No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Pfilates and Hypopressives for the Treatment of Urinary Incontinence After Radical Prostatectomy: Results of a Feasibility Randomized Controlled Trial
Abstract
Background
Urinary incontinence (UI) is an important side effect of radical prostatectomy (RP). Co‐activation of surrounding muscles via novel techniques for pelvic floor rehabilitation known as Pfilates and Hypopressives have not been compared to pelvic floor muscle exercises (PFMX) for UI.
Objective
To assess the feasibility and efficacy of isolated PFMX with and without the addition of Pfilates and Hypopressives on UI recovery following RP.
Design
Randomized controlled trial
Setting
Participants were recruited from a community and tertiary cancer centre in Toronto, Canada
Participants
A total of 226 patients undergoing RP were assessed for eligibility. One hundred twenty‐two patients were eligible and 50 consented to participate.
Methods
Participants were randomized to either isolated PFMX (control) or PFMX plus Pfilates and Hypopressives (advanced pelvic floor exercises; APFX). PFMX participants received instructions for isolated pelvic floor contractions starting with 30 contractions per day during weeks 1‐2 up to 180/day for weeks 7‐26. The APFX group received comparable volume of exercises.
Outcome measurements
Feasibility was assessed by rates of recruitment, adverse events, and study‐arm compliance. UI and quality of life were collected 1 week prior to surgery and at 2, 6, 12, and 26 weeks after surgery.
Results
Recruitment rate was 41%, adherence to the PFMX and APFX was greater than 70%, and no reported adverse events. Between‐group differences were observed in frequency of self‐reported 24‐hour urinary leakage (rate ratio: 0.45, 95%CI: 0.22, 0.98) and during waking hours (rate ratio: 0.43, 95%CI: 0.20, 0.91) at 26‐weeks post‐surgery favouring APFX. This study was limited by the small sample size and short follow‐up.
Conclusions
Pfilates and Hypopressives are feasible in men undergoing RP and preliminary data suggest potential benefit in aiding recovery of UI. Larger studies with longer follow‐up are warranted.
This article is protected by copyright. All rights reserved.
... Figure A2 shows total percentage plot of the overall risk of bias. . Low risk studies: [16,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][35][36][37][39][40][41][42][43][45][46][47][48][49][50][51][52][53], some concerns studies: [17,18,34,38,44,54], high risk studies [62,[72][73][74][75][76][77][78][79][80][81][82][83][84][85][86]. Figure A1. RoB analysis (n = 55). ...
... RoB analysis (n = 55). Low risk studies: [16,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][35][36][37][39][40][41][42][43][45][46][47][48][49][50][51][52][53], some concerns studies: [17,18,34,38,44,54], high risk studies [62,[72][73][74][75][76][77][78][79][80][81][82][83][84][85][86]. Figure A1. RoB analysis (n = 55). ...
... RoB analysis (n = 55). Low risk studies: [16,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][35][36][37][39][40][41][42][43][45][46][47][48][49][50][51][52][53], some concern studies: [17,18,34,38,44,54], high risk studies [62,[72][73][74][75][76][77][78][79][80][81][82][83][84][85][86]. ...
Urinary incontinence (UI) is a serious health issue that affects both women and men. The risk of UI increases in men with age and after treatment for prostate cancer and affects up to 32% of men. Furthermore, UI may affect up to 69% of men after prostatectomy. Considering such a high incidence, it is critical to search for effective methods to mitigate this issue. Hence, the present review aims to provide an overview of physiotherapeutic methods and evaluate their effectiveness in treating UI in men. This systematic review was performed using articles included in PubMed, Embase, WoS, and PEDro databases. A total of 6965 relevant articles were found. However, after a risk of bias assessment, 39 studies met the inclusion criteria and were included in the review. The research showed that the available physiotherapeutic methods for treating men with UI, including those after prostatectomy, involve pelvic floor muscle training (PFMT) alone or in combination with biofeedback (BF) and/or electrostimulation (ES), vibrations, and traditional activity. In conclusion, PFMT is the gold standard of UI therapy, but it may be complemented by other techniques to provide a personalized treatment plan for patients. The effectiveness of the physiotherapeutic methods varies from study to study, and large methodological differences make it difficult to accurately compare individual results and draw unequivocal conclusions.
... Seven articles were excluded due to a PEDro score < 4. Finally, 8 papers were included in the present review (Fig. 1). Two of the included studies were conducted in Korea [38,39], two in Germany [40,41], one in Poland [42] and one in Canada [43], two originated from the same department in Brazil [44,45]. The data on this topic are quite recent considering that all studies were published in the past eight years (2012-2020). ...
... The data on this topic are quite recent considering that all studies were published in the past eight years (2012-2020). Five were RCTs [38,[41][42][43][44][45], two were PRPPTs [40], and one was a prospective observational study of a post-RP population during CFPT intervention [39]. ...
... For each intervention, there were one to five sessions a week, with a median length of follow-up of 22.6 weeks. Intervention for five of the studies combined CFPT + PFMT [38][39][40][41][42], and for the three remaining studies CFPT without PFMT [43][44][45]. Two studies compared CFPT to no treatment [44,45] and one compared CFPT to PFMT [43]. ...
Current literature indicates that CFPT was shown to be safe, non-invasive, and
particularly effective in terms of UI recovery. CFPT could result in more positive
outcomes, including physical capacities, physical and emotional functioning and
HRQoL, than PFMT alone. Further standardized, physiotherapist-guided and welldesigned
clinical trials conducted by experienced multidisciplinary clinicians are still
called for.
... Seven articles were excluded due to a PEDro score < 4. Finally, 8 papers were included in the present review (Fig. 1). Two of the included studies were conducted in Korea [38,39], two in Germany [40,41], one in Poland [42] and one in Canada [43], two originated from the same department in Brazil [44,45]. The data on this topic are quite recent considering that all studies were published in the past eight years (2012-2020). ...
... The data on this topic are quite recent considering that all studies were published in the past eight years (2012-2020). Five were RCTs [38,[41][42][43][44][45], two were PRPPTs [40], and one was a prospective observational study of a post-RP population during CFPT intervention [39]. ...
... For each intervention, there were one to five sessions a week, with a median length of follow-up of 22.6 weeks. Intervention for five of the studies combined CFPT + PFMT [38][39][40][41][42], and for the three remaining studies CFPT without PFMT [43][44][45]. Two studies compared CFPT to no treatment [44,45] and one compared CFPT to PFMT [43]. ...
Introduction
Radical prostatectomy (RP) can generate multidimensional physiological changes, like decrease in physical and emotional functioning, as well as Health Related Quality of Life (HRQoL). However, only pelvic floor muscle training (PFMT) is commonly recommended as conservative treatment after RP. More comprehensive interventions than only PFMT, such as physiotherapy promoting general coordination, flexibility, strength, endurance, fitness and functional capacity may seem more relevant and patient-centered.
Aim of the review
Our aim was to evaluate whether a more Comprehensive Functional Physical Therapy (CFPT) than PFMT alone, focused on lower limb and lumbo-pelvic exercises, would improve physical capacities and functions (including urinary continence (UI)), emotional functions and HRQoL in patients after RP.
Evidence acquisition
A systematic review was performed in accordance with the PRISMA reporting guidelines. A literature search was conducted in PubMed, PEDro, Web of Science and Cochrane Library databases from inception to January 2022. The PICO approach was used to determine the eligibility criteria. According to the quality of selected studies, levels of evidence were given.
Evidence synthesis
Eight clinical trials met the eligibility criteria. Regarding UI, all the studies reported positive outcomes for CFPT between pre- and post-physiotherapy (P < 0.05). The selected studies reported positive outcomes for physical capacities as well as for physical and emotional functioning, and for HRQoL (P < 0.05).
Conclusion
Current literature indicates that CFPT was shown to be safe, non-invasive, and particularly effective in terms of UI recovery. CFPT could result in more positive outcomes, including physical capacities, physical and emotional functioning and HRQoL, than PFMT alone. Further standardized, physiotherapist-guided and well-designed clinical trials conducted by experienced multidisciplinary clinicians are still called for.
... This scale classified studies from strongest (level 1) to weakest (level 5) strength of evidence based on study design and data quality. Figure 1 presents the RoB summary of the six RCTs (13)(14)(15)(16)(17)(18). Taken together, included studies showed a low risk of bias in terms of selection, performance, detection, attrition and reporting. ...
... No adverse events were reported in all included studies (13)(14)(15)(16)(17)(18). Patients receiving APFMT had a similar attrition rate to those receiving CPFMT (18/236 vs. 22/282, P=0.61). ...
... Patients receiving APFMT had a similar attrition rate to those receiving CPFMT (18/236 vs. 22/282, P=0.61). Two studies (13,15) reported the numbers of participants with short-term continent status and three studies (14,16,18) reported the numbers of patients with intermediate-term continent status. No significant difference was observed between APFMT group and CPFMT group irrespective of short-term (P=0.08) and intermediate-term followup (P=0.31). ...
Background:
The underutilization of additional supportive muscles is one of the potential reasons for suboptimal efficacy of conventional pelvic floor muscle training (CPFMT). The present study concentrates on any advantage of advanced pelvic floor muscle training (APFMT) in patients with urinary incontinence (UI) after radical prostatectomy (RP).
Methods:
Literature search was conducted on PubMed, Embase, Cochrane Library and Web of Science from database inception to February 2020. The data analysis was performed by the Cochrane Collaboration's software RevMan 5.3.
