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Early 3‐month treatment with comprehensive physical therapy program restores continence in urinary incontinence patients after radical prostatectomy: A randomized controlled trial

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Early 3‐month treatment with comprehensive physical therapy program restores continence in urinary incontinence patients after radical prostatectomy: A randomized controlled trial

Abstract

Aims The objective of this study is to ascertain whether an early three‐month treatment with electrotherapy and biofeedback restores continence in urinary incontinence patients after radical prostatectomy (RP). Methods Design: The study performed a randomized, controlled trial of parallel and open groups. Configuration: Secondary care, urology department of a university hospital complex. Participants: Patients sent for RP due to prostate cancer (n = 60), 47 patients finally completed the study. Interventions: The treatment group (TG) received physiotherapy consisting of electrotherapy and biofeedback, 3 days a week for 3 months, while the control group (CG) received no specific treatment. Both groups received a guide to perform pelvic floor exercises at home. The measurement instruments used were the 1‐ and 24‐hour pad tests and the International Consultation on Incontinence Questionnaire Short‐Form. The recording method used was a micturition (urinary) diary. Results The results of the 1‐hour pad test (PT) show statistically significant differences between groups at 3 months (P = .001) and 6 months (P = .001), in favor of those in the TG. Sixty‐four percent of patients in the TG recovered continence as against 9.1% in the CG after 3 months in the 1‐hour PT, in line with the objective of this study. Conclusions An early physiotherapy program helps RP patients with urinary incontinence recover continence after 3 months. Moreover, they lead a better quality life.
Neurourology and Urodynamics. 2020;19. wileyonlinelibrary.com/journal/nau © 2020 Wiley Periodicals LLC
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1
Received: 11 March 2020
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Accepted: 6 May 2020
DOI: 10.1002/nau.24389
ORIGINAL CLINICAL ARTICLE
Early 3month treatment with comprehensive physical
therapy program restores continence in urinary
incontinence patients after radical prostatectomy:
A randomized controlled trial
Mercedes Soto González PhD
1
|Iria Da Cuña Carrera PhD
1
|
Manuel Gutiérrez Nieto PhD
1
|Sabela López García
2
|
Antonio Ojea Calvo PhD
2
|Eva M Lantarón Caeiro PhD
1
1
Department of Functional Biology and
Health Sciences, Faculty of Physiotherapy,
University of Vigo, Vigo, Spain
2
Urology Service, University Hospital
Complex of Vigo, Vigo, Spain
Correspondence
Iria Da Cuña Carrera, PhD, Faculty of
Physiotherapy. University of Vigo,
Campus A Xunqueira s/n,
CP 36005 Pontevedra, Spain.
Email: iriadc@uvigo.es
Funding information
Official College of Physiotherapists of
Galicia (Spain), Grant/Award Number:
17032017
Abstract
Aims: The objective of this study is to ascertain whether an early threemonth
treatment with electrotherapy and biofeedback restores continence in urinary
incontinence patients after radical prostatectomy (RP).
Methods: Design: The study performed a randomized, controlled trial of
parallel and open groups.
Configuration: Secondary care, urology department of a university hospital
complex.
Participants: Patients sent for RP due to prostate cancer (n = 60), 47 patients
finally completed the study.
Interventions: The treatment group (TG) received physiotherapy consisting of
electrotherapy and biofeedback, 3 days a week for 3 months, while the control
group (CG) received no specific treatment. Both groups received a guide to
perform pelvic floor exercises at home. The measurement instruments used
were the 1and 24hour pad tests and the International Consultation on In-
continence Questionnaire ShortForm. The recording method used was a
micturition (urinary) diary.
Results: The results of the 1hour pad test (PT) show statistically significant
differences between groups at 3 months (P= .001) and 6 months (P= .001), in
favor of those in the TG. Sixtyfour percent of patients in the TG recovered
continence as against 9.1% in the CG after 3 months in the 1hour PT, in line
with the objective of this study.
Conclusions: An early physiotherapy program helps RP patients with urinary
incontinence recover continence after 3 months. Moreover, they lead a better
quality life.
