Treating Post Prostatectomy Incontinence - Diane Newman

Continence Nurse Practitioner and Biofeedback-Certified Specialist, Diane Newman presents on one of the most challenging complications and an independent predictor of global quality of life, post-prostatectomy incontinence. 

Diane K. Newman, DNP, ANP-BC, FAAN, Adjunct Professor of Urology in Surgery, Perelman School of Medicine, University of Pennsylvania and Co-Director of the Penn Center for Continence and Pelvic Health. She is the author of several books. The most recent is as lead editor of the 1st edition of the SUNA Core Curriculum for Urologic Nursing and of Clinical Application of Urologic Catheters, Devices, and Products.

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Diane Newman: Welcome. I'm Diane Newman, a continence nurse specialist. I'm also certified as a biofeedback specialist. I am the Editor of the Bladder Health Center of Excellence on UroToday, which is an excellent resource for individuals, professionals, and non-professionals, who want to learn about voiding dysfunction, pelvic floor disorders. And today what I'd like to present is some information on treating urinary incontinence after prostate cancer surgery. So I hope you enjoy this presentation as I think it's really quite informative and gives you the current information on incontinence in men after prostate cancer surgery.

So post-prostatectomy urinary incontinence is one of the most feared complications following prostate cancer surgery, and this has been shown in studies of men who have undergone this procedure. It has been shown to be an independent predictor of global quality of life. The prevalence ranges from 2% to 90%, so this research defines what urinary incontinence is, the quantity, and also when the research has been done, whether it's six months, one year, or two years after having the surgery. But it can be quite a significant problem. We do know that it does typically decrease over time. So usually there's a higher percentage of men, immediately post-prostatectomy surgery, who will have urine leakage, but over time that does decrease. So when you read this research, you need to note when was the survey of these men done, how long after that surgery? And that's important to determine what the true prevalence is.

Now, there's some recent research, and that's why I thought this presentation will really help viewers at the UroToday website, is that there was a nice study that was published in JAMA earlier this year that was looking retrospectively at patient-reported outcomes through five years after specific treatments for prostate cancer. And the treatments were just active surveillance, where they just watch men's PSAs, who had been elevated PSAs, those that underwent surgery for prostate removal, underwent brachytherapy or external beam radiation with or without androgen deprivation therapy. So they studied these men. And I think that if you want more information, it's really important that you read the whole article. But I wanted to give you some important information as far as urinary and sexual function that they found.

They found that men undergoing prostatectomy reported clinically meaningful worse incontinence through those five years that they followed these men compared with any other option of treatment. Men undergoing prostatectomy for unfavorable-risk disease reported worse sexual function after five years compared with men who underwent external beam radiation therapy or androgen deprivation therapy. And what this tells us is that, really, men do have complications, no matter what type of treatment. Of course, the least complication was active surveillance where there was no type of intervention to that prostate cancer. You'll find a blog on the UroToday website also that gives you much more information, so I really suggest that you read the entire article because if you're working with men in this area, it's very informative.

We also see detrusor instability in about a third of men post-prostatectomy. So I bring that up because you're going to see that that might be an option as far as treatment of that overactive bladder in some men, especially men who may be aging because we do also see that in this population. There's low urethral compliance noted in about 30% of cases, and this is associated with scarring from the prostate cancer surgery. But most of these men will persist with stress urinary incontinence, which is of course urine leakage with laughing, coughing, sneezing, or any type of effort. It tends to be episodic and may not be occurring all the time. The more active the man is, the more they'll complain there may be incontinence. But there are men who have urgency frequency and urinary incontinence after urgency.

Now, what I want to concentrate on though for this presentation is pelvic floor muscle training because that's specifically what I do with men post-prostatectomy. Now, when you look at the evidence, this is the International Consultation on Incontinence, which is the sixth edition, which came out in 2017. There was a committee on adult conservative management and basically what they recommended with a B grade rating that pelvic floor muscle training in men post-prostatectomy should be offered. And they talk about the fact of using a more intensive intervention versus digital exam. And they really felt that the more intensive the intervention is for teaching men pelvic floor muscle training probably is more effective. So there is evidence.

