Impact of early pelvic floor rehabilitation after transurethral resection of the prostate.

Impact of Early Pelvic Floor
Rehabilitation After Transurethral
Resection of the Prostate
Daniele Porru,1* Giuliana Campus,2 Alessandro Caria,2 Giuliana Madeddu,2
Antonio Cucchi,1 Bruno Rovereto,1 Roberto M. Scarpa,2 Pierpaolo Pili,2 and
Enzo Usai2
1Divisione Urologia Policlinico S. Matteo, Pavia, Italy
2Clinica Urologica, Universita` di Cagliari, Ospedale SS. Trinita`, Cagliari, Italy
We examined the results of teaching pelvic floor muscle exercises (PME) on micturition
parameters, urinary incontinence, post-micturition dribbling, and quality of life in patients
after transurethral prostatectomy (TURP). Fifty-eight consecutive patients who were se-
lected to undergo TURP for benign prostatic hyperplasia (BPH) were admitted into the
study: 28 were randomly assigned to a control group (A), 30 formed the investigational
group (B) during an initial visit conducted before surgery. In group B patients, perineal
exercises were demonstrated in detail, and tested for their correct use via simultaneous rectal
and abdominal examination. After the removal of the urethral catheter, these patients were
instructed to perform pelvic floor muscle exercises at home and were evaluated before the
exercises and at weekly intervals postoperatively. The American Urological Association
Symptom Score improved significantly after TURP in both groups. The average quality of
life score improved more significantly in group B after TURP, from 5.5 to 1.5 (P < 0.001).
The grade of muscle contraction strength after 4 weeks of PME increased from 2.8 to 3.8
in group B (P < 0.01); it was unchanged in the group A. The number of patients with
incontinence episodes and post-micturition dribbling was significantly lower in the group B
at weeks 1, 2, and 3 (P < 0.01). Our results show that pelvic floor muscle re-education
produces a quicker improvement of urinary symptoms and of quality of life in patients after
TURP. Its early practice reduces urinary incontinence and post-micturition dribbling in the
first postoperative weeks. The exercises are simple and easy to perform in the clinical
setting and at home, and therefore should be recommended to all cooperative patients after
TURP. Neurourol. Urodynam. 20:53–59. © 2001 Wiley-Liss, Inc.
Key words: pelvic floor exercise; TURP; voiding symptoms; post-prostatectomy incontinence
INTRODUCTION
Urinary frequency, terminal dribbling, and urinary incontinence are common
postoperative symptoms of transurethral prostatectomy (TURP). Pelvic floor muscle
exercises (PME) may provide men with an acceptable option for long-term manage-
ment, and there have been several reports that explored PME as a treatment for men
*Correspondence to: Daniele Porru, M.D., Divisione Urologia Policlinico S. Matteo, Piazzale Golgi 2,
27100 Pavia, Italy. E-mail: danieleporru@tin.it
Received for publication 15 July 1999; Accepted 8 June 2000
Neurourology and Urodynamics 20:53–59 (2001)
© 2001 Wiley-Liss, Inc.
PROD #1175

