You know we have this fabulous Facebook group for Women’s Health – it’s an international phenomenon- well we have all become BFF- yes Best Friends Forever- but in a virtual way. Most of us have never met but because we communicate on a daily basis, solving the pelvic floor and continence issues of all you out there in the WORLD, we know heaps about each other. We know some of us love cats more than dogs; we know that our kids are precious despite them contributing to our lack of sleep at times, but mostly we know we all have a common bond in our passion for our profession. But I decided I needed another MALE blog to join the OTHER blog I have done about men- yes embarrassing that there are a total of two when there are now 157 blogs posted. So I thought I’d ask the talented, and obviously beautiful (from that glamorous photo I found on the internet), Joanne Milios to write one for me. The brief was simple. Write me a blog Jo- anything male. I feel there is this yawning gap out there- we need an upsurge in interest from particularly young, energetic males to embrace their own gender and get moving with Men’s Health. Of course all girls are equally encouraged to follow Jo’s wonderful lead into Men’s Health!
Get a cup of (decaf tea) because it’s a longer read than usual- Jo’s blog follows….
SEX? Imagine you are a bloke, say 62years of age- which just happens to be the median age of men diagnosed with Prostate Cancer (PCa) in Australia(1),who is one day told, ‘tomorrow is the end of your sex life.’ Kaputsky. All over red rover….’and, this by the way, is the good news’.
The bad news,’ if we don’t operate or treat your cancer, your may have 2-3 years life left’, might actually hit a little harder. You may not, however, hear the next few words, ‘Oh, and did I mention that after your surgery you will most likely be incontinent for a few months, that you will need to wear continence pads 24/7(!%&!), that you’ll be infertile, never ejaculate again, may leak urine if you orgasm, most likely have penile shrinkage and there’s a small risk of infection, Peyronies Disease, follow up radiation therapy, reconstructive or implant surgery and possible death from anaesthesia?’.
Welcome to my waiting room, except that after a decade of working as a Men’s Health Physiotherapist, I’m pleased to report that conversations about prostate cancer, urinary incontinence (UI), erectile dysfunction (ED) and more recently chronic pelvic pain (CPP)/ pudendal neuralgia (PN) are far more optimistic today.
In fact, given the gains in such a relatively short time, it almost feels like I’m on a different planet….
So how did this all start? A trip across the Nullarbor Plains to visit Peter Dornan in 2010 proved pivotal in this change. Here I met a man with 45 years physiotherapy experience, an open door and an open heart who, in 2003, had published a book titled, Conquering Incontinence(2). This 100 page document changed my life and has since changed the lives of 2000+ prostate cancer patients I have so far had the privilege to work with.
Peter’s own seven year battle with post prostatectomy incontinence (PPI), following surgery for prostate cancer, led this spirited fellow to climb a mountain to cure himself of the impossible leak/loss/grief cycle that had dominated his post-PCa life. Peter was afraid, however, that his self-designed, functional pelvic floor rehabilitation program would be scorned at or worse still, fail. So he did what men do… and went off to climb a mountain!
On the 14th Feb 2002 as a 60year old, mountaineering pioneer, Peter Dornan gave himself a Valentine’s day present and reached the peak of “Kili’, Mt Kilimanjaro, pad free and cured of incontinence. It is this story of courage that motivates me to push boundaries and more importantly, encourage my patients to ‘look for the gift’ (2) in the face of their own adversities, with no peak being too high to aim for.
Back to the 2010 Brisbane trip. Whilst there, I happened to encounter the lovely, frank and candidly refreshing physiotherapist, Pauline Chiarelli who was presenting on Pelvic Floor Exercise and Urinary Incontinence at Peter’s QLD Prostate Cancer Support Network meeting. I was just another bottom on a seat amidst the 70 others or so, but I heard one critical statement:
’Men’s Health is 30 years behind Women’s Health in Australia, if not the world’.
I was aghast! As the daughter of a pro-feminist, anti-male, ’don’t rely on a man’, social-worker, women’s lib, bra-burning, 70’s, hippy-spirited mother, I was bemused. Had the pendulum swung that far back the other way?
Returning back to Perth, I dusted off the bike in my shed, cycled my way to the University of Western Australia and commenced a PhD in Men’s Health with a specific focus on Quality of Life issues after Prostate Cancer. Or that’s what I planned to do. Instead, I quickly ascertained that it would take at least 5-7 years to produce the quality research that might provide the evidence for my ultimate goal, which was to provide a community-based exercise and support program for men with Prostate Cancer. Fortunately, I was able to convince the Sports Medicine Professors that their budding Breast Cancer program needed a male counterpart and with more prostate cancer diagnosis in Australia- (1 in 7 men)(1) vs the equivalent Breast Cancer (1 in 9 in women)(1), it seemed a logical fit!
So after a few bingles here and there, ‘PROST! Exercise 4 Prostate Cancer Inc’ was born. Before long, professional partnerships with UWA’s School of Sports Science, Exercise & Health, Simmo’s Ice creamery* and PROST!inc became an affiliated support group of the Prostate Cancer Foundation of Australia(PCFA). Two & half years on, we now have a dedicated Prostate Cancer Exercise program for men running out of the WAFL’s Subiaco Football Club (Home of the Lions), four times per week with a club membership of more than 200 PROSTIES! As ‘PROST!’ (‘to your health’ or ‘Cheers’ in German) is our slogan and Building Mood, Muscle and Mateship during your Prostate Cancer Journey, our mission, we are finding men are regaining their manhood and mojo just by attending the ‘boys only’ club!
Using Peter Dornan’s program, new evidence-based research (3) and a deliberate U-turn on the part of the urologists in Western Australia, to refer men 4 to 6 weeks prior to radical prostatectomy, post-prostatectomy incontinence (PPI) was becoming a much smaller problem. Indeed, from the 6-12 month typical incontinence journey of a decade ago, an expected 6-12 week ride to full, pad-free continence is now the norm. Using the anecdotal evidence of my 2000 + cases, I’ve guesstimated that the average Male Pelvic Floor takes approximately 3 months to physiologically train to functional requirements following prostate resection and I’m only too happy to share the following ‘theory’. It’s not evidence, but it’s rational and based on a large sample size, specific to men and can be used (with caution) as a general guideline for patients.
Milios’ Male Pelvic Floor Training Theory:
If a man gets referred for physiotherapy pelvic floor muscle training at six weeks pre-op radical prostatectomy he can usually expect to have six weeks or less, post prostatectomy incontinence.
If he’s had just two weeks pre-op physio, then it’s an approx ten weeks time-frame wearing continence pads post-op.
If only 1 day of pre-op PFMT training is possible, it can ensure a much smoother changeover, from what I call the ‘automatic’ to ’manual’ system of continence control following treatment. To add further weight to this observation, I also have a sample size of >20 Prostate Cancer patients to draw from, who for one reason or another, have had 3 months or more pre-op physio, with 100% of the group- all twenty patients – experiencing zero incontinence. Given the relative predictability of this pattern, I now ask a patient to add 3 months from the date of our first post-op visit, (usually a fortnight out from surgery) to write this date down and to set it as the ‘goal’ date for complete resolution of his urinary leakage and bladder issues. The aim is to be pad free, back to work, tennis, lifting grandchildren and breaking wind (without the usual wet)by this date, the finishing post!
It’s a plan and an approach, I believe, that seems to work on a number of levels that click with the goal-orientated, competitive, action-focussed way a man thinks. However, this is just my theory and it needs scientific back up, further development, validity, reliability, reproducibility, etcetera…. (And I’m getting there), but here’s something interesting!