Results:
Both APFMT and CPFMT groups indicates superiority over baseline in terms of pad number, the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score, pad weight at short-term follow-up, and PFME and PFMS at intermediate-term follow-up. No adverse events were reported in all included studies. Patients receiving APFMT had a similar attrition rate to those receiving CPFMT (18/236 vs. 22/282, P=0.61). Compared to CPFMT group, APFMT group provided intermediate-term advantages in terms of pad number (MD: -0.75, 95% CI: -1.36 to -0.14; P=0.02), ICIQ-SF score (MD: -3.79, 95% CI: -5.89 to -1.69; P=0.0004), PFME (MD: 1.93, 95% CI: 0.99 to 2.87; P<0.0001) and pad weight (MD: -1.40, 95% CI: -1.70 to -1.00; P<0.00001).
Conclusions:
Current evidence indicated that APFMT might facilitate the recovery of UI after RP according to intermediate-term advantages over CPFMT in terms of pad number, ICIQ-SF score, PFME and pad weight. Further standardized, physiotherapist-guided and well-designed clinical trials conducted by large multicenter and experienced multidisciplinary clinicians are still warranted.
... A continuación se procede al análisis de los artículos 5,7,9,[19][20][21][22][23][24][25][26][27][28][29][30][31] reflejados en la Tabla 3 mostrando el número de muestra, sexo de la muestra, la duración de la intervención y de la sesión así como las variables analizadas e instrumentación utilizada y por último los resultados obtenidos. ...
... El grupo muscular más estudiado ha sido el suelo pélvico 5,7,9,21,25,26,28,30,31 , seguido de los músculos abdominales 5,7,9,20,28,31 . Varios autores 23,24,29,30 evalúan también el efecto de los ejercicios hipopresivos en la incontinencia urinaria, ya que esta se asocia, entre muchos factores, a la debilidad de la MSP y la musculatura abdominal 32 . Además, se ha estudiado el efecto sobre otras patologías como el dolor lumbar o la escoliosis 19,27 , muy relacionadas directamente con la faja abdominal ya que proporcionan estabilidad lumbopélvica 33 , e incluso en la evaluación de factores metabólicos, como predictores de riesgo cardiovascular 20 o de recuperación de peso 22 . ...
... En gran parte de los trabajos analizados, el efecto de los ejercicios hipopresivos se evalúa a largo plazo a través de una intervención basada en un programa de ejercicios 9,19,20,[22][23][24][25][26][27][28][29][30] . En todos ellos, se han observado efectos positivos de los mismos sobre la musculatura abdominal y la MSP con intervenciones entre 5 y 12 semanas 9,20,22,23,[25][26][27][28]30 . ...
Introducción: la Gimnasia Abdominal Hipopresiva es un método creado en la década de los 80 por el Dr. Marcel Caufriez en el ámbito de la reeducación postparto. Actualmente es una técnica muy popularizada, sin embargo, hasta el momento existe poca evidencia en la literatura científica que avale la eficacia de dichos ejercicios. Objetivo: revisar la evidencia publicada en los últimos cinco años sobre los efectos de los ejercicios abdominales hipopresivos. Método: para la realización de este trabajo se llevó a cabo una revisión de la literatura en las bases de datos PubMed, Medline, CINAHL, Scopus, Web Of Science, SPORTDiscus, Science Direct, PEDro y Dialnet en febrero de 2020. Se incluyeron artículos publicados en los últimos cinco años, y en idioma inglés o español. Resultados: Se obtuvieron 16 artículos. Los estudios analizados evalúan el efecto de los abdominales hipopresivos sobre el suelo pélvico, abdomen, incontinencia urinaria, dolor lumbar, escoliosis y factores metabólicos. Conclusiones: los ejercicios hipopresivos pueden ser utilizados como método complementario al tratamiento clásico de fortalecimiento de la musculatura del suelo pélvico o abdominal. Las conclusiones de esta revisión se deben tomar con precaución debido a las limitaciones que presenta, como la baja calidad de los artículos analizados.
... In total, 10 different assessment methods were used to assess sexual dysfunction in the included studies, all of which were questionnaires or single questions. 8 studies (34%) used the specific sexual function questionnaires IIEF-15 27,34 and IIEF-5, 28,[41][42][43][44]46 while twelve (52%) studies used questionnaires that included a sexual function subscale. 26,27,29,31,33,[35][36][37][38][39][40]45 These are the EORTC QLQ-PR25, 26,27,29,31,33,35 the EPIC, 27 the EPIC-26, 37,40 the ...
... The Jadad score assessment for the included studies is shown in Table 7. 16 (73%) of the 22 studies were scored 3. Studies were primarily downgraded due to a lack of double-blinding and partly due to a lack of mentioning randomization method or a lack of reasons for withdrawals and drop-outs. Eight 26,28,29,31,33,35,36,44 (89%) of the 9 studies showing significant between-group differences in favor of IG were scored 3. 11 26,29,31,33,35,36,[41][42][43][44]47 (85%) of the 13 studies that were scored ≥6 in the PEDro assessment were scored 3 in the Jadad score. Sources of funding of the included RCTs are summarized in Table 8 (Supplemental Material). ...
Background: Emerging evidence suggests that exercise interventions may improve sexual dysfunction, one of the most common and distressing long-term adverse effects of cancer treatment.
Aim: The aim of this systematic review is to provide an overview of the effects of exercise on sexual dysfunction in prostate cancer patients.
Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. The systematic literature search was performed on 13th July 2021 using CINAHL, Cochrane Central Register of Controlled Trials, Embase, Medline and Web of Science. Studies were included if they were randomized controlled trials (RCTs) assessing sexual function in prostate cancer patients conducting an exercise intervention alone or in combination with other supportive interventions. The methodological quality was assessed using the Physiotherapy Education Database Score and Jadad scale. Outcomes were reported as between-group differences. Intragroup differences were also reported if significant.
Outcomes: Positive intervention effects on sexual function were primarily observed in patients following prostatectomy and undergoing anti-hormone treatment and for pelvic floor muscle exercises as well as aerobic and resistance exercise.
Results: 22 RCTs (n = 1.752 patients) met the eligibility criteria, conducting either an exercise-only intervention (n = 10), a multimodal (exercise plus other supportive therapy) intervention (n = 4), or pelvic floor muscle exercises (n = 8). 6 RCTs assessed sexual dysfunction as a primary endpoint and 8 RCTs used dedicated assessment methods. 9 of the 22 RCTs found significant between-group differences in favor of the intervention group.
Clinical Implications: The multifaceted etiology of sexual dysfunction provides a strong rationale to further investigate the effects of exercise on sexual dysfunction in prostate cancer patients and also to consider a multidisciplinary approach.
Strengths and Limitations: A strength is the comprehensive literature search to identify RCTs involving different exercise interventions and a wide range of sexual function assessments. Further, this is the first systematic review on this topic. The main limitations include the difficulty to compare studies due to the heterogeneity of exercise interventions and low questionnaire completion rates in some studies.
Conclusion: Preliminary data from a small number of studies suggest that certain exercise interventions may improve sexual dysfunction in prostate cancer patients, however further trials involving sexual dyfunction as a primary outcome and more comprehensive assessment tools are needed to confirm the rehabilitative and preventive effects of exercise on sexual dysfunction in prostate cancer patients.
Key Words: Prostate Cancer; Sexual Dysfunction; Erectile Dysfunction; Exercise; Pelvic Floor Muscle Exercises
... Too weak a synergy between PFM and other muscles is believed to be one of the reasons for the non-optimal effectiveness of PFMT [52]. This mainly applies to the musculus transversus abdominis, as well as the musculus gluteus major and the musculus adductor femoris. ...
A commonly used physiotherapeutic method for the treatment of urinary incontinence (UI) after radical prostatectomy (RP) is pelvic floor muscle training (PFMT). The aim of this study was to evaluate the effectiveness of PFMT by enhanced biofeedback using the 1h pad-weighing test. The following factors were taken into consideration in the analysis of PFMT effectiveness: the relevance of the patients’ age, time from RP, BMI, mental health, functional state, and depression. A total of 60 post-RP patients who underwent 10-week PFMT were studied. They were divided into groups: A (n = 20) and B (n = 20) (random division, time from RP: 2–6 weeks) and group C (time from RP > 6 weeks). Group B had enhanced training using EMG biofeedback. UI improved in all groups: A, p = 0.0000; B, p = 0.0000; and C, p = 0.0001. After the completion of PFMT, complete control over miction was achieved by 60% of the patients in group A, 85% in group B, and 45% in group C. There was no correlation between the results of PFMT efficacy and patients’ age, BMI, time from RP, mental health, functional state, and depression. PFMT is highly effective in UI treatment. The enhancement of PFMT by EMG biofeedback seems to increase the effectiveness of the therapy.
... The primary outcomes pertained to the feasibility of conducting a phase II RCT and included deriving rates of recruitment, attendance, compliance, retention, and adverse events. Feasibility thresholds were derived from previous exercise studies in patients with cancer (Au et al. 2020;De Jesus et al. 2017). Recruitment was assessed through a recruitment log maintained by the research coordinator and was defined as the proportion of consenting participants relative to the total number of eligible participants approached (feasibility target: ≥25% of eligible patients). ...
Background:
This study assessed the feasibility of a phase II randomized controlled trial of high-intensity interval training (HIIT), resistance training (RT), and usual care (UC) in men with prostate cancer (PCa) on active surveillance (AS) and evaluated changes in clinically relevant outcomes.
Methods:
Eighteen men undergoing AS for PCa were randomized to HIIT (n=5), RT (n=7), or UC (n=6). Exercise participants attended two supervised sessions weekly and were instructed to complete one home-based session weekly for 8 weeks. UC participants were provided with physical activity guidelines.
