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Tags >> Prostate
Sep 23, 2014

male sling

Surgery for prostate cancer can impair urinary function, and in the case of persistent urinary incontinence, patients may progress to surgical interventions. In order for physicians to conduct optimal patient counseling and surgical candidate selection for post-prostatectomy urinary incontinence (UI), the records of 95 patients were reviewed in this study. The patients were retrospectively placed into "ideal", n = 72, or "non-ideal", n = 23, categories based on chosen characteristics, and the results of their outcomes and satisfaction were consolidated. Men in the "ideal" group had the following characteristics: mild to moderate UI, external urethral sphincter that appeared intact on cystoscopy, no prior history of pelvic radiation or cryotherapy, no previous UI surgeries, volitional detrusor contraction with emptying of the bladder, and a post-void residual of < 100 mL. Patients who did not meet all listed criteria for the "ideal" group were placed into the "non-ideal" classification.

 

A cure for the surgery was considered total resolution of post-prostatectomy incontinence with the sling. Of the patients fitting into the ideal classification, 50% reported cure, and of the non-ideal group, 22% reported a cure. Satisfaction rates within the ideal group for the procedure were 92%, whereas the non-ideal group reported a 30% satisfaction. Although uncommon, complications occurring in both groups included prolonged pelvic pain and worsened urinary incontinence. The authors describe the importance of placing the correct amount of tension through the sling, and of leaving as much of the external urethral sphincter in place as possible. Another complication that occurred more frequently is that of acute urinary retention. In the ideal cohort, the 11 cases of urinary retention resolved within 6 weeks of surgery. Of interest is that 12 of the 23 men in the "non-ideal" category had to undergo further surgery with an artificial urethral sphincter.

 

This information can assist surgeons in guiding and advising patients about operative procedures for post-prostatectomy incontinence. (Ideally, every patient would "fail" a trial of pelvic rehabilitation prior to progressing to a surgery!) If a patient wishes to proceed with a sling surgery despite being in a "non-ideal" category, he could be advised of the known potential outcomes. This article offers support for pre-operative investigation techniques such as urodynamics. Our role as pelvic rehabilitation providers may allow us to discuss such research with patients and providers, and participate in discussions about the role of rehabilitation pre-operatively or post-operatively. If you would like to learn more about working with men who have pelvic floor dysfunctions, you still have time to book a flight to Orlando for the Male Pelvic Floor Function, Dysfunction, & Treatment course, where you can learn about male pelvic pain, incontinence and BPH, and male sexual dysfunction. This is the last opportunity to take this course this year!


Aug 18, 2014

baby

According to the American Cancer Society, approximately 233,000 new cases of prostate cancer will be diagnosed this year, and nearly 30,000 men will die from the disease. The diagnosis and treatment of prostate cancer in the United States has experienced significant shifts in the past few years, making management of cancer survivors challenging.  One of the big changes in prostate cancer screening took place in 2011; the US Preventive Services Task Force recommended against routine prostate specific antigen, or PSA testing due to the level of potential harm such as psychological distress and complications from the biopsy. You can read a prior post about that here. New guidelines for providing care to prostate cancer survivors have been published by the American Cancer Society so that providers can better identify and manage the side effects and complications of the disease and recognize appropriate monitoring and screening of survivors. 

 

 

In patients younger than 65 years of age, radical prostatectomy surgery is the most common intervention for prostate cancer. Long-term side effects of radical prostatectomy commonly include, according to the guidelines, urinary and sexual dysfunction. Urinary incontinence or retention can occur following prostatectomy, and sexual issues can range from erectile dysfunction to changes in orgasm and even penile length. Other common treatments, such as radiation and androgen deprivation therapy, are also related to urinary, sexual, and bowel dysfunction, as well as a long list of "other" effects. 

 

 


May 17, 2014

Prostate removal via open, laparoscopic or robotic surgical techniques has been a treatment of choice for patients with prostate cancer. Historically, patients have been keen to inquire about "nerve-sparing" procedures for prostatectomy with a goal of reducing erectile dysfunction or urinary incontinence, two common unwanted side effects of prostate surgery. Research published in Prostate International journal proposes that exquisite knowledge of fascial anatomy is a key to minimizing negative impact from surgery caused by damage to the prostatic neurovascular bundles. The authors in this paper point out that anatomical controversy exists in the  literature and that the anatomy is still being investigated, increasing the surgical challenge for those physicians who aim to identify the structures. 

 

 

The pelvic organs are covered by pelvic, also called endopelvic, fascia, that is commonly divided into two layers: that which covers the viscera (wrapping around each organ structure), and the parietal component which covers the medial levator ani, obturator internus, and piriformis. Access to the prostate gland is gained by an anterolateral incision through the endopelvic fascia at the fusion of the visceral and parietal fascia, according to the article. Layers of prostatic fascia and the endopelvic fascia attach laterally at the tendinous arch of the pelvic fascia, and these structures attach to the puboprostatic ligaments. The puboprostatic ligaments anchor the prostate to the pubic bone, creating an important aspect of continence through fascial tension and support. 

 

 

While nerve-sparing techniques have focused on preserving pelvic plexus autonomic nerve fibers, the authors argue that there is not a definite anatomy of the periprostatic nerve fibers, possibly contributing to the variability in surgical outcomes reporting for nerve-sparing procedures. Various approaches have been detailed in the literature, and are described in this article, with emphasis on dissection plane and intra- and interfascial techniques utilized. 


Mar 13, 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.

 

 

The authors in this study point out that chronic pelvic pain is not a disease, but rather is a symptom complex. Despite the persistent attempts to identify a specific pathogen as the cause of prostatitis-like pain, this article states that "…no postulated molecular mechanism explains the symptoms…" As with any other chronic pain condition, research in pain sciences tells us that behavioral tendencies such as catastrophizing is not associated with improved health. The authors utilized a psychotherapy model in developing a cognitive-behavioral symptom management approach and found significant reductions in CPP symptoms. The relevance of this information for our patient population includes having the ability to screen our patients for depression, to recognize tendencies to catastrophize, and to implement useful strategies for our patient. 


Mar 04, 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. 

 

 

While the numbers of referrers (11), providers (14), and patients (13) do not represent a large population, the recorded and transcribed interview allowed the subjects to express themselves without constraint. Some of the providers described the challenge of patients getting lost between the general practitioner and the specialists, the physiotherapists stated that formal training for male pelvic rehab was lacking and that providers were in the habit of referring for women, rather than men, and that the physiotherapist had not made an attempt to market services for male 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. 

 

Therapist-guided PFM assessment and training consisted of the following: history and assessment of comorbidities, education in bladder, urethra, and pelvic floor muscle anatomy and function, and instruction in PFM activation in various functional positions. Transabdominal ultrasound was utilized to provide feedback to the patient during training. Technique was corrected so that overactivity in the superficial abdominals was avoided, and so that breath holding was avoided. Home exercise program instruction included completion in 10 contractions of 10 seconds each to be done in supine, in sitting, and in standing. Functional activation of PFM was encouraged such as during lifting, coughing, and squatting. 

 


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. 

 

If you are interested in joining the Society of Urologic Nurses, or in ordering their Journal, you can access the information here. It is only $45/year to receive the journal, and the annual conference will take place in San Antonio, Texas this October. 


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