KEYWORDS
physical therapy modalities, prostatectomy, urinary incontinence, urology
1|INTRODUCTION
Prostate cancer is the second most diagnosed cancer in
men worldwide and the first in Europe and Spain. Its
early detection, thanks to the use of PSA and subsequent
biopsy, caused the incidence rate to increase significantly
in the 1990s
1
but led to significant decrease in mortality.
2
According to the latest data, prostate cancer currently
has a high cure rate, where the relative survival at 5 years
is almost 100%. This is because 90% of the cases are di-
agnosed in the localized stage, meaning that the cancer
has not yet spread outside the prostate gland, which
would explain the high survival rate.
3
Radical prostatectomy (RP) has become the gold
standardto treat prostate cancer and seems to be the
best method for cancer control in the long term. How-
ever, this procedure is not exempt from morbidity, since
urinary incontinence affects patient's quality of life.
4
Data on urinary incontinence rates after RP are dis-
parate and have been the source of controversy in
recent years. Rodriguez Escobar
5
explains that the reason
behind the wide range in incontinence incidence is the
use of different definitions of continence and methods for
quantifying it, where one can find definitions, such
as total control,”“occasional leakage but without pad,
and less than one pad.
From a medical point of view, incontinence causes
skin irritation, chronic dependence on catheters and ur-
ine collecting devices, and a significant increase in mor-
bidity. The cost of this pathology (materials, nursing care,
diagnostic tests, treatments, etc) in the United States has
been directly or indirectly estimated to be about 8 billion
dollars a year.
6
The conservative treatment today for post
prostatectomy urinary incontinence includes training of
the pelvic floor muscles, biofeedback (BF), and electro
stimulation. The above must be combined with a proper
life style that includes a decrease or elimination of caf-
feine, tobacco, performance of physical exercise and
bladder training, creation of a voiding schedule, and
gradually increasing voiding interval.
7
The objective of this study is to ascertain whether an
early threemonth treatment with electrotherapy (ET) and
BF restores continence in RP patients with urinary
incontinence.
2|MATERIALS AND METHODS
A randomized controlled trial of parallel and open groups
was carried out, to compare the efficacy of physiotherapy
intervention in improving continence in patients who un-
derwent RP due to prostate cancer. The study is registered in
Assign ISRCTN with reference ISRCTN48761809, https://
doi.org/10.1186/ISRCTN48761809.
Power calculation was based in the study of Manassero
et al,
8
showing a 67% of continence at 3 months in patients
undergoing RP in the group with physiotherapy treatment
and 22.5% in the control group (CG). Assuming a 95%
confidence level, 80% potency and a 1:1 treatment and
control ratio, 56 patients would need to be included in
each of the groups. Assuming a percentage of losses during
the followup of 20% of these groups should be 67.
Statistically significant results were achieved before
reaching the calculated sample size, and therefore it was
decided to stop the clinical trial.
9
The sample consisted of 60 patients (two groups of
30 patients each) who underwent RP surgery at the
Complejo Hospitalario Universitario de Vigo. Only RP
patients with stress incontinence who consented to par-
ticipate in the study were included, those with neurolo-
gical pathology, such as advanced Parkinson's disease,
multiple sclerosis with deterioration of cognitive or sen-
sitive abilities or with muscular weakness were excluded.
Also excluded were patients with other serious illnesses,
such as cancer, severe chronic obstructive pulmonary
disease, severe pulmonary hypertension, etc, patients
with pacemakers, patients treated with muscle relaxants,
and patients with previous urinary incontinence.
Five patients from the CG declined participation upon
learning that they would not be part of the experimental
group, while one had to receive chemotherapy and
two had urinary continence. In the experimental
group, three patients manifested urinary continence and
two received chemotherapy. Finally, as shown in
Figure 1, the sample consisted of 47 males, 25 from the
treatment group (TG), and 22 from the CG.
All patients signed the informed consent form ap-
proved by the Regional Committee on ethics and re-
search of Galicia before participation in any of the study
procedures. Patients, doctors, and evaluators were not
blinded for treatment. We expect no limitation of results
since the main outcome variables are completely objec-
tive. All patients were subject to the same measurements
and evaluations, irrespective of the group to which they
belonged.
