The next few blogs are going to be in note form – snippets, pearls of wisdom, new research etc. These blogs are for me just as much for you- and I am going to put everything in – and it may not even make sense, but later I will be able to follow up at a later date, so I apologise if it’s a disjointed read.

Modern physiotherapy management of the post prostatectomy patient (transperineal ultrasound workshop)

Stuart Baptist, (e.stuartbaptist@ssop.com.au) a Men’s Health physio in Sydney, conducted this workshop and I think he did a great job. He made the content practical and no-nonsense and I will be implementing some of this in a practical sense in our treatment of our male patients – mainly with respect to our handout- I will be making it better directed at the different male approach to health management and also with the exercise prescription.

We had the opportunity to see a former patient of Stuarts have a transperineal scan- he had a prostatectomy last year and he is now dry and being very active. His candour was appreciated by the group and we are grateful to him for his wonderful cooperation. Having followed Ryan Stafford’s work and use of perineal RTUS already, it was great to have Stuart live scanning and see the difference in the contraction with different cueing. He closely explained the optimal direction of the pull of the muscles in the front compartment mid urethra (P4) (gaining a better mid-urethral posterior displacement) as opposed to a cuing as though you are holding wind (a more anal squeeze giving more posterior lift). Remember that Ryan’s work has shown that best choice of words for best cueing for optimal contraction is ‘shorten the penis’ – with good explanation I’m sure men get the concept, but if they don’t like that thought then Stuart gave other examples- pull in the turtle’s head; reverse the train back into the station and Jo Milios likes ‘nuts to guts‘.

Stuart also reiterated the different mindset of the male brain and approach to health issues and highlighted the importance of the way physios give information to the man who is quite often in shock from his diagnosis.

He spoke of the Emotional intelligence of the Physio

Pull back when giving too much information – the patient is male, frustrated, frightened, stressed, having received multiple messages and sometimes conflicting ideas; he recommended choosing words wisely-words are very powerful. Educate gently and with compassion; men need to understand why things happen, to develop compliance. Male functional view of life- if its not broken don’t fix it.Men need to know what you have right now and what needs to be done to get you back to normal. Men can’t ‘see’ the PF muscles, therefore it’s hard for them to connect easily with them.

3 sphincters

• Internal (prostate/bladder neck) Autonomic in nature- often damaged during TURP- often affected by surgery (stops retrograde ejaculation); External sphincter(autonomic) used during filling phase, Moderate distension of bladder inhibits parasympathetic activity When full increases parasympathetic tone (bladder); External (voluntary) aka rhabdosphincter. Striated used to voluntarily stop urine.

Surgical trauma to

• muscular structure
• nerve- from a recoverable neurapraxia to a complete surgical resection

Recovery of:

• continence (can be weeks to months)
• erectile function (months to year)
• no guarantee of outcomes
• many variables- such as obesity

Autonomic training:

• Very important
• Fluid type (what you drink, how much)
• Bladder training strategies, urge control more urine storing more training for autonomic sphincter has to work- bladder used to holding more. Demand more of the system during the day

URILOG Chris Robinson-App for logging fluid/urine

Activity modification– if doing too much too soon immediately post-op- encourage to slow down in early bit- use pads -tells how much failing in the system; PACE AND GRADE return to work/ exercise

VOLUNTARY PFM TRAINING

Was originally developed from Kegals; Recent RCTs questioned the effectiveness of PFMT- Glazener 2011- anal probe so not effective way to train muscles. Ryan Stafford UQ pioneering work from 2012-2017 – target more effective PFMT gaining better urethral compression.Transperineal US is reliable and valid- Judith Thompson

Sean Mungovan, Westmead we can identify at risk patients and selectively target for greater effectiveness. Mungovan SF, Sandhu JS, Akin O, Smart NA, Graham PL, Patel MI. Preoperative Membranous Urethral Length Measurement and Continence Recovery Following Radical Prostatectomy: A Systematic Review and Meta-analysis. Eur Urol. 2017 Mar;71(3):368-378. doi: 10.1016/j.eururo.2016.06.023. Review.  Open Access Link: http://www.sciencedirect.com/science/article/pii/S0302283816303414

Stafford 2017– looking at continent men and incontinent men http://onlinelibrary.wiley.com/doi/10.1002/nau.23371/abstract

