Grace Dorey

Pelvic floor exercises for erectile dysfunction.

Associate Editor

Developing a pelvic floor muscle training regimen for use in a trial intervention

This paper explains the rationale behind the intervention used for a large multi-centred randomised controlled trial for men following transurethral resection of prostate or radical prostatectomy. It shows the content of the protocol used and explains why this particular protocol of pelvic floor muscle exercises and urge suppression techniques was chosen for men in the intervention group. The trial will evaluate whether this intervention will be effective for men with urinary incontinence and sexual dysfunction after prostate surgery. ISRCTN number: ISRCTN87696430.

Conservative treatment for urinary incontinence in Men After Prostate Surgery (MAPS): two parallel randomised controlled trials.

OBJECTIVE To determine the clinical effectiveness and cost-effectiveness of active conservative treatment, compared with standard management, in regaining urinary continence at 12 months in men with urinary incontinence at 6 weeks after a radical prostatectomy or a transurethral resection of the prostate (TURP). BACKGROUND Urinary incontinence after radical prostate surgery is common immediately after surgery, although the chance of incontinence is less after TURP than following radical prostatectomy. DESIGN Two multicentre, UK, parallel randomised controlled trials (RCTs) comparing active conservative treatment [pelvic floor muscle training (PFMT) delivered by a specialist continence physiotherapist or a specialist continence nurse] with standard management in men after radial prostatectomy and TURP. SETTING Men having prostate surgery were identified in 34 centres across the UK. If they had urinary incontinence, they were invited to enroll in the RCT. PARTICIPANTS Men with urinary incontinence at 6 weeks after prostate surgery were eligible to be randomised if they consented and were able to comply with the intervention. INTERVENTIONS Eligible men were randomised to attend four sessions with a therapist over a 3-month period. The therapists provided standardised PFMT and bladder training for male urinary incontinence and erectile dysfunction. The control group continued with standard management. MAIN OUTCOME MEASURES The primary outcome of clinical effectiveness was urinary incontinence at 12 months after randomisation, and the primary measure of cost-effectiveness was incremental cost per quality-adjusted life-year (QALY). Outcome data were collected by postal questionnaires at 3, 6, 9 and 12 months. RESULTS Within the radical group (n = 411), 92% of the men in the intervention group attended at least one therapy visit and were more likely than those in the control group to be carrying out any PFMT at 12 months {adjusted risk ratio (RR) 1.30 [95% confidence interval (CI) 1.09 to 1.53]}. The absolute risk difference in urinary incontinence rates at 12 months between the intervention (75.5%) and control (77.4%) groups was -1.9% (95% CI -10% to 6%). NHS costs were higher in the intervention group [£ 181.02 (95% CI £ 107 to £ 255)] but there was no evidence of a difference in societal costs, and QALYs were virtually identical for both groups. Within the TURP group (n = 442), over 85% of men in the intervention group attended at least one therapy visit and were more likely to be carrying out any PFMT at 12 months after randomisation [adjusted RR 3.20 (95% CI 2.37 to 4.32)]. The absolute risk difference in urinary incontinence rates at 12 months between the intervention (64.9%) and control (61.5%) groups for the unadjusted intention-to-treat analysis was 3.4% (95% CI -6% to 13%). NHS costs [£ 209 (95% CI £ 147 to £ 271)] and societal costs [£ 420 (95% CI £ 54 to £ 785)] were statistically significantly higher in the intervention group but QALYs were virtually identical. CONCLUSIONS The provision of one-to-one conservative physical therapy for men with urinary incontinence after prostate surgery is unlikely to be effective or cost-effective compared with standard care that includes the provision of information about conducting PFMT. Future work should include research into the value of different surgical options in controlling urinary incontinence.

Assessing muscle function of the male pelvic floor using real time ultrasound

Following surgical removal of the prostate, there may be compromise to the function of the pelvic floor muscles causing continence problems. Assessing the pelvic floor muscles of male patients can be an invasive process that causes discomfort, making it worthwhile to evaluate alternatives to the conventional method of Digital Rectal Examination (DRE). Real time ultrasound (RTUS) has been used with female patients as an alternative to internal assessments. This paper examines the reliability and validity of assessing the male pelvic floor using abdominal RTUS.

Investigation of optimal cues to instruction for pelvic floor muscle contraction: a pilot study using 2D ultrasound imaging in pre-menopausal, nulliparous, continent women.