But there's also a more recent publication that was a meta-analysis of the impact of pelvic floor muscle training on incontinence in men after radical prostatectomy. And this was a systematic review done at the end of 2019. So again, the publication is on the slide if you want to read for yourself. But they really summarized the outcomes of every study done where they did institute pelvic floor muscle training. And basically what it showed was that men became dry quicker if they were put into a program which was somewhat intensive as far as teaching them how to contract the pelvic floor. And this is study after study. So this is a nice systematic review. I'm not going to go through each study, but please, this is a nice systematic review showing the evidence to support the pelvic floor muscle training that I'm sure many of you are doing with this population.

Now, when we talk about the pelvic floor is pelvic floor muscles and it is a large skeletal muscle that attaches to the pelvic bone in the front and slings around the rectum. It doesn't really attach in the back, but it does support the urinary and rectal sphincters. The voluntary sphincters of the pelvic floor are really what we're talking about here. These sphincters are not removed or cut during surgery, but because of the trauma during surgery or from radiation therapy, they can cause some urinary symptoms such as stress incontinence, which we see with post-prostatectomy incontinence. With radiation, we can see overactive bladder and urgency frequency with incontinence. This is a picture that I actually use in my education of patients before they start pelvic floor muscle training to really show them what happened with, say, if they had surgery, radiation, or brachytherapy, and again, what I'm talking about as far as retraining this muscle.

I explain to the patient that this is a voluntary striated skeletal muscle like your thigh. It has both slow- and fast-twitch muscle fibers. And I explain to them that if we really strengthen this muscle, you hypertrophy and you increase the muscle fibers, which actually improve that support of the sphincter, thus making it tighter, so you have less incontinence with effort or pressure from above. You increase that bulk. And you want to really, really increase those motor unit activations, so that's why we really work both types of muscle fiber, slow- and fast-twitch muscle. What that translates into is a program that we give of both quick muscle contractions to work those fast-twitch muscle fibers, and slow to work those more bulky fibers to increase the strength and bulk.

What we really find that whenever we assess this pelvic floor muscle is that there are usually three different types. Underactive, where the patient's very weak, cannot really contract the muscle and really cannot hold that contraction for more than one to two seconds. Overactivity, where they really aren't able to relax that muscle after they contract it. And I actually see both underactive and overactive muscle when I do the first assessment of patients I see after surgery, who refer to me for treatment of stress incontinence. So I usually see a mixed assessment of the muscle. And how I assess the muscle is with EMG biofeedback. And I'll show you some of those outcomes as far as the screens that the patients see as far as the graphs.

So when you talk about pelvic floor muscle training, you're really talking about the rehabilitation of the pelvic floor muscle. And we want to improve that urethra resistance. What we want is really to provide support to that external urinary sphincter, so when there is increased pressure above, which occurs with, say, lifting your leg, coughing, laughing, sneezing, bending over, I have a man when they do a golf swing, when they get out of their car or out of their truck, you want to make sure there's resistance there so that no urine leaks out. And the way to do that is by strengthening the pelvic floor muscles. There are certain components, and it's basically proper identification of the muscle, coordination so they can contract and relax the muscles, just as important as you relax this muscle if you contract it. They do a planned exercise and they use the muscle during incontinent episodes. So there are actually four components to pelvic floor muscle training.

The benefits have been shown in multiple studies. And it's been shown with MRI that intentional, effective pelvic floor muscle contraction, you lift the pelvic floor muscles upward and forward so that you actually clamp that urethra. And this again increases urethral pressure, preventing that urine from leaking out. Think of it like a garden hose that you're stepping on so that muscle contract, compresses that's hose so that no water, no urine, leaks out of the urethra. It also, at the bladder neck, so the base of that bladder, receives support from a strong, toned pelvic floor muscle. And I think that this is important with downward movement that occurs with increases in intraabdominal pressure. So there's a physiological reason why there's a benefit to pelvic floor muscle training, and this again has been published in research.

It's a little bit different than Kegel exercises, although most men will present and say, "I do my Kegels." Kegel exercises were first coined by Dr. Ronald Kegel, who was an obstetrician-gynecologist in the 1940s, in Southern California was his practice. And he talked about testing women and found that women had relaxed vaginas, that when they strengthened the pelvic floor muscles, you noticed that the incontinence and that vaginal muscle, which was the pelvic floor muscle, increased in strength. So that became what a lot of men do, tighten your muscle down there, or they stop and start the stream of urine. I have to tell you that I do not teach that. And I just recently read a publication where it was harmful to stop the stream of urine. They tested in women and they found that it led to dysfunctional voiding, so I don't teach patients to do this exercise during voiding. I tell them to do it as a planned exercise. So I kind of tell them it's more advanced than just Kegel exercises. And they are more advanced because Dr. Kegel just talked about working the slow muscle fibers, sustain the muscle contraction for 10 seconds. And we now incorporate both fast- and slow-twitch muscle fibers into our training.