with urinary incontinence, urinary frequency, and terminal dribbling [Paterson et al.,
1997; Chang et al., 1998].
Some authors [Moulonguet et al., 1981; Ceresoli et al., 1993] reported their
striking experience of the effectiveness of early functional treatment of urinary in-
continence after prostatectomy. They showed that, with their treatment, improvement
and cures in urinary incontinence after prostatectomy occur much earlier with the aid
of functional treatment than spontaneously. Thus, such treatment is worth undertak-
ing. A favorable result was obtained with six weeks of treatment.
Meaglia et al. [1990] reviewed a number of patients who were incontinent
between 5 and 198 months after either radical retropubic, total perineal, or TURP and
found that a significant number of patients who are incontinent after prostatectomy
(especially those without a prior transurethral resection) can improve dramatically
with a behavioral training program that provides a strong support system.
Kegel [1951] was the first to describe PME in the treatment of stress urinary
incontinence in women. He reported a cure rate of 84%. Few reports followed this
first presentation; however, during the past two decades, there has been renewed
interest for this non-invasive treatment modality.
According to the medical literature, the treatment of post-prostatectomy incon-
tinence is almost always limited to pharmacological or surgical therapy. Because of
the failure of the standard treatment options, many men are left to live with their
incontinence. The guidelines for the treatment of urinary incontinence recommend the
use of behavioral methods as first-line treatment for stress and urge incontinence
[Harris, 1997].
We describe the results of PME on urinary incontinence, micturition frequency,
terminal dribbling, and its impact on quality of life in patients after TURP.
MATERIALS AND METHODS
Sixty-three consecutive patients with a diagnosis of symptomatic benign pros-
tatic hyperplasia (BPH) were selected to undergo TURP. Fifty-eight were admitted to
this study from October 1998 to April 1999. Patients aged over 80 years old or with
a history of urethral or pelvic surgery, neurogenic bladder, or prostatic carcinoma
were excluded from study. Twenty-eight of them were randomly selected to form the
control group (group A), 30 patients were randomly selected to form the investiga-
tional group (group B). Three patients, one assigned to group A and two to group B,
dropped out; they did not attend all the established visits at the Clinic, therefore their
data were not available to be included into the study. Mean age was 66 years (range,
53–71) of the control group and 67.5 years (range, 55–73) in the investigational
group.
Informed consent was given by all patients. The American Urological Associa-
tion (AUA) Symptom Score and a quality of life questionnaire were administered
before TURP and 30 days after surgery in both groups. The ICS male questionnaire
was used to assess quality of life [Donovan et al., 1996; Peters et al., 1997]. There
were seven specific questions concerning quality of life, including three fixed-format
questions, two global quality of life questions, and two open-ended questions that
allow men to describe their worries about their urinary problems in free text. Uro-
flowmetry was obtained before TURP and repeated 1 month after discharge in both
groups. In all patients, a preoperative pressure-flow study confirmed the existence of
54 Porru et al.

a bladder outflow obstruction (BOO). The initial visit was conducted before surgery:
for group B patients, the program was explained to each patient and an evaluation was
made of his motivation, physical abilities, and appropriateness of the program. One
urologist, who was blinded to the study group of the patients, performed only the
digital evaluation of the pelvic floor muscle contraction and established and reported
the grading during all the visits; the training session at follow-up visits (weeks 1, 2,
3, and 4) was not performed by the same urologist who assessed pelvic floor muscle
contraction. The patient was placed into the lateral decubitus position, and a finger
was inserted into the rectum. The patient then was invited to contract the anal muscles
around the finger while the examiner’s second hand was placed in the lower abdomen
to detect contraction of the abdominal musculature. After digital evaluation of the
extent of perineal and anal contraction, a grade was assigned from 0 (none) to 4
(strong). The endurance and strength of muscle contractions were assessed using a
grading method similar to that reported by McIntosh et al. [1993].
For group B patients, verbal instruction, feedback on contractions, and verbal
reinforcement of appropriate responses were used to teach selective contractions of
anal sphincter muscles and relaxation of abdominal muscles. Verbal and written
instructions for home PME were given to them with instructions to practice them 45
times a day, divided into three sessions of 15 exercises each.
Both groups of patients began voiding diaries immediately after removal of the
catheter, and then every week for 4 weeks postoperatively. The voiding diary was for
a 48-hour period and recorded times of voiding, volume voided, urges to void, and
episodes of incontinence. The strength of pelvic floor muscles was reassessed after
removal of the Foley catheter and at each weekly visit in both groups of patients.
Student’s t-test was used to measure the statistical significance of differences
between the groups. Differences before and after PME were measured using paired
t-test. Chi-square test was calculated to compare differences in the strength of pelvic
floor musculature between the two groups. The analysis of variance (ANOVA) for
correlated proportions was used to compare patient satisfaction.
RESULTS
Symptom score. The average symptom score changed significantly after TURP
in both groups, from 24 to 10 in group A and from 22 to 9 in group B. There was no
statistically difference between the two groups.
Quality of life. The improvement of quality of life was statistically different in
both groups after surgery, and there was a significantly better satisfaction with life of
patients in group B than those in group A. Average score values were comparable in
groups A and B before surgery, 5.5 and 5.8, respectively. Four weeks after TURP,
they were 3.2 in group A and 1.5 in group B (P < 0.001).
Muscle contraction strength. There was a significant increase in the grade of
muscle contraction strength after 4 weeks of exercise in group B, the average score
increasing from 2.8 to 3.8 (P < 0.01) (Table I); muscle contraction strength was not
significantly changed after 4 weeks in group A, 2.5 and 2.4 (Fig. 1; Table I). Muscle
assessment was performed at the initial visit before TURP, and then repeated after
removal of the catheter and at each weekly visit.
Voiding diary. When analyzing the voiding diaries, the volume of daily water
Pelvic Floor Rehabilitation After TURP 55

intake and average voided volume were similar in the two groups. The voiding
interval showed a significant difference between the two groups 2 and 3 weeks after
TURP (P < 0.01). However, after 4 weeks, the difference did not reach statistical
significance (Fig. 2).
The peak flow rate, average flow rate, and voided volume increased signifi-
cantly after TURP in both groups; there was no statistically significant difference in
these parameters between the two groups.
Urinary incontinence. The evaluation of continence status was conducted by
means of the voiding diary after surgery and after catheter removal, before the patient
was discharged and before PME were initiated at home. Urge and dribbling in-
continence were the symptoms most commonly reported. The number of patients
with incontinence episodes and post-micturitional dribbling was comparable, 20 and
21, in the two groups after catheter removal. It was significantly lower in group B, to
whom instructions were given for home practice of PME, than in the control group at
weeks 1, 2, and 3 (P < 0.01), nine versus 17, five versus 16, and four versus 12,
respectively; however, the difference was not significant between the two groups at week
4 (Fig. 3).
Fig. 1. Average pelvic floor muscle contraction strength before and 4 weeks after TURP in groups A
and B. Columns illustrate 95% confidence intervals of the means. Means are shown were horizontal lines.
Group A, open columns, group B, shaded columns.
TABLE I. Grade of Pelvic Floor Muscle Contraction in Patients
Who Underwent TURP
Average score for muscle contraction
± SD
Group A Group B
Before PME 2.5 ± 0.4 2.8 ± 0.3
Week 1 2.5 ± 0.3 2.8 ± 0.4
Week 2 2.6 ± 0.4 3.0 ± 0.3
Week 3 2.6 ± 0.3 3.4 ± 0.2
Week 4 2.4 ± 0.2 3.8 ± 0.3
56 Porru et al.

DISCUSSION AND CONCLUSIONS
The success rates using PME for urinary incontinence vary in the literature from
20 to 80% [Burgio et al., 1986; Henalla et al., 1988]. The premise of Kegel’s pro-
cedure [1951] was that stress incontinent women need first to gain awareness of the
function of the pubococcygeal muscle.
Some authors [Ceresoli et al., 1993] reviewed their experience with patients
who were incontinent 10 to 24 months after prostatectomy. These patients were
treated with bladder training. Perineal exercises were taught in detail; all patients
improved in the number of incontinence episodes, five patients achieved total conti-
nence, and only one showed little change.
Our study focused on the results of pelvic floor muscle re-education on urinary
symptoms and quality of life after TURP. As other authors previously reported
Fig. 3. Decrerase in the number of patients with episodes of incontinence and terminal dribbling in
groups A (diamonds) and B (squares) before PME and at weeks 1, 2, 3, and 4.
Fig. 2. Voiding interval after TURP groups A (diamonds) and B (squares). Group A: average minimum
± SD: before PME, 50.5 ± 12; week 2, 75 ± 15, week 4, 110 ± 23. Group B: average minimum ± SD:
before PME, 55 ± 10; week 2, 110.5 ± 17; week 4, 118.5 ± 24. *P < 0.01.
Pelvic Floor Rehabilitation After TURP 57