Highlights from the Post Prostatectomy Incontinence Masterclass

A Post Prostatectomy Incontinence Masterclass at the Asia-Pacific Prostate Cancer Conference 2017 was convened by Shan Morrison and Rachel Heerey. The masterclass brought together experts in urology, pelvic floor physiotherapy, nursing, and psychology.  We were very lucky to have such an expert faculty presenting on the day, including surgeons Mr Daniel Moon, Mr Peter Sutherland and Mr Homi Zargar, pelvic floor researcher Dr Ryan Stafford, specialist physiotherapist Dr Trish Neumann, and psychologist Dr Chris Nelson from Memorial Sloan Kettering in USA. Here are 10 highlights from the day.

1. Individual features of pelvic floor muscle control influence PPI

Unravelling the physiology and biomechanics of post-prostatectomy incontinence by Dr Ryan Stafford, research fellow.

Dr Ryan Stafford and his research group from the University of Queensland have spent the last 10 years researching the male pelvic floor and continence mechanism, originally in normal men, and more recently in men following radical prostatectomy.

Ryan presented some fascinating new research published this year, with three key messages:

a. In normal men, 3 key components of the pelvic floor contribute to continence; puborectalis, striated urethral sphincter (SUS), and bulbocavernosus.
b. Combined strength of SUS, puborectalis and bulbocavernosus is associated with better continence outcomes post radical prostatectomy¹
c. SUS function is the key to return of continence after surgery, with a prediction model finding good SUS function can compensate for poor PR and BC function, but good PR and BC function cannot compensate for poor SUS function.¹

2. Real-time transperineal ultrasound is the ideal way to assess the male pelvic floor

The nuts and bolts of physiotherapy for post-prostatectomy incontinence by Ms Shan Morrison and Dr Patricia Neumann, Pelvic Floor Specialist Physiotherapists.

Traditional assessment of the male pelvic floor has been via digital rectal examination (DRE).  DRE is a good assessment of puborectalis function, but doesn’t give information about the striated urethral sphincter (which we now know is so important).  Real-time transperineal ultrasound allows visualisation of all the striated muscles involved in continence. It is also a powerful form of visual biofeedback – men love being able to see their pelvic floor muscles in action!

3. The psychological impact of PPI is HUGE

The psychological impact of post prostatectomy incontinence and decisional regret by Dr Chris Nelson, Psychologist

Unfortunately, approximately 50% of men report severe emotional distress associated with urinary incontinence!

Men with incontinence display:

• Lower self-esteem
• Social isolation
• Increased feelings of anxiety and depression
• Decreased participation in social activities and physical activities
• Increased time spent at home

Screening for psychological distress is very important in these men, as they will often not be forthcoming.  Distress is more likely in the presence of anxiety, a low affect, when there is a lack of partner support & if men identify strongly with a masculine role.

4. Bladder dysfunction commonly plays a role in PPI

PPI – Not necessarily a surgical issue by Dr Michael Whishaw, Geriatrician

In addition to intrinsic sphincter deficiency, bladder dysfunction also commonly contributes to PPI. Bladder dysfunction could be in the form of detrusor overactivity, detrusor underactivity, or impaired compliance².  It can be pre-existing, or de-novo following surgery due to denervation or surgical changes.

Urodynamics is recommended if incontinence does not seem to be straightforward stress urinary incontinence.  If there is suspicion of bladder dysfunction such as detrusor overactivity (present in up to 63% of men after radical prostatectomy²), then a trial of medical management is recommended.

5. Each case of PPI is different – and needs to be treated that way

The nuts and bolts of physiotherapy for post-prostatectomy incontinence by Ms Shan Morrison and Dr Patricia Neumann, Pelvic Floor Specialist Physiotherapists

A thorough and detailed assessment of incontinence is essential, using outcome measures such as pad weigh diaries and bladder diaries, in order to accurately diagnose the mechanism of incontinence.  Each man will have hugely different contributing factors that need to be addressed, for example inadequate pelvic floor muscle function, detrusor overactivity, poor fluid habits such as excessive caffeine, or constipation. Individualised management programs are crucial to ensure men reach their goals and return to their pre-operative lifestyle including work, general exercise, and hobbies.  