So Kegel exercises alone are often inadequate. I feel that you need more than a simple handout for some men. Some men who may not have much trauma or damage to the pelvic floor and the sphincter after surgery, or say with radiation or brachytherapy, may just need a simple handout. But there's a percentage of men who I see who really have significant leakage that need a more intensive program.

So it is training the muscle. I use biofeedback, and I also teach them skill training, which teaches them how to use the muscle during the times they need to, like contract the muscle prior to let's say bending over, and we'll talk about that too.

I have published on this, and in Urologic Nursing several years ago. I outlined my program if you want another reference to aid you as you've moved forward with training. So "Pelvic Floor Muscle Rehabilitation Using Biofeedback" was published in Urologic Nursing. And you can see by this picture that actually this is one of my older units that I used off a laptop for biofeedback. And I'll explain that in more detail.

So what is biofeedback? Biofeedback has been around for many, many years, and it's been pretty well accepted in medicine. It's a painless, effective way to give patient feedback on a physiological response, such as muscle contraction. It may be lowering your blood pressure, decreasing temperature, so you use it in a lot of different modalities. But it really can help the patient isolate and identify what muscle was correct and then learn to use the muscle during increases in inter-abdominal pressure. And it has been shown to help eight out of ten people. So it's not an actual intervention, but it is a technique to use for training. In this sense, it's for teaching patients pelvic floor muscle training.

So it helps that person find the muscle. Are they doing the right muscle? And it's similar to, say, an athlete using special equipment to train, say, in a gym or for any other type of sports. And you can really increase your muscle strength by using other techniques. Maybe it's a weight or whatever. This is using biofeedback. And we use a computer and have muscle activity is shown on a graph so you can visualize if you're doing the muscle contraction correctly.

This is my setup. And I use the Prometheus Morpheus® equipment. And as you can see, I use an exam table in an upright position. The patient sits on it for the initial visit. I do have them lie more supine when I assess the muscle with visual and digital exams. The monitor there on the right of the screen of the slide is actually what the patient sees. And then I sit in front of the computer on the left of the patient and control the biofeedback and change parameters as I see is necessary. These are pictures of two patients who are visualizing the biofeedback screen. And then as you can see, it's very visual and they're monitoring the screen as they contract and relax their muscle.

The definition of biofeedback is the use of special instruments to measure electrical activity. So I use an EMG biofeedback electromyograph. And it's electrical activity of the skeletal muscles of the pelvic floor. In recent years, this is also called surface EMG or sEMG. And basically, this is a measurement of muscle activity, not muscle force. The measurement of muscle force would be manometry. I use EMG, not manometry biofeedback. I use an active electrode and I'll show you where I place them that picks up the target muscle. And a ground electrode to try to eliminate all that is outside environmental noise. So you'll see as far as there are actually two, three electrodes.

And this is actually the cable that I use, and these are surface electrodes. The green goes, and that's the top electrode, goes on a grounder, which I use the iliac crest or bone. And the two red electrodes go around the anus at the 9:00 and 3:00 or the 10:00 and 3:00. So I use skin surface electrodes. Many individuals will use sensors such as a rectal sensor. Either one is fine because, on my practices within a hospital setting, I have to follow JCAHO regulations. So I use disposable skin surface electrodes, but you can use an internal rectal sensor that has longitudinal electrodes, and a lot of practices will have the patient purchase that electrode, I think it's around 20 something dollars, and use that electrode for each biofeedback session.

Now I want to show you a few of the graphs that the patient would see so you kind of understand. This is an EMG assessment of the muscle for baseline muscle activity. So what is the amount? And it's measured in microvolts generated by the target muscle during rest. So basically, it should be as close to zero as possible. So there should be no movement as far as during the muscle at rest. So this is what the patient would see as far as ... And I have them make sure they can rest.