The urinary catheter was removed 3 weeks after RP
and patients were subject to physiotherapy protocol
4 weeks after surgery.
The measurement instruments used were the 1 and
24hour pad tests, following recommendations of the
International Continence Society and the International
Consultation on Incontinence Questionnaire Short
Form (ICIQSF) validated for the Spanish language.
Moreover, the recording method used was a micturition
diary.
2
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GONZÁLEZ ET AL.
Measurements were carried out at the start of treat-
ment, and after 1, 2, 3, and 6 months. Initial measure-
ment and treatment, in the case of the experimental
group, began 7 days after catheter removal since im-
mediate measurements may not be representative of later
urinary incontinence.
The treatment group received physiotherapy consist-
ing of electrotherapy and BF, 3 days a week for 3 months,
while the CG did not receive any specific treatment, but
both groups received a printed guide to perform pelvic
floor exercises (PFEs) at home.
The intervention consisted of a first awareness phase
where patients received basic notions of anatomy, func-
tioning of the musculature and the process of urination,
and were then given recommendations on control of
liquid intake, limitation of substances, such as coffee,
alcohol, etc, and instructions on how to fill in the urinary
diary. Moreover, they were trained to perform a reliable
contraction, that is to say, perform contraction of the
pelvic floor muscles, by avoiding parasitic contractions of
buttocks, abdominals, adductor muscles, etc. This phase
was adapted to each patient since getting quality con-
traction is of utmost importance here.
Patients received ET every alternate day, that is, for
15 minutes 3 days a week, with square wave pulses of
20 Hz, 300 ns pulse duration and maximum intensity of
24 mA. This was because the literature review indicates this
to be the type of electrostimulation that gets best results.
Electromyography BF: the duration of treatment with
BF was approximately 30 minutes every day and patient
gradually exercised for strength, endurance and speed to
obtain the objectives.
PFEs should be in line with the patient's muscular
condition, and hence should vary in terms of force of
contraction, duration of contraction, pause times, speed
and position adopted by adapting to the muscle condition
of each patient. These exercises were done at home
three times/day spread over several sets.
2.1 |Statistical analysis
Data were analyzed with SPSS version 22. The Shapiro
Wilk test was used to check the distribution of sample
normality. The descriptive statistics of the quantitative
variables are provided through the mean and standard
FIGURE 1 Study flow chart of the
patients in the study. Number of patients (n)
GONZÁLEZ ET AL.
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3
deviation, while qualitative variables are expressed as
percentages. The Wilconson test compared the results of
urinary incontinence between the two groups at the start
of treatment, after 1, 2, and 3 months. A Pvalue of .05
was considered as statistically significant.
3|RESULTS
The relationship between the treatment and CGs at
baseline and before start of treatment did not show sig-
nificant differences in any of the measurement instru-
ments used: 1hour pad test (P= .641), 24hour pad test
(P= .983), and ICIQSF (P= .079) (Table 1).
The results of the 1hour pad test show statistically
significant differences between groups at 3 months
(P= .001) and 6 months (P= .001) in favor of the treat-
ment group (Table 1). Figure 2shows the evolution of
urine loss by group and time.
With regard to continence rates after 3 months in the
1hour PT, and in relation to the objective of this study,
64% of patients in the TG recovered continence as against
9.1% in the CG.
The results with the 24hour pad test show significant
differences between groups after 3 months (P= .003) and
6 months (P= .001), once again in favor of the treatment
group (Table 1; Figure 3).
However, if we take into account continence rates at
3 months for the 24hour pad test, the figure is 44% in the
treatment group, which is lower than that seen in the
1hour pad test. There is nevertheless evidence of dif-
ference between groups, since the CG reported a 4.5%
continence rate.
Finally, the results of the ICIQSF scores show sig-
nificant differences between groups at 2 months (P=.014),
3months(P= .001), and 6 months (P= .0001), once again
in favor of the treatment group (Table 1and Figure 4).
