Physiotherapy and male pelvic health
David Cowley, Amelia Moir, Jason Crow, Thomas Harris and Alexandra Diggles from the Women’s, Men’s and Pelvic Health group present five discussion points about pelvic health in boys and men.
1. Preoperative physio leads to better continence outcomes after prostatectomy
Radical prostatectomy yields excellent survival rates for men with localised prostate cancer (Røder et al 2014), but often leads to symptoms of urinary incontinence (Sacco et al 2006).
Encouraged by the evidence for pelvic floor muscle training for incontinence management in women (Hay-Smith & Dumoulin 2006), physiotherapists began providing men with similar programs.
A 2015 Cochrane review (Anderson et al 2015) demonstrated that although several clinical trials produced better continence outcomes compared to controls, others did not and overall there was insufficient evidence that pelvic floor muscle training was effective for the management of post-prostatectomy incontinence.
A recent meta-analysis sought to identify features of the programs that led to more successful patient outcomes (Hall et al 2020).
The study concluded that starting pelvic floor muscle training before surgery, including biofeedback (for example, electromyographic biofeedback) and providing urethral (rather than global or anal) instructions were features associated with better patient outcomes.
This has been supported by a recent Australian clinical trial, which demonstrated better continence and quality of life outcomes for men who underwent a preoperative pelvic floor muscle training program, which included ultrasound biofeedback and urethral cues, than for men who did not (Milios et al 2020).
2. Bedwetting is more likely to affect boys than girls
Bedwetting, also known as nocturnal enuresis, can often be embarrassing for the affected child and distressing for the child’s carers.
Persistent bedwetting may be caused by nocturnal polyuria, reduced bladder capacity or an overactive bladder.
Population-based surveys indicate that in children under 12 years of age, boys are 2–2.5 times more likely to wet the bed than girls (Shreeram et al 2009, Yeung et al 2006).
Fortunately, once children reach adolescence, these gender differences seem to diminish, with a general prevalence of 2.3 per cent across the whole population from age 16 onwards (Bower 2015).
Persistent bedwetting beyond the age of seven years is due to a combination of factors.
A boy may wet the bed because his body continues to produce large volumes of urine at night (nocturnal polyuria) or if he has a reduced bladder capacity or overactive bladder.
Wetting will occur if the brain is unable to be adequately aroused by bladder signals, resulting in the bladder emptying without awareness while the child is still sleeping.
Bedwetting alarms should be offered as first-line treatment to all children and adolescents with bedwetting.
The use of alarms requires long-term commitment from both the young person and their carers; however, they have been shown to have high long-term success rates (National Clinical Guideline Centre 2010).
3. Physiotherapy management may help decrease symptoms of urinary urgency
Urinary urgency is ‘a sudden, compelling desire to pass urine which is difficult to defer’ (International Continence Society 2015).
Causes of urinary urgency in men vary.
It may occur due to an enlarged prostate gland, after a prostatectomy or as a symptom of an overactive bladder.
Physiotherapy management may help decrease symptoms of urinary urgency.
There are a number of treatments that can assist, including bladder retraining, simple lifestyle modifications, pelvic floor exercises, electrical stimulation for neuromodulation and medication.
The goal of bladder retraining is to increase the time between voids, starting with five minutes at first. Simple strategies include:
- contracting pelvic floor muscles—lifting and imagining stopping the flow of urine, helping to decrease bladder muscle contractions and the urge to void
- positional changes—the patient curling their toes or lying down on their back
- distraction—directing attention away from the bladder, for example by doing a crossword or checking emails.
Other lifestyle changes include trying to store more urine in the bladder, maintaining appropriate fluid intake (1.5 litres of water per day) and moderating bladder irritants such as caffeine and alcohol.
Through these options, men can reduce their symptoms and find ways to maintain and improve quality of life.
4. Exercise can improve erectile dysfunction in men
Erectile dysfunction (ED) is the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance, with prevalence ranging from 26 per cent in men aged 50–59 through to 40 per cent in men aged 60–69 (Smith et al 2010).
Symptoms of erectile dysfunction in men may be significantly improved by aerobic exercise of moderate to vigorous intensity.
ED is a multifactorial condition, with cardiovascular and metabolic disorders commonly linked (Smith et al 2010).
