Physiotherapy management of incontinence in men

 

The latest issue of the Journal of Physiotherapy includes a host of excellent research articles, including an Invited Topical Review on physiotherapy for men with incontinence. Q&A with Irmina Nahon.

We hear a lot about physiotherapists’ involvement with women who have urinary incontinence. How common is incontinence among men and are the causes of incontinence the same?

Male urinary incontinence, while not as common as female incontinence, still affects one in eight men.

Men of all ages can have issues such as overactive bladder, urgency and frequency due to poor bladder habits in the same way women do.

Due to the location of the prostate, men develop lower urinary tract symptoms related to the prostate, impeding urine flow.

These symptoms include frequency of emptying, incomplete emptying and a slow stream.

These symptoms are not indicative of prostate cancer; they can and should be assessed and managed. Often a transurethral resection of the prostate can make life much more comfortable.

When followed by a continence and pelvic floor assessment, we ensure return to ‘good’ bladder and bowel habits.

Prostate cancer is common and highly treatable. In the same way that prehabilitation improves orthopaedic surgery outcomes, prehab before prostate surgery improves continence.

Is it worth trying to categorise specific types of urinary incontinence the way we do with women?

As for women, the treatment for incontinence in men must be targeted to the cause of the leakage.

Doing pelvic floor exercises will not change poor bladder habits. Men develop urgency or frequency over their lifetime and doing pelvic floor exercises will not change their symptoms significantly.

Constipation stretches the pelvic floor, and when unmanaged will impede continence recovery.

After prostate surgery, a careful assessment will uncover if leakage is due to damage to the continence mechanism, poor coordination of pelvic floor muscles or if the bladder is emptying inappropriately.

It is possible that different types of incontinence coexist in one person and identifying this will speed up recovery.

There is a difference in how we assess the pelvic floor in men versus women.

The continence mechanism of women can be assessed via the vagina.

In men attempts have been made to validate assessment per rectum.

Unfortunately, the urinary continence mechanism cannot be accessed via the anus, and men are left training the external anal sphincter and the puborectalis muscle rather than the muscles that maintain continence.

Men need to learn to contract the anterior pelvic floor. When they do it correctly the shaft of the penis retracts, and the testicles move upwards.

Take care that he does not use his abdominal muscles to move the scrotum and skin or tighten the buttocks or anus. It is easy to assess and train in front of a mirror, giving him visual feedback on technique.

What about faecal incontinence?

There is very little research on the conservative management of faecal incontinence in adults.

Radiation therapy for prostate cancer is one of the more common causes of faecal incontinence in men.

As the effects of radiation may take five or more years to develop, men have usually been discharged from their cancer care team and don’t link the worsening soiling to their treatment.

Nor do they seek help as faecal incontinence is so stigmatised that people refuse to talk to health professionals about it.

Advice and support as well as treatment to improve soiling and encourage a return to a normal lifestyle should be offered.

Men who have had pelvic radiation should be screened for faecal incontinence.

No matter what a physio is seeing these men for, please ask the question so that they can be referred to a pelvic health physio for help.

Which physiotherapy treatments are effective for incontinence in men?

After a careful assessment to identify the type of incontinence, physio treatment is tailored to the cause.

Urgency, overactive bladder and frequency are trained with fluid management, urgency suppression and bladder training.

Bowel incontinence requires a multidisciplinary team approach, with physiotherapy aimed at ensuring the external anal sphincter is working at full strength.

Biofeedback training, in both men and women, is supported by emerging evidence to improve defecation and emptying of the bowel.

Training the male pelvic floor after prostate surgery is different to pelvic floor muscle training in women.

This is because the cause of incontinence is less due to weak muscles and more due to how the continence mechanism works.

With the loss of support of the bladder neck when the prostate is removed, the pelvic floor must activate before the intra-abdominal pressure pushes the bladder down, opening the bladder neck. Coordination rather than strength is needed.

Teach men to activate the muscles in anticipation of a leak and do strength exercises only if weak muscles require it.

What about future research in this area?

We still need to find the optimum training routine, including when it should start.

Knowing which men will have post-prostatectomy incontinence would help to target who needs to be prioritised in a resource-poor system.

Dr Irmina Nahon works as a pelvic health physiotherapist in a private practice and is a senior lecturer and professional practice coordinator at the University of Canberra. Irmina is passionate about continence promotion, as well as research into the assessment and management of incontinence.

 

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