4|DISCUSSION
The results of the 1hour pad test show statistically sig-
nificant differences at 3 months, which was the deadline
for achieving the continence objective in this study. Hence,
a comparison of continence rates from the different studies
for this period showed a large difference, where the best
results were obtained by Kongtragul et al
10
and Van
Kampen et al
11
at 95% and 88%, respectively. With regard
to the intervention, worth mentioning is that Kongtragul
et al
10
only used PFE while Van Kampen et al
11
combined
it with BF. Also noteworthy is the exercise intensity, since
in Kongtragul et al
10
patients performed 240 contractions/
day, while those of Van Kampen et al
11
only performed
90 contractions/day, which may explain the better results.
As shown in the section on results, the present study
obtained 64% continence in the 1hour pad test at
3 months, which is slightly lower than the one obtained
in the mentioned studies, but it must be borne in mind
that continence is defined as 0 g of loss. For studies using
the same definition but with different tools (score 0 in the
TABLE 1 Contrast of means between groups in PT1 h, PT24 h, and ICQSF
Variable Time n (TG) Mean ± te (TG) n (CG) Mean ± te (CG) CI 95% Pvalue
1h PT Start, mo 25 72.48 ± 19.24 22 61.09 ± 15.64 11.39 [60.29, 37.51] .741
1 25 26.76 ± 6.43 22 56.00 ± 16.26 29.24 [5.79, 64.27] .162
2 25 13.12 ± 4.10 21 51.67 ± 15.77 38.55 [5.62, 71.47] .069
3 25 4.64 ± 1.83 20 35.30 ± 9.91 30.66 [10.19, 51.13] <.001*
6 23 0.70 ± 0.35 18 19.50 ± 7.34 18.80 [3.75, 33.86] <.001*
24h PT Start, mo 25 465.48 ± 99.23 22 443.91 ± 93.16 21.57 [289.81, 246.67] .983
1 25 258.60 ± 66.65 22 352.64 ± 111.65 94.04 [164.11, 352.18] .565
2 25 128.64 ± 38.98 21 276.38 ± 81.28 147.74 [32.30, 327.78] .242
3 25 27.32 ± 11.69 20 196.70 ± 65.40 169.38 [34.38, 304.38] .003*
6 23 4.00 ± 1.50 18 107.78 ± 43.00 103.78 [15.58, 191.97] <.001*
ICIQSF Start, mo 25 13.48 ± 0.80 22 15.36 ± 0.70 1.88 [0.20, 3.97] .079
1 25 12.32 ± 0.66 22 13.77 ± 0.68 1.45 [0.42, 3.32] .102
2 25 9.28 ± 0.86 21 12.48 ± 0.93 3.20 [0.69, 5.70] .011*
3 25 5.68 ± 0.86 20 12.20 ± 0.77 6.52 [4.24, 8.80] <.001*
6 23 3.87 ± 0.84 18 9.94 ± 1.12 6.07 [3.31, 8.84] <.001*
Note: The Pvalue refers to the difference between the groups. *P< .05.
Abbreviations: CG, control group; CI, confident interval; ISIOSF, International Consultation on Incontinence Questionnaire ShortForm; n, number of
patients; PT, pad test; te, typical error; TG, treatment group.
4
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GONZÁLEZ ET AL.
FIGURE 2 Evolution of urine loss by
group and time in the 1hour pad test (PT)
FIGURE 3 Evolution of urine loss by
group and time in 24hour PT. PT, pad test
GONZÁLEZ ET AL.
|
5
ICIQ and no loss recorded in the urinary diary), the rates
were slightly lower, such as 59.3% reported by Cen-
temero, 57.7% by Pedrialli, 50% by Tienforti, and 43.6% by
DijkstraEshuis. The first two authors performed inter-
ventions consisting of preoperative PFE and PFE +
ET + BF, while the latter two authors performed inter-
ventions with BF + PFE.
The results with the 24hour pad test show that
there are significant differences between groups after
3 and 6 months, once again in favor of the treatment
group. The continence rate at 3 months with this test in
the present study was 44%. There is a group of authors
who used this test and obtained similar continence
rates of between 40%50%,
8,1214
and as can be seen,
these rates are lower than those achieved with the
1hour pad test.