Optimal urethrovesical positioning (UVP) may be important for continence. Pelvic floor muscle contraction (PFMC) influences UVP. PFMC instruction cues vary and often encourage anterior PFM recruitment that may result in sub‐maximal posterior facilitation. Study hypothesis: posterior or combined cues are more influential in optimizing UVP during PFMC following a brief practice period than anterior cue.

Physiotherapy for the Relief of Male Lower Urinary Tract Symptoms: A Delphi study

Summary Purpose To explore the physiotherapy currently used for the relief of male lower urinary tract symptoms. Design The Delphi study used 14 experts from differing urology specialties in five countries. Method A survey consisting of four rounds of questions was sent to the experts. After each round the results were correlated and sent back to the experts to correct previous data and provide further information. After four rounds the multiple data produced were summarised. Results A new classification system for male urinary incontinence was generated. New subjective and objective assessment forms were developed. Treatment options and advice were generated for stress incontinence, urge incontinence, post micturition dribble, post-prostatectomy incontinence, and functional incontinence. Conclusion Further randomised controlled trials are needed to add to this poorly researched specialty.

Conservative Treatment of Urinary Incontinence in Men A review of the literature

The aim of this article is to give an overview of the conservative treatment of urinary incontinence in men. Eight articles and seven abstracts addressing the effect of pelvic floor muscle exercises, biofeedback, electrical stimulation, behavioural strategies and advice were compiled by computerised and hand searches. Studies of women and those not in English were excluded. Only three randomised studies were found; the remaining were all pre-test post-test designs. It is concluded that pelvic floor muscle exercises with biofeedback appear promising as strategies of treatment of urinary incontinence in men but that further research is required to determine which men are most likely to benefit from therapy. Currently, there is no strong evidence to support electrical stimulation as a routine treatment for post-prostatectomy incontinence. Evaluation of the current research on treatment of incontinence in men is hampered by the paucity of literature in the field. The paper concludes with several questions for further research.

Physiotherapy for Male Continence Problems

Summary A survey was sent to the total (531) membership of two British organisations of physiotherapists who treat patients with urinary continence problems. They were asked about aspects of current physiotherapy treatment of male urinary incontinence. Replies were received from 319, giving a response rate of 60%. Twenty-six physiotherapists did not treat continence patients. Female continence problems were treated by 293 respondents; of these only 81 treated male continence problems. In the 12 months prior to the survey, the respondents had treated only 390 male patients. Most post-prostatectomy out patients (70%) were taught pelvic floor exercises. Many (50% of all patients) were given bladder training, few (20% in the department and 8% at home) received electrical stimulation and even fewer (7%) received biofeedback. Most patients were given advice on fluid intake (68%), caffeine products (69%), alcohol intake (55%) and bulbar massage (32%). The main problems identified were lack of referrals and lack of training.

Post-prostatectomy Incontinence

Summary This case study of a patient suffering from post-prostatectomy incontinence from initial assessment to discharge reflects on the methodology used and explains, challenges and critically analyses each decision. The patient suffered from post-micturition dribble, severe stress incontinence on moving, and enuresis. Treatment consisted of graduated pelvic floor exercises concentrating on the external urethral sphincter. Continence was achieved in six weeks. Examination, assessment and treatment choice were based on relevant research. Much further work needs to be done to evaluate varying methods of assessment and treatment for patients with post-prostatectomy incontinence. The effectiveness of pre-operative pelvic floor exercises concentrating on the external urethral sphincter also needs evaluation.

Professional ArticlesPhysiotherapy for the Relief of Male Lower Urinary Tract Symptoms: A Delphi study

Summary Purpose To explore the physiotherapy currently used for the relief of male lower urinary tract symptoms. Design The Delphi study used 14 experts from differing urology specialties in five countries. Method A survey consisting of four rounds of questions was sent to the experts. After each round the results were correlated and sent back to the experts to correct previous data and provide further information. After four rounds the multiple data produced were summarised. Results A new classification system for male urinary incontinence was generated. New subjective and objective assessment forms were developed. Treatment options and advice were generated for stress incontinence, urge incontinence, post micturition dribble, post-prostatectomy incontinence, and functional incontinence. Conclusion Further randomised controlled trials are needed to add to this poorly researched specialty.