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Tags >> Prostate
Mar 14, 2014

A recent article titled "Pain, Catastrophizing, and Depression in Chronic Prostatitis/Chronic Pelvic Pain Syndrome" describes the variations in patient symptom report and perception of the condition. The article describes the  evidence-based links between chronic pelvic pain and anxiety, depression, and stress, and highlights the important role that coping mechanisms have in reported pain and quality of life levels. One of the ways in which a provider can assist in patient perception of health or lack thereof is to provide current information about the condition, instruct the patient in pathways for healing, and provide specific care that aims to alleviate concurrent neuromusculoskeletal dysfunction. 

 

 

Most pelvic rehabilitation providers will have graduated from training without being informed about chronic pelvic pain syndromes. And as most pelvic rehabilitation providers receive their pelvic health knowledge from continuing education courses, unless a therapist has attended coursework specifically about male patients, the awareness of male pelvic dysfunctions remains low. If you are interested in learning about male pelvic health issues, the Institute introduces participants to male pelvic health in the Level 2A series course. The practitioner who would like more information about male patients can attend the Male Pelvic Floor Function, Dysfunction, and Treatment course that is offered in Torrance, CA at the end of this month.

 


Mar 05, 2014

In a study conducted in Western Sydney, Australia, researchers aimed to discover the barriers and enablers to attending preoperative pelvic floor muscle training for men scheduled for a radical prostatectomy. Semi-structured interviews were completed with referral sources (urological cancer surgeons, nurses, and general practitioners), pelvic rehabilitation providers (physical therapists and continence nurses), and male patients having surgery at a public and a private hospital. 

 

 

Key factors that encouraged men to attend pelvic muscle training included having a referral from a provider that was for a specific therapist or center. Barriers to attending rehabilitation included potential cost of private pelvic floor muscle training, and lack of awareness about pelvic muscle rehab among both providers and patients. The providers were often not aware of public sector providers of pelvic muscle training, and patients were unaware of potential benefits of rehabilitation. 

 


Nov 25, 2013

 

Urinary incontinence (UI) and erectile dysfunction (ED) are two well-known risks of a prostatectomy surgery. You may be familiar with research completed by Burgio et al. that treated men with one session of preoperative biofeedback training for pelvic muscle strengthening. The authors concluded that a single session of biofeedback and a daily home exercise program "…can hasten the recovery…and decrease the severity of incontinence following radical prostatectomy." While the conclusions of the study were positive, recommendations for preoperative care were difficult to make from one study.

 

A recent publication in The International Journal of Urology added to this body of work. Researchers in Australia retrospectively analyzed the results of 284 subjects operated on by one "high-volume" surgeon. The 152 men in the intervention group received physiotherapy-guided pelvic floor muscle (PFM) training preoperatively while the control group (n = 132) was instructed in pelvic floor muscle exercise by the surgeon alone. The surgeon's recommendations included verbal instructions to complete PFM exercises daily until the surgery. Postoperatively, all subjects were instructed in physiothrapist-guided PFM training. Outcome measures included 24-hour pad weight at 6 weeks and 3 months postoperatively, percentage of patients who were categorized as experiencing severe UI, and patient-reported time to one and zero pad usage daily. 

 


Feb 14, 2013

You may recall that late in 2011, the United States Preventive Services Task Force created significant controversy by recommending against routine PSA (prostate specific antigen) testing. (A blog post from November 2011 covers the topic if you would like to review the recommendations.) The recommendations against use of routine PSA for prostate cancer screening is thought to avoid unnecessary biopsies as well as prevent urinary incontinence and erectile dysfunction related to procedures for prostate cancer.  In this year's January edition of the Annals of Internal Medicine we have updated information that addresses the implications of screening among different age groups.

 

Authors from the Fred Hutchinson Cancer Research Center and the University of Washington in Seattle ran computer models to determine risk reduction and mortality levels in populations of men. The bottom line is this: in men who are at low risk of developing prostate cancer, reducing the frequency of PSA testing significantly reduces the potential for harm from interventions, while not significantly increasing the risk of death. For example, in men ages 50-74 (who have low PSA levels) screening every other year versus annually increases lifetime death risk by 0.1% The number of PSA tests would be reduced by 59% and false positive tests (blamed for significant amount of pain and unnecessary treatments) would be reduced by nearly half. Click here for the journal abstract. 

 

Even if you are not working specifically with male pelvic rehab patients, you are likely working with male patients who are at an age when screening for prostate disease is recommended. How else can we promote prostate health with our patients? The Fred Hutchinson Cancer Research Center has found that eating dark green and cruciferous vegetables, drinking moderate amounts of red wine, and avoiding deep fried foods, smoking, and obesity can improve a man's chances of avoiding prostate cancer. As with many cancers, family history plays a role. Screening male patients, especially those who are in their 5th decade of life, is important. The American Cancer Society estimates more than 238,000 new cases of  prostate cancer will be diagnosed this year in the US. Be alert to male patients who have pain in the low back or pelvis, as these areas are typical sites of metastasis. The National Cancer Institute has an excellent summary of prostate cancer risks, general information, and images related to anatomy that you might find useful for your own knowledge or for patient education. 