Results:
Feasibility was met for attendance, compliance, and retention, but not recruitment. HIIT increased leg press (mean: +8.2kg, 95%CI 1.1, 15.3) from baseline to 8 weeks. RT increased seated row (mean: +11.7kg, 95%CI 6.1, 17.3) and chest press (mean: +10.4kg, 95%CI 5.3, 15.5), leg press (mean: +13.1kg, 95%CI 5.9, 20.3), serum insulin-like binding protein-3 (IGFBP-3) (mean: +400.0ng/ml, 95%CI 94.5, 705.5), and decreased interferon-γ (mean: -3.1pg/ml, 95%CI -5.7, -0.4). No changes were observed in the UC group.
Conclusion:
HIIT and RT may be effective strategies for improving muscle strength; however, only RT may increase serum IGFBP-3. Strategies that can enhance recruitment in men on AS are important prior to conducting a phase II trial.
Trial registration number:
ClinicalTrials.gov number NCT04266262 Novelty bullets • High-intensity interval training or resistance training are feasible during active surveillance for prostate cancer. • Resistance training may suppress the tumor-promoting effects of insulin-like growth factor-I (IGF-I) via increased expression of IGFBP-3.
... These exercises are demonstrated to decrease intraabdominal pressure and activate the pelvic floor muscles and the abdominal wall, and thus, they are designed for the prevention and treatment of perineal dysfunctions, especially in postpartum [1]. Consequently, HE are mainly performed by women, with benefits in pelvic floor dysfunctions or urinary incontinence [2][3][4][5][6][7][8], but recently new scientific research has demonstrated that men with urinary incontinence, scoliosis, or low back pain could also be benefited from these exercises [9][10][11][12]. Other studies have shown that HE could induce changes in postural muscles, such as increases in muscle thickness, cross-sectional area, or length [10][11][12]. ...
This study analyzes the effects of hypopressive exercises on the abdominal thickness of healthy subjects and compares the performance between women and men. We conducted a transversal observational study in 98 subjects (63% women). The muscle thickness is analyzed in transversus abdominis, internal oblique, external oblique, and rectus abdominis with ultrasound imaging at rest and during the hypopressive exercise (HE) in supine and standing position. Comparisons between rest and hypopressive exercise are carried out in the two different positions and between women and men. In the supine position, there is a significant activation of the transversus abdominis and internal oblique during hypopressive exercise (p < 0.001), and it is similar in both sexes, the external oblique is only activated significantly by men (p < 0.001) and rectus abdominis had no significant activation (p > 0.05). Our results show that standing transversus abdominis and external oblique significantly increased their thickness during HE with higher effects in men. Internal oblique also increased significantly, but with higher effects in women, and rectus abdominis had no significant increase. Men had similar effects to women during HE, with an activation of the deepest abdominal muscles. The unequal anatomy and the position could explain the different results obtained between the sexes.
... 73 Various forms of exercise have been suggested as forms of augmenting PFMT, including Pilates, hypopressive exercises, trunk muscle training, whole body vibration and diaphragm training. [74][75][76][77][78] Unfortunately, a recent meta-analysis was unable to find any benefit for the use of these protocols over PFMT alone. 79 This could be explained physiologically if we consider that these muscles, when activated out of sequence, could cause pressure on the pelvic floor and increase the movement that occurs at the bladder neck. ...
Background
In a previous article, we have underlined the emerging level of evidence for the effectiveness of a more comprehensive functional physical therapy than solely pelvic floor muscles training (PFMT) for men after radical prostatectomy (RP). More and more authors suggest that physiotherapy programs should not focus only on the side effect of continence, but more generally on the interaction of continence disorders with all other side effects related to the physical and emotional functioning of the patient.
Research question
The aims of this narrative review are to highlight rehabilitation approaches unrelated to analytical PFMT that would seem relevant to consider in the future for post-RP men.
Method
Our narrative review sought to map the body of literature relevant to the primary objective (non-PFMT), supplementing the data from our previous review with additional recent articles that were not eligible due to not meeting the inclusion criteria for a systematic review.
Results
After full text screening, 13 interventional studies have been selected. Intervention strategies were based on five major type of exercices : flexibility, synergism & co-activation, coordination & movement control, strength & endurance, aerobic & games therapy. Most of the studies of this narrative review focused on synergies, co-activations and movement control techniques that emphasized the deep abdominal muscles and PFMs reflexive activation. The wide variety of countries represented in the 13 studies with consistent results point to the potential effectiveness and replicability across various socio-cultural, ethnical, or religious contexts.
Conclusion
We found 13 studies from 9 different countries that provide a more complete rehabilitation approach than PFMT alone in men post-RP. Intervention strategies were built around five main types of exercises, with the majority of them emphasizing synergies, co-activations, and movement control techniques. In light of these data, we hope that future research will enable us to offer the most relevant and patient-centered physiotherapy treatment.
Keywords : Post-prostatectomy; Urinary incontinence; Physiotherapy; Intervention; Exercices
Aims:
To describe and synthesize non-pharmacological and nonsurgical interventions for male urinary incontinence from the existing literature.
Methods:
A scoping review was conducted following the methodology suggested by Arksey and O'Malley: (1) identification of the research questions; (2) identification of relevant studies using a three-step search recommended by JBI: an initial search within PubMed and CINAHL, a comprehensive literature search within PubMed, CINAHL, EMBASE, PsycINFO, Cochrane Library, and literature search of references lists; (3) study selection; (4) data extraction and charting; (5) collation, summarization, and reporting of the results. The PRISMA-ScR Checklist was used to report.
Results:
A total of 4602 studies were identified, of which 87 studies were included. Approximately 78% were randomized controlled trials. More than 88% of the participants were men with prostate cancer. Exercising pelvic floor muscles 30 times per day for 12 weeks was the most frequently reported. Parameters of electrical stimulation were typically set up to 50 Hz and 300 μs for frequency and width of pulse, respectively, and lasted for 15 min. Pure pelvic floor muscle training, Pilates, Yoga, whole body vibration, diaphragm/abdominal muscle training, micturition interruption exercise, acupuncture, and auriculotherapy showed positive effects on reducing urinary incontinence.
Conclusion:
The findings suggested implementing pelvic floor muscle training alone before or after surgery can both prompt the recovery of continence in men after prostate cancer surgery. The decision to use biofeedback or electrical stimulation to enhance the therapeutic effect of pelvic floor muscle training should be approached with caution. More rigorous designed studies are needed to validate the effectiveness of Traditional Chinese Medicine techniques and diverse novel methods.
Relevance to clinical practice:
Physicians and nurses need to be up to date on the latest evidence-based non-pharmacological and nonsurgical interventions in male urinary incontinence and select appropriate interventions based on available medical resources and patient preferences.
Background:
Men may need to undergo prostate surgery to treat prostate cancer or benign prostatic hyperplasia. After these surgeries, men may experience urinary incontinence (UI). Conservative treatments such as pelvic floor muscle training (PFMT), electrical stimulation and lifestyle changes can be undertaken to help manage the symptoms of UI.
Objectives:
To assess the effects of conservative interventions for managing urinary incontinence after prostate surgery.
Search methods:
We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearched journals and conference proceedings (searched 22 April 2022). We also searched the reference lists of relevant articles.
Selection criteria:
We included randomised controlled trials (RCTs) and quasi-RCTs of adult men (aged 18 or over) with UI following prostate surgery for treating prostate cancer or LUTS/BPO. We excluded cross-over and cluster-RCTs. We investigated the following key comparisons: PFMT plus biofeedback versus no treatment; sham treatment or verbal/written instructions; combinations of conservative treatments versus no treatment, sham treatment or verbal/written instructions; and electrical or magnetic stimulation versus no treatment, sham treatment or verbal/written instructions.
Data collection and analysis:
We extracted data using a pre-piloted form and assessed risk of bias using the Cochrane risk of bias tool. We used the GRADE approach to assess the certainty of outcomes and comparisons included in the summary of findings tables. We used an adapted version of GRADE to assess certainty in results where there was no single effect measurement available.
Main results:
We identified 25 studies including a total of 3079 participants. Twenty-three studies assessed men who had previously undergone radical prostatectomy or radical retropubic prostatectomy, while only one study assessed men who had undergone transurethral resection of the prostate. One study did not report on previous surgery. Most studies were at high risk of bias for at least one domain. The certainty of evidence assessed using GRADE was mixed. PFMT plus biofeedback versus no treatment, sham treatment or verbal/written instructions Four studies reported on this comparison. PFMT plus biofeedback may result in greater subjective cure of incontinence from 6 to 12 months (1 study; n = 102; low-certainty evidence). However, men undertaking PFMT and biofeedback may be less likely to be objectively cured at from 6 to 12 months (2 studies; n = 269; low-certainty evidence). It is uncertain whether undertaking PFMT and biofeedback has an effect on surface or skin-related adverse events (1 study; n = 205; very low-certainty evidence) or muscle-related adverse events (1 study; n = 205; very low-certainty evidence). Condition-specific quality of life, participant adherence to the intervention and general quality of life were not reported by any study for this comparison. Combinations of conservative treatments versus no treatment, sham treatment or verbal/written instructions Eleven studies assessed this comparison. Combinations of conservative treatments may lead to little difference in the number of men being subjectively cured or improved of incontinence between 6 and 12 months (RR 0.97, 95% CI 0.79 to 1.19; 2 studies; n = 788; low-certainty evidence; in absolute terms: no treatment or sham arm: 307 per 1000 and intervention arm: 297 per 1000). Combinations of conservative treatments probably lead to little difference in condition-specific quality of life (MD -0.28, 95% CI -0.86 to 0.29; 2 studies; n = 788; moderate-certainty evidence) and probably little difference in general quality of life between 6 and 12 months (MD -0.01, 95% CI -0.04 to 0.02; 2 studies; n = 742; moderate-certainty evidence). There is little difference between combinations of conservative treatments and control in terms of objective cure or improvement of incontinence between 6 and 12 months (MD 0.18, 95% CI -0.24 to 0.60; 2 studies; n = 565; high-certainty evidence). However, it is uncertain whether participant adherence to the intervention between 6 and 12 months is increased for those undertaking combinations of conservative treatments (RR 2.08, 95% CI 0.78 to 5.56; 2 studies; n = 763; very low-certainty evidence; in absolute terms: no intervention or sham arm: 172 per 1000 and intervention arm: 358 per 1000). There is probably no difference between combinations and control in terms of the number of men experiencing surface or skin-related adverse events (2 studies; n = 853; moderate-certainty evidence), but it is uncertain whether combinations of treatments lead to more men experiencing muscle-related adverse events (RR 2.92, 95% CI 0.31 to 27.41; 2 studies; n = 136; very low-certainty evidence; in absolute terms: 0 per 1000 for both arms). Electrical or magnetic stimulation versus no treatment, sham treatment or verbal/written instructions We did not identify any studies for this comparison that reported on our key outcomes of interest.
Authors' conclusions:
Despite a total of 25 trials, the value of conservative interventions for urinary incontinence following prostate surgery alone, or in combination, remains uncertain. Existing trials are typically small with methodological flaws. These issues are compounded by a lack of standardisation of the PFMT technique and marked variations in protocol concerning combinations of conservative treatments. Adverse events following conservative treatment are often poorly documented and incompletely described. Hence, there is a need for large, high-quality, adequately powered, randomised control trials with robust methodology to address this subject.
Zusammenfassung
Hintergrund Sexuelle Dysfunktionen sind Lebensqualität mindernde Nebenwirkungen von Standardtherapien bei Prostatakarzinom.
Ziel Diese Untersuchung erfasst den aktuellen wissenschaftlichen Kenntnisstand bezüglich Effektivität von Bewegungstherapie zur Kompensation sexueller Dysfunktionen in Folge von Standardtherapien bei Prostatakarzinom.
Methode Systematisches Review in Anlehnung an „Preferred Reporting Items for Systematic Reviews and Meta-Analyses“ (PRISMA). Die Literaturrecherche wurde von 2 unabhängigen Gutachter*innen in den Datenbanken Pubmed und PEDro durchgeführt. Eingeschlossen wurden Randomized Controlled Trials (RCT) mit dem American Society of Clinical Oncology (ASCO) Evidenzlevel I, die sexuelle Funktionen von Patienten mit standardtherapierten Prostatakarzinom unter Bewegungstherapie evaluieren.
Ergebnisse 17 Publikationen mit 1175 Patienten mit Prostatakarzinom erfüllten die Einschlusskriterien. 11 Studien berichten signifikante Verbesserungen der sexuellen Funktionen durch Bewegungstherapie.
Schlussfolgerung Da die Mehrzahl der Studien nicht vergleichbar war, ist keine generalisierte Aussage bezüglich der Wirksamkeit von Bewegungstherapie möglich. Weitere kontrollierte Studien sind unabdingbar, um den Einfluss von Bewegungstherapie auf sexuelle Dysfunktion bei Patienten mit Prostatakarzinom unter Standardtherapien aufzuzeigen.
Objective:
The relationship between physical activity (PA) and quality of life (QOL) relative to active treatment for prostate cancer (PCa) has been well-studied; however, little is known about this relationship during active surveillance (AS). Moreover, whether PA is associated with better emotional well-being (EWB) in men with low-risk PCa requires further investigation. Accordingly, we examined the association between self-reported PA and the average change in QOL and EWB over time during AS.
Methods:
A total of 630 men on AS were included in this retrospective, longitudinal study from AS initiation until AS discontinuation. Generalized estimated equations were used to determine the association between self-reported PA (independent variable), QOL and EWB (dependent variables) over time, adjusting for participants' age.
Results:
QOL was higher over time in active (
β
&c.circ;
(95%CI) = 1.14 (0.11, 2.16), p=0.029) and highly active participants (
β
&c.circ;
(95%CI) =1.62 (0.58, 2.67), p=0.002) compared to their inactive counterparts. Highly active participants had 55% greater odds of experiencing high EWB relative to inactive participants (OR (95%CI) =1.55 (1.11, 2.16), p= 0.010). In men with low EWB at baseline (median = 3 months after diagnosis), the highest levels of PA (> 1000 metabolic equivalent-minutes per week) were associated with higher EWB over time (OR (95%CI) = 2.17 (1.06, 4.46), p= 0.034).
Conclusion:
These data further support the importance of PA as a supportive care strategy for men on AS. Our findings suggest that engaging in higher volumes of PA post-diagnosis may be beneficial particularly for men exhibiting low emotional well-being early on during AS. This article is protected by copyright. All rights reserved.
Background:
Radical prostatectomy is the most common and effective treatment for localized prostate cancer. Unfortunately, radical prostatectomy is associated with urinary incontinence and has a significant negative impact on quality of life. Pelvic floor exercises are the most common non-invasive management strategy for urinary incontinence following radical prostatectomy; however, studies provide inconsistent findings regarding their efficacy. One potential reason for sub-optimal efficacy of these interventions is the under-utilization of regional muscles that normally co-activate with the pelvic floor, such as the transverse abdominis, rectus abdominis, and the diaphragm. Two novel approaches to improve urinary continence recovery are 'Pfilates' and 'Hypopressives' that combine traditional pelvic floor exercises with the activation of additional supportive muscles. Our study will compare an advanced pelvic floor exercise training program that includes Pfilates and Hypopressives, to a conventional pelvic floor exercises regimen for the treatment of post-radical prostatectomy urinary incontinence.
Methods/design:
This is a pilot, randomized controlled trial of advanced pelvic floor muscle training versus conventional pelvic floor exercises for men with localized prostate cancer undergoing radical prostatectomy. Eighty-eight men who will be undergoing radical prostatectomy at hospitals in Toronto, Canada will be recruited. Eligible participants must not have undergone androgen deprivation therapy and/or radiation therapy. Participants will be randomized 1:1 to receive 26 weeks of the advanced or conventional pelvic floor exercise programs. Each program will be progressive and have comparable exercise volume. The primary outcomes are related to feasibility for a large, adequately powered randomized controlled trial to determine efficacy for the treatment of urinary incontinence. Feasibility will be assessed via recruitment success, participant retention, outcome capture, intervention adherence, and prevalence of adverse events. Secondary outcomes of intervention efficacy include measures of pelvic floor strength, urinary incontinence, erectile function, and quality of life. Secondary outcome measures will be collected prior to surgery (baseline), and at 2, 6, 12, 26-weeks post-operatively.
Discussion:
Pfilates and Hypopressives are novel approaches to optimizing urinary function after radical prostatectomy. This trial will provide the foundation of data for future, large-scale trials to definitively describe the effect of these advanced pelvic floor exercise modalities compared to conventional pelvic floor exercise regimes for men with prostate cancer undergoing radical prostatectomy
Trial registration:
Clinicalstrials.gov Identifier: NCT02233608 .
Context
Patients with prostate cancer and their physicians need knowledge of
treatment options and their potential complications, but limited data on complications
are available in unselected population-based cohorts of patients.Objective
To measure changes in urinary and sexual function in men who have undergone
radical prostatectomy for clinically localized prostate cancer.Design
The Prostate Cancer Outcomes Study, a population-based longitudinal
cohort study with up to 24 months of follow-up.Setting
Population-based cancer registries in 6 geographic regions of the United
States.Participants
A total of 1291 black, white, and Hispanic men aged 39 to 79 years who
were diagnosed as having primary prostate cancer between October 1, 1994,
and October 31, 1995, and who underwent radical prostatectomy within 6 months
of diagnosis for clinically localized disease.Main Outcome Measures
Distribution of and change in urinary and sexual function measures reported
by patients at baseline and 6, 12, and 24 months after diagnosis.Results
At 18 or more months following radical prostatectomy, 8.4% of men were
incontinent and 59.9% were impotent. Among men who were potent before surgery,
the proportion of men reporting impotence at 18 or more months after surgery
varied according to whether the procedure was nerve sparing (65.6% of non–nerve-sparing,
58.6% of unilateral, and 56.0% of bilateral nerve–sparing). At 18 or
more months after surgery, 41.9% reported that their sexual performance was
a moderate-to-large problem. Both sexual and urinary function varied by age
(39.0% of men aged <60 years vs 15.3%-21.7% of older men were potent at ≥18
months [P<.001]; 13.8% of men aged 75-79 years
vs 0.7%-3.6% of younger men experienced the highest level of incontinence
at ≥18 months [P = .03]), and sexual function
also varied by race (38.4% of black men reported firm erections at ≥18
months vs 25.9% of Hispanic and 21.3% of white men; P
= .001).Conclusions
Our study suggests that radical prostatectomy is associated with significant
erectile dysfunction and some decline in urinary function. These results may
be particularly helpful to community-based physicians and their patients with
prostate cancer who face difficult treatment decisions.
Prostate cancer is the most frequently diagnosed solid tumor in US men.
An estimated 179,300 men will be diagnosed as having the disease in 1999,1 and in more than 70% of these patients, the disease
will be clinically localized.2 Treatment options
for men with tumors confined to the prostate who have at least a 10-year life
expectancy include radical prostatectomy, external beam radiation, brachytherapy,
or expectant management. Each of these approaches is associated with a different
spectrum of morbidity and effects on quality of life, which may be short-term
or long-term.
To make informed choices about treatment alternatives, patients with
prostate cancer and their physicians need accurate information to assess the
potential and pattern of complications associated with each option. Numerous
investigators have assessed urinary and sexual function 1 or more years after
radical prostatectomy, with rates of incontinence ranging from 4% to 40% and
impotence from 29% to 75%.3- 12
These findings reflect the experiences of patients from selected clinical
practices,3- 5,7- 9,12
a health maintenance organization,10 and Medicare
recipients.6,11 Differences in
patient mix, study size, and data collection methods may explain the wide
range of results.
