Stress Urinary Incontinence Post-Prostatectomy May Lead to Pelvic Floor Overactivity

A study published in International Urology and Nephrology suggested that the majority of men who have post-prostatectomy induced stress urinary incontinence (SUI) have pelvic floor overactivity in addition to pelvic floor underactivity.¹

Researchers suggested that a more individualized approach for treating SUI, geared toward normalizing pelvic floor function, is a potentially valid way to manage post-prostatectomy urinary incontinence and pelvic pain. 

“This is perhaps the first study to look at the type of muscle dysfunction present in men after they’ve had this surgery. Are the muscles actually weak and need to be strengthened, or are they actually tight and just need to be relaxed and lengthened?” Kelly M. Scott, MD, associate professor in the Department of Physical Medicine and Rehabilitation at UT Southwestern and first author of the study, said in a press release.²

In this retrospective study cohort of 136 patients with post-prostatectomy SUI treated with pelvic physical therapy (PT), outcomes were measured in pad usage per day and pain rated on the numeric pain rating scale. Twenty-five of the patients were found to have underactive pelvic floor dysfunction (PFD) and were treated with strengthening, 13 of the patients had overactive PFD and were treated with relaxation training, and the remaining 98 patients had mixed-type PFD and were treated with a combination of relaxation training followed by strengthening.

Eighty-seven percent of the patients achieved improvement in urinary incontinence, and 58% achieved the optimal outcome of a decrease in urinary incontinence to the point where they required pad utilization of 2 or less per day. Overall, 90% of participants had pelvic floor underactivity and 82% had overactivity. 

Both those with uptraining and downtraining protocols showed significant improvement in the number of pads used per day (P < 0.001). Those in the overactive and mixed-type groups attended significantly more therapy sessions (P = 0.004) but tended to improve urinary incontinence more quickly during their course of treatment. Biofeedback (BF) was used more frequently in the patients treated with strengthening (P = 0.001). 

After participation with pelvic PT, for the entire sample of patients the mean pain score decreased with treatment from 0.88 to 0.30 (P < .001). On the initial evaluation, 27% of patients reported having pelvic pain, while on the final evaluation 86% reported no pain and 14% reported still having some pain. Additionally, 79% of the participants were deemed to be compliant with all of their treatment recommendations. 

“We theorize that the improvement in strength in the patients who received downtraining (including the downtraining-only group) may be a function of the muscle length-tension relationship,” the authors wrote. “By relaxing the pelvic floor and functionally increasing the muscle length, more cross-links are available to generate a stronger and more functional contraction.” 

The findings presented did not reach statistical significance, possibly because of the small number of patients studied. The researchers indicated that more research is necessary into the nature of post-prostatectomy PFD and optimal treatment algorithms for SUI in this population. Moreover, prospective and randomized trials would be helpful to ascertain whether individualized pelvic PT treatment is preferable to standard Kegel prescription in this population.

According to the study, SUI is one of the most feared complications of a prostatectomy and is shown to have a prevalence ranging from 2% to 90%. Though this incontinence rate generally decreases over time, an estimated 5% to 20% of men will continue to have some degree of incontinence 1-2 years after surgery.

References:

1. Scott KM, Gosai E, Bradley MH, et al. Individualized pelvic physical therapy for the treatment of post-prostatectomy stress urinary incontinence and pelvic pain. International Urology and Nephrology. doi:10.1007/s11255-019-02343-7.

2. Individualized physical therapy reduces incontinence, pain in men after prostate surgery [news release]. Dallas, Texas. Published December 30, 2019. newswise.com/articles/individualized-physical-therapy-reduces-incontinence-pain-in-men-after-prostate-surgery?sc=mwhr&xy=10024642. Accessed January 24, 2020.