**2. Rehabilitation of urinary continence after prostatectomy**

The prostatectomized patient has transient SUI, and maintenance of this condition may still prevail in 8% of patients, 2 years after surgery. The prevalence that precedes this period is variable, since it depends on the definition of incontinence, severity, degree of discomfort, and methodology for evaluating the magnitude. The evolution of surgical techniques, with regard to the greater or less prevalence of post-prostatectomy UI, has still been the subject of debate [1].

When talking about robot-assisted laparoscopic prostatectomy, the prevalence of incontinence can be influenced by the patient's preoperative characteristics, surgeon's experience, surgical technique, and methods used to collect and present data. The characteristics of patients that may influence postsurgical continence are age, body mass index, comorbidity, presence of lower urinary tract symptoms, and prostate volume [2].

The damage generated during the surgical procedure can occur in the urethral sphincter complex, in the supporting structures, or in its innervations, leading to the high prevalence of UI, being the anatomical support and pelvic innervation, important etiological factors of the loss of the continence post-prostatectomy. Excessive dissection during surgery, neurovascular bundle injury, and postoperative fibrosis also contribute negatively to the maintenance of continence. On the other hand, the maintenance of the bladder neck and fixation of the bladder-urethral anastomosis, before and after, are favorable for continence [3].

Prostate removal surgery favors stress urinary incontinence and urgency. The urgency, associated or not with incontinence, is also present in the detrusor overactivity not infrequently found in patients, making it more prevalent, since they add to the age factors, which reduces bladder complacence and prostatic enlargement, which leads to emptying dysfunction, obstructive [4].

Post-micturition dribble may also be present post-prostatectomy. There is usually no bladder alteration, but rather the inability of PFM, the bulbospongiosus muscle in particular, to eject the urinary volume contained in the ureter after the end of urination [5].

### **2.1 Physiotherapeutic treatment of urinary incontinence after prostatectomy**

The prostatectomized patient has a great impact on their quality of social life and often with important limitations in their physical activities and daily life due to loss of urine. Considering the social and pathophysiological aspects of post-prostatectomy urinary incontinence (PPUI), physical therapy for male pelvic health has been offering therapeutic strategies through perineal kinesiotherapy, biofeedback, electrostimulation, behavioral therapies, and lifestyle changes [6].

### **2.2 Functional assessment of the pelvic floor**

Perineal kinesiotherapy, also known as pelvic floor muscle training (PFMT), is performed after a careful functional assessment of the PFM where the muscular capacity of resistance and strength, symmetry, tone, and presence of pain are observed. This evaluation is not yet standardized for the male pelvic floor, and most of the protocols used to evaluate the female PFM are used, such as the modified

**153**

**Table 1.**

*The Pelvic Health Physical Therapy and the Prostatectomy*

able for the evaluation of the pelvic floor of the man.

Oxford scale, for example, which has a bidigital touch reference in the vagina and with the patient evaluated in supine. The Ortiz scale (**Table 1**) does not assume patient positioning and does not mention the female anatomy, being quite reason-

In the inspection of the male pelvic floor, we observe the retraction of the anus and elevation of the penis, which is presented subtly. Dynamic palpation is one of the few methods, if not the only one at present, for the assessment of the pelvic floor of both sexes. The anorectal touch is necessary for the evaluation of the pubococcygeus muscle, assessing its contractile capacity bilaterally, strength, and endurance. Palpation of the perineal body can also assess muscle activity and

The pad test can be a useful tool to quantify urinary loss. It can be 24 or 1 hour. However, there is evidence that the 24 hour pad test is statistically more relevant for PPUI assessment. The accomplishment of this one becomes important, since some authors have it like a criterion of discharge of the treatment or cure of the inconti-

The voiding diary is a semi-objective method to quantify symptoms such as urinary frequency and incontinence and degree of urgency, use of absorbents, and fluid intake. Urinary volume may contribute to the diagnosis of overactive bladder (OAB) and polyuria. The diary can be carried out for 3–7 days. Although it is a level of evidence 3 and recommendation grade D, it is recommended for the evaluation and measurement of the symptoms and discomforts of urinary incontinence, both

The questionnaires, as well as the scales and index, also serve to measure some

factors related to urinary incontinence, such as the severity of symptoms and quality of life. Some are more generic like Medical Outcomes Study SF-36 Health Status Profile, and others bring more specific conditions like the King's Health

Although physical therapy is part of the pull first-line treatment offers, the urodynamic examination, requested in the failure of these primary resources, offers a functional evaluation of the lower urinary tract. There is limited evidence that the preliminary urodynamic examination influences the results of the treatment for male urinary incontinence, although it is able to distinguish the different causes of

After the evaluation and a kinetic-functional diagnosis of the pelvic floor, as well as a functional diagnosis of the lower urinary tract, a therapeutic program can be developed. For pelvic health physiotherapy, the rehabilitation of urinary incontinence consists of behavioral and physical therapies, such as bladder training (BT)

 Objective perineal function absent, detectable only by palpation Weak objective perineal function, detectable by palpation Objective perineal function, without resistance to palpation Objective perineal function and resistance not maintained by

5 Objective perineal function and resistance by palpation maintained for more than 5 seconds

and the therapeutic exercises of the pelvic floor muscles, respectively.

0 No objective perineal function, even to palpation

palpation

nence. It can enter such criteria from the use of a pad by day to none [9].

at the beginning of treatment and to assess the impact of therapy [10].

*DOI: http://dx.doi.org/10.5772/intechopen.86979*

tone [8].

Questionnaire [3].

incontinence [11].

**Functional assessment of pelvic floor**

*Functional assessment of pelvic floor by [7].*

*Male Reproductive Health*

male urinary incontinence.

prostate volume [2].

end of urination [5].

urinary urgency with or without loss of urine is commonly associated with prostatic disease, needing to be investigated, with the pelvic floor having little influence on

The prostatectomized patient has transient SUI, and maintenance of this condition may still prevail in 8% of patients, 2 years after surgery. The prevalence that precedes this period is variable, since it depends on the definition of incontinence, severity, degree of discomfort, and methodology for evaluating the magnitude. The evolution of surgical techniques, with regard to the greater or less prevalence of

When talking about robot-assisted laparoscopic prostatectomy, the prevalence of incontinence can be influenced by the patient's preoperative characteristics, surgeon's experience, surgical technique, and methods used to collect and present data. The characteristics of patients that may influence postsurgical continence are age, body mass index, comorbidity, presence of lower urinary tract symptoms, and

The damage generated during the surgical procedure can occur in the urethral sphincter complex, in the supporting structures, or in its innervations, leading to the high prevalence of UI, being the anatomical support and pelvic innervation, important etiological factors of the loss of the continence post-prostatectomy. Excessive dissection during surgery, neurovascular bundle injury, and postoperative fibrosis also contribute negatively to the maintenance of continence. On the other hand, the maintenance of the bladder neck and fixation of the bladder-urethral

Prostate removal surgery favors stress urinary incontinence and urgency. The urgency, associated or not with incontinence, is also present in the detrusor overactivity not infrequently found in patients, making it more prevalent, since they add to the age factors, which reduces bladder complacence and prostatic enlargement,

Post-micturition dribble may also be present post-prostatectomy. There is usually no bladder alteration, but rather the inability of PFM, the bulbospongiosus muscle in particular, to eject the urinary volume contained in the ureter after the

**2.1 Physiotherapeutic treatment of urinary incontinence after prostatectomy**

electrostimulation, behavioral therapies, and lifestyle changes [6].

**2.2 Functional assessment of the pelvic floor**

The prostatectomized patient has a great impact on their quality of social life and often with important limitations in their physical activities and daily life due to loss of urine. Considering the social and pathophysiological aspects of post-prostatectomy urinary incontinence (PPUI), physical therapy for male pelvic health has been offering therapeutic strategies through perineal kinesiotherapy, biofeedback,

Perineal kinesiotherapy, also known as pelvic floor muscle training (PFMT), is performed after a careful functional assessment of the PFM where the muscular capacity of resistance and strength, symmetry, tone, and presence of pain are observed. This evaluation is not yet standardized for the male pelvic floor, and most of the protocols used to evaluate the female PFM are used, such as the modified

**2. Rehabilitation of urinary continence after prostatectomy**

post-prostatectomy UI, has still been the subject of debate [1].

anastomosis, before and after, are favorable for continence [3].

which leads to emptying dysfunction, obstructive [4].