Limited data are available to describe the outcome experiences of unselected
population-based patients. We report results from the multicenter Prostate
Cancer Outcomes Study (PCOS), which has completed longitudinal assessments
of functional status in a large community-based cohort of patients with prostate
cancer treated with radical prostatectomy for clinically localized disease.
The reliability and concurrent validity of a simple questionnaire to assess leisure time physical activity has been investigated on 306 self-selected healthy adults of both sexes (163 M; 143 F). Values of body fat (BF) and maximum oxygen intake (VO2 max) expressed as percentiles of appropriate age and sex categories were used as criteria of validity for the questionnaire. BF and VO2 max were predicted from the Durnin and Womersley skinfold equations, and the laboratory version of the Canadian Home Fitness Test respectively. The strongest correlation was between VO2 max (percentile) and reported strenuous exercise (r = 0.35). The optimum discriminant function for VO2 max was based on a combination of reported strenuous and light activity. This yielded a correct 2-way classification of 69% of the subjects. A combination of sweat-inducing and moderate exercise yielded a correct 2-way classification of BF for 66% of subjects. The reliability coefficients for the optimum discriminant functions classifying VO2 max and BF were 0.83 and 0.85 respectively. We conclude that this simple instrument has potential value for the assessment of leisure time exercise behavior, offering the possibility of examining changes in behavior following the implementation of health and physical fitness promotion programmes in the community.
Pelvic floor muscle exercises prescribed for the treatment of incontinence commonly emphasize concurrent relaxation of the abdominal muscles. The purpose of this study was to investigate the interaction between individual muscles of the abdominal wall and the pelvic floor using surface and intramuscular electromyography, and the effect of their action on intra-abdominal pressure. Four subjects were tested in the supine and standing positions. The results indicated that the transversus abdominis (TA) and the obliquus internus (OI) were recruited during all pelvic floor muscle contractions. It was not possible for these subjects to contract the pelvic floor effectively while maintaining relaxation of the deep abdominal muscles. A mean intra-abdominal pressure rise of 10 mmHg (supine) was recorded during a maximum pelvic floor muscle contraction. These results suggest that advice to keep the abdominal wall relaxed when performing pelvic floor exercises is inappropriate and may adversely affect the performance of such exercises.
Urinary incontinence impacts 15 to 35% of the adult ambulatory population. Men after the removal of the prostate for cancer can experience incontinence for several weeks to years after the surgery. Women experience incontinence related to many factors including childbirth, menopause and surgery. It is important that incontinence be treated since it impacts not only the physiological, but also the psychological realms of a person's life. Depression and decreed quality of life have been found to co-occur in the person struggling with incontinence.
Interventions include pharmacological, surgical as well as behavioral interventions. Effective treatment of incontinence should include the use of clinical guidelines and research to promote treatment efficacy.
To investigate the incidence of urinary incontinence and its development over time, to compare the effects of alternative definitions on the incontinence rate and to explore risk factors for incontinence after radical retropubic prostatectomy (RRP) for clinically localized prostate cancer.
Urinary continence was assessed using a questionnaire administered by a third party in 1144 consecutive patients after undergoing RRP at our department from January 1986 to December 2001. Overall, 985 men (86%) were suitable for evaluation (mean age 64.5 years, mean follow-up 95.5 months). We compared the effects of three definitions on the actuarial rate of continence: (1) no or occasional pad use; (2) 0 or 1 pads used daily, but for occasional dribbling only; (3) 0-1 pads daily. The time to recovery of continence was defined as the date on which the patient met the continence definitions. The impact of incontinence on health-related quality of life (HRQoL) was also evaluated. Univariate and multivariate analyses were used to identify predictors of incontinence, using data gathered prospectively.
At the last follow-up at 24 months after RRP, 83%, 92.3% and 93.4% of men achieved continence according to definitions 1, 2 and 3, respectively. The difference in time to recovering continence was significant for definition 1 compared to the others (P < 0.001). Most men using 1 pad/day complained of occasional dribbling only (89.3%), considered themselves continent (98%) and their HRQoL was not as seriously affected as those requiring > or = 2 pads/day. Men continent (by definition 3) at 2 years had an actuarial probability of preserving continence of 72.2% at the last follow-up. On multivariate analysis the age at surgery (P = 0.009), anastomotic stricture and follow-up interval (both P < 0.001) were independent prognostic factors. Bilateral neurovascular bundle resection was another independent predictive factor (P = 0.03) in the subset of the last 560 men with available data on surgical technique. The reduction in the incidence of incontinence over time was as high as 86%.
Continence improves progressively until 2 years from RRP but some patients can become incontinent later. The criterion of pad use discriminates well between men with a limited reduction in their QoL (no or one pad used) and those with a markedly affected QoL (> or =2 pads/day). It could be clinically valid to consider users of 1 pad/day as continent. Age, bilateral neurovascular bundle resection and anastomotic stricture are significant risk factors for incontinence. There was a marked trend for the incidence of incontinence and anastomotic stricture to decrease with time.
Systematic review exploring the evidence for conservative management of incontinence after prostate surgery
Urinary incontinence can cause social isolation and be a financial and hygienic burden to the individual. Pelvic floor muscle exercises can be effective in maintaining and improving urinary incontinence and associated bladder symptoms following a successful course of biofeedback and electrical stimulation.
The number of cancer survivors continues to increase because of both advances in early detection and treatment and the aging and growth of the population. For the public health community to better serve these survivors, the American Cancer Society and the National Cancer Institute collaborate to estimate the number of current and future cancer survivors using data from the Surveillance, Epidemiology, and End Results cancer registries. In addition, current treatment patterns for the most prevalent cancer types are presented based on information in the National Cancer Data Base and treatment-related side effects are briefly described. More than 15.5 million Americans with a history of cancer were alive on January 1, 2016, and this number is projected to reach more than 20 million by January 1, 2026. The 3 most prevalent cancers are prostate (3,306,760), colon and rectum (724,690), and melanoma (614,460) among males and breast (3,560,570), uterine corpus (757,190), and colon and rectum (727,350) among females. More than one-half (56%) of survivors were diagnosed within the past 10 years, and almost one-half (47%) are aged 70 years or older. People with a history of cancer have unique medical and psychosocial needs that require proactive assessment and management by primary care providers. Although there are a growing number of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based resources are needed to optimize care. CA Cancer J Clin 2016. © 2016 American Cancer Society.
Urinary incontinence is one of the most common complications following radical prostatectomy. The incidence of urinary incontinence has a large reported range, from 2 to 87 % [1]. By understanding the risk factors and the pathophysiology of post-prostatectomy incontinence (PPI), patients can be risk stratified for long-term voiding dysfunction that may require intervention. There are currently a number of options available for Urologists to offer patients to manage this incontinence, dependent upon the type and degree of incontinence and its effect on quality of life. For this reason, a thorough and detailed evaluation is important in all patients, which includes a detailed history and physical exam as well as specific diagnostic tests, when appropriate. It is equally important to avoid unnecessary diagnostic tests that do not aid in management of a particular patient.
Context:
Radical prostatectomy is the most common reason for male stress urinary incontinence. There is still uncertainty about its diagnostic and therapeutic management.
Objective:
To evaluate current evidence regarding the diagnosis and therapy of postprostatectomy incontinence (PPI).
Evidence acquisition:
A systematic review of the literature was performed in October 2015 using the Medline database.
Evidence synthesis:
Diagnosis and conservative treatment of PPI are currently mostly based on expert opinions. Pelvic floor muscle training is the noninvasive treatment of choice of PPI. For invasive management of moderate to severe PPI, the artificial urinary sphincter is still the treatment of choice, but an increasing number of adjustable and nonadjustable, noncompressive as well as compressive devices are used more frequently. However, no randomized controlled trial has yet investigated the outcome of one specific surgical treatment or compared the outcome of different surgical treatment options.
Conclusions:
The level of evidence addressing the surgical management of PPI is still unsatisfactory. Further research is urgently needed.
Patient summary:
Incontinence after the removal of the prostate (postprostatectomy incontinence) is the most common cause of male stress urinary incontinence. First-line therapy is physiotherapy and lifestyle changes. If no satisfactory improvement is obtained, various surgical treatment options are available. The most commonly used is the artificial urinary sphincter, but other treatment options like male slings are also available.
This analysis uses data from the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) national registry to report on changes in the types of treatment patients with low-risk prostate cancer received from 1990 through 2013.
A growing literature supports the safety and efficacy of active surveillance for patients with low-risk prostate cancer. However, the experience behind this literature is based almost entirely in academic centers, and prior reports have consistently found surveillance generally underused in most other settings.¹,2 Conversely, high-risk tumors have been undertreated with androgen deprivation treatment alone.²,3 Recent trends in community-based practice patterns have not been well documented.
The response of the abdominal muscles to voluntary contraction of the pelvic floor (PF) muscles was investigated in women with no history of symptoms of stress urinary incontinence to determine whether there is co-activation of the muscles surrounding the abdominal cavity during exercises for the PF muscles. Electromyographic (EMG) activity of each of the abdominal muscles was recorded with fine-wire electrodes in seven parous females. Subjects contracted the PF muscles maximally in three lumbar spine positions while lying supine. In all subjects, the EMG activity of the abdominal muscles was increased above the baseline level during contractions of the PF muscles in at least one of the spinal positions. The amplitude of the increase in EMG activity of obliquus externus abdominis was greatest when the spine was positioned in flexion and the increase in activity of transversus abdominis was greater than that of rectus abdominis and obliquus externus abdominis when the spine was positioned in extension. In an additional pilot experiment, EMG recordings were made from the pubococcygeus and the abdominal muscles with fine-wire electrodes in two subjects during the performance of three different sub-maximal isometric abdominal muscle maneuvers. Both subjects showed an increase in EMG activity of the pubococcygeus with each abdominal muscle contraction. The results of these experiments indicate that abdominal muscle activity is a normal response to PF exercise in subjects with no symptoms of PF muscle dysfunction and provide preliminary evidence that specific abdominal exercises activate the PF muscles. Neurourol. Urodynam. 20:31–42, 2001. © 2001 Wiley-Liss, Inc.
To investigate methods to determine the size of a pilot study to inform a power calculation for a randomized controlled trial (RCT) using an interval/ratio outcome measure.
Calculations based on confidence intervals (CIs) for the sample standard deviation (SD).
Based on CIs for the sample SD, methods are demonstrated whereby (1) the observed SD can be adjusted to secure the desired level of statistical power in the main study with a specified level of confidence; (2) the sample for the main study, if calculated using the observed SD, can be adjusted, again to obtain the desired level of statistical power in the main study; (3) the power of the main study can be calculated for the situation in which the SD in the pilot study proves to be an underestimate of the true SD; and (4) an "efficient" pilot size can be determined to minimize the combined size of the pilot and main RCT.
Trialists should calculate the appropriate size of a pilot study, just as they should the size of the main RCT, taking into account the twin needs to demonstrate efficiency in terms of recruitment and to produce precise estimates of treatment effect.
The aim of the study was to compare the effect of hypopressive exercises including pelvic floor muscle contraction, pelvic floor muscle training (PFMT) alone and control on pelvic floor muscle function in women with pelvic organ prolapse (POP).
Fifty-eight women with a mean age of 55.4 (± 9.8) years old with stage II POP were randomly assigned to participate in the PFMT group, the hypopressive exercises associated with PFMT (HE + PFMT) group or the control group. Each treatment group underwent a 3-month course of treatment. The three groups received lifestyle advice regarding weight loss, constipation, coughing, and the avoidance of heavy lifting. Participants were evaluated before and after the treatment. Maximal voluntary contraction (MVC) and endurance were assessed using the Modified Oxford grading system. To evaluate muscle activation, surface electromyography (SEMG) was used.
The two treatment group significantly increase pelvic floor muscle function as measured by MVC (P < 0.001) using the Modified Oxford grading system, as well as muscle activation (P < 0.001), measured by SEMG. The PFMT group was superior regarding endurance (P = 0.007). Both groups were superior to the control group regarding MVC, endurance and muscle activation.
Adding hypopressive exercises to PFMT does not improve PFM function. Both treatment groups performed better than the control group.
Incontinence after radical prostatectomy is common yet poorly defined in the current literature. We aimed to accurately characterize incontinence after robot-assisted radical prostatectomy to achieve improved preoperative patient counseling.
After receiving institutional review board approval we performed a cross-sectional survey of the first 600 patients with prostate cancer who underwent robot-assisted radical prostatectomy at our institution. The International Consultation on Incontinence Modular Questionnaire-Lower Urinary Tract Symptoms Quality of Life and Urinary Incontinence Short Form were used to evaluate incontinence and quality of life after robot-assisted radical prostatectomy. Surveys were mailed by a third party. Data were analyzed on the prevalence of incontinence after robot-assisted radical prostatectomy. More specifically we characterized in detail the nature of incontinence and its effect on quality of life.
The response rate was 68% (408 of 600 participants). Response time since surgery was 2.5 months to 4 years. Overall incontinence bother scores and ratings of life interference were quite low. Patients reported that most incontinence occurred during physical activity but 35% reported interference with sleep. Of the patients 31% experienced some anxiety due to urinary difficulties and 51% had to occasionally change clothes due to leakage. Patients did not report much interference with traveling, visiting friends or family and family life. The most bothersome aspects of incontinence were its effects on partner relationship, sexual life and energy levels.
Despite patient concerns of incontinence after prostatectomy they report little interference with quality of life.
Despite improvements in surgical techniques, urinary incontinence (UI) is not uncommon after radical prostatectomy (RP), and it may dramatically worsen quality of life (QoL).
To determine the benefit of starting pelvic floor muscle exercise (PFME) 30d before RP and of continuing PFME postoperatively for early recovery of continence.
A randomised, prospective study was designed. Men with localised prostate cancer (PCa) who underwent an open radical retropubic prostatectomy (RRP) at our department of urology were included.
Patients were randomised to start PFME preoperatively and continue postoperatively (active group: A) or to start PFME postoperatively alone (control group: B).
The primary outcome measure was self-reported continence after surgery. Secondary outcome measures were assessed by degree of UI based on a 24-h pad test and QoL instruments (International Continence Society [ICS] male short form [SF]).
Of 143 men evaluated for the study, 118 were randomised either to start PFME preoperatively and continue postoperatively (group A; n=59) or to start postoperative PFME (group B; n=59). After 1 mo, 44.1% (26 of 59) of patients were continent in group A, while 20.3% (12 of 59) were continent in group B (p=0.018). At 3 mo, 59.3% (35 of 59) and 37.3% (22 of 59) patients were continent in group A and group B, respectively (p=0.028). The ICS male SF mean score showed better results in group A than in group B patients at both 1 mo (14.6 vs 18.3) and 3 mo (8.1 vs 12.2) after RP (p=0.002). In age-adjusted logistic regression analyses, patients who performed preoperative PFME had a 0.41-fold lower risk of being incontinent 1 mo after RP and a 0.38-fold lower risk of being incontinent 3 mo after RP (p≤0.001).
Preoperative PFME may improve early continence and QoL outcomes after RP. Further studies are needed to corroborate our results.
Although the bladder neck is elevated during a pelvic floor muscle (PFM) contraction, it descends during straining. This study aimed to investigate the relationship between bladder neck displacement, electromyography (EMG) activity of the pelvic floor and abdominal muscles and intra-abdominal pressure (IAP) during different pelvic floor and abdominal contractions.
Nine women without PFM dysfunction performed maximal, gentle and moderate PFM contractions, maximal and gentle transversus abdominis (TrA) contractions, bracing, Valsalva and head lift. Bladder neck position was assessed with perineal ultrasound. PFM and abdominal muscle activities were recorded with a vaginal probe and fine-wire electrodes, respectively. IAP was recorded with a rectal balloon.
Bladder neck elevation only occurred during PFM and TrA contractions. PFM EMG and IAP increased during all tasks from 0.5 (gentle TrA) to 45.7 cmH2O (maximal Valsalva).
Bladder neck elevation was only observed when the activity of PFM EMG was high relative to the IAP increase.
We analyzed the benefit of the early combined use of functional pelvic floor electrical stimulation and biofeedback in terms of time to recovery and rate of continence after radical prostatectomy.
A total of 60 consecutive patients who underwent radical prostatectomy were included in the study. Patients were prospectively randomized to a treatment group (group 1) vs a control group (group 2). In group 1 a program of pelvic floor electrical stimulation plus biofeedback began 7 days after catheter removal, twice a week for 6 weeks. Each of the 12 treatment sessions was composed of biofeedback (15 minutes) followed by pelvic floor electrical stimulation (20 minutes). The evaluation of continence was performed at time 0, at 2 and 4 weeks, and at 2, 3, 4, 5 and 6 months during followup. Evaluations were performed using the 24-hour pad test and the incontinence section of the International Continence Society questionnaire.
The mean leakage weight became significantly lower (p <0.05) in group 1 than in group 2 starting at 4 weeks until 6 months of followup. A significant difference (p <0.05) between groups 1 and 2 in terms of percentage of continent patients was achieved from 4 weeks (63.3% group 1 and 30.0% group 2) to 6 months (96.7% group 1 and 66.7% group 2).
Early, noninvasive physical treatment with biofeedback and pelvic floor electrical stimulation has a significant positive impact on the early recovery of urinary continence after radical prostatectomy.
To assess patient responses to radical prostatectomy and its effects.
A national sample was taken of 1072 Medicare patients who underwent radical prostatectomy for prostate cancer (1988 through 1990) by mail, telephone, and personal interviews. The effects of the surgery and its complications on these patients' lives were studied through: (1) patient ratings of the extent to which sexual and urinary dysfunctions were "problems" in their lives; (2) two general measures of quality of life, the Mental Health Index and the General Health Index; (3) patient reports of how they felt about the results of treatment and whether they would choose surgery again.
On average, dripping urine, particularly to the point where subjects were wearing pads, had a more significant effect on patients than loss of sexual function; incontinence had significant adverse effects on the measures of quality of life and self-reported results of surgery. Overall, postsurgical patients scored comparatively high on the quality of life measures (similar to a cohort of patients with benigh prostatic hyperplasia who had undergone transurethral resection of the prostate), reported feeling positive about the results (81%), and would choose surgical treatment again (89%). Nonetheless, there was variability in patient response to the effects of surgery.
The results demonstrate the ability of many Medicare patients to adapt to adverse outcomes, such as loss of sexual function and incontinence. They also provide evidence of the variability of individual patients' responses to surgical results and reinforce the importance of individualized decision making for patients facing a decision about radical prostatectomy for prostate cancer.
