Cochrane review: postprostatectomy urinary incontinence

A colleague recently sent an inquiry through the Institute asking if there is new research supporting pelvic floor muscle training after radical prostatectomy. As a matter of fact, I chose not to report on some recent research that I read, because it does not support conservative care for urinary incontinence (UI). The Cochrane review for postprostatectomy UI was updated this year, and the results of the review indicate that we need more and better research. (If you are unfamiliar with the Cochrane library, one of its 6 databases contains systematic reviews of the literature that are updated periodically.) Although within the abstract of the reviewthe report states that there is a lack of consistency in the interventions, the populations, and in the outcome measures, the value of conservative approaches is deemed "uncertain." The authors do conclude that benefit from one-to-one pelvic floor muscle training is "unlikely" following transurethral resection of the prostate, or TURP.

The critiques of the research listed in the review include the above mentioned lack of consistency in outcomes and interventions. Most of the studies also did not include a report of pre-surgical outcome status, of adverse effects, and lifestyle changes as an intervention was never identified in any of the research. This leads us to this question: why are we treating men for UI or erectile dysfunction (ED) if this systematic review brings into question the efficacy of what we do? Certainly patients are improving as a result of pelvic rehabilitation, or I doubt that the medical providers would continue to refer patients to the offices who provide rehabilitation to these patients. What we do not know about each of the studies is how much of the male anatomy was affected by the procedure for the prostate. The patient's pre-surgical status and the skill level of the surgeon are both known factors for outcomes following prostatectomy, yet how are those quantified in the literature?

Most importantly, how can we be a part of the solution when it comes to creating research to support the services that we provide. It may be helpful as therapists to be certain that we are maximizing the level of knowledge about the surgeries, the anatomy involved, and about the available treatments. This can mean attending coursework that is specific to or includes discussion of male pelvic floor issues. (Check out the Pelvic Floor Series level 2A course or the Male Pelvic Floor Courses offered by the Institute, especially if more male patients are finding their way to your door.) Speak with referring physicians about surgical techniques, observe some surgeries, or attend a urology conference (maybe there's one near your hometown, or you want to attend with your local referring urology group.) Always document using outcomes studies when you can. Write a case study. You can even purchase a text book that teaches you step-by-step how to write a case study. I know that you don't have time...so, create a weekly lunch meeting at work with a colleague where you each work on and critique each other's project. Getting involved with local university programs can also allow you to be part of the research solution.

In summary, we need more and better research that documents how we are helping our patients. In relation to male patients following prostate procedures, who is screening these men to decide if they have tight, painful pelvic floor muscles versus weak muscles with lack of awareness of their use? We are the best chance the patient has in helping with the rehabilitation process. It is also imperative that we are testing muscle function in men to help categorize the patient as someone who might improve with an exercise-based approach or as someone who might need a trial of pelvic floor muscle electrical stimulation. If you tend to complete internal muscle testing with women, yet feel uncomfortable with this approach in men, I encourage you to move forward in your practice of this critical skill. We need to catch the patients early on who seem to have no muscle function and no awareness, and then refer that patient back to the surgeon within a reasonable time frame if there is a lack of progress. A few of the men I worked with who went on to have a male sling had very positive outcomes, and they also were very grateful that they had a pelvic rehabilitation provider to give guidance and feedback along the way. Patients who are more aware of their pelvic muscles, how to use them (and not use them!), and who know how to take care of their pelvic muscles throughout their lifespan are better poised to handle the post-surgical pathway if they should require further intervention.