This is a peak muscle contraction. So this would be a patient that's contracting quickly for two seconds and then relaxing. So you see this is a quick pelvic muscle contraction. So this is working the fast-twitch muscle fibers. And you can see that in this one, the patient's able to contract for two seconds and relax down. This is actually someone who's trying to maybe do a five- or two- to five-second contraction that is unable to really relax down quickly. And this actually shows slow de-recruitment, so slow latency of a return to baseline. I want to show you this because to relax the muscle is just as important to contract it. And you want that patient to be able to drop that muscle down as quickly as possible. And you can see how they're having a little bit difficult time getting it down to relaxation.

This is someone who really is inconsistently relaxing. They contract a little and really don't relax down that far before they recontract again. And you can see the inconsistency in all, both with the muscle relaxation, but also with the muscle contraction. This is more of what I call hypertonic pelvic floor muscle that really isn't relaxing well. This is a nice graph of a patient. The top is quick pelvic floor muscle contractions, two-second contractions at the baseline visit. And then you can see at the second visit four weeks later, how much increase they have in muscle strength. We call these sub-maximal short, quick contractions. And that they returned back to relaxation very quickly. So this is actually kind of someone who's increasing the strength of the fast-twitch muscle fibers over a four week period.

This is another graph comparing a quick baseline with four weeks later, and these are sustained muscle contractions. So what you can see here by the graph is I have two-second contractions on the graph on the left at their baseline. They did two-second quick. You can see down on the bottom one, four weeks later, that quick one again. But actually, they've increased the strength from probably about five microvolts up to 10. So they've doubled their strength. The graph which you see on the right is really ten-second holds at baseline. Now you can see when we first started at baseline, they weren't really able to hold it up for 10 seconds. It fell back down. And you can see by that second graph there, it falls down and they had a hard time. But you can see four weeks later that they really were easily able to contract that muscle, sustain that contraction like a plateau at that level for 10 seconds, and then drop it. And this is just a nice example of really someone who's increasing their pelvic floor muscle strength and bulk and endurance.

This is a graph of someone who really is unable to relax. But over time, as they kept contracting, relaxation, and relaxing the muscle, this improved. And sometimes I just let the EMG run and just say, "Okay, now contract, relax, contract, relax, contract, try to hold it." And as they get in the rhythm of contraction and relaxation, they start to get into what I call a better pattern of the differentiation between contraction and relaxation. This is nice to see these numbers improve. So even though it is the relaxation elevated, I think it averaged around 4.2. As they continue to work the muscle, this did improve. And this you see in any muscle exercise as far as working your muscle improves, the more repetitive muscle contraction, relaxation that you do.

This is an example of a really overactive pelvic floor muscle. They're attempting to recontract the muscle. They really don't have much bulk and they really are not able to drop that down to really an adequate muscle relaxation. On that second picture graph that you see on the bottom of the slide, they really lost the muscle contraction after maybe two to three seconds. And what I was saying to them, so I guide them through this measurement, I'll say, "Now, can you recontract?" And while they're looking at the graph, they see as they can track back up. But you see in between each contraction here, they're not really relaxing well, and their muscle, actually, relaxation is really quite elevated. This is typically what I see the first time I test the patient with the biofeedback EMG, that they're really not, even though most of these men who are referred to me after surgery will say, "I've been doing them, Diane." And a lot of them will say to me, "But I'm not sure I'm contracting the right muscle," which is why the biofeedback is helpful. But when I do the testing, some of them really can't contract at all or they're hyper-overactive. They're not really adequately relaxing the muscle. So I work with them, and actually through a biofeedback session, to show them what to do.

By the way, usually, my biofeedback sessions are about maybe 30 minutes long, especially initially. Now, this is an example of someone who I'm using two EMGs on. So you can do this. And this may be someone who really cannot isolate the muscle. So the top EMG is the pelvic floor muscle, so the surface electrodes, the skin electrodes, or the rectal sensors in their pelvic area. But the bottom one is about one inch below the umbilicus. And I can put skin surface electrodes. So that the goal here is that you keep your muscle quiet, relaxed, while you contract the pelvic floor. And what you can see with these graphs is almost synergy that when the patients contract the pelvic floor, they're also contracting their stomach. So you're working with them on keeping that stomach quiet, the abdominal muscle relaxed, while you contract the pelvic floor. So this can be really, really important initially, when you first start your treatment, to educate the patient as far as isolation, identification of just the pelvic floor muscle and not using accessory muscles like a co-contraction with the abdominal muscle.

