate and a decreased PVR urine volume. The flow rates were 6.96, 12.39, 13.96, and 16.27 ml/s before surgery and after 2 weeks, 1 month, and 3 months, respectively (P = 0.058; P = 0.403), while PVR urine volume was 132 cc, 45.22 cc, 5 cc, and 9.33 cc, respectively (P = 0.257; P = 0.351).
[Table 5] shows the data on the pelvic floor muscle strength of patients after using the pressure ball. The pelvic muscle strength included the hip flexors, hip extensors, hip adductors, hip abductors, internal rotation (sit), and internal rotation (lie down). After regular practice, the BPH group improved from 12.3% to 18.2%, while the PC group did not achieve obvious improvement.
Table 5: The pelvic floor muscle strength status before and after surgery of benign prostate hyperplasia and prostate cancer group Discussion Postoperative UI remains one of the most common bothersome complications after prostate surgery including RP for PC and TURP/AEEP for BPH. Although most patients recover in 6 months, this complication may restrict the patient's activities and reduces their QoL. The complication can discourage patients from receiving the surgery. Thus, it is important to decrease the incidence of UI complications and shorten the recovery time. In the present study, the aim was to analyze the change in urine leakage amount and symptom severity after PFME.
Various risk factors of postoperative UI have been reported.[12],[13] Physicians should inform patients of the possibility of UI complications before surgery and should intraoperatively perform a meticulous surgical plan. Although UI gradually improves after weeks or months, PFME can speed up the recovery of UI.[14]
PFME is a behavior treatment for UI that works by strengthening the pelvic flow muscles to restore the continence function. It may result in hypertrophy of the striated muscles, thereby increasing the external mechanical pressure on the urethra. PFM function can be assessed by visual observation, digital palpation, electromyography, manometry, or ultrasound.[15] In this study, we designed a device (pressure ball) that can evaluate pelvic muscle strength with objective data and provide feedback for the patients. The pressure ball can quantify the strength of the pelvic muscle and increase the motivation for patients to practice. After regular practice, improvements were noted. UI in male patients can be managed via nonsurgical and surgical approaches. Nonsurgical approaches include conservative treatment, such as behavior adjustment, pelvic floor muscle ES, and pharmacological treatment. In the case of stress UI, more invasive surgical procedures such as intramural urethra bulking agent injection, male sling surgery, artificial urinary sphincter, and stem cell therapy can be considered.[16],[17] PFME is a recommended noninvasive treatment and should be prescribed to all patients after surgery.[18] However, better results depending on the patient's motivation and compliance in addition to a thorough exercise program. In this study, a regular intensive exercise program, comprehensive education before surgery, and real-time feedback of pelvic muscle training using biofeedback and a pressure ball were used to increase motivation and compliance. ES was also applied when performing biofeedback.
PFM ES has two kinds of actions: contraction of PFMs and inhibition of unwanted detrusor contractions.[19] ES is effective for improving UI in women. Although fewer studies have been conducted in men, ES may accelerate the recovery of continence after prostatectomy.[20] The postoperative incontinence rate in the TURP and AEEP with a wide range because of different definitions of incontinence, the timing to evaluate incontinence after the operation, or different techniques by surgeons. Nam et al.[6] reported a UI rate of 16.6% at postoperative 2 weeks, and the recovery rates of transient UI after HoLEP at 1, 2, and 3 months were 45%, 60%, and 80%, respectively. Hirasawa et al.[21] demonstrated a UI rate of 17.3% at postoperative 1 week, and the recovery rates of UI after transurethral enucleation with bipolar at 1 month and 3 months were 22% and 82%, respectively. In the present study, the UI rate was 60% and the postoperative recovery rates after 2 weeks, 1 month, and 3 months were 42.8%, 66.7%, and 95%, respectively. The recovery rate of incontinence in this study was higher than those in previous studies, and the recovery time was shortened by intensive PFME and ES both at the hospital and at home.
Ray et al.[22] recorded the efficacy and safety of TURP. The IPSS/QoL scores were 21.6/4.9, 11.5/2.4, and 9.8/1.9 before surgery and at postoperative 1 month and postoperative 3 months, respectively. Before surgery and after 3 months, the uroflow rate was 10.04 ml/s and 20.8 ml/s, respectively, and PVR urine volume was 263.6 ml and 88.8 ml, respectively. Compared with the results of our study, the IPSS/QoL scores were 17.9/4.8, 5.94/1.89, and 2.71/0.91 before surgery and at postoperative 1 month and postoperative 3 months, respectively. Before surgery and after 3 months, the uroflow rate was 10.82 ml/s and 21.84 ml/s, respectively, and PVR urine volume was 99.32 ml and 28.29 ml, respectively. Thus, patients trained with PFME and ES had better outcomes. In our study, patients with PC post-RP and trained with PFME combined with ES, 55.6% of them achieved continence postoperative 1 month. Compared with the results of Dijkstra-Eshuis et al.,[23] the continence rate was 43.6%, which is similar to that in our study at postoperative 3 months (44.4%), but only 20.8% of patients achieved continence at postoperative 6 weeks among patients without PFME.
The functional results of surgery of PCa (laparoscopic RP, robot-assisted RP [RaRP], and open RP) have been compared with those in previous studies,[24],[25] showing improved lower urinary tract symptoms in a RaRP group. In our study, only one patient received RaRP, so the program may be applied to patients who received RaRP.
The incidence rate of post-TURP urinary retention was 3%–9%. In some patients, the Foley catheter may not be removed before discharge, which might be because of primary detrusor failure or temporary edema of the urethra.[26] Differently, the Foley catheter in patients who underwent RP could not be removed before discharge because their bladder and urethra anastomosis were not healed yet. In the present study, 16 patients were unable to complete the entire protocol due to poor compliance with a long period of exercise; most of them were lost to follow-up in the early stage of this program. This may indicate that if patients can participate in our intensive program for a period, they had good compliance to complete it.
This prospective research has some limitations. First, the sample size is small, but all enrolled patients accomplished the whole intensive program with a comprehensive evaluation. Second, there is no control group in our study. However, we conducted pioneer research regarding newly designed tools (pressure balls) for measuring the strength of the pelvic floor muscles and strictly monitored the compliance of patients with an intensive schedule. Third, enrolled patients have a heterogeneous background, which may be confounding factors that have an impact on UI complications. Therefore, further prospective studies with a control group are warranted to determine the benefits of the early intensive PFME program.
ConclusionWe demonstrated an early intensive PFME program with strict monitoring of the schedule and using pressure balls to quantify the strength of pelvic floor muscles, which can shorten the recovery time of UI after prostate surgery. Regarding the QoL, measured by several questionnaires, and outcomes of uroflow and PVR urine volume, the outcome was better in patients who trained with PFME with ES.
Financial support and sponsorship
Nil.
Conflicts of interest
Prof. Yung-Shun Juan, Prof. Hsiang-Ying Lee, editorial board members at Urological Science, had no roles in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.
References
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