Achieving an erection involves a number of key processes, two of which are adequate blood flow into the penis and pelvic floor strength to maintain blood in the penis (Duca et al 2019).
Aerobic exercise at a moderate to vigorous intensity has shown a significant improvement in ED measures and is considered a first-line treatment for non-surgical-related ED (Silva et al 2017).
Physiotherapy can help men overcome other health and musculoskeletal issues in order to exercise at a high enough intensity (typically greater than 60 per cent maximum heart rate) to improve erectile function (Silva et al 2017).
In addition, aerobic exercise has a synergistic effect with commonly prescribed PDE5 inhibitor medications (Duca et al 2019).
Guided pelvic floor muscle training has also been shown to improve erectile function in men, in both prostatectomy and non-prostatectomy settings (Dorey et al 2005, Milios et al 2020).
5. Personalised intervention may lead to improvements in persistent pelvic pain in men
Chronic prostatitis/chronic pelvic pain syndrome is characterised by pelvic pain lasting longer than 3 months and is often associated with symptoms of the lower urinary tract and sexual dysfunction.
Common complaints include testicular, perineal and penile pain; uncomfortable urination; the sensation of residual urine; frequency; slow stream; urgency; and sexual pain.
It is the most common urologic condition in men under 50, with a mean prevalence of 8.2 per cent.
For many years, prostatitis and urinary tract bacterial infection had been considered the major causes of male pelvic pain and this has delayed a more biopsychosocial approach to the condition.
Additionally, men are often treated with single end-organ interventions, creating a significant diagnostic delay (7–8 years).
Treatment of these patients remains a challenge due to diverse clinical signs and domains/phenotypes.
The UPOINT system—urinary, psychosocial, organ specific, infection, neurologic/systemic and tenderness of skeletal muscle—is used to classify individuals and guide treatment more specifically.
Pelvic floor muscle dysfunction is common and studies suggest that symptom-oriented and personalised intervention—including patient education about chronic pelvic pain syndrome, biofeedback training for correct muscle function, myofascial release techniques, bladder and bowel strategies and graded physical activity—may lead to improvements in function and pain.
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>> David Cowley, APAM, is the Men’s Health Clinical Stream Leader at Active Rehabilitation Physiotherapy in South Brisbane. He is also undertaking a PhD in how posture, breathing, surgery and electrical stimulation influence pelvic floor muscle anatomy and function in men at the University of Queensland with Paul Hodges and Ryan Stafford.
>> Amelia Moir, APAM, is an Advanced Physiotherapist – Continence at the Queensland Children’s Hospital. Amelia works in the Physiotherapy Paediatric Continence Service, treating children and adolescents with urinary incontinence, bedwetting, constipation, faecal incontinence and other pelvic health issues.
>> Jason Crow, APAM, graduated from the University of Queensland in 2009 and has developed a keen interest in men’s health and continence. Jason provides pelvic floor rehabilitation for men, including prostatectomy preoperative and postoperative assessment and treatment. He is the current APA national chair of the Women’s, Men’s and Pelvic Health group.
>> Thomas Harris, APAM, is a physiotherapist with extensive interests in men’s health. He is the clinical manager at Target Physio in Brisbane, runs menshealth.physio, is a research assistant on the MaTch UP trial at the University of Queensland and is completing postgraduate study in exercise medicine (oncology) at Edith Cowan University.
>> Alexandra Diggles, APAM, is an advanced practice physiotherapist working in private practice in Brisbane and a visiting lecturer at the Australian Catholic University. She is a registrar of the Australian College of Physiotherapists, becoming a titled member in 2017. She has a keen interest in researching and promoting the role of multidisciplinary care for endometriosis management.
Anderson, C.A., Omar, M.I., Campbell, S.E., Hunter, K.F., Cody, J.D., Glazener, C.M.A. Conservative management for postprostatectomy urinary incontinence. Cochrane Database of Systematic Reviews. 2015(1).
Bower, W.F. (2015). Nocturnal enuresis in children (including refractory) 24th National Conference on Incontinence—the Continence Foundation of Australia in association with the UroGynaecological Society of Australasia 25–28 November 2015 Melbourne, Victoria. Australian & New Zealand Continence Journal, 21(4), 102.
