The Case of Post-prostatectomy Urinary Incontinence

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Patient History

Ted is a 67-year-old male with a primary concern of stress urinary incontinence (SUI) and secondary concerns of erectile dysfunction. Ted reports he was diagnosed with prostate cancer in September 2013 and underwent a “bilateral nerve-sparing radical suprapubic prostatectomy”, a procedure in which the nerves must be cut in order to remove the cancerous tissue, later that fall. He said he did not require radiation or chemotherapy treatment.

Ted complained of an onset of SUI after his surgery, and was referred by his urologist to pelvic floor PT. During his evaluation, Ted said he was wearing two to three pads a day with moderate saturation when changing them. He said he was “fairly” dry at night and was waking once a night to urinate.

Ted’s symptoms of SUI were aggravated with walking, standing, and an increase in intra-abdominal pressure with coughing, laughing, and sneezing. His symptoms interfered with prolonged standing and flying. He said he was “always looking for the nearest restroom”. In addition, he was unable to achieve an erection, but had a moderate erection with medication. His goal for physical therapy was to improve his incontinence.

Assessment

Based on Ted’s history, I chose to evaluate the following:

  • Abdominal wall assessment for a diastasis recti, which is a separation of the abdominal muscles.
  • Scar tissue assessment for mobility and hypersensitivity.
  • Assessment of the transversus abdominis (TrA), the deepest layer of the abdominal muscles.
  • Assessment of muscle tone in the pelvic floor musculature.
  • Assessment of pelvic floor motor control.

The reason why I chose to assess these specific details was because I wanted to know if Ted’s incontinence was caused by poor integrity of the abdominal wall, scar tissue impairments, and/or pelvic floor dysfunction. These three components can often lead to SUI.

Objective Findings

Here’s what I found upon examination:

Ted had pelvic floor muscle weakness, poor endurance, as well as transverse abdominis (TrA) weakness. He could not contract his pelvic floor with an increase in abdominal pressure. Ted also presented with minimal to moderate scar tissue restrictions over his incision site and a posterior pelvic tilt of the pelvis in standing. A posterior tilt is when the front of the pelvis rises and the back of the pelvis drops due to shortened/tight muscles.

His symptoms of SUI developed due to his weak pelvic floor musculature and TrA. Low tone, or weakness of the pelvic floor muscles, can contribute to SUI with coughing, laughing, and sneezing as well as with dynamic activities such as walking. TrA weakness can also contribute to SUI because the abdominals are poorly supported. Ted’s standing urinary incontinence was due to his poor standing posture, which inhibited the pelvic floor from working properly. Ted did not have a diastasis recti.

Initial Treatment Plan

Ted’s initial treatment plan consisted of scar mobilization, pelvic floor strengthening, postural education, core strengthening, and dynamic strengthening exercises.

I worked on mobilizing the scar to increase the flexibility of Ted’s lower abdomen, and thus allow for proper contraction of TrA. This would then improve the integrity of the abdominal wall.

I gave Ted pelvic floor strengthening and endurance exercises in supine, sitting, and standing in order to increase his pelvic floor strength, and decrease his urinary incontinence. Specifically, I gave Ted the “knack” exercise which taught Ted how to contract his pelvic floor muscles in order to help prevent SUI with a cough, laugh, or sneeze.

I also educated Ted about his posture when sitting and standing in order to help place the pelvis in a neutral position, and allow for good motor control of the pelvic floor muscles. The core stabilization exercises were to help strengthen his TrA, and the dynamic strengthening exercises with pelvic floor contraction were to help decrease any SUI with walking.

Ted’s home program included self-scar mobilization, pelvic floor and TrA strengthening exercises. Lifestyle modifications included bladder retraining in order to allow the bladder to fill instead of frequently voiding to prevent SUI.

Goals

Ted’s goal to “improve incontinence” was within reason and realistic. He understood that he might not achieve complete continence, however he wanted to improve his quality of life. I felt there was room for improvement due to the low tone of his pelvic floor musculature. An increase in strength would help decrease his incontinence and improve his quality of life.

My goals for him were the following:

Short Term Goals (two to three weeks):

  1. For Ted to demonstrate the “knack” exercise correctly.
  2. To achieve an increase in his pelvic floor muscle strength and endurance.
  3. To decrease pad usage, and to have minimal saturation.

Long Term Goals (four to eight weeks):

  1. For patient to wear only one pad per day.
  2. To eliminate all SUI with standing and walking.
  3. No longer avoid prolonged standing and flying.
  4. No longer look for the nearest restroom and to void within normal limits.

Summary of Treatment

As Ted’s pelvic floor and TrA became stronger, I progressed his exercises to a more advanced level with exercises, such as core stabilization on a foam roller. After seven months of treatment, Ted said he felt like he had plateaued, but did have significant changes.

At the time of his last visit, Ted only wore one pad per day, and was no longer incontinent at night. Ted now voided three to four times per day instead of voiding frequently, and was able to identify the difference between feeling the urge to void, versus not having an urge but still voiding due to a fear of being incontinent. Ted was no longer looking for the nearest restroom, and he was no longer anxious about flying. He also stated that he felt better overall.

However, Ted continued to have urinary incontinence with prolonged standing. We discussed other treatment options, such as a penis clamp. I also referred him back to his doctor to discuss surgical options, i.e. artificial sphincter or sling.

Ted did well with PT. Despite his continued incontinence with prolonged standing, which I believe continued to be caused by poor posture, he reported an overall improvement in his quality of life.

If you have any questions about this case study, please do not hesitate to leave them in the comments section below!

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9 thoughts on “The Case of Post-prostatectomy Urinary Incontinence

  1. I just finished treatment for CPPS caused by Chronic non Bacterial Prostatitus. It seemed to work. I just had a real bad flair up two weeks ago and wet myself quite a bit. Once even at the Dr office. My issue is,I get real bad muscle and pelvic spasms when I have these chronic attacks and it causes me to leak prostatic fluid and urine. Any thing you guys know of to help with that. The therapy helped with day to day leakage but this it did not help. I get recurrent attacks at least 7 to 9 times a year. HELP!!!!!

    • Hello Wilburn,

      Did your treatment involve internal manual therapy? I would be happy to recommend a local therapist if possible. Receiving a second opinion may be helpful for you.

      Best,

      Malinda

      • Yes, it consisted of both internal and external therapy. It worked as far as my being able to sit for more than an hour in a car. It also helped with the constant ache I always had. I’m asking if there is anything that can be done for the chronic prostititis? Also when I get these occurrences, it causes tension in my pelvic area as well as incontinence and spasms with severe pain.I don’t know if you deal with that or not. My Urologist doesn’t have a clue. I’m about to give up and I guess will just have to live with it.

  2. A therapist local to the Los Angeles area would be helpful. Currently seeing a urologist at a specialist clinic and not satisfied with my results.

    • Hello Jacob,

      We have an office in Los Angeles and would be happy to treat you. Please contact us for more information. (424) 293-2305

      Regards,

      Casie

  3. My Dad has the same problem from the radiation (he could not have the surgery due to his heart). He has the urge to go all the time and that unfortunately keeps him up all night and he isn’t getting any sleep and that in turn doesn’t help his heart. What are some options for him, he is in Edmonton Alberta Canada. Any referrals there?
    thanks,
    Lisa – his concerned only daughter in California

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