Physical Therapy for Prostatectomy

By Dr. Brauna Carl, PT, DPT, PRPC, WCS

Prostatectomy is surgical removal of the prostate gland. It’s often a necessary part of cancer treatment, but it comes with negative impacts to quality of life. After prostatectomy, up to 66% of men will leak urine and up to 85% will have erectile dysfunction. Many also experience core weakness and loss of muscle mass, especially if their treatment plan includes testosterone deprivation therapy. Fortunately, there are many resources available to help deal with the mental and emotional consequences of prostatectomy. For the physical consequences, there is pelvic health physical therapy. Up to 92% of men see improvement in strength, continence, and erectile function if they participate in pre- and post-prostatectomy physical therapy. 

Preoperative Physical Therapy: Preparing the Body for Surgery

1. Pelvic Floor Muscle Motor Control: Before prostatectomy, many men never think about staying continent. Most can cough, laugh, sneeze, run, and lift heavy things without leaking urine. After prostatectomy, though, men have to consciously engage their pelvic floor muscles to prevent leaks. It’s much easier to learn how to engage the pelvic floor muscles before they’ve been disrupted by surgery. 
2. Pelvic Floor Muscle Strength: It takes above average pelvic floor muscle strength to remain leak-free after prostatectomy. Beginning a strengthening program before surgery gives you a head start.
3. Core and Hip Strength: Many core and hip muscles help to support the pelvic floor. Getting them in top shape before surgery helps decrease incontinence afterward.
4. Myofascial Flexibility: Tight muscles in the inner thighs, abdomen, buttock, and back can restrict blood flow to the muscles of the pelvic floor and contribute to erectile dysfunction. Physical therapy will show you ways to stretch these tight muscles. 
5. Cardiovascular Fitness: Blood flow to the penis causes erection, and aerobic exercise builds blood vessels. Physical therapists tailor a cardiovascular training routine to help you build stronger blood flow to your penis before surgery so you can return to sexual activity more quickly after surgery.

Postoperative Physical Therapy: Supporting Recovery

1. Addressing Urinary Incontinence: The prostate surrounds the urethra and supports it to help keep urine from leaking out. After prostatectomy, the pelvic floor muscles have to work extra hard to make up for the loss of the support the prostate used to provide. Physical therapy helps by:
   • Guiding you through progressive pelvic floor exercises.
   • Using biofeedback tools to ensure proper muscle activation.
   • Teaching bladder control strategies to reduce leakage.

Research shows that men who participate in pelvic health physical therapy after prostatectomy have fewer leaks and better erections than those who don’t.

1. 1. Managing Abdominal and Pelvic Pain: Post-surgical pain or discomfort in the pelvic region can hinder recovery. Pain is often compounded by radiation, which makes body tissues thinner and less supple. Physical therapy employs techniques like myofascial release, gentle stretching, and relaxation exercises to reduce tension and improve mobility.
   2. Supporting Sexual Function: Erectile dysfunction can be a significant concern after prostatectomy due to potential nerve damage, even in nerve-sparing surgeries. Physical therapy can assist with:
      • Pelvic floor exercises to increase blood flow and support erectile function.
      • Penile rehabilitation including specific guidance on using vacuum erection devices and other tools for improving erectile hardness and endurance and to prevent loss of penile length. 
   3. Improving Overall Mobility and Strength: A tailored exercise program helps rebuild overall strength and mobility, preventing secondary issues like muscle stiffness or back pain, which can result from prolonged immobility during recovery.

• Improving Emotional and Psychological Factors: Physical therapy provides more than just physical benefits—it can also enhance mental well-being. The structured approach offers patients a sense of control over their recovery, reducing feelings of helplessness or frustration. Additionally, therapists often provide encouragement and emotional support, fostering a positive outlook.

Key Takeaways

Incorporating physical therapy before and after prostatectomy is a proactive step toward a smoother recovery and improved quality of life. By focusing on pelvic floor health, pain management, and overall fitness, patients can regain continