Men Have Pelvic Floors Too! How PTs Can Help Before and After a Prostatectomy
By: Nataliya Zlotnikov, MSc, HBSc
By: Nataliya Zlotnikov, MSc, HBSc
Pelvic Floor Dialogue
Before we delve into today's blog, we invite our community to take a look at an excerpt from a play that we here at Embodia have been diligently working on:
We need to talk.
What would you like to talk about?
Take a guess...
...I'm not a mindreader, all I wanted was to be a pelvic floor physio.
And all I wanted was to have a pelvic floor physio...men have pelvic floors too.
Admittedly that was pretty terrible. Thankfully, we're not really working on a play. We are however still working on all your favourite Embodia-related things like HEP, continuing education, practice management, and more. And in case you missed the reference, the above mini-script is a parody of this catchy Old Spice commercial.
The script alludes to the more serious fact that in a female-dominated profession, not only are pelvic floor PTs who treat males harder to come by, but it can be difficult for a male person to discuss certain issues surrounding their pelvic health with female PTs. This results in men not receiving the help they need, withdrawing and isolating themselves, and having a decreased quality of life.
That is why it is imperative for us to be well-versed in treating males, or know who to refer to.
We don't want our male patients getting the short end of the stick (the terrible humour never sleeps)!
This blog is based on one of our excellent male pelvic health courses by the same name, Male Pelvic Health, with PTs Sandy Hilton and Sarah Haag.
The online healthcare course provides foundational information for treating men with pelvic pain, incontinence, constipation issues, and sexual dysfunction.
The course covers a lot of great content, but in this blog, we will only discuss a small piece of the course content that is very specific to males, prostate cancer.
To get the full picture, we invite you to take a look at Sandy and Sarah's course below.
Prostate cancer is a common issue affecting males in Canada.
Screening for Prostate Cancer
So how do we screen for it? Prostate cancer can be diagnosed using the following 4 methods:
- Prostate-specific antigen blood test
- Digital rectal exam
- Prostate biopsy
- Core needle biopsy
But Should Your Patients Be Screened?
Routine screens for prostate cancer are no longer recommended by the guidelines.
This is owing to most prostate cancers growing at a very slow rate or not at all, and screening sometimes finding prostate cancer in men who would have otherwise continued to live asymptomatically (Centers for Disease Control and Prevention, 2021).
If cancer is found, the common treatment options include prostatectomy, radiation therapy, and hormonal therapy; with prostatectomy being the gold standard.
Another reason why routine screening is no longer recommended is that although nowadays having prostate cancer may not be too much of a pain most of the time, living with the common post-operative consequences of urinary incontinence and sexual dysfunction is much more uncomfortable, to say the least.
Post-prostatectomy urinary incontinence ranges from 1-90%.
With regards to sexual function, post-prostatectomy orgasms are dry and erectile dysfunction is highly prevalent. Recovery from erectile dysfunction ranges with 54-90% of men recovering in 12 months, and 63-94% recovering in 24 months.
Can PTs Make A Difference in Prostate Cancer Recovery?
Let's discuss prehab first. Should men about to undergo a prostatectomy see a PT preoperatively?
Currently, there is limited evidence in support of prehab for prostatectomies and more studies are needed. From Sarah's clinical observations, she shares that prehab education really helps. Her patients report increased confidence and report feeling better knowing what is ahead.
And I am inclined to agree with her. From a pain science, biopsychosocial perspective, education is extremely effective at reducing pain and improving quality of life.
Just imagine how distressing it would be to find out you are now having dry orgasms if you didn't know about it beforehand.
Similar to prehab, post-prostatectomy evidence still isn't very strong for rehab. However, some studies have found that physiotherapy helps men regain continence following a prostatectomy, and that starting physiotherapy interventions sooner resulted in a greater effect.
Regaining Continence After a Prostatectomy
The following interventions can be used by PTs following a prostatectomy to help patients regain urinary incontinence:
- Pelvic floor exercises
- Functional training
- Bladder training
- Electrical stimulation
But which ones should you prescribe to your patients? There isn't one blanket answer to what is most effective. Creating an individualized plan works best.
What about stacking them all together into a combo? This might not necessarily be the most beneficial: research has found that the addition of biofeedback and electrical stimulation did not improve outcomes over CBT and exercise.
Pelvic Floor Exercises Definitely Work
Pelvic floor exercises have been found to be effective at treating urinary incontinence in general as well as following a prostatectomy.
Consistently with what we've written so far, research in this category is also lacking. Under normal circumstances, in the absence of a prostatectomy, men are much less likely than women to experience urinary incontinence, therefore, most studies have been conducted on females.
But in 2016, Stafford et al., published a study looking at which pelvic floor engagement cues work best for men.
These are the cues they looked at:
- 'Stop the flow of urine'
- 'Elevate the bladder'
- 'Shorten the penis'
- 'Lift the testes'
- 'Tighten around the anus'
- 'Prevent passing gas'
They found that different cues are best for achieving different things!
'Elevate the bladder' resulted in the greatest increase in abdominal EMG and IAP.
'Tighten around the anus' resulted in the greatest anal sphincter muscle activity
While, 'shorten the penis', resulted in the greatest dorsal displacement of the mid-urethra and SUS muscle activity!
Pre-prostatectomy Patient Education
Here is a great patient education video from the Male Pelvic Health course.
In this video, Sarah shares with us a drawing she does for all her gentlemen when they come for a pre-op visit to show them how things are working currently, and how they might change after surgery.
To read more about treating and examining males, take a look at our blog, Happy Pride Month! Let’s Talk Treating & Examining Males.
Date written: 5 April 2022
Last update: 7 April 2022
Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and earned a Doctor of Physical Therapy degree from Des Moines University in December 2013.
Sandy teaches Health Professionals and Community Education classes on returning to function following back and pelvic pain, and co-teaches Advanced Level Male Pelvic Floor Evaluation/Treatment for Entropy Physiotherapy as well as Neurodynamics and Sensory Integration for Pelvic Pain and a Practical Application of Pain Science course with Pelvic Health Solutions.
Sandy’s clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is also pursuing opportunities for collaboration in research into the clinical treatment of pelvic pain conditions. Sandy has co-authored two papers, 2 book chapters and "Why Pelvic Pain Hurts" a patient focussed book.