6. Pads are not always the best option for containment

Continence aids and containment by Ms Janie Thompson, Continence Nurse

Approximately 60% of containment aids are inappropriate to needs, typically being suited to more severe leakage than indicated.  Re-assessing a man’s choice of, or even requirement for a pad, is important.  Other containment options include penile clamps, condom drainage, and the different varieties of male-specific pads. Men often prefer a variety of containment options suited to different social situations.

7. Prehabilitation is best practice

The nuts and bolts of physiotherapy for post-prostatectomy incontinence. Ms Shan Morrison and Dr Patricia Neumann, pelvic floor specialist physiotherapists

Research shows that pelvic floor muscle (PFM) training is more effective when started before radical prostatectomy.  The important elements of prehablitation include:

• Getting to know the man “in his environment” – using a biopsychosocial assessment
• Provide education about what will happen
• Establish realistic expectations
• Empower with knowledge
• Assess & teach PFM technique
• Individualised PFM training program
• Provide emotional support on the road to recovery of continence

8. Red flags after radical prostatectomy

Complications after radical prostatectomy by Mr Homi Zargar, Urologist

Common and rare urinary complications to be aware of after radical prostatectomy, including (but not limited to):

• Urethral stricture, which is commonly indicated by slow flow & no incontinence.
• Anastomotic leak, characterized by pain, possible fever, and minimal incontinence.
• Recurrent UTIs can be the result of an internal infection at the surgical site.
• Urinary retention after trial of void can be a sign of catheter removal too early
• Lymphoceles are rare but can lead to lower abdominal discomfort, constipation, urinary frequency & oedema of the genitals/legs.

9. Surgical management of persistent PPI has a huge benefit to quality of life

Optimising and restoring continence following prostate cancer surgery by Mr Daniel Moon, Urologist

Slings and artificial urinary sphincters are often very effective procedures, and lead to a drastic improvement in a man’s quality of life.  Regaining continence has a huge impact on restoring a man’s confidence, masculinity, socialisation, exercise, relationships, and returning to normal life.  If men have ongoing incontinence after prostatectomy surgery, they should be offered surgical resolution of their symptoms.

10. Helping men re-engage in life is so important

The psychological impact of post prostatectomy incontinence and decisional regret by Dr Chris Nelson, Psychologist

Men with post-prostatectomy incontinence commonly withdraw from important activities, which leads to depression, anxiety, and despair.  Chris highlighted the Importance of helping men reengage in life, and acceptance and commitment therapy (ACT) was endorsed as a line of enquiry.

Acceptance and commitment therapy guide:

• What are the avoided tasks?
• What is the importance/value of these activities?
• Can the anxiety/feelings that are triggered be accepted? Anxiety/sadness/anger are part of a normal emotional spectrum. These don’t need to be suppressed or ignored.  
• Is there a willingness to engage despite these emotions? This calls for courage in foregoing short-term relief, to avoid a vicious cycle of long term struggle.
• Can they commit to engaging in the activity again? It can support personal growth & mental flexibility.

We all have a role in encouraging men to keep living; encouraging socialisation, exercise, and doing things they enjoy.

References

¹Stafford, R. E., van den Hoorn, W., Coughlin, G., & Hodges, P. W. (2017). Postprostatectomy incontinence is related to pelvic floor displacements observed with trans-perineal ultrasound imaging. Neurourology & Urodynamics, epub

²Hennessey B, Hoag N, Gani J. Impact of bladder dysfunction in the management of post-prostatectomy stress urinary incontinence – a review. Transl Androl Urol 2017; 6(Suppl 2): S103-S111

November 2017