Oct 09, 2011

The United States Preventive Services Task Force has recommended against routine PSA tests for prostate cancer screening. This is noted as a "Level D" recommendation, meaning that "There is moderate or high certainty that the service has no net benefit or that harms outweigh the benefits." You can read the task force draft report by clicking here. The official recommendation will be published next week. 

 

A PSA (prostate specific antigen) test  is commonly utilized in conjunction with a digital rectal exam for screening of prostate cancer in men 50 years or older. If the PSA level is high or is rising in relation to prior tests, a biopsy of the prostate is usually recommended. It is thought that over diagnosis occurs in many men who have a slow-growing tumor that will not be the cause of death. In terms of potential harm, the task force cites the research indicating that false positive results can lead to psychological distress, and that risk of biopsies such as infection, fever, bleeding, or transient urinary issues is moderate.

 

The New York Times published an article recently addressing this issue. Highlighted in this article is the fact that the panel who recommended against PSA testing is the same panel who advised against routine mammograms, creating quite a controversy. Will the advice against routine PSA testing be met with as much disagreement? The disease is reported to be rare in men under age 50, and with most deaths from prostate cancer occurring in men over age 75. Even so, many men credit the PSA test as having "saved their life." It remains to be seen how insurance providers, medical practitioners, and patients will respond to the advisement against PSA testing. 


Oct 05, 2011

While it is well-documented that prostatectomy surgery negatively impacts sexual and urinary function in a significant portion of men, this case series asks if correcting the surgery-related incontinence can improve sexual function. This article looks at a group of men who were all treated by the same surgeon for radical prostatectomy (RP) surgery. 15 men who experienced urinary incontinence after the RP were then surgically treated with an anti-incontinence surgery, either a male sling or an artificial urinary sphincter  (AUS) . 11 of these 15 men were sexually active and they completed post-surgical outcomes for both urinary and sexual function.

 

Of the 11 men described in the study, 4 of them had the AUS and the remaining 7 had the sling surgery. All of the men reported significant improvements in urinary incontinence (the goal of the surgery.) Most of them also reported a significant increase in their sexual quality of life. It was noted that the 4 men treated with the AUS reported a marked improvement, and in the group of 7 men who had the sling procedure, more than half of them reported marked improvements. 

 

This is encouraging information for men who are suffering from the effects of prostate surgery. Could it be that overall sense of wellness and virility improved because urinary incontinence in general was improved, or that urinary leakage during sexual activity was improved? The authors acknowledge that more research is needed to determine if a UI surgery would be beneficial for men who have UI only with sexual health.


Aug 31, 2011

I recall vividly the patient who attended his first physical therapy appointment one day after having his catheter removed following a radical prostatectomy surgery. He appeared a bit pale and mildly sweating. I asked him if how he was feeling, and he replied that he did not feel well. No fever, aches, chills, but something just did not seem right to him. I inquired if he had in fact been able to void since his catheter was removed. "Oh yes," he replied, "I have been peeing a little all night." I then asked him to quantify how much he was voiding, and he stated that it was 1-2 Tablespoons several times in the night. Although voiding amounts decrease typically in the evening, we also find that patients who have just had radical prostatectomies leak in the evening early in recovery. He had not been leaking during the evening. I was able to immediately contact the patient's surgeon and express my concern that the patient was in urinary retention. The patient was instructed to go immediately to the emergency room and an extraordinary amount of fluid was removed from his over-distended bladder.

 

This is a situation that pelvic rehab therapists need to be very alert towards. It is not only post-surgical patients who can be retaining urine, however, it is a common risk following a procedure such as a prostatectomy or a TURP (transurethral resection of the prostate.) An article appearing in the Urologic Nursing Journal identifies risk factors for such retention following a TURP procedure (these may be completed to remove part of an enlarged prostate gland that is limiting voiding.) A chart audit of 156 patients revealed that 15.4% of the patients had acute urinary retention.  The risk factors included prostate size, clot retention, and pre-surgical UTI (urinary tract infection) or a failed voiding trial post-surgically. 

 

Keep in mind that if you are treating patients who have recently had a procedure such as prostate surgery, urinary retention can be an even more urgent issue than urinary leakage. Even if a patient reports that he has been voiding, it is important to ask further questions to determine amounts voided. Because of the risk of post-operative infection, anytime a patient does not look right (perhaps pale, clammy, confused) it may be important to request that the patient follow-up with a physician or other medical provider. It is also helpful to keep screening items in your office such as a thermometer with disposable sleeves, blood pressure cuff, and to use them when needed. 


Aug 21, 2011

The latest Journal of Urology reports on a single-center prevalence study of urinary incontinence during sexual activity that occurred in men following prostate cancer surgery. 

 

Nearly 1500 men were surveyed to determine the post-operative prevalence of urinary incontinence (UI) with sexual activity and stress UI in the absence of sexual activity. The participants completed the UCLA-PCI pre-operatively and again at 3, 6, 12 and 24 months following surgery. All men had been treated by the same surgeon. 12.1% of men reported major bother from urinary incontinence with sexual activity at 24 months post-operatively. Of these men, more than half of them also experienced significant bother from stress urinary incontinence. Interestingly, more than 10% of men who did not report stress incontinence did report leakage with sexual activity. The take home point: men can have leakage during sexual activity even if coughing, laughing, golfing, transitional movements are leak-free.