Doggweiler, R., Whitmore, K.E., Meijlink, J.M., Drake, M.J., Frawley, H., Nordling, J., Tomoe, H. et al (2017). A standard for terminology in chronic pelvic pain syndromes: a report from the chronic pelvic pain working group of the international continence society. Neurourology and urodynamics, 36(4), 984–1008.
Dorey, G., Speakman, M.J., Feneley, R.C., Swinkels, A. and Dunn, C.D. (2005). Pelvic floor exercises for erectile dysfunction. BJU International, 96: 595–597. https://doi-org.ezproxy.library.uq.edu.au/10.1111/j.1464-410X.2005.05690.x
Duca, Y., Calogero, A.E., Cannarella, R. et al. Erectile dysfunction, physical activity and physical exercise: Recommendations for clinical practice. Andrologia, 2019; 51:e13264. https://doi-org.ezproxy.library.uq.edu.au/10.1111/and.13264
Fall, M., Baranowski, A.P., Elneil, S., Engeler, D., Hughes, J., Messelink, E.J., Oberpenning, F. & Williams, A.C. de C. (2010). EAU guidelines on chronic pelvic pain. European Urology, 57(1), 35–48.
Hall, L.M., Neumann, P., Hodges, P.W. 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):533–46.
Hay‐Smith, J., Dumoulin, C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews. 2006(1).
International Continence Society Fact Sheets (2015). Prepared by the Publications and Communications Committee, www.ics.org.
Klotz, S.G., Schoen, M., Ketels, G., Loewe, B. & Bruenahl, C.A. (2019). Physiotherapy management of patients with chronic pelvic pain (CPP): a systematic review. Physiotherapy theory and practice, 35(6), 516–532.
Milios, J.E., Ackland, T.R. & Green, D.J. Pelvic floor muscle training in radical prostatectomy: a randomized controlled trial of the impacts on pelvic floor muscle function and urinary incontinence. BMC Urology, 2019;19(1):116.
Milios, J.E., Ackland, T.R. & Green, D.J. Pelvic Floor Muscle Training and Erectile Dysfunction in Radical Prostatectomy: A Randomized Controlled Trial Investigating a Non-Invasive Addition to Penile Rehabilitation. J Sex Med 2020;8:414–421.
National Clinical Guideline Centre (2010). Nocturnal enuresis: The management of bedwetting in children and young people. London: National Clinical Guideline Centre. Available from www.nice.org.uk.
Røder, M.A, Brasso, K., Christensen, I.J., Johansen, J., Langkilde, N.C., Hvarness, H. et al. Survival after radical prostatectomy for clinically localised prostate cancer: a population-based study. BJU International, 2014;113(4):541–47.
Sacco, E., Prayer-Galetti, T., Pinto, F., Fracalanza, S., Betto, G., Pagano, F. et al. Urinary incontinence after radical prostatectomy: incidence by definition, risk factors and temporal trend in a large series with a long-term follow-up. BJU International, 2006;97(6):1234–41.
Salvatore, S. et al (2019). Urinary Urgency: A Symptom in Need of a Cure. Research and Reports in Urology,11: 327–331.
Shoskes, D.A. & Nickel, J.C. (2013). Classification and treatment of men with chronic prostatitis/chronic pelvic pain syndrome using the UPOINT system. World Journal of Urology, 31(4), 755–760.
Shreeram, S., He, J.P., Kalaydjian, A., Brothers, S. & Merikangas, K.R. (2009). Prevalence of enuresis and its association with attention-deficit/hyperactivity disorder among U.S. children: results from a nationally representative study. Journal of the American Academy of Child and Adolescent Psychiatry, 48(1), 35–41. https://doi.org/10.1097/CHI.0b013e318190045c
Silva, A.B., Sousa, N., Azevedo, L.F. et al. Physical activity and exercise for erectile dysfunction: systematic review and meta-analysis. British Journal of Sports Medicine 2017; 51:1419–1424.
Smith, I., McLeod, N., Rashid, P. Erectile dysfunction—when tablets don’t work. Australian Family Physician Vol. 39, No. 5, May 2010.
Yeung, C.K., Sreedhar, B., Sihoe, J.D., Sit, F.K. and Lau, J. (2006). Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU International, 97: 1069–1073. https://doi.org/10.1111/j.1464-410X.2006.06074.x
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