Filocamo et al
15
and Cornel et al,
16
respectively re-
ported 74% and 70% continence at 3 months, which is the
exception. However, it must be borne in mind that even
though Filocamo et al
15
used the 24hour pad test tool,
they grouped patients who used one diaper/day under
continence and this could clearly bias results. In the case
of Cornel et al
16
and Mariotti et al,
14
who obtained a rate
of 63%, both classified continence as losses of less than or
equal to 2 g, which could justify the higher rates when
compared with the present study, which classifies con-
tinence as 0 g of loss or a completely dry pad.
On the other hand, Yamanishi et al
17
and Terzoni
et al
18
achieved rates of around 63% but their definition of
continence differs greatly from the rest of the studies
(carried out in males). The former considered continence
as 8 g, (the definition accepted at the time for females
which took into account the weight of the vaginal flow)
which cannot be applied in the case of males since it
would skew this percentage. The latter included all
patients with less than 10 g loss/day, which again pre-
vents any comparison.
There seems to be a noticeable difference in rates
depending on the pad test used. This coincides with a
previous study conducted by Soto et al,
19
where the dis-
crepancy in continence rates depended on whether it was
measured with the 1or 24hour pad test; a higher per-
centage of continence was observed for the 1hour pad
test. However, this fact would not alter the significant
differences found between the study groups.
The initial conditions of both groups in the present
study were similar in terms of loss evidenced in all
measurement instruments used. Moreover, based on the
mean loss in grams reflected in the different studies, we
can observe that they are quite similar for the 24hour
FIGURE 4 Evolution of urine loss by
group and time in International Consultation
on Incontinence Questionnaire ShortForm
(ICIQSF)
6
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GONZÁLEZ ET AL.
pad test, since they vary between 217 and 287 g in most
studies that refer to this variable.
7,8,12,2022
These data are
below the mean loss observed in the present study since it
lies at 465.48 ± 99.23 for the treatment group and
443.91 ± 93.16 for the CG. Therefore, the level of severity
of incontinence is greater in this sample. Yokoyama
et al
23
reported losses of 680 g, which is a much higher
figure than the means in the rest of the studies, but it
should be noted that this amount corresponds to the
first day of urinary catheter withdrawal. Most studies per-
formed measurements 1 week after catheter withdrawal, to
obtain a more realistic measure of incontinence.
Authors that used the 1hour pad test observed means
that lay between 28
24
and 40 g,
25
and once again, our study
indicates a higher severity level, since the mean is
72.48 ± 19.24 g for the treatment group and 60.69 ± 15.64 g
for the CG.
This indicates that baseline losses are not homogeneous,
thereby revealing differences in the initial severity of pa-
tients from the different studies, which may also affect the
results obtained and prevent any comparison. It is striking
that many studies do not specify the initial losses although
they do use tests that include them.
10,13,16,18,20,2628
The interventions that reported best results combined
PFE + BF,
11,16
BF + ET,
20
but the intervention that ob-
tained the best results is an intensive PFE program.
10
The ICIQSF results show significant differences at
2 months in favor of the intervention group, in studies
that used this same questionnaire for assessment of ur-
inary incontinence,
13,17,21,29,30
where significant im-
provements were observed after the first month. At this
point, it should be emphasized that this tool obtains
improvements before those obtained objectively in the
1and 24hour pad tests. This could be due to the specific
question related to quality of life, that is, the patient
perceives an improvement even though it may not be
significant. Earlier studies found discrepancies in the
severity level determined by the ICIQSF and the pad
tests, since they do not coincide much.
31
The most commonly used methods to treat urinary in-
continence are ET, BF, and PFE, which have been studied
traditionally in the treatment of female incontinence but, as
we shall see below, they have also been evaluated in the
treatment of male urinary incontinence after RP.
Electrotherapy has shown its effectiveness in various
studies,
7,17,20,23,29,32
although most studies used a com-
bination of ET + PFE to obtain better results.
20,29
As an
exception, Goode et al
33
reported that the addition of PFE
to an ET program did not increase continence rates, but
ET in this case was performed by the patient himself at
home, which could affect the results. But what seems
evident is that ET is the most appropriate treatment when
muscle weakness is pronounced.
