in prostate cancer

(1)

ALESHA SAYNER

Ballarat Health Services, University of Canberra & Western Health

Hot off the press:

Recent evidence for physiotherapy

in prostate cancer

(2)

Acknowledgment of Country

I begin today by acknowledging the Wathaurong people of the Kulin nation, the traditional

custodians of the land on which I am presenting today. I pay my respects to their Elders, past and

present. I extend that respect to Aboriginal and

Torres Strait Islander peoples participating today.

(3)

Objectives

• Overview of key publications 2019-2021

Pelvic floor

muscle training  Physiotherapy 

(4)

1 exp Prostatic Neoplasms/ (135204)

2 (prostat* adj3 (cancer* or neoplasm*)).ti,ab. (136674) 3 1 or 2 (172537)

4 exp Prostatectomy/ (33154)

5 ("radical prostatectom*" or radical-prostatectom* or prostatectom*).ti,ab. (32125) 6 exp Radiotherapy/ (194295)

7 (radiotherap* or "radiation therap*" or radiation-therap*).ti,ab. (243813) 8 6 or 7 (342863)

9 3 and 8 (23633)

10 ("androgen deprivation therap*" or androgen-deprivation-therap* or "ADT").ti,ab. (8000) 11 3 or 4 or 5 or 9 or 10 (190118)

12 ("pelvic floor muscle training" or pelvic-floor-muscle-training or "pelvic floor muscle exercis*" or pelvic-floor-muscle-exercis* or

"PFMT").ti,ab. (1272) 13 kegel.af. (689)

14 exp Physical Therapy Modalities/ (163127) 15 Physical Therapists/ (2299)

16 (physio* or "physical therap*" or physical-therap*).ti,ab. (821047) 17 12 or 13 or 14 or 15 or 16 (959518)

18 11 and 17 (3976)

19 limit 18 to yr="2019 -Current" (529)

Search strategy Acknowledgement: Eve Hutcheon, Western Health Library

(5)

Post prostatectomy incontinence and pelvic floor muscle training

Radiotherapy

Sexual function

(6)

Post prostatectomy

incontinence and pelvic

floor muscle training

(7)

Reviews, reviews, reviews… General messages

“Not everyone responds to pelvic floor muscle training”

“Contrary to previous work, the results presented here indicated

that preoperative PFME

protocols did not reduce the rate of UI”

Lack of consensus around mode and

dosage

Assessment techniques and

biofeedback Anal focus V’s urethral focus

Definitions of

continence

(8)

Reviews – acknowledging the limitations

“This review investigated whether outcome of meta analysis difers ‐ based on presence or not of specific RCT features”

• PFMT reduces PPI

• Better outcomes for

• Pre-operative PFMT

• Anal BFB Vs no anal BFB (?consider mode of training)

• Urethral focus

• Continence defined as no leakage

• Interpret with care -> heterogeneity

(9)

Reviews – recent understanding of

anatomy

(10)

Reviews – recent understanding of anatomy

• Targeted training

• Address the pathophysiology of PPI

• Principles of motor learning

• Promote striated urethral sphincter activation

• DO NOT focus on the anal sphincter

• Transperineal real time ultrasound

• Consider detrusor function in PPI

Image adapted from Hodges, et. al, 2019.

(11)

Does a source of truth exist?

“Prior to radical prostatectomy, patients may be offered pelvic floor muscle exercises or pelvic floor muscle training. (Conditional

Recommendation; Evidence Level: Grade C)”

• Commenced 3-4 weeks prior

• Focus on neuromuscular adaptation

• More work needed to determine effectiveness

(12)

Quantitative

PFMT Vs PFMT + BFB Vs BFB + Pilates

Conventional PFMT Vs Pfilates + hypopressives PFMT Vs Control – Pamphlet guided, post-op only PFMT + EMG

Limitations:

• Bridging PFMT

• Assessment unclear

• DRE as assessment

• Instructions unclear

• Dosage unclear

• Non-guided

• Poorly defined

inclusion/exclusion

• Small sample size Whole body vibration + PFMT

Diaphragmatic + abdominal training

(13)

Quantitative

• RCT, N = 97

• Control: Low volume rehab

• Intervention: High volume, slow and fast contractions

• PFMT commenced 5 weeks pre-op

• “Stop the flow”

• Significantly less leakage (p<0.05) on 24 hour pad weigh at 2, 6, 12

weeks

(14)

Quantitative

• Prospective cohort study, N = 116

• 36 accepted assessment via TPRTUS

• Pre-operative and 4 weeks post-operative

• Bladder neck closure on ultrasound

• Control group: verbal instruction alone

• Continence recovery shorter in IG (mean 75.6 days, p<0.037)

Aim: To examine whether

transperineal US- guided PFMT

promotes early

recovery of post-

RARP incontinence.

