Throw us a bone

by Donna Canada, RN, CURN

Behavioral treatments can successfully improve urinary incontinence symptoms that occur after prostate cancer treatments or prostatectomy.

Lifestyle changes to control bladder problems and urinary incontinence after PCa treatment

The frequency of toileting (voiding) indicates the degree of irritability of the bladder and the autonomic nervous system that innervates the bladder. The prompt for toileting can be a gentle or strong urge. It can be as simple as the individual telling himself to toilet before leaving home "just in case." Frequent toileting decreases the size of the bladder thus increasing the number of times the individual must toilet each day.⁵ Understanding the behavioral components that impact bladder health can improve continence.

The average bladder capacity is anywhere from 12 to 20 ounces. Maintaining adequate hydration with proper fluid intake and a timed voiding schedule (every 2 to 3 hours) can be very helpful. Many people who have bladder control problems reduce the amount of liquids they drink because they fear urinary frequency, urgency and incontinence. Drinking less liquid does result in less urine in the bladder, however the smaller amount of urine may be more highly concentrated and irritate the bladder lining, perhaps actually causing urgency and frequency.⁷

Key Components of lifestyle changes: (from Diane Newman's Managing and Treating Urinary Incontinence)

• Adjust daily fluid intake to approximately 2,500 mls. (Roughly 60-80 oz/day) or 30 mls per kilogram of body weight per day. Modifying excessively low or high fluid intake may be helpful for some individuals.
• Modify the diet to reduce potential bladder irritants such as carbonated beverages, artificial sweeteners (particularly aspartame), citrus juices and fruits, and highly spiced foods. Alcohol intake is related to worsening of overactive bladder symptoms.
• Reduce caffeine intake to less than 400 mg per day. Caffeine reduction should be tapered slowly to avoid severe headache by reducing by 4-6 oz per day or 3-5 cups per week.
• Regulate bowel function to prevent constipation and straining during bowel movements through use of dietary fiber, fluid intake, and exercise.
• Limit fluid intake 2-3 hours prior to bedtime if nocturia (excessive night-time urination) is a problem.
• Quit smoking.
• Lose weight if moderately or morbidly obese. ⁷

Kegel exercises and pelvic floor muscle rehabilitation for men

Daily Kegel (pronounced Kay-gul) exercises are very important to begin as soon as your physician permits.

The book, Beyond Kegels by Janet A. Hulme, M.A., P.T. offers some insightful information that is particular to men:

"There is a tendency for men who experience leaking to tighten every muscle in the pelvic area in an attempt to stop the involuntary flow of urine. They tighten the buttocks, pelvic muscles, external anal sphincter, and abdominal muscles in a chronic maximal contraction. These muscles eventually fatigue and even more leaking occurs.^"5

About Kegel Exercises

How to Locate the correct muscle:
To find the proper muscle, imagine having to pass gas while in a elevator full of people. To prevent embarrassment, you squeeze the muscles around your rectum to hold the gas back. This is the muscle you want to exercise. Also, lift towards the front around your bladder as if trying to hold back urine. To check yourself for good technique, stand nude in front of a full length mirror. When properly lifting the pelvic floor muscles you should see your penis move slightly.

In the past ten to fifteen years, new exercise protocols have evolved that based on historical information from Dr. Arnold Kegel (1940's) but with new perspectives on the anatomy and function of the urinary and pelvic muscle systems. Some physical therapists and BCIA (Biofeedback Certification International Alliance) certified urologic nurses use different protocols that have not yet been standardized. According to Janet Hulme the "overload principle" states "that for pelvic muscles to strengthen they must be pushed to the limit and just a little beyond. If over-exercised, the muscles fatigue and cannot function, so other muscles must try to compensate. If the muscles are under-exercised, they are not challenged to increase in strength, endurance, or speed.⁵ For instance, if your muscle begins to fatigue after holding a contraction for six seconds, your initial exercise protocol may be to hold for eight seconds. This challenges you to improve while protecting you from overextending the muscles.

Incorporating the PFMs (pelvic floor muscles) with the core abdominal muscles (pelvic brace)
Lower abdominal strengthening often facilitates better support to the lower back. This core strengthening can be coordinated with Kegel exercises to prevent urinary incontinence.

1. Strengthening is usually started while lying on the back with the knees bent.
2. Tighten and pull in the lower abdominals—these are the TAs (transverse abdominals). Think about drawing the belly button and the muscles below it toward your spine. Exhale with a sssss or a whooshh sound as you contract up your bottom (PFMs) and then pull in your TAs.
3. Don't hold your breath during this exercise. While counting out loud to 10, tightening the lower abs can facilitate normal breathing. Breath holding can increase intra-abdominal pressure against the PFM's.