 

The study concludes that treatment of the problem requires further research. While that is true, you can find some wonderful patient education materials related to post-prostatectomy pelvic muscle awareness and strengthening on physiotherapist Grace Dorey's website. One such resource is "Living and Loving After Prostate Surgery." It is so helpful to be able to direct patients to such resources that speak candidly about issues of urinary and sexual function for men. 


Aug 03, 2011

In a PubMed article about erectile function preservation following prostatectomy surgery, Dr's Segal and Burnett review treatment options. You may find this article interesting because, if you are treating male patients for pelvic rehabilitation, you will be asked some questions that you don't usually learn the answers to in school. 

 

Urinary incontinence and erectile dysfunction are the 2 most common complications following prostate removal surgery. Erectile dysfunction affects not only the quality of life of the man who had surgery, but the man's partner can suffer as well. There are various types of erectile dysfunction, and this article describes several medication approaches towards the various types of dysfunction. One of the post-surgical approaches that has been prevalent in the literature over the past decade is the use of some type of medication to periodically produce erections immediately in the weeks following surgery to maximize functional recovery. You can familiarize yourself with some of the literature and medication approaches available in this review.

 

Why should we be familiar with medications such as those discussed in the article? It has been my experience that even when you don't "solve" the patient's sexual dysfunction, the patients are desperate to talk with someone about what is happening to the body and about what options are available for recovery. Oftentimes, male patients remark that they feel much more comfortable addressing the issue with a physician once they have some basic information. It is also much more interesting to engage in a discussion with a physician about his or her preferred practice pattern or clinical experience when you have perused the options that the doctor encounters in the literature. 


Jul 28, 2011

In this brief and interesting Medscape video lecture, Dr. Gerald Chodak discusses the relevance of new research addressing men’s expectations following prostate surgery. 152 patients who had received extensive preoperative counseling regarding prostate surgery and expected outcomes completed a survey prior to and one year following their surgery. The surveys asked for responses about incontinence, bowel and sexual function, among other variables.

 

At one year following surgery, 47% and 44% of the men reported having lower than expected function for urinary incontinence and sexual function, respectively. The researchers report surprise that 12-17% of the men expected better than baseline urinary and sexual function following surgery. The study concludes that “Men have unrealistic expectations of…function after prostatectomy despite preoperative counseling.” The study also hypothesizes possible psychological causes for this reaction.

 

We have all met patients who are frustrated with post-surgical outcomes when their expectations are not achieved. These patients can sometimes be so frustrated that it may impair the ability to “move on” and focus on the level of function or healing that is available. It may be that we have opportunities to work with these men on a pre-operative basis, and it may be helpful for us to discuss the follow-up issues, if only for the patient to air any concerns and be directed towards the physician with any significant concerns.


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Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Durham, NC (SOLD OUT)
Apr 25, 2014 - Apr 27, 2014
Location: Duke University Medical Center

Myofascial Release for Pelvic Dysfunction - Portland, OR
Apr 25, 2014 - Apr 27, 2014
Location: Legacy Meridian Park Medical Center

Finding the Driver in Pelvic Pain - Milwaukee, WI
May 01, 2014 - May 03, 2014
Location: Marquette University

Visceral Mobilization of the Urologic System - Winfield, IL
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Rehabilitative Ultrasound Imaging: Women's Health and Orthopedic Topics - Seattle, WA
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Rehabilitative Ultrasound Imaging Orthopedic Topics - Seattle, WA
May 03, 2014 - May 04, 2014
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Pelvic Floor Level 1 - Scottsdale, AZ (SOLD OUT)
May 16, 2014 - May 18, 2014
Location: Womens Center for Wellness and Rehabilitation

Pelvic Floor Level 2A - Maywood, IL (SOLD OUT!)
May 16, 2014 - May 18, 2014
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Pelvic Floor Level 3 - San Diego, CA
May 30, 2014 - Jun 01, 2014
Location: FunctionSmart Physical Therapy

Pelvic Floor Level 1 - Arlington, VA (SOLD OUT)
Jun 06, 2014 - Jun 08, 2014
Location: Virginia Hospital Center

Care of the Postpartum Patient - Houston, TX
Jun 07, 2014 - Jun 08, 2014
Location: Texas Children’s Hospital

Bowel Pathology and Function - Minneapolis, MN
Jun 07, 2014 - Jun 08, 2014
Location: Park Nicollet Clinic--St. Louis Park

Oncology and the Female Pelvic Floor - Orlando, FL
Jun 21, 2014 - Jun 22, 2014
Location: Florida Hospital Sports Medicine and Rehabilitation

Myofascial Release for Pelvic Dysfunction - Dayton, OH
Jun 22, 2014 - Jun 23, 2014
Location: Southview Hospital

Pelvic Floor Level 2A - Derby, CT
Jun 27, 2014 - Jun 29, 2014
Location: Griffin Hospital