(15)

Qualitative

"While I had been asked to exercise in preparation for surgery and received written resources, I had no idea how to do the exercise. One session with the continence physiotherapist made a

whole lot of difference…."

• EBCD methodology

• Qualitative component

• Lacking physiotherapy prehab in radiotherapy and active surveillance

• Physiotherapy highly

valued

(16)

Watch this this space….

(17)

Radiotherapy

(18)

• Non-randomised experimental study

• N = 30

• Intervention group:

• Pamphlet informed (no assessment)

• “Lift the base of the penis”

• Progressive repetitions and length of contraction

• UI at 4 weeks

• IG 10%, CG 13.3%

• UI at 8 weeks

• IG 3.3%, CG 16.7%

Aim: To evaluate the effect of Kegel exercises on the prevention of

urinary and fecal incontinence in prostate cancer patients

undergoing radiotherapy.

Limitations:

• No examination

• Small sample size

• Sitting position only

(19)

• Initial study

• Physiotherapy + nursing

• 4 weeks post radiation

• Physiotherapy

• PFMT, balance, strengthening

• Static holds

• ?Individualised assessment

• IG = significantly less urinary incontinence

• Follow up (3 years)

• Better outcomes in IG

• Not significant

Aim: To assess late adverse effects of radiotherapy and evaluates the rehabilitative long-term effects of a previously implemented

intervention.

(20)

Sexual function

(21)

Erectile dysfunction

• 5 studies, varied methodological quality

• No short term benefit with PFMT +/- BFB

•  ED outcomes at 12 months with PFMT+BFB

• Recommended SUS/PR/BC training

• PFMT has  likelihood of erectile function recovery versus placebo or no intervention

• Low certainty/low methodological rigour

• Need for well designed RCTs

(22)

Erectile dysfunction

• RCT, N = 97

• Control: Low volume rehab

• Intervention: High volume, slow and fast contractions

• PFMT commenced 5 weeks pre-op

• “Stop the flow”

• IG: Clinical and statistical better function at 2 weeks (p<0.05)

• Limitations: Larger sample size with power calculations required

(23)

Climacturia

• Anal focus PFMT

• Commenced > 12 months post-op

• Subjective improvement

• Limitations

• Three articles, N=128

• Methodological low quality

• PFMT +/- anal electrical stimulation

• Benefit of PFMT inconclusive

(24)

Summary

• Pelvic floor muscle training and PPI

• Evidence for prehabilitation

• Requires ongoing exploration around mode, dosage and delivery

• Understanding of male continence mechanism -> further research

• Sparse qualitative literature

• Emerging and watch this space!

• Sexual function and radiotherapy

• Sparse

• Indications that PFMT is beneficial

• More research needed

(25)

Thank you

Alesha Sayner

Physiotherapist and PhD candidate University of Canberra/Western Health/Ballarat Health Services [email protected]

@aleshasayner

1. Shabataev V, Saadat SH, Elterman DS. Management of erectile dysfunction and LUTS/incontinence: the two most common, long-term side effects of prostate cancer treatment. The Canadian journal of urology.

2020;27(1S1):17-24.

2. Cheng H, Wang Y, Qi F, Si S, Li X, Chen M. Preoperative pelvic floor muscle exercise does not reduce the rate of postprostatectomy incontinence: evidence from a meta-analysis and a systematic review. Translational Andrology and Urology. 2020;9(5):2146.

3. Hall LM, Neumann P, Hodges PW. Do features of randomized controlled trials of pelvic floor muscle training for postprostatectomy urinary incontinence differentiate successful from unsuccessful patient outcomes? A systematic review with a series of meta analyses. ‐ Neurourology and Urodynamics. 2020;39(2):533-546.

4. Hodges PW, Stafford RE, Hall L, et al. Reconsideration of pelvic floor muscle training to prevent and treat incontinence after radical prostatectomy. Urologic Oncology: Seminars and Original Investigations (In Press).

2019.

5. Mungovan SF, Carlsson SV, Gass GC, et al. Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy. Nature Reviews Urology. 2021;18(5):259-281.

6. Sayner A, Nahon I. Pelvic Floor Muscle Training in Radical Prostatectomy and Recent Understanding of the Male Continence Mechanism: A Review. Paper presented at: Seminars in Oncology Nursing2020.

7. An D, Wang J, Zhang F, et al. Effects of Biofeedback Combined With Pilates Training on Post-prostatectomy Incontinence. Urology. 2021;155:152-159.

8. Au D, Matthew AG, Alibhai SM, et al. Pfilates and hypopressives for the treatment of urinary incontinence after radical prostatectomy: results of a feasibility randomized controlled trial. PM&R. 2020;12(1):55-63.