Performing the pelvic brace exercise actually displaces abdominal pressure upward and inward towards the rib cage rather than downward onto the bottom of the pelvic floor. This abdominal "bracing" is the foundation for other exercises to help stabilize the pelvic floor and the lumbar spine. Once bracing is mastered, the exercise can be appropriately progressed by a physical therapist to include adding resistance with various arm and/or leg lifts while maintaining the taut abdominals and neutral spine in various positions.⁸

Strengthening the core muscles that are connected to the pelvic floor will make the Kegels much more effective. This bracing of the abs and the PFM's should be done automatically with any physical activity such as simply getting up out of a chair. It does take patience and practice to learn to do the movement smoothly. It is like learning a dance when practice makes perfect. Remember to "take your PFM's with you where ever you may go." Daily practice produces very rewarding results.

Biofeedback for men with incontinence

Biofeedback is a great tool for empowering patients to actually see their muscle activity recorded and displayed on a computer screen. The painless recording utilizes EMG (electromyography) instruments to test muscle recruitment and strength. The measurement can be done with surface electrode patches or a small anal probe. Biofeedback works like a mirror for a patient and his therapist to see and measure the muscle action potential. Imagine the first time you tried to learn how to wiggle your ears as a child. Didn't you catch yourself looking at a mirror to see if you were doing it correctly? During these sessions the nurse or therapist can act as your coach to correct any mistakes and to make certain you are performing the exercises correctly.

When used in conjunction with a pelvic floor exercise regimen, biofeedback is a non-surgical, cost-effective therapy that can decrease or eliminate embarrassing urinary incontinence. Pelvic Floor (PF) re-education with biofeedback helps patients learn to reuse PF musculature and can eliminate urinary incontinence in 54% to 77% of patients who use it.⁹

Dr. Ribeiro and colleagues evaluated the impact of early postoperative pelvic floor biofeedback to minimize incontinence in patients undergoing radical prostatectomy (RP). Of 122 patients screened, a total of 73 patients were randomly assigned to two groups after RP. The two groups included a control group of 37 patients and a treatment group of 36 patients who received biofeedback-pelvic floor muscle training (BFB-PFMT). The intervention was initiated after catheter removal 15 days post RP and continued weekly for as long as patients were incontinent up to 12 weeks. Sessions lasted 20 minutes and included verbal and written instruction, as well as electromyography to aid the patient in identifying the proper muscle bodies. During these sessions, patients practiced 3 series of 10 rapid pelvic floor contractions, sustained up to 10 seconds and performed during prolonged expiration, avoiding a Valsalva (bearing down) maneuver. Patients in the control group received only a brief instruction from their urologists on how to contract the pelvic floor and nothing else. The average number of sessions in the treatment group was 8.8. The results clearly showed an advantage in the treatment group. At 12 months, continence rates were 96% for the treatment group and 75% for the control group. This resulted in an absolute risk reduction of 21.2%.¹⁰

Surgical options for urinary incontinence after prostate cancer treatment

Surgical treatment is recommended for patients with persistent post-prostatectomy incontinence of the stress urinary incontinence (SUI) type. This option is not suggested until conservative, noninvasive treatment has failed or offers only incomplete continence. There are no guidelines, however, concerning the timing of the surgical treatment in the post operative period.¹¹ Continence may improve significantly during the first year after surgery and some studies show significant improvement within the first two years. Up to ten percent of patients with post-prostatectomy incontinence ultimately require surgical treatment.¹¹

Artificial Urinary Sphincter
According to the European Association of Urology (EAU) guidelines, the artificial urinary sphincter (AUS) (the AMS 800, manufactured by American Medical systems, Minnitonka, MN, USA) is still the treatment of choice for persistent moderate to severe stress urinary incontinence. The success rate for the AUS is still the highest when compared with all other treatment options for stress urinary incontinence. Even long term rates are very good, with success rates up to ninety percent. Studies show a lower success rate with increased risk of infection and erosion following radiotherapy. The downsides of the AUS are expense, risk of infection, erosion, mechanical failure and infection.¹¹

The AUS is made from silicone and has three components that are implanted into the patient. The portion that provides circular compression of the urethra and therefore prevents leakage of urine from occurring is the cuff, which is placed around the urethra after an incision is made in the perineum (the area between the scrotum and the rectum). A small fluid-filled pressure-regulating balloon is placed in the abdomen and a small pump is placed in the scrotum to be controlled by the patient. The fluid in the abdominal balloon is transferred to the urethral cuff, closing the urethra and preventing leakage of urine. When the patient needs to urinate he presses the scrotal pump which releases the fluid back to the abdominal balloon thereby opening the urethra and allowing the patient to void.

Male Sling
Several new, minimally-invasive sling systems for male SUI have been recently introduced. Optimal results are achieved in patients with mild to moderate SUI and no previous radiotherapy. The Advance Sling by AMS works by relocating the lax and descended supporting structures of the posterior urethra and sphincter region. In a follow up period of at least one year, dry rates of up to seventy percent can be achieved. The complications are short term post-operative urinary retention, local wound infection, urinary infection with fever, and persistent moderate perineal pain.¹¹ The procedure is done with a segment of soft mesh that compresses the urethra against the pubic bone. It is placed through an incision in the perineum (the area between the scrotum and the rectum).

References:

1. SUNA 2010 Clinical Practice Guideline Prevention and Control of Catheter Associated urinary Tract Infection. Available at: http://www.suna.org. Accessed Feb.2, 2010.
2. Eastham et.al. Risk Factors for urinary incontinence after radical prostatectomy. J urol 1996;156L1707.
3. U.S. Dept of Health and Human Services,1996, Clinical Practice Guideline number 2 (Update). Rockville, MD Agency for health Care Policy and Research.Publication No. 96-0682.
4. Ellsworth et al. 100 Q & A about Prostate Cancer, 2007, 184,185,187,189.
5. Hulme Janet a. Beyond Kegels s 2nd Edition Phoenix Publishing Co. 2002; 124,11,120,72,73.
6. Sandhu J.S. Nat Rev Urol.7, 222-228 (2010);doi1038/Nrurol.2010.26.
7. Newman D, Wein A. Managing and Treating Urinary Incontinence, Second Edition, Health Professionals Press-Baltimore, MD. 2009, 234,235,371,459.
8. Mayo Clinic. Kegel exercises for men: Understand the benefits. Available at: http://www.mayoclinic.com/health/kegel-exercises-for-men/MY01402. Accessed on June 9. 2011.
9. Bernier F, Sims TW. Management of clients with urinary disorders. Medical-surgical nursing: Clinical management for positive outcomes (8th ed. P 727-778). St Louis, MO. Elsevier Saunders; 2009.
10. Ribeiro LH. Gomes CM et al. Prostate Cancer. Journal of Urology 184: 1034-9,2010.
11. Bauer et al. Contemporary Management of post prostatectomy incontinence. European Urology (volumes 59 issue 6 page(s) 985-996 EOI: 10.1016/j.eururo.2011.03.020) European Urology 2011/03/18. Available at: http://www.ncbi.nlm.nih.gov./pubmed/20518761. Accessed on June 9, 2011.
12. Bioderm. Liberty 3.0. Available at: http://www.bioderm.us/index.php?option=com_content&view=article&id=52&Itemid=168. Accessed June 9, 2011.
13. SeekWellness. Afex for managing male incontinence. Available at: www.seekwellness.com/male_incontinence/afex.htm. Accessed June 9, 2011.
14. Omni. URINCare. Available at: www.urinCare.com. Accessed on June 9, 2011.
15. NIH consensus conference. Impotence. NIH Consensus Development Panel on Impotence. JAMA 1993: 270 (1): 83-90.
16. Mulhall. Saving Your Sex life. Munster, IN: Hilton Publishing Company. 2008.
17. International Journal of Impotence Research. 2008:20, 121-126.
18. Nature Reviews. Urology. Volume 6, August 2009. p.424.
19. Urologic Nursing. December 2007:27:6-563.
20. Albaugh. Urologic Nursing. May-June 2010;30-3.
21. Raina R, PahlajaniG, Agarwai, Zippe C. The early use of transurethral alprostadil after radical prostatectomy. BJU Int. 1998;100;1317.
22. Burnett AL. Erectile dysfunction following radical prostatectomy. JAMA 2005;293(21).
23. J Urol 1997; 158 (4): 1408-1410.
24. Walsh PC, Worthington JF. Dr. Patrick Walsh's Guide to Surviving Prostate Cancer, Second Edition. New York: Wellness Central; 2007:435-441.
25. Moyad M. Promoting Wellness for prostate Cancer patients, 3rd edition, Ann Arbor: Ann Arbor Editions, 2010:93-104.
26. Radiation Oncology, Division of Nursing, James Cancer Hospital and Solove Research Institute, Patient Education Handout, The Ohio State University Medical Center.
27. Bostwicket al. Complete Guide to Prostate Cancer. Atlanta: American Cancer Society; 2005:306-308.

This article has been reviewed by a member of the Wellness Partners Editorial Board.

Posted June 2011