• Incontinent men strained and got worse- PFMT necessary; Striated urethral sphincter should be the principle action, that’s where Transperineal US helps
• 

Principles of Motor leaning

• Identify the sensation
• Repeat it
• Give feedback
• Repeat it
• Give realistic expectations to patients

PF Hypertonicity

• Chronic frequency
• SIJ
• Korisani 2012, Transab US scan CPP reduction in bladder base motion
• Davis 2011 statistically valid inc in anorectal angle in men with CPP; Draw a line tracking the anorectal angle

Preop training

• Down training first
• Breathing
• PF muscular release
• Global muscle flexibility
• SIJ/LBP (guarding
• CBT
• Then commence gentle motor training

Preop and early postop motor training protocol

• Looking to reinforce the difference between sensations
• Vary the challenge
• Anal/ testicular/Penile
• Testicular and penile (NO ANAL)
• Each effort is a lift/sustain (3 small breaths- no diaphragm)

Reps and sets

• Motor learning principles during skill acquisition
• Mental engagement and focus(environment) in car when arrived home
• 5 circuits (20 contractions)
• 4x?day
• @20% effort(max)
• If bulbocavernosis motion poor but urethral sphincter good don’t worry
• After th posterior motion/displacement

POST OP PERIOD

Catheter period

• No PF exs during this period- maybe visualisation exercises without actually doing
• Do down training if needed
• Rest
• Exs for respiratory circulation bowel’

Early catheter removal

• relative rest
• modify all activities
• resume light motor control ex
• ICIQ-SF
• 24 hr pad weight checking
• Optimal daily URILOG; Busy quiet day= average weekly scores

ICIQ-SF: Light <20g/24hrs ICIQ<6; Moderate >20-<200 ICQ-SF;Heavy >200 ICI-Q

Targeted Rehab Strategy

Heavy leaker

• Wet overnight
• Disruption to autonomic sphincter
• Rest and bladder retraining+++
• Light motor control exercises develop
• Penile clamp- only as firm as need (trial and error)-Max 3 hrs at one time, Periods of higher activity more than rest periods, Phasing out approach over 6 weeks 3hrs 3 times a day, down to
• Monitor pad weigh and record weights of pad
• Consistent fluid intake.
• Copies the empty storage empty phase of the normal bladder.
• Stimulate the autonomic phase of the bladder- awaking the system againDiscuss with urologist if not getting improvement- ?more rabdosphincter damage.

Moderate leaker

• Spurty leakage, not dripping all the time
• Dry overnight
• Get pad free as soon as possible onight
• Dry physical activity- progress to HIIT- stairs, hill climbing 45 secs recovery level- more bladder volume- 3 units of rest
• 1 unit of work 95% of capacity
• Highest intensity of exercise they can be dry
• Stair climbing
• 2 mths out exercise bike
• Light motor control ex develop into increasing intensity (without loss of accuracy/anterior bias)
• Rapid reaction time training
• Record PB for x20 contractions (how fast can you do reps and maintain form)
• Off to on off to on
• Progress to functional training

Light Leakers

• End of day
• No pad o’night
• What is the PFs function thru the day
• Interaction of PF and diaphragm(Smith 2014)

Treatment

• Postural control and pad phasing-get them away from pads
• Pilates /Global postural rehabilitation (Fozatti2010) Megan? Men’s class?
• Get fitness up a bit

Video of diaphragm and PF work FRENCH

Urgency/OAB leaker

• Pattern of leaking is not related to physical activity but more due to caffeine/ETOH/poor bladder habits
• Often poor sleeping due to nocturia
• Rx Bladder training
• Deferral strategies
• Neuromodulation PTNS
• Medications

PF downtraining

• Evaluate SIJ/LS
• Functional Specific training Stafford 2017

If valsalvering and leaking under load- breathing out as they start to move and move smoothly

Examples of higher end functional challenges

• Strength training 75-80% of max contraction
• Need to add resistance  as doing PFMT- resistance training
• Sit to stand stand to sit NOT SQUAT
• Pick up and put down NOT A DEADLIFT
• Twist and reach – timing of PF intensity
• Golf swing- back swing and follow thru
• Step up
• Bent over row
• Turkish get up

PROGRESSIVE DEMAND

Resistance

• Specific to body part- heavier for legs theyre lifting 5kg in training but leak when lift the 20kg of mulch. Match the challenge to what theyre lifting

Depth of Motion

• Deeper is harder vary the height of the chair

Speed of motion

• Faster is harder Theraband Golf swing

Bladder volume -Backpressure causing increasing Intrabdominal back pressure

VOLUNTARY TO AUTOMATIC SHIFT

Do you practise driving a car? It is practising your skills. Humans very plastic. Takes 10000 hrs to get expert/high performance- P Plate driver concept- check the rear vision get a honk every so often. Skill consolidation means ongoing training/compliance is essential; Continence muscles and the aging process affects recovery.; 2 weeks post op; Record pad weight scores.

Penile clamps

• Dribble stop
• Weissner clamp

ERECTILE DYSFUNCTION

• Penile rehabilitation
• What you always wanted to ask
• 3^rd part of the trifector
• Veil of afrodite not just the main NV bundle laterally
• Erections=blood flow night time erections 6-8 times a night- housekeeping- maintains health doesnt have to be penetrative sex- maintain length of penile tissue. Normal nocturnal penile tumescence
• Penile fibrosis, shortening and peyronnes- difficult for penetrative sex further down the track

When should rehab start

• Urologist led- get good relationshop with the urologist
• Liase with sexual health dr and counsellor/sex therapists if needed- teaching about intimacy with partner doesn’t have to be penetrative sex- find a good one for the men
• There is natural recovery
• Manaual massage/stimulation- try and get an erection- get partner to do it- intimacy together (shower if urinary leakage)
• Pills– Viagra Cialis Levitra- daily dose (endothelial dose) empty stomach first ting in the morning; Booster dose- 45-60 mins prior to sexual activity Viagra 25 mg daily booster up to 100mg; Cialis can be as low as 2.5mg Up to 20mg- longer half-life in the body. Start straight away after prostate surgery. Stay on until get natural recovery. Some research start before the surgery SSRIs for 9 months- better long term outcome
• Pumps not dependent on stage of neural recovery- get an erection passively- even if no stimulation or romance – cost $10 in a sex shop to $2000- huge variability- patient confusion- poorly taught and poorly understood when used well can develop an erection sufficient for penetration – may need a penis ring to maintain. Stuart sells $100. What makes a good pump- one  power pump (insert photo) has a good seal; How to use- trim/shave- (hairs get trapped in seal clear hair around base of pump); Lubricant (water based) for seal; Pressure gauge- LOW PRESSURE GENERATION- 3 pumps and then look at it- watch blood move in- penis starts moving into the tube- then give it another pump- give it time (up to 30 mins if needed); include bulb filling time (5 mins) one pump every minute use the right penis ring (avoid metal ones- get rubber one)- tell patient to buy a couple (we need to order into the clinic size #3-remind patient there will be a dry orgasm-seminal vesicles and prostate tissue been removed. (Tantric sex- yogis-pump half an hour, ring for 15mins)
• Pricks (injections) aka Intracavanosal injection- erection in 30sec. Surgeons routinely give an injection; Cavajet-simple to usedial a dose; between 10-2 oclock; side effect can be pain; TriMix-Dr led/Self draw; more modifiable

Doctor guidance very important

Programme

• Every morning in shower penile massage
• 3 times a week pump
• Once a week injection
• Which should I recommend? Patient specific

 CONCLUSION/SUMMARY

• EMOTIONAL INTELLIGENCE USE IT
• EDUCATE WITH COMPASSION
• EARLY MOTOR CONTROL EFFECTIVELY RTUS
• BE AWARE OF HYPERTONICITY
• MANAGE AUTONOMIC AND VOLUNTARY REHAB
• CLASSIFY TYPE OF INCONTINENCE AND TREAT SPECIFICALLY
• INTEGRATE PFM TRAINING INTO FUNCTIONAL SPECIFIC TRAINING
• FEEL COMFORTABLE TALKING ABOUT SEX
• AFTER 2 YEARS OF NO ERECTILE FUNCTION- HARD TO ACHIEVE RESULT
• PENILE PROSTHESIS- BRILLIANT
• INECTIONS

To the physios who may read this -I would recommend this workshop to you if you get the opportunity.