34
Many articles report that BF has been used in the treat-
ment of male urinary incontinence
11,14,16,20,25,26,30,33,3538
and
the benefits of this therapy are that it facilitates learning of
PFEs, giving the patient the possibility to conduct self
assessments, thereby increasing motivation towards treat-
ment.
39
There are diverse results after application of BF, with
positive result in the most of the studies,
11,16,20,26,30,37
when
used on its own or combined with other treatments.
A group of authors did not find benefits after addition
of BF to their interventions. All these studies performed a
total of 1 to 5 BF sessions
14,33,35,38
which may be the
cause of the ineffectiveness of the technique since the
number of sessions seems to be less than that required for
obtaining good results. On the other hand, the effective
studies had carried out between 1 to 2 sessions/week,
over a 3 month interval.
11,16,20,16,29,40,15,28,39
Many studies
do not provide details of therapy implementation and
hence cannot be reproduced.
Finally, PFE are the most widely used treatment for
treating male urinary incontinence with good results in
all studies that include them as sole treatment or com-
pare them with placebo or no intervention.
The performance of PFEs is considered as one of the
most effective treatments today.
Although earlier literature reports that there is no
established protocol on duration of contractions, resting
time or the number of repetitions or sets, GarcíaSánchez,
after reviewing several articles related to therapeutic PFE,
provides a protocol of 30 to 40 contractions four times/
day. A maximum of 200 contractions/day and up to
300 contractions/day in athletic women
41
could justify
the better results obtained with a more intensive program
as seen above.
The fact is that patients who perform exercises at
home cannot be controlled for adherence to the exercise
program, which may affect treatment results.
5|CONCLUSION
An early physiotherapy program helps recover continence
after 3 months in urinary incontinence patients that under-
went RP. Moreover, these patients lead a better quality life.
ACKNOWLEDGMENT
This study has received funding from a research com-
petition of the Official College of Physiotherapists of
Galicia with a resolution of 17 March 2017.
CONFLICT OF INTERESTS
The authors declare that there are no conflict of interests.
GONZÁLEZ ET AL.
|
7
ETHICS STATEMENT
Regional Committee on ethics and research of Galicia
(IBAC). Reference number: 2014/351.
ORCID
Mercedes Soto González http://orcid.org/0000-0001-
6541-988X
Iria Da Cuña Carrera http://orcid.org/0000-0002-
9507-789X
Manuel Gutiérrez Nieto http://orcid.org/0000-0001-
6020-808X
Eva M Lantarón Caeiro http://orcid.org/0000-0002-
5625-7628
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How to cite this article: Soto González M, Da
Cuña Carrera I, Gutiérrez Nieto M, García SL,
Calvo AO, Caeiro EML. Early 3month treatment
with comprehensive physical therapy program
restores continence in urinary incontinence
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2020;19. https://doi.org/10.1002/nau.24389
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... 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]. ...
... 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]. These modifications could influence the low back, but also the pelvic floor or the abdominal muscles [13], with implications in the biomechanics of balance, gait, and posture [14,15]. ...
... To the best of the authors′ knowledge, this is the first study analyzing the contraction of the abdominal muscles during HE in both sexes and considering sex differences. Up to now, the benefits of HE have been studied and described in women with pelvic floor or abdominal dysfunctions; however, the results presented in this study provide for the first time information about the activation of the abdominal muscles in men during HE, and support their use in several situations, such as urinary incontinence after prostatectomy or pelvic floor muscles′ dysfunctions, where men and women need similar treatments, but from different perspectives, according to their anatomy and also to the activation of their muscles [12,35,36]. ...
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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.
... By contrast, another RCT demonstrated that PFMT before holmium laser enucleation of the prostate promotes early recovery of continence [54]. Other techniques, such as pilates, oscillating rod, and the combination of biofeedback with electrostimulation and whole-body vibration training, increase pelvic floor muscle strength and promote quick recovery of continence [55][56][57][58]. ...