Now, when can you see a person improve? Well, and usually it's about three to six months, I tell patients. And I tell them that it may take time. You're not going to come back in a week or two weeks and say to me, "Oh, Diane, I'm 100% better. I have no leakage." It depends on the severity of the leakage. But what I try to say to patients is you're going to come back and tell me, "Well, you know what? My pads are not as heavy. They're not as wet." Or they may say to you, "I'm not using as many pads. Or at nighttime, I have no problem. Or I'm now noticed that I'm urinating more volume of urine." And they will tell you that. But it can take some time. I really set the patient up for realistic expectations because they come to me and some of them, literally, as soon as that catheter comes out, they're calling my office to be seen.

I'd like patients to wait at least about four weeks after surgery before they see me. I mean, now patients may need to go back to work very quickly. And after robotic surgery, they feel so good, they don't want to stay home for long. I will see them earlier. Initially, as I said, my first visit may be as long as 45 minutes. Biofeedback sessions can be 20 to 30 minutes each time. We do have new biofeedback codes that were instituted in January of 2020. So those actually provide much better reimbursement, so that's really good. And I want you to look at those codes because they are time-based codes. So they allow you to spend that time with the patient, but you need to really set them up. And I have, actually, a handout I give as far as an education tool that anybody's referred to me. The physician or the nurses will give that to them or email them.

Once they mastered a muscle contraction, really in a reclining position, I have them do it sitting and standing. So I actually give them a muscle retraining program like a prescription where I have them work both quick, fast-twitch muscle fibers, and then slow-twitch so longer holds. And this is the prescription that I use. You're welcome to use it. I actually have a handout and it actually says, "This is the exercise prescription I want them to do." It's a planned program. I have them do a set, three positions, lying, sitting, standing in the morning, and three sets in the afternoon. They will find that their leakage tends to be greater in the evening hours whenever the muscle is fatigued. So I tell them that. And I say, "If your muscles fatigue, try to do it before you go to bed, maybe, but also do a set in the morning where actually that muscle's probably is best as far as being able to do these exercises."

I also will give them a CD, an audio CD. It's kind of a quick five-second exercise program. They can also download it as MP3 off a website. So I do give them that information to get them to really make it part of their lives to do these. Some of the men will put it on their iPhone, listen to it in the car, or whatever. And it's an easy way to do five minutes of exercises.

Again, I do not allow them to do it while they're urinating, while they're peeing, by stopping the stream of urine. I say that that is not something that I recommend. I want this to be a planned exercise program like you would exercise any other muscle that has been damaged or traumatized.

What they should feel when they contract the muscles may be closure around the anus. They also may see movement in their scrotum or penis. But again, they should start to feel, if they're sitting, that whole perineum pull in while the muscle of the abdomen stays quiet, does not contract.

As they get strength in their muscle, I do something called the KNACK or the "stress strategy". And this is where they incorporate the muscle contraction into an activity that may be triggering the muscles. So it's the knack of doing something. So the concept is they do a quick pelvic floor muscle contraction prior to laughing, coughing, sneezing. So what I'll say to the man, "Listen, tell me when the leakage occurs." And some of them will say, "Well, Diane, when I go standing from sitting down in a chair when I bend over." So the concept is you quickly contract the muscle before you go to bend over, which will close the sphincter. That muscle will tighten, clamp down on that sphincter, and you won't leak. You hold that contraction as you go from sitting to standing. If you keep doing this every time you do that event or that activity, it becomes a reflex. So you don't have to remember to do it. So it becomes reflexive. And that's why I want to get them to.

I also ask the patient, some patients will tell me they have severe urgency. I may recommend an antimuscarinic or a beta-3 adrenergic. And here's just a list of medications that I use. I tend to like to use mirabegron, but there's also the antimuscarinics. That may help patients because some of the older men may be leaking from overactivity of the bladder. And they may have some urgency. So you may want to ask them about any of those symptoms.

So that's really a kind of a quick overview of pelvic floor muscle training using biofeedback or biofeedback-assisted pelvic floor muscle training. I hope this was helpful. And please email me via UroToday and I'll answer any questions. But this is a very rewarding intervention in a urology practice. So I'm hopeful that this is something that you find helpful. Thank you.