By Melinda Fontaine, DPT, PHRC Walnut Creek
Peter was a 63 year old experiencing urinary urgency and leakage three months after having his prostate surgically removed for prostate cancer. Luckily, his surgeon referred him to a pelvic floor physical therapist. He was using at least two incontinence pads per day, but was mostly dry at night. He had a strong urge of having to urinate often when his bladder was not full. He reported having good erections when he used sildenafil, but leaking urine during arousal was making sex difficult. Leaking during sexual activity is common after prostatectomy. Essentially, the “valve” that prevents urine from being pushed through the urethra during arousal, erection, and orgasm is removed with the prostate. Sometimes this improves as the pelvic floor muscles get stronger, and some people use a constriction band during sex to apply enough pressure to the urethra to stop leaks. Leaking during sex is not harmful to you or your partner, and most partners are not bothered by it. You can read more about sex after prostatectomy on our blog.
You may expect me to start talking about the pelvic muscles first, but there is so much more to continence than just pelvic floor strength. Before I get to the pelvic muscles and after a thorough Q&A, I examine the abdomen. During a laparoscopic surgery, the surgeon inflates the abdomen with carbon dioxide to be able to do the procedure. This puts patients at risk for an abdominal injury known as diastasis recti. Sometimes it heals on its own, and sometimes it needs rehabilitation. When I checked Peter’s abdomen, he did not have a diastasis recti, but his abdominal/core muscles were only moderately strong. Since the strength of these muscles is positively correlated with continence, we set a goal to improve his core strength. On his abdomen, I noticed he had multiple tiny scars as expected. They were well healed, but when I touched them, I could feel they were thick and rigid. We talked about how to mobilize scar tissue to prevent complications. To learn more, check out this blog about The Role of Scar Tissue.
Okay, now let’s get to what we’ve all been waiting for: the pelvic floor muscles! These are the muscles responsible for keeping the urine in (also keeping poo in, having erections, supporting pelvic organs, and stabilizing the pelvis among other things, but let’s get back to the urine…) Peter’s pelvic floor muscles were moderately strong. This would have been plenty strong to keep the urine in before prostate removal, but after surgery, he needed extra strong muscles to create good closure of the urethra. Stronger muscles are also bulkier and provide better support for the urethra and bladder. I also noticed that the smaller muscles in the front of the pelvis that are optimally positioned to help close the urethra were not contracting. We tried half a dozen different cues to get these muscles to fire. If he was going to spend time strengthening his muscles, we might as well strengthen them all. I see a lot of people struggling with urinary incontinence who need my help to learn how to do a proper kegel before they can progress, so we made sure to perfect this before I taught him a personalized home exercise program for pelvic floor strengthening.
Lastly, I believed the different sensations in his body combined with his uncertainty about when his bladder was going to leak was contributing to his urgency, so we discussed this and the techniques for retraining the system. Learn more in the blog titled Gotta Go Right Now: Urinary Urgency Explained.
After three months of physical therapy, Peter told me he was “pretty darn continent most of the time,” and after four months he reported that he forgot to wear a pad one day and was dry! He had one incident of urinary urgency in the past two weeks, and it made him realize that he had not had urgency for a long time before that. He also told me he was retiring that month! With all his physical therapy goals met, we stopped meeting, so he could have more time for music, tennis, and fly fishing.
If this was a fairytale, it would end right here. Here comes the twist. The following year, Peter had radiation treatment for prostate cancer, and afterwards he had right scrotal pain and urinary leakage mostly when he had the urge to urinate and was getting up from a chair. Luckily, he knew a good pelvic PT.
This time, I found that his pelvic muscles were still strong from his exercises but actually were having a hard time lengthening fully. This means that he could not use the full range of motion and could not generate the same amount of closure on the urethra as before. We added some exercises designed to allow the pelvic floor to fully lengthen.
We also noticed some tension in the inner thighs, abdomen, and right groin contributing to his scrotal pain. We treated this with manual therapy and some self release techniques, which helped over time. We also practiced core strengthening exercises for two reasons. First, we know that having a strong core helps get good closure around the urethra for holding urine in. Second, having a strong core could prevent his body from creating too much tension in the inner thighs and groin, which led to his scrotal pain.
Speaking of scrotal pain, he noticed that it sometimes hurt at the same time that he felt food moving through his digestive system. We were also reminded at this time that he had a history of a break in his pubic bone and a hernia repair at least four years before I met him. We came up with some questions for his doctor. The doctor did a CT scan which showed nothing abnormal in the scrotum, but did find diverticulitis, an inflammation of the intestines. He treated it with antibiotics and the pain with digestion improved. Peter’s hernia surgeon said it is possible that the mesh used in the hernia repair could be affecting a nerve and causing pain. The surgeon gave Peter the option to do a genitofemoral nerve block to see if that helped, and he is considering it. This would also explain how digestion created scrotal pain because the same nerve that runs through the lower abdomen innervates the scrotum.
Currently, Peter reports most days he does not notice the pain, and it does not interfere with his activities. He is very happy with the improvement in continence. He is able to manage it with a single pad per day, which is not even very full by the end of the day, and if he does a kegel when he gets up from the chair, known as the “knack”, he stays dry. Read more about prostatectomy and physical therapy on our blog! Find Peter’s story in next weeks’ blog!
Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
Melissa Patrick is a certified yoga instructor and meditation teacher and is also available virtually to help, for more information please visit our therapeutic yoga page.
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