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Context: Urinary incontinence (UI) is a common condition in elderly men causing a severe worsening of quality of life, and a significant cost for both patients and health systems. Objective: To report a practical, evidence-based, guideline on definitions, pathophysiology, diagnostic workup, and treatment options for men with different forms of UI. Evidence acquisition: A comprehensive literature search, limited to studies representing high levels of evidence and published in the English language, was performed. Databases searched included Medline, EMBASE, and the Cochrane Libraries. A level of evidence and a grade of recommendation were assigned. Evidence synthesis: UI can be classified into stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence. A detailed description of the pathophysiology and diagnostic workup has been reported. Simple clinical interventions, behavioural and physical modifications, and pharmacological treatments comprise the initial management for all kinds of UI. Surgery for SUI includes bulking agents, male sling, and compression devices. Surgery for UUI includes bladder wall injection of botulinum toxin A, sacral nerve stimulation, and cystoplasty/urinary diversion. Conclusions: This 2022 European Association of Urology guideline summary provides updated information on definition, pathophysiology, diagnosis, and treatment of male UI. Patient summary: Male urinary incontinence comprises a broad subject area, much of which has been covered for the first time in the literature in a single manuscript. The European Association of Urology Non-neurogenic Male Lower Urinary Tract Symptoms Guideline Panel has released this new guidance, with the aim to provide updated information for urologists to be able to follow diagnostic and therapeutic indications for optimising patient care.
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Aims and Objectives The aim of this study was to evaluate the risk factors for lower urinary tract symptoms in prostate cancer patients underwent radical prostatectomy, thus providing therapeutic evidence for post-operative nursing. Background Prostate cancer is one of the most commonly diagnosed male malignancy in recent years. With surgical treatments, patients with prostate cancer indeed have satisfying survival rate. However, the presence of postprostatectomy lower urinary tract symptoms which affect quality of life significantly is more worthy of attention. Design Patients underwent surgical therapies were followed up and the symptoms were recorded. Methods A total of 65 prostate cancer patients underwent radical prostatectomy from January 2019 to October 2020, and pathologically diagnosed with prostate cancer were enrolled in our study. These patients were followed up 3 months after surgery and their medical records were retrospectively collected and analysed. Results were reported according to the STROBE Statement. Results The incidence of post-operative lower urinary tract symptoms at 3 months after surgery is similar to that of pre-operation. Univariate and multivariate analyses revealed that the independent risk factor for postprostatectomy lower urinary tract symptoms is body mass index, whereas pelvic floor muscle exercise is a protective factor. Conclusions The incidence of postprostatectomy lower urinary tract symptoms is non-negligible, which significantly affects quality of life. Body mass index is found as an independent risk factor for postprostatectomy lower urinary tract symptoms, while pelvic floor muscle exercise is a strong protector. Relevance to clinical practice Patients with prostate cancer would benefit from post-operative pelvic floor muscle exercise. These findings contribute to tailor post-operative nursing strategy.
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The aim of the study was to evaluate the effect of pelvic floor muscle (PFM) assessment and training before and after robot-assisted laparoscopic radical prostatectomy (RARP) in improving PFM strength and urinary continence. We performed an analysis of a database of patients who underwent robot-assisted laparoscopic radical prostatectomy (RARP) performed by two urologists from 2011 to 2013. Pelvic floor muscle (PFM) activation and strength were graded by a trained pelvic floor physiotherapist. Patients were given an exercise program, grouped according to the strength of their pelvic floor as graded by assessment, to complete before and after surgery. PFM strength was recorded preoperatively, 4 days post-catheter removal and 4 weeks post-catheter removal. Continence was recorded at 4 weeks postop and was defined as the requirement of no continence aids. A total of 98 patients had RARP and a preoperative physiotherapy assessment plus postoperative appointments at around 1 and 4 weeks post-RARP. The majority of men improved their PFM strength regardless of preoperative strength with no significant predictors of postoperative strength found. Age was the only significant predictor of postoperative incontinence. In this pilot study, a majority of patients increased their pelvic floor strength with time. Pelvic floor physiotherapy is an important modifiable patient factor, which does have an impact in improving patients’ urinary continence by strengthening the pelvic floor muscles. Patient age influences response to pelvic floor physiotherapy.