It just so happens that my PhD supervisors, Prof Daniel Green and Prof Tim Ackland, are world leaders in cardio-vascular health (CVH). They also happened to teach me, that in 1998, three chaps, by the name of Furchgott, Ignarro and Murad, won the Nobel Peace Prize in Medicine for their discovery of the Nitric Oxide (NO) atom, fuel of the cardio-vascular system (CVS)(4). Exercise, they proved, leads to compression of vascular walls, which leads to the production of nitric oxide, which leads to healthy endothelial tissue and enhanced vascular function(5).
Lack of exercise, aging, fatty diets, obesity, a sedentary lifestyle, hereditary factors, diabetes, metabolic syndrome and surgical interventions can ALL greatly impact of the efficacy of the CV system and local blood flow.(6) Putting this together, with the wonderful work of the father of urology, Prof Patrick Walsh who pioneered the first Nerve Sparing Radical Prostatectomy in 1984(7), I knew that, just perhaps, I was onto something….
Back in my waiting room, the fully continent pad-free, cancer–free men were sitting pretty chuffed with themselves around 6 weeks post treatment, but with one lingering question. With 2 out 3 treatment goals already achieved they now wanted the trifecta. They wanted their sexual potential back and they wanted it NOW!
They wanted to feel like men again. They wanted to stand to attention and wake up with a morning glory. I have observed one very important thing – whether they were 37yrs, as has been my youngest PCa patient, or 87yrs, as has been my oldest, without a doubt not one single man, was content with erectile dysfunction. So long as a bloke is breathing, he wants his boy bits to be working. Relationship or not. Gay or straight. Young or old. To feel like the man he was created, with the potential to have an erection, is critical to male self-esteem.(8,9).
Moreover, should anything at any time go wrong with a man’s penile function at any age- be it curvature, reduced rigidity, pain, anorgasm, premature ejaculation, shortening, shrinkage or complete breakdown– the consequences can be devastating (10). And often are.
Loneliness. Isolation. Avoidance behaviours. Relationship breakdown. Depression and Anxiety.(8) Suicide……
I have seen it all…..and at times it has greatly bothered me. But, then SMACK!! right there, in the middle of the fork in my road, along came Professor Grace Dorey- with hope and a solution(11).
Courtesy of Google Scholar, I was soon on my own Tour de France! Searching the romantics, I found the Italians do it best- Lumbroso, Ianco, Ficarra, Briganti, Rabanni, Pardo, Di Pierro, Porpiglia, Costello. Salonia, Montorsi– to name just a few, were producing lots of research and I quickly surmised, that yes!, we do have some evidence and that EUREKA!, a leading Professor of Physiotherapy in Britain has provided the bulk of it.
Grace Dorey’s research is novel, illuminating, translatable, and transferable and transcends into real patient outcomes (11, 12, 13). Her pioneering studies on Post Void Dribble, Pelvic Floor Muscle Assessments for Men and, what I consider her yellow Guernsey- Pelvic Floor Exercises for Erectile Dysfunction are readily available (12), widely cited and form the basis to a whole new weight training system known as the ‘Male Private Gym’. With Prof Dorey’s endorsement and the backing of a randomized controlled study displaying 85% satisfaction rate,(currently under review), I believe this is perhaps the exercise tool of the 21st century. Physiotherapists should look, learn and embrace it. We already have the female equivalent, so why not?
BUT, there’s still a very big BUT! If you’re a man with prostate cancer, there’s an approx. two year waiting period before neurovascular damage caused by radical prostatectomy heals sufficiently to allow penetrative sex (10). And that’s a maybe, with just 23% under 60yrs and 4% men over 60yrs regaining their sexual function (13) following prostatectomy, with the odds of success clearly not in the ball court for the average bloke. Worse still, something like the Private Gym can’t really be used in the early months following treatment as an erection is required for base-loading of the penile weight and yet, if penile rehabilitation (PR) is not commenced, immediately, possibly even before treatment, very few men will recover sexual function. To add insult to injury, a recent prospective study of 453 men showed that sexual bother increased from 18% in the month preceding surgery to 66% at 1 year post surgery (Steinsvik EAS 2012 BJUI) and that depressed symptoms persisting for at least 4 years post-treatment were common.