The aim of the present study was to describe co-activity patterns of the striated urethral wall muscle and the pelvic floor muscles (PFM) during contraction of outer pelvic muscles. Six healthy nulliparous physical education students, mean age 19.5 years (19-21) participated in the study. Concentric needle EMG and a Dantec amplifier were used for registrations. EMG activity was continuously recorded with the participants lying in a supine position. EMG was recorded during relaxation, contraction of the PFM, valsalva maneuver, coughing, hip adductor contraction, gluteal muscle contraction, backward tilting of the pelvis, and sit-ups. The procedure was performed with the needle in the striated muscle of the anterior wall of the urethra and then repeated with the needle set lateral to the urethra in the PFM. The results showed that the striated urethral wall muscle was contracted synergistically during PFM, hip adductor, and gluteal muscle contraction, but not during abdominal contraction. Both hip adduction, gluteal muscle, and abdominal muscle contraction gave synergistic contraction of the PFM. Thus the urethral wall striated muscle and the PFM react differently during abdominal contraction.
To examine the (1) short-term effectiveness of behavioral therapies in homebound older adults and (2) characteristics of responders and nonresponders to the therapies.
Prospective, controlled clinical trial with cross-over design.
Adults aged 60 and older with urinary incontinence and who met Health Care Financing Administration criteria for being homebound were referred to the study by homecare nurses from two large Medicare-approved home health agencies in a large metropolitan county in southwestern Pennsylvania.
Structured continence and medical history, OARS Physical and Instrumental Activities of Daily Living scales, Folstein Mini-Mental State Examination Score, Clock Drawing Test, Geriatric Depression Scale, Performance-Based Toileting Assessment, bladder diaries, and physical examination.
One hundred five subjects were randomized to biofeedback-assisted pelvic floor muscle training (53 to the treatment group and 52 to the control groups). Control subjects with complete pre- and post-control data (n = 45) experienced a median 6.4% reduction in urinary accidents in contrast to a median 75.0% reduction in subjects with complete pre- and post-treatment data (n = 48, P < .001). Following the control phase, subjects crossed over to the treatment protocol. Eighty-five subjects completed treatment, achieving a median 73.9% reduction in UI. Exercise adherence was the most consistent predictor of responsiveness to the behavioral therapy.
Clinically significant reductions in urinary incontinence are achievable with behavioral therapies in many cognitively intact homebound older adults despite high levels of co-morbidity and functional impairment.
Urinary incontinence is a common long-term complication after radical prostatectomy. Spontaneous recovery of normal urinary control after surgery can take 1-2 years. We aimed to investigate whether there was any beneficial effect of pelvic-floor re-education for patients with urinary incontinence as a result of radical prostatectomy.
102 consecutive incontinent patients who had had radical retropubic prostatectomy for clinically localised prostate cancer and who could comply with the ambulatory treatment schedule in our hospital were randomised, after catheter removal, into a treatment group (n=50) and a control group (n=52). Patients in the treatment group took part in a pelvic-floor re-education programme for as long as they were incontinent, and for a maximum of 1 year. The control group received placebo therapy. The primary endpoint was continence rate at 3 months. Incontinence was assessed objectively with the 1 h and 24 h pad tests and subjectively by the visual analogue scale. The groups were analysed on an intention-to-treat basis by ANOVA and chi2-test.
In the treatment group continence was achieved after 3 months in 43 (88%) of 48 patients. In the control group, continence returned after 3 months in 29 (56%) of 52 patients. At 1 year, the difference in proportion between treatment and control group was 14% (95% CI 2-27). In the treatment group improvement in both duration (log-rank test, p=0.0001) and degree of incontinence (Wald test, p=0.0010) was significantly better than in the control group.
Pelvic-floor re-education should be considered as a first-line option in curing incontinence after radical prostatectomy.
The response of the abdominal muscles to voluntary contraction of the pelvic floor (PF) muscles was investigated in women with no history of symptoms of stress urinary incontinence to determine whether there is co-activation of the muscles surrounding the abdominal cavity during exercises for the PF muscles. Electromyographic (EMG) activity of each of the abdominal muscles was recorded with fine-wire electrodes in seven parous females. Subjects contracted the PF muscles maximally in three lumbar spine positions while lying supine. In all subjects, the EMG activity of the abdominal muscles was increased above the baseline level during contractions of the PF muscles in at least one of the spinal positions. The amplitude of the increase in EMG activity of obliquus externus abdominis was greatest when the spine was positioned in flexion and the increase in activity of transversus abdominis was greater than that of rectus abdominis and obliquus externus abdominis when the spine was positioned in extension. In an additional pilot experiment, EMG recordings were made from the pubococcygeus and the abdominal muscles with fine-wire electrodes in two subjects during the performance of three different sub-maximal isometric abdominal muscle maneuvers. Both subjects showed an increase in EMG activity of the pubococcygeus with each abdominal muscle contraction. The results of these experiments indicate that abdominal muscle activity is a normal response to PF exercise in subjects with no symptoms of PF muscle dysfunction and provide preliminary evidence that specific abdominal exercises activate the PF muscles.
Urinary incontinence can cause social isolation and be a financial and hygienic burden to the individual. Pelvic floor muscle exercises can be effective in maintaining and improving urinary incontinence and associated bladder symptoms following a successful course of biofeedback and electrical stimulation.
Post-radical prostatectomy incontinence occurs in 0.5% to 87% of patients. This condition may be attributable to intrinsic sphincteric deficiency, and/or detrusor abnormalities. Previous studies of pelvic floor exercise (PFE) for improving post-prostatectomy incontinence have shown mixed results. We determined whether preoperative and early postoperative biofeedback enhanced PFE with a dedicated physical therapist would improve the early return of urinary incontinence.
A total of 38 consecutive patients undergoing radical prostatectomy from November 1998 to June 1999 were randomly assigned to a control or a treatment group. The treatment group of 19 patients was referred to physical therapy and underwent PFE sessions before and after surgery. Patients were also given instructions to continue PFE at home twice daily after surgery. The control group of 19 men underwent surgery without formal PFE instructions. All patients completed postoperative urinary incontinence questionnaires at 6, 12, 16, 20, 28 and 52 weeks. Incontinence was measured by the number of pads used with 0 or 1 daily defined as continence.
Overall 66% of the patients were continent at 16 weeks. A greater fraction of the treatment group regained urinary continence earlier compared with the control group at 12 weeks (p <0.05). Three control and 2 treatment group patients had severe incontinence (greater than 3 pads daily) at 16 and 52 weeks. Of all patients 82% regained continence by 52 weeks.
PFE therapy instituted prior to radical prostatectomy aids in the earlier achievement of urinary incontinence. However, PFE has limited benefit in patients with severe urinary incontinence 16 weeks after surgery. There is a minimal long-term benefit of PFE training since continence rates at 1 year were similar in the 2 groups.
The pelvic floor muscles (PFM) are part of the trunk stability mechanism. Their function is interdependent with other muscles of this system. They also contribute to continence, elimination, sexual arousal and intra-abdominal pressure. This paper outlines some aspects of function and dysfunction of the PFM complex and describes the contribution of other trunk muscles to these processes. Muscle pathophysiology of stress urinary incontinence (SUI) is described in detail. The innovative rehabilitation programme for SUI presented here utilizes abdominal muscle action to initiate tonic PFM activity. Abdominal muscle activity is then used in PFM strengthening, motor relearning for functional expiratory actions and finally impact training.
We performed a global self-assessment of continence following radical retropubic prostatectomy (RRP) and determined how this global self-assessment of continence correlates with commonly used definitions of continence.
Between October 2000 and February 2002 all men who underwent RRP were encouraged to complete the University of California-Los Angeles Prostate Cancer Index 3, 6, 12 and 24 months postoperatively. Beginning October 2002 a single question capturing the patient global self-assessment of continence status was added to the postoperative continence assessment. The study design was cross-sectional since only continence surveys submitted between October 2002 through February 2003 were evaluated. Sensitivity, specificity and kappa coefficient was determined for the relationship between the patient global assessment of continence vs the definition of continence based on pad requirement, problem due to incontinence and frequency of incontinence.
Continence progressively improved 3 to 24 months following RRP for all continence outcomes. At 24 months following RRP 97.1% of men considered themselves continent, while 97.1%, 94.1% and 97.1% were considered continent using continence definitions, including the requirement of no or 1 pad in a 24-hour interval, no or slight bother due to incontinence and total control or occasional dribbling, respectively. Our 3 definitions of continence derived from responses to the University of California-Los Angeles Prostate Cancer Index had excellent agreement with patient global self-assessment of continence (kappa coefficients between 0.76 and 0.83).
The majority of men achieve continence without invasive intervention following RRP. Final continence status should be ascertained at 24 months. The patient global assessment of continence provides face validity for other definitions of continence based on responses to validated self-administered questionnaires.
Slow, controlled breathing has been shown by cross-spectral techniques to potentiate arterial baroreflex control of heart rate. However, crucial aspects of the effects of slow breathing on the arterial baroreflex remain unsettled, namely whether the major function of the arterial baroreflex (i.e. the control of blood pressure) is also potentiated and whether baroreflex function is differentially modulated according to the age of the individual.
To examine the bradycardic and depressor responses to selective carotid baroreceptor stimulation by the neck chamber technique (-15 and -30 mmHg neck suction) and the cross-spectral R-R interval/systolic blood pressure relationship (alpha index).
In 24 resting, supine healthy male volunteers (aged 19-66 years, mean +/-SEM 37.5 +/- 3.19 years), blood pressure (Finapres), R-R interval (electrocardiogram) and ventilation (impedance) were recorded continuously. Both assessments were performed during spontaneous breathing and during 6 cycles/min controlled ventilation in random order.
The depressor and bradycardic responses to neck suction were significantly larger during slow breathing than in spontaneous breathing (+32 and +85%, respectively; both P < 0.01). The alpha index was also significantly larger during slow breathing (+62%; P < 0.01). Even after the volunteers were divided into older (> 50 years, n = 9) and younger (< 30 years, n = 9) groups, the baroreflex potentiation related to slow breathing was clearcut and significant for both the depressor (+46 and +24% older and younger volunteers; both P < 0.01) and the bradycardic (+130 and +73% older and younger volunteers; both P < 0.01) responses. When the assessment was made by computing the cross-spectral alpha index, a marked potentiation related to slow breathing was observed in younger volunteers (+99%; P < 0.01), whereas in older volunteers only a trend to an enhancement (by 32%; P < 0.055) was observed.
Slow controlled breathing is associated with potentiation of both the depressor and the cardio-inhibitory components of the arterial baroreflex, the potentiation being largely similar regardless of the age of the individual.
The aims of this study were to determine the intra-therapist reliability for digital muscle testing and vaginal manometry on maximum voluntary contraction strength and endurance. In addition, we assessed how reliability varied with different tools and different testing positions.
Subjects included 20 female physiotherapists. The modified Oxford scale was used for the digital muscle testing, and the Peritron perineometer was used for the vaginal resting pressure and vaginal squeeze pressure assessments. Strength and endurance testing were performed. The highest of the maximum voluntary contraction scores was used in strength analysis, and a fatigue index value was calculated from the endurance repetitions. Bent-knee lying, supine, sitting, and standing positions were used. The time interval for between-session reliability was 2-6 weeks.
Kappa values for the between-session reliability of digital muscle testing were 0.69, 0.69, 0.86, and 0.79 for the four test positions, respectively. Intra-class correlation coefficient (ICC) values for squeeze pressure readings for the four positions were 0.95, 0.91, 0.96, and 0.92 for maximum voluntary contraction, and 0.05, 0.42, 0.13, and 0.35 for endurance testing. ICC values for resting pressure were 0.74, 0.77, 0.47, and 0.29.
Reliability of digital muscle testing was very good in sitting and good in the other three positions. vaginal resting pressure demonstrated very good reliability in all four positions for maximum voluntary contraction, but was unreliable for endurance testing. Vaginal resting pressure was not reliable in upright positions. Both measurement tools are reliable in certain positions, with manometry demonstrating higher reliability coefficients.
The relative levels of pelvic floor muscle (PFM) activation and pressure generated by maximum voluntary PFM contractions were investigated in healthy continent women. The normal sequence of abdominal and PFM activation was determined. Fifteen women performed single and repeated maximum voluntary PFM contractions in supine, sitting and standing. PFM electromyographic (EMG) signals and associated intra-vaginal pressure data were recorded simultaneously. Surface EMG data were recorded from rectus abdominus (RA), external obliques (EO), internal obliques (IO) and transversus abdominus (TA). Abdominal and PFM EMG and intra-vaginal pressure amplitudes generated during voluntary PFM contractions were not different among the positions. Muscle activation sequence differed by position. In supine, EO activation preceded all other muscles by 27 ms (p = 0.043). In sitting, all of the muscles were activated simultaneously. In standing, RA and EO were activated 11 and 17 ms, respectively, prior to the PFMs and TA and IO were activated 10 and 12 ms, respectively, after the PFMs (p<0.001). The results suggest that women are able to perform equally strong PFM contractions in supine, sitting and standing, however the pattern of abdominal and PFM activation varies by position. These differences may be related to position-dependent urine leakage in women with stress incontinence.
There is little published guidance concerning how large a pilot study should be. General guidelines, for example using 10% of the sample required for a full study, may be inadequate for aims such as assessment of the adequacy of instrumentation or providing statistical estimates for a larger study. This article illustrates how confidence intervals constructed around a desired or anticipated value can help determine the sample size needed. Samples ranging in size from 10 to 40 per group are evaluated for their adequacy in providing estimates precise enough to meet a variety of possible aims. General sample size guidelines by type of aim are offered.
We sought to identify determinants of health-related quality of life after primary treatment of prostate cancer and to measure the effects of such determinants on satisfaction with the outcome of treatment in patients and their spouses or partners.
We prospectively measured outcomes reported by 1201 patients and 625 spouses or partners at multiple centers before and after radical prostatectomy, brachytherapy, or external-beam radiotherapy. We evaluated factors that were associated with changes in quality of life within study groups and determined the effects on satisfaction with the treatment outcome.
Adjuvant hormone therapy was associated with worse outcomes across multiple quality-of-life domains among patients receiving brachytherapy or radiotherapy. Patients in the brachytherapy group reported having long-lasting urinary irritation, bowel and sexual symptoms, and transient problems with vitality or hormonal function. Adverse effects of prostatectomy on sexual function were mitigated by nerve-sparing procedures. After prostatectomy, urinary incontinence was observed, but urinary irritation and obstruction improved, particularly in patients with large prostates. No treatment-related deaths occurred; serious adverse events were rare. Treatment-related symptoms were exacerbated by obesity, a large prostate size, a high prostate-specific antigen score, and older age. Black patients reported lower satisfaction with the degree of overall treatment outcomes. Changes in quality of life were significantly associated with the degree of outcome satisfaction among patients and their spouses or partners.
Each prostate-cancer treatment was associated with a distinct pattern of change in quality-of-life domains related to urinary, sexual, bowel, and hormonal function. These changes influenced satisfaction with treatment outcomes among patients and their spouses or partners.
To test the effectiveness of weekly postoperative pelvic floor muscle training (PFMT) versus supportive telephone contact by a urology nurse for men at 4 weeks after radical prostatectomy.
This was a randomized controlled trial in three Canadian centers. At 4 weeks after surgery, standardized verbal and written instruction about PFMT was provided to all subjects. Randomization occurred after initial instruction. Continence was defined as 8 g or less of urine loss on a 24-hour pad test. Primary outcome was grams of urine loss on pad test; secondary outcomes were International Prostate Symptom Score (IPSS), Incontinence Impact Questionnaire (IIQ-7) score, cost, and perception of urine loss as a problem. Data were obtained at baseline (preoperatively) and at weeks 4, 8, 12, 16, and 28 and 1 year after surgery.
A total of 216 men were enrolled; 11 were dry or withdrew at 4 weeks. Ninety-nine were randomized to the control group and 106 to the treatment group. There were no group differences at baseline for prostate-specific antigen level (mean [standard deviation] 8.4 [10.4] ng/mL; 7.6 [4.6] ng/mL), Gleason score (6.3 [0.86]), IPSS, IIQ-7 score, pad test, or voiding diary. At 8 weeks 23% of the control group and 20% of the treatment group were continent; at 12 weeks, 28% and 32%; 16 weeks, 40% and 44%; 28 weeks, 50% and 47%; and at 52 weeks, 64% and 60%, respectively. There were no significant differences between groups at any time point for the outcome variables.
Verbal instruction and written information with telephone support seemed to be as effective as intensive PFMT. Less-intense therapy may be more cost-effective.
Most research on point-nonpoint trading focuses on the choice of trading ratio (the rate point source controls trade for nonpoint
controls), although the first-best ratio is jointly determined with the optimal number of permits. In practice, program managers
often do not have control over the number of permits—only the trading ratio. The trading ratio in this case can only be second-best.
We derive the second-best trading ratio and, using a numerical example of trading in the Susquehanna River Basin, we find
the values are in line with current ratios, but for different reasons than those that are normally provided.
The impact of urinary incontinence on self-efficacy and quality of life. Health and Quality of Life Outcomes
- Bas Broome
Broome BAS. The impact of urinary incontinence on self-efficacy and quality of life. Health and
Quality of Life Outcomes. 2003;1(1):35. http://hqlo.biomedcentral.com/articles/10.1186/1477-7525-1-35.
Pelvic Dysfunction in Men: Diagnosis and Treatment of Male Incontinence and Erectile Dysfunction
- G Dorey
Dorey G. Pelvic Dysfunction in Men: Diagnosis and Treatment of Male Incontinence and Erectile
Dysfunction. West Sussex, England: John Wiley & Sons Ltd; 2006.
Conservative management for postprostatectomy urinary incontinence. The Cochrane database of systematic reviews
- C A Anderson
- M I Omar
- S E Campbell
- K F Hunter
- J D Cody
- Cma Glazener
Anderson CA, Omar MI, Campbell SE, Hunter KF, Cody JD, Glazener CMA. Conservative
management for postprostatectomy urinary incontinence. The Cochrane database of systematic reviews.
2015;1(1):CD001843. doi:10.1002/14651858.CD001843.pub5.
Can hypopressive exercises provide additional benefits to Accepted Article This article is protected by copyright
- Apm Resende
- L Stüpp
- B T Bernardes
Resende APM, Stüpp L, Bernardes BT, et al. Can hypopressive exercises provide additional benefits to
Accepted Article
This article is protected by copyright. All rights reserved.
Accepted Article pelvic floor muscle training in women with pelvic organ prolapse? Neurourology and urodynamics
Accepted Article
pelvic floor muscle training in women with pelvic organ prolapse? Neurourology and urodynamics.
2012;31(1):121-125. doi:10.1002/nau.21149.
Quality of Life and Satisfaction with Outcome among ProstateCancer Survivors
- M G Sanda
- R L Dunn
- J Michalski
Sanda MG, Dunn RL, Michalski J, et al. Quality of Life and Satisfaction with Outcome among ProstateCancer Survivors. New England Journal of Medicine. 2008;358(12):1250-1261.
doi:10.1056/NEJMoa074311.
Preoperative Pelvic Floor Muscle Exercise for Early Accepted Article This article is protected by copyright
- A Centemero
- L Rigatti
- D Giraudo
Centemero A, Rigatti L, Giraudo D, et al. Preoperative Pelvic Floor Muscle Exercise for Early
Accepted Article
This article is protected by copyright. All rights reserved.
Accepted Article Continence After Radical Prostatectomy: A Randomised Controlled Study
Accepted Article
Continence After Radical Prostatectomy: A Randomised Controlled Study. European Urology.
2010;57:1039-1044.