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To verify the efficacy of a Pilates exercise program compared to conventional pelvic floor muscle exercise (PFME) protocol in the conservative treatment of post-prostatectomy urinary incontinence (PPUI). Baseline assessment was performed four weeks postoperatively and included 24 hr pad test, bladder diary, and the ICIQ-SF. Patients were randomised into three groups: Pilates (G1), PFME combined with anal electrical stimulation (G2), and a control group (G3). Both treatment groups had to perform 10 weekly treatment sessions. Primary outcomes were mean reduction of daily pads and mean reduction of ICIQ-SF score four months after surgery. The significance level was set at P < 0.05. 85 patients completed the study. Differences between treatment groups (G1 and G2) in terms of mean reduction in daily pad usage, 24 hr pad test, and ICIQ-SF scores were not statistically significant (P > 0.05). The control group differed from G1 in daily pad usage (P = 0.01) and ICIQ-SF score (P = 0.0073). Intergroup comparisons revealed that 57.7% of the volunteers in G1 and 50% of the individuals from G2 no longer used pads by the end of the treatment period (P = 0.57). In the control group, 22.6% were not using pads four months after surgery, with statistical difference compared to G1 (P < 0.05). The Pilates exercise program proved to be as effective as conventional PFME to speed up continence recovery in PPUI. It also achieved a higher rate of fully continent patients when compared to the control group in the short-term. Neurourol. Urodynam. © 2015 Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.
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The Vall d'Hebron multidisciplinary prostate cancer (PC) team reviews recent advances in the management of this neoplasm. Screening studies with long follow-up show a reduction in mortality, whereas active surveillance is emerging as a therapeutic approach of non-aggressive cancers. New markers increase the specificity of PSA and also allow targeting suspected aggressive cancers. Multiparametric magnetic resonance (mMRI) has emerged as the most effective method in the selection of patients for biopsy and also for local tumor staging. The paradigm of random prostatic biopsy is changing through the fusion techniques that allow guiding ultrasonography-driven biopsy of suspicious areas detected in mMRI. Radical prostatectomy (RP) and radiotherapy (RT) are curative treatments of localized PC and both have experienced significant technological improvements. RP is highly effective and the incorporation of robotic surgery is reducing morbidity. Modern RT allows the possibility of high tumor dose with minimal adjacent dose reducing its toxicity. Androgen deprivation therapy with LHRH analogues remains the treatment of choice for advanced PC, but should be limited to this indication. The loss of bone mass and adverse metabolic effects increases the frequency of fractures and cardiovascular morbimortality. After castration resistance in metastatic disease, new hormone-based drugs have demonstrated efficacy even after chemotherapy resistance. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.
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Urinary incontinence is common after radical prostatectomy. Pelvic floor muscle training (PFMT) and functional electrical stimulation (FES) can be used to reduce urine leakage. Some patients have difficulty in performing PFMT, and do not obtain clinically significant results. FES might be helpful to them, but its role is unclear in the literature. To verify if FES can reduce urine leakage in patients who do not benefit from PFMT. To obtain mid-term data regarding the persistence of the results through FES or PFMT, associated with a maintenance programme. Prospective and retrospective study (104 PFMT patients, 34 FES) using 24-h pad-test to quantify leakage. Rehabilitation ended when patients obtained leakage <10 g/day. Rehabilitated patients followed a maintenance PFMT programme and performed a follow-up 24-h pad test after 3 months; 51% (PFMT) and 32% (FES) of patients reached leakage <10 g/day. Overall, 82.3% in the PFMT group and 82.3% in the FES group reduced leakage by at least 50% through rehabilitation. No significant difference existed between the two treatments (p = 0.32). After 3 months, 51 rehabilitated patients out of 56 (PFMT) and 11 out of 11 (FES), respectively, showed persistence of the results. PFMT cannot be replaced by machines, but FES can help those who are unable to execute PFMT to strengthen their sphincter and later learn PFMT. Even those who did not achieve rehabilitation had clinically relevant results in both groups. These methods seem useful for incontinent patients after prostatectomy.