9. Jalalinia SF, Raei M, Naseri-Salahshour V, Varaei S. The Effect of Pelvic Floor Muscle Strengthening Exercise on Urinary Incontinence and Quality of Life in Patients after Prostatectomy: a Randomized Clinical Trial. Journal of caring sciences. 2020;9(1):33.

10. Kim JK, Oh JJ, Lee H, et al. Effect of personalized extracorporeal biofeedback device for pelvic floor muscle training on urinary incontinence after robot-assisted radical prostatectomy: A randomized controlled trial.

Journal of Urology. 2019;201(4 Supplement 1):e738-e739.

11. Lira GHSd, Fornari A, Cardoso LF, Aranchipe M, Kretiska C, Rhoden EL. Effects of perioperative pelvic floor muscle training on early recovery of urinary continence and erectile function in men undergoing radical prostatectomy: a randomized clinical trial. International braz j urol. 2019;45(6):1196-1203.

References

(26)

Thank you

Alesha Sayner

Physiotherapist and PhD candidate University of Canberra/Western Health/Ballarat Health Services [email protected]

@aleshasayner

12. Pan LH, Lin MH, Pang ST, Wang J, Shih WM. Improvement of Urinary Incontinence, Life Impact, and Depression and Anxiety With Modified Pelvic Floor Muscle Training After Radical Prostatectomy. American Journal of Men's Health. 13 (3) (no pagination), 2019. Date of Publication: 01 May 2019.; 2019.

13. Scott KM, Gosai E, Bradley MH, et al. Individualized pelvic physical therapy for the treatment of post-prostatectomy stress urinary incontinence and pelvic pain. International urology and nephrology. 2020;52(4):655-659.

14. Zachovajeviene B, Siupsinskas L, Zachovajevas P, Venclovas Z, Milonas D. Effect of diaphragm and abdominal muscle training on pelvic floor strength and endurance: results of a prospective randomized trial. Scientific reports. 2019;9(1):1-9.

15. Milios JE, Ackland TR, Green DJ. Pelvic floor muscle training in radical prostatectomy: a randomized controlled trial of the impacts on pelvic floor muscle function and urinary incontinence. BMC Urol. 2019;19(1):116.

16. Yoshida M, Matsunaga A, Igawa Y, et al. May perioperative ultrasound guided pelvic floor muscle training promote early ‐ recovery of urinary continence after robot assisted radical prostatectomy? ‐ Neurourology and urodynamics. 2019;38(1):158- 164.

17. Tang CY, Turczyniak M, Sayner A, Haines K, Butzkueven S, O’Connell HE. Adopting a collaborative approach in developing a prehabilitation program for patients with prostate cancer utilising experience-based co-design methodology. Supportive Care in Cancer. 2020:1-8.

18. Hodges P, Stafford R, Coughlin GD, et al. Efficacy of a personalised pelvic floor muscle training programme on urinary incontinence after radical prostatectomy (MaTchUP): Protocol for a randomised controlled trial. BMJ Open. 9 (5) (no pagination), 2019. Article Number: e028288. Date of Publication: 01 May 2019.; 2019.

19. Urvaylıoğlu A, Kutlutürkan S, Kılıç D. Effect of Kegel exercises on the prevention of urinary and fecal incontinence in patients with prostate cancer undergoing radiotherapy. European Journal of Oncology Nursing. 2021;51:101913.

20. Dieperink KB, Hansen S, Hansen O, Wagner L, Minet LR. Long-term follow-up 3 years after a randomized rehabilitation study among radiated prostate cancer survivors. Journal of cancer survivorship : research and practice. 2020.

21. Kannan P, Winser SJ, Choi Ho L, et al. Effectiveness of physiotherapy interventions for improving erectile function and climacturia in men after prostatectomy: a systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation. 2019;33(8):1298-1309.

22. Sari Motlagh R, Abufaraj M, Yang L, et al. Penile Rehabilitation Strategy after Nerve Sparing Radical Prostatectomy: A Systematic Review and Network Meta-Analysis of Randomized Trials. The Journal of urology. 2021;205(4):1018-1030.

23. Wong C, Louie DR, Beach C. A systematic review of pelvic floor muscle training for erectile dysfunction after prostatectomy and recommendations to guide further research. The journal of sexual medicine. 2020;17(4):737-748.

24. Milios JE, Ackland TR, Green DJ. Pelvic floor muscle training and erectile dysfunction in radical prostatectomy: a randomized controlled trial investigating a non-invasive addition to penile rehabilitation. Sexual Medicine. 2020;8(3):414-421.

25. Kannady C, Clavell-Hernández J. Orgasm-associated urinary incontinence (climacturia) following radical prostatectomy: a review of pathophysiology and current treatment options. Asian journal of andrology. 2020;22(6):549-554.