Case Study: Post Prostatectomy Incontinence
- Fred, a 69 year old farmer, was referred to WMHP by a friend for management of post-prostatectomy incontinence, 2 months following a robotic-assisted radical prostatectomy for organ confined prostate cancer.
- At initial consultation, Fred had significant incontinence, filling 3-4 pull-ups per 24 hours.
- He reported stress urinary incontinence with typical rises in intra-abdominal pressure such as sit to stand and bending, urgency urinary incontinence with nocturnal voids and first void in am, and also constant insensible urine leakage throughout the day.
- He was only voiding small volumes 2-3 times per day in the toilet, nocturia of 3-4.
- He reported no voiding dysfunction, with “much better flow than before”.
- Pre-operative LUTS: Fred reported episodes of urgency urinary incontinence a few times per week, increased frequency, nocturia of 2-3, and voiding dysfunction with slow stream and incomplete emptying.
- Bowel function: Fred was prone to constipation and straining, eats a lot of meat and potatoes but “not too keen on veggies”.
- Erectile function: no current erectile function, pre-operative things had been “slowing down” and his wife was “not that keen”.
- Social history: married with 2 daughters and 4 grandchildren, manages dairy farm, brother also has prostate cancer. Fred was very embarrassed by his incontinence and was avoiding leaving the house. His wife reported that he was becoming very irritable and angry.
- Exercise: increased BMI of 29, no regular exercise program currently or pre-op, but long hours working on the farm which he runs largely by himself. Had been doing pelvic floor exercises that he learnt on the internet but was finding they “weren’t making any difference”.
- Observation: minimal penile retraction and testicular lift with attempted pelvic floor muscle contraction, global response with breath holding and abdominal / gluteal contraction.
- Real-time 2D transperineal ultrasound (TPUS) examination: poor ability to isolation a pelvic floor muscle contraction, minimal urethral occlusion with mild activation of puborectalis (2mm bladder neck elevation) and bulbocavernosus, urethral sphincter flickering in and out only, unable to sustain.
- Pad weight diary: leaking 870mls per 24/hrs, including ~150mls overnight.
- Bladder diary: diurnal urinary frequency of 2-3 (volumes 30-150mls), nocturia of 3-4 (volumes of 40-150mls), fluid intake 1.2-1.4L inc. 2-3 coffee per day.
- Bladder scan: no post void residual.
- Dipstick urinalysis: NAD.
- TPUS assessment and biofeedback: Fred was educated how to correctly contract his pelvic floor muscles using TPUS for biofeedback, with a focus on the striated urethral sphincter, puborectalis, and bulbocavernosus activation. TPUS is a very beneficial tool in men with post-prostatectomy incontinence, as it enables the therapist to visualise all the striated muscles involved in continence, including the striated urethral sphincter (which cannot be assessed via rectal examination).
- Pelvic floor muscle training program: Fred’s program was focused initially on correct technique of activation, followed by a strengthening program and functional integration into his daily activities which caused leakage such as lifting and bending during farm duties.
- Fluid modification: it was recommended that Fred minimise his caffeine intake, and aim for around ~1.5L total fluid intake.
- Behavioural bladder retraining: a bladder retraining program was commenced, focusing on urge suppression, and then urge deferral aiming to increase his functional bladder capacity.
- Referral to surgeon for opinion on medical management for OAB: Fred was reviewed by his surgeon and commenced on Betmiga.
- Weight loss advice: Fred was educated about the impact of increased BMI on incontinence and the benefit of dietary changes and increasing general exercise for weight loss.
- Treat constipation: Fred was educated in dietary changes for stool softening and taught how to empty his bowels without straining.
- Psychological: Fred was offered referral to a psychologist (which he declined), however his physio had many discussions with him about the importance of re-engaging in social and leisure activities to reduce his social isolation and improve his recovery.