**152**

Oxford scale, for example, which has a bidigital touch reference in the vagina and with the patient evaluated in supine. The Ortiz scale (**Table 1**) does not assume patient positioning and does not mention the female anatomy, being quite reasonable for the evaluation of the pelvic floor of the man.

In the inspection of the male pelvic floor, we observe the retraction of the anus and elevation of the penis, which is presented subtly. Dynamic palpation is one of the few methods, if not the only one at present, for the assessment of the pelvic floor of both sexes. The anorectal touch is necessary for the evaluation of the pubococcygeus muscle, assessing its contractile capacity bilaterally, strength, and endurance. Palpation of the perineal body can also assess muscle activity and tone [8].

The pad test can be a useful tool to quantify urinary loss. It can be 24 or 1 hour. However, there is evidence that the 24 hour pad test is statistically more relevant for PPUI assessment. The accomplishment of this one becomes important, since some authors have it like a criterion of discharge of the treatment or cure of the incontinence. It can enter such criteria from the use of a pad by day to none [9].

The voiding diary is a semi-objective method to quantify symptoms such as urinary frequency and incontinence and degree of urgency, use of absorbents, and fluid intake. Urinary volume may contribute to the diagnosis of overactive bladder (OAB) and polyuria. The diary can be carried out for 3–7 days. Although it is a level of evidence 3 and recommendation grade D, it is recommended for the evaluation and measurement of the symptoms and discomforts of urinary incontinence, both at the beginning of treatment and to assess the impact of therapy [10].

The questionnaires, as well as the scales and index, also serve to measure some factors related to urinary incontinence, such as the severity of symptoms and quality of life. Some are more generic like Medical Outcomes Study SF-36 Health Status Profile, and others bring more specific conditions like the King's Health Questionnaire [3].

Although physical therapy is part of the pull first-line treatment offers, the urodynamic examination, requested in the failure of these primary resources, offers a functional evaluation of the lower urinary tract. There is limited evidence that the preliminary urodynamic examination influences the results of the treatment for male urinary incontinence, although it is able to distinguish the different causes of incontinence [11].

After the evaluation and a kinetic-functional diagnosis of the pelvic floor, as well as a functional diagnosis of the lower urinary tract, a therapeutic program can be developed. For pelvic health physiotherapy, the rehabilitation of urinary incontinence consists of behavioral and physical therapies, such as bladder training (BT) and the therapeutic exercises of the pelvic floor muscles, respectively.


**Table 1.** *Functional assessment of pelvic floor by [7].*

### **2.3 Physiotherapeutic resources**

In bladder training, the patient is instructed on bladder function and fluid intake, including bowel habits and restriction of caffeine use, for example. Patients with independent urination may be advised of micturition habit and time. In the case of urgency and nocturnal incontinence, BT is as effective as oxybutynin, tolterodine, and solifenacin. It may also promote some improvement in frequency and nocturia when associated with other pharmacological therapies [6].

The PFMT increases urethral closure pressure and stabilizes the urethra. It can be performed with the aid of biofeedback which can be pressure, electromyography, and manual. Visual, auditory, or tactile resources are used to guide the patient in performing the contraction and relaxation of the pelvic floor musculature. Electrotherapy may be another alternative associated with PFMT. Both resources are not superior to PFMT, but when used as a combination therapy, it can favor the evolution of the condition, improving the performance and coordination of the PFM [12].

The PFMT should be offered as first-line therapy [10]. The therapeutic exercises are proposed after a thorough evaluation of the PFM, where the effective time and the repetition of the contraction, without reaching the fatigue, are determined. From there an exercise program is developed, aiming at endurance, strength, coordination, and pre-contraction of muscles.

It should be noted that during PFMT, the patient does not use accessory muscles, such as the abdominals, buttocks, and thigh adductors. The inadequate use of these muscles leads to poor perception of the effective performance of the PFM. The physiotherapist needs to guide the patient on how to perform the most effective contraction without using the accessory muscles. Although the abdominal muscles are considered accessory, the transverse abdominis muscle in particular has a synergistic function to the pelvic floor [13].

The transverse abdomen muscle and the PFM are considered postural muscles, with the support function, that is, they have predominance of tonic muscle fibers and are responsible for the maintenance of orthostatism. Performing a therapeutic exercise program for these synergistic muscles is critical to the functionality and daily life activities of the patient. These muscles activated together favor the dissipation of abdominal load, which would lead to increased intra-abdominal pressure and consequently loss of urine to the effort [14].

Biofeedback for pelvic floor rehabilitation is used to gain a greater awareness of the functions of the PFM, mainly using instruments that provide information about the activity of these muscles. Intracavitary (anal) pressure probes can be used, measuring the contraction in millimeters of mercury or electromyographic that detects the potential of muscular action in microvolt, the latter being also possible through a perineal surface electrode. Its purpose is to better muscle functionality, providing greater proprioception, consequently greater effectiveness in the coordination, strength, and endurance of the PFM [15].

Functional electral stimulation (FES) is a biphasic current transmitted from transcutaneous (**Figure 1**) or intracavitary (**Figure 2**) electrodes. The intensity of the current is given according to the patient's sensitivity, without generating any discomfort or pain [16].

Usually the contractions generated by the electric current assist the voluntary activation of the PFM. Because it is a muscle with a predominance of tonic fibers, the frequency (in hertz) used is low and the pulse width (in microseconds) higher, for example, 20 Hz and 700 μs. The contraction time is variable, on average over 4 seconds, but given individually according to the PFM functional evaluation. The resting time may be one to two times the contraction time.

**155**

*The Pelvic Health Physical Therapy and the Prostatectomy*

It is not uncommon for patients who have undergone prostatectomy to also have urinary urgency, associated or not with incontinence. Sometimes the urgency is related to a detrusor overactivity, and complaints of nocturia and polaciuria are present. OAB may already manifest even before prostate withdrawal surgery. Changes in the bladder wall, as well as the increase in prostatic volume related to age

In the cases of post-prostatectomy patients who present OAB, the electral therapy with (neuro) modulation objective should be used. A different action in PFM, the electral therapy used in this case is transcutaneous electrical nerve stimulation (TENS). Surface electrodes may be used in the parasacral (**Figure 3**) or tibial (**Figure 4**) regions. The frequency usually used varies between 5 and 10 Hz and the pulse width between 300 and 700 μs; the intensity is given before reaching the motor point, remaining at sensitive levels. The treatment should be performed under physiotherapeutic assistance, with prescription of the home and/or outpa-

tient electrotherapy device. The treatment time is around 12 weeks [15].

In addition to electrotherapy, BT is also indicated. In the case of urinary urgency,

Post-micturition dribbling may also be another complaint in prostatectomized patients. This situation does not influence the function, or dysfunction, of the bladder. It occurs due to the inability of the bulbospongiosus muscle to eliminate

it may also be performed through contraction of PFM and inhibition of voiding reflex, allowing the patient to lose the urge to urinate and being able to reach the bathroom more comfortably or delaying urination, in the case of polaciuria.

*DOI: http://dx.doi.org/10.5772/intechopen.86979*

**Figure 1.**

**Figure 2.**

*Intracavitary electrode.*

*Transcutaneous electrodes.*

(elderly), may be related to OAB [17].

*The Pelvic Health Physical Therapy and the Prostatectomy DOI: http://dx.doi.org/10.5772/intechopen.86979*

**Figure 1.** *Transcutaneous electrodes.*

*Male Reproductive Health*

PFM [12].

**2.3 Physiotherapeutic resources**

coordination, and pre-contraction of muscles.

synergistic function to the pelvic floor [13].

and consequently loss of urine to the effort [14].

strength, and endurance of the PFM [15].

resting time may be one to two times the contraction time.

discomfort or pain [16].

In bladder training, the patient is instructed on bladder function and fluid intake, including bowel habits and restriction of caffeine use, for example. Patients with independent urination may be advised of micturition habit and time. In the case of urgency and nocturnal incontinence, BT is as effective as oxybutynin, tolterodine, and solifenacin. It may also promote some improvement in frequency

The PFMT increases urethral closure pressure and stabilizes the urethra. It can be performed with the aid of biofeedback which can be pressure, electromyography, and manual. Visual, auditory, or tactile resources are used to guide the patient in performing the contraction and relaxation of the pelvic floor musculature. Electrotherapy may be another alternative associated with PFMT. Both resources are not superior to PFMT, but when used as a combination therapy, it can favor the evolution of the condition, improving the performance and coordination of the

The PFMT should be offered as first-line therapy [10]. The therapeutic exercises are proposed after a thorough evaluation of the PFM, where the effective time and the repetition of the contraction, without reaching the fatigue, are determined. From there an exercise program is developed, aiming at endurance, strength,

It should be noted that during PFMT, the patient does not use accessory muscles, such as the abdominals, buttocks, and thigh adductors. The inadequate use of these muscles leads to poor perception of the effective performance of the PFM. The physiotherapist needs to guide the patient on how to perform the most effective contraction without using the accessory muscles. Although the abdominal muscles are considered accessory, the transverse abdominis muscle in particular has a

The transverse abdomen muscle and the PFM are considered postural muscles, with the support function, that is, they have predominance of tonic muscle fibers and are responsible for the maintenance of orthostatism. Performing a therapeutic exercise program for these synergistic muscles is critical to the functionality and daily life activities of the patient. These muscles activated together favor the dissipation of abdominal load, which would lead to increased intra-abdominal pressure

Biofeedback for pelvic floor rehabilitation is used to gain a greater awareness of the functions of the PFM, mainly using instruments that provide information about the activity of these muscles. Intracavitary (anal) pressure probes can be used, measuring the contraction in millimeters of mercury or electromyographic that detects the potential of muscular action in microvolt, the latter being also possible through a perineal surface electrode. Its purpose is to better muscle functionality, providing greater proprioception, consequently greater effectiveness in the coordination,

Functional electral stimulation (FES) is a biphasic current transmitted from transcutaneous (**Figure 1**) or intracavitary (**Figure 2**) electrodes. The intensity of the current is given according to the patient's sensitivity, without generating any

Usually the contractions generated by the electric current assist the voluntary activation of the PFM. Because it is a muscle with a predominance of tonic fibers, the frequency (in hertz) used is low and the pulse width (in microseconds) higher, for example, 20 Hz and 700 μs. The contraction time is variable, on average over 4 seconds, but given individually according to the PFM functional evaluation. The

and nocturia when associated with other pharmacological therapies [6].

**154**

**Figure 2.** *Intracavitary electrode.*

It is not uncommon for patients who have undergone prostatectomy to also have urinary urgency, associated or not with incontinence. Sometimes the urgency is related to a detrusor overactivity, and complaints of nocturia and polaciuria are present. OAB may already manifest even before prostate withdrawal surgery. Changes in the bladder wall, as well as the increase in prostatic volume related to age (elderly), may be related to OAB [17].

In the cases of post-prostatectomy patients who present OAB, the electral therapy with (neuro) modulation objective should be used. A different action in PFM, the electral therapy used in this case is transcutaneous electrical nerve stimulation (TENS). Surface electrodes may be used in the parasacral (**Figure 3**) or tibial (**Figure 4**) regions. The frequency usually used varies between 5 and 10 Hz and the pulse width between 300 and 700 μs; the intensity is given before reaching the motor point, remaining at sensitive levels. The treatment should be performed under physiotherapeutic assistance, with prescription of the home and/or outpatient electrotherapy device. The treatment time is around 12 weeks [15].

In addition to electrotherapy, BT is also indicated. In the case of urinary urgency, it may also be performed through contraction of PFM and inhibition of voiding reflex, allowing the patient to lose the urge to urinate and being able to reach the bathroom more comfortably or delaying urination, in the case of polaciuria.

Post-micturition dribbling may also be another complaint in prostatectomized patients. This situation does not influence the function, or dysfunction, of the bladder. It occurs due to the inability of the bulbospongiosus muscle to eliminate

**Figure 3.** *Parasacral electrodes.*

### **Figure 4.**

the voiding residue present in the bulbar urethra. The treatment consists of the therapeutic exercises of this musculature, aiming to acquire greater muscular force for the expulsion of the urine of the urethra, after the urination. The urethral milking maneuver and bulbar massage may also be associated, but the effectiveness of bulbospongiosus muscle contraction is greater [5].

The loss of urine during orgasm, climacturia, is not uncommon in these patients. The inevitable surgical damages generated in the bladder neck, as well as the event in the sympathetic fibers, responsible for contraction of the bladder neck and relaxation of the external sphincter during the ejaculation expulsion phase, are one of the suggested mechanisms for climacturia [18]. And the proposed physiotherapeutic treatment is PFMT.
