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.
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.
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.
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):
- For Ted to demonstrate the “knack” exercise correctly.
- To achieve an increase in his pelvic floor muscle strength and endurance.
- To decrease pad usage, and to have minimal saturation.
Long Term Goals (four to eight weeks):
- For patient to wear only one pad per day.
- To eliminate all SUI with standing and walking.
- No longer avoid prolonged standing and flying.
- 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.
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