PPI - The Benefits Of Prehab Pelvic Floor Training

Key Messages

  • Urinary incontinence is a common problem after surgery for prostate cancer
  • Evidence shows the benefit of prehab pelvic floor muscle training
  • Prehab training is more beneficial due to enhanced motor skill learning
  • Real time transperineal ultrasound enhances assessment
  • Post graduate trained Physiotherapists are able to deliver evidence based management for men

Urinary incontinence is a common problem after surgery for prostate cancer and it has a huge impact on quality of life. Over 15 years ago, when we started seeing men post-operatively, there was minimal research and understanding of the contribution of the pelvic floor to the male continence mechanism.  Since then we have learnt so much about how to optimise recovery of post-prostatectomy incontinence (PPI).

Aetiology of post-prostatectomy incontinence is complex. Male continence is maintained by a combination of factors including the mucosa, smooth muscle sphincters, the prostate itself, the striated urethral sphincter muscles and the levator ani, particularly the puborectal sling which elevates the bladder neck. These striated muscles combine to increase urethral closure pressure whenever intra-abdominal pressure increases.  

The most common cause of PPI is intrinsic sphincter deficiency, when the urethral closure pressures are insufficient to prevent leakage. Typically, this happens when men get up from a chair, when they are walking, bending, coughing etc. Detrusor overactivity can also be a contributing factor whether pre-existing, or de novo after surgery.

A detailed subjective assessment, preferably pre-operatively is essential and ensures identification of pelvic floor muscle risk factors and pre-existing lower urinary tract or bowel symptoms that may impact on post-operative recovery. Baseline measures of bladder function should be obtained pre-surgery using a bladder diary. Understanding each man’s lifestyle and general exercise habits also assists in setting realistic post-operative goals.

Evidence Supports Pre-Operative Pelvic Floor Muscle

Physiotherapy management of PPI has evolved due to enhanced understanding of the male continence mechanism thanks to research by Physiotherapists Professor Paul Hodges at the University of Queensland and Dr Patricia Neumann at UniSA.  In the past, men attended post op for pelvic floor exercises and the training protocols used were predominately strength based. There is now greater emphasis on pre-operative or prehab pelvic floor muscle training, as the evidence shows this is more beneficial due to enhanced motor skill learning.

Assessment is focussed on correct technique and isolation, enhanced more recently by pelvic floor physiotherapists using real time transperineal ultrasound, which allows the physio and the man to see all the striated muscles involved in maintaining continence in action. Training programs must have a functional focus as the pelvic floor muscles are most useful when they are tightened before movements that trigger incontinence.

Management By Post Graduate Trained Pelvic
Floor Physiotherapists

The pelvic floor muscles are out of sight inside the body, so expert help from a pelvic floor physiotherapist will ensure best possible technique and training. Knowing that they are doing the exercises correctly boosts men’s confidence going into surgery and allows them to contribute to their post op recovery. Our post graduate trained Physiotherapists are able to deliver this evidence based management to the men we see at Women’s &Men’s Health Physiotherapy.

 As many of you are aware, I am passionate about supporting men to recover from post prostatectomy incontinence . One of my favourite sayings is “Let’s not only focus on adding years to life but also adding life to years”. Unfortunately, many pelvic floor physio’s lack knowledge in treating men and not all men are able to access specifically trained Physiotherapists.

Spreading The Word

In order to provide health professionals and pelvic floor physiotherapists across Australia access to up to date education I’m proud to be involved in the following:

  • Committee member of the Nursing and Allied Health meeting held annually at the Asia-Pacific Prostate Cancer conference which ensures that updated physiotherapy research and education is presented at the conference
  • Teaching at the Melbourne University post graduate course on male pelvic floor dysfunction, focusing on management of PPI
  • Recording a webinar for the Continence Foundation of Australia’s education website Australia Continence Exchange regarding PPI
  • Writing a resource for the Australian Physiotherapy Association and the Prostate Cancer Foundation of Australia called Physiotherapy before and after prostate cancer surgery. This informative booklet is being distributed to those in remote and rural areas and others unable to access specialised physio.

We’ve come a long way in treating men for PPI and the evidence clearly shows the enormous benefits of pre-operative pelvic floor training. It’s my mission to ensure that all men can access evidence based care wherever they live so that they can recover their continence and quality of life.

Shan Morrison
Women’s & Men’s Health Physiotherapy


July 2016