Except that since then, the science of penile rehabilitation and medications such as low dose Cialis, a PDE5 inhibitor medication, have emerged and are showing significant improvements in results, with a doubling to 48% improvement if (13) In my experience, therefore, penile rehabilitation is not really a question of if, but when and the sooner the better. (14).
So what is penile rehabilitation? It’s anything that provides blood flow to the corpus cavernous and corpus spongiosum to stimulate and provide penile blood flow to help restore the structural changes that occur during radical prostatectomy (15). With the Veil of Aphrodite, Nerves of Walsh, neurovascular bundles, fascia and nearby pudendal nerve (S2-S4 nerve of the Greek n. ‘private parts or shamefuls’) also affected, the resultant neuropraxia causes immediate loss of erectile function in up to 95% of men(14).
If left out to dry, the combined loss of 1500/ year average ‘housekeeping’ /nocturnal erections/night and the loss of enhanced blood flow with sexual activity, combined with increased collagen deposition and decreased smooth muscle and elastic fibre tissue as a result of surgery, the need for artificial ‘’irrigation’’ is paramount, for long term potential function is to be preserved(15). The jury is also out as to how long full functional recovery takes with 1- 5 years after surgery commonly quoted, varying from surgeon to surgeon and surgical approach, but most agree that this is definitely a case of ’use it or lose it’.
So how do we do penile rehabilitation? Well, it is essentially a multi-disciplinary team (MDT) approach with initially, the treating urologist providing the most important link. His skill, experience and choice of technique will greatly determine the outcomes for patients in terms of erectile nerve sparing. The biggest factor of all, however, is the uniqueness of the patient before him.
The aggressiveness of his prostate cancer, co-morbidities, level of fitness, age, weight, pre-existing urinary, sexual, mental and physical health, will often determine how much a surgeon can do for each individual (16). Given the position of the prostate, deep within the pelvic cavity, a radical prostatectomy is a highly skilled procedure and, having observed all three surgical approaches- open, laparoscopic and robotic- the ‘jig saw puzzle’ of each patient should never be under-estimated. Once the operation is complete, however, it’s time for other members of the multi-disciplinary team(MTD) to step in.
Physiotherapy should be playing a very big role here…
So how? Around 6/52 post radical prostatectomy most blokes I treat are continent, or down to one security liner/pad/24 hours, have had their 6 week post-op PSA and urology visit, have returned to work ,the gym, can have an occasional coffee or red wine, and have hopefully commenced on daily Cialis.
My role here is to educate, Educate, EDUCATE!!
Talk, listen, communicate and ask questions about pain, bladder, bowel and sexual function and let questions be asked and answered.
Next, it’s important to address these issues with physical tasks, individually tailored to each patient’s unique needs. This may be general bladder training, education on diuretics, pelvic floor testing- revision, progression, reduction and prescription, general exercise programs, referral to gyms, dieticians, counsellors, PCFA support groups etc. A referral to a Sexual Health Physician specializing in ED is also essential around now if not before, to access Vacuum Pumps (14), intra-cavernosal injections (14) or a more rigorous medication regime (17).
Interestingly, Pelvic Floor Exercises for ED remain a very undervalued treatment option. Physiotherapists need to look at Grace Dorey’s work and pick it up and run and play with it. Then take it further.
As physical therapists we are in a wonderful position to guide, train and support the physical needs of our patients with the physical applications we already do so well. Men’s Health is really just a matter of listening, learning and observing, because as we all know, it is the patients that teach us the most. The aim is to translate from our respective fields of expertise, to transfer this knowledge from one area to another and to then transcend change, to the betterment of our patients and their quality of life issues.
Those bumps in the road need not be too difficult to negotiate, if men like Peter Dornan can climb mountains…. Meanwhile I’m off to research the potential benefits of Therapeutic Ultrasound in Peyronies Disease (scar tissue causes a nasty bend in the penis), as I have a young male patient (25yr) desperate for help. Together, it’s the kind of learning curve we should not be afraid to pursue. Think big. Think different. Men’s Health needs it. PROST!
*Garth ‘Simmo’’ Simpson, from Simmo’s Ice-creamy is a public face of Prostate Cancer Awareness in Western Australia and generously donates a specially designed ’Blue Resection’’ ice cream flavour to PROST! inc awareness and education sessions
- AIHW. Australia’s health 2010: The twelfth biennial health report of the Australian Institute of Health and Welfare 2010;12:1-579
- Dornan, P. 2003. Conquering Incontinence.
- Prota C, Gomes C, Ribiero L, de Bassa D. Early post-operative pelvic floor biofeedback improves erectile function in men undergoing radical prostatectomy: A prospective, randomized, controlled trial. Int J Impot Res. 2012;24:174-8.
- Green DJ, Walsh JH, Maiorana A, Best M, Taylor RR, O’Driscoll JG. Exercise-induced improvement in endothelial dysfunction is not mediated by changes in cv risk factors: A pooled analysis of diverse patient populations. Am J Physiol. 2003;285:H2679-2687
- Maiorana A, O’Driscoll G, Dembo L, Cheetham C, Goodman C, Taylor R, Green DJ. Effect of aerobic and resistance exercise training on vascular function in heart failure. Am. J. Physiol. 2000;279:H1999-H2005
- Eyre H, Kahn R, Robertson RM. Preventing cancer, cardiovascular disease, and diabetes: A common agenda for the american cancer society, the american diabetes association, and the american heart association. CA Cancer J Clin. 2004;54:190-207
- Walsh , Parlin A.
- Wittman D, Chang H, Coehlo M, Hollenbeck B, Montie J, Wood D. Patient preoperative expectations of urinary, bowel, hormonal and sexual functioning do not match actual outcomes 1 year after radical prostatectomy. J Urol. 2011;186:494-99.
- Shikanov SA. A prospective report of changes in prostate cancer related quality of life after robotic prostatectomy. J Psych Oncol. 2011;29:1157-167.
- Telekon, Mulhall
- Dorey G, Speakman MJ, Feneley RCL, Swinkels A, Dunn C, Ewings P. Pelvic floor exercises for Erectile Dysfunction BJU Int. 2005;96:595-7. 11.
- Dorey G. Pelvic Floor Exercises for Erectile Dysfunction. London: Whurr Publishers Ltd; 2004.
- Nelson C, Scardino R, Eastham B, Mulhall J. JSM 2013 Vol 10, 6.
- Glina S. Erectile dysfunction after radical prostatectomy.Treatment options. Drugs & Aging. 2011;28(4):257-66.
- Ianco et al 2005, J Urol ).
- Graefen M, et al. Retropubic, laparoscopic and robot-assisted radical prostatectomy: A systematic review and cumulative analysis of comparative studies. Eur Urol. 2009;55(5):1037-63.
- Montorsi F, Nathan HP, McCullough AR, Brock GB, Broderick G, Ahuja S, Whitaker S, Hoover A, Novack D, Murphy A, Varanese L. Tadalafil in the treatment of erectile dysfunction following bilateral nerve sparing radical retropubic prostatectomy: A randomized, double-blind, placebo controlled trial. J. Urol. 2004;172:1036-1041
- Park SW, Kim TN, Nam JK, Ha HK, Shin DG, Lee W, et al. Recovery of overall exercise ability, quality of life, and continence after 12-week combined exercise intervention in elderly patients who underwent radical prostatectomy: A randomized controlled study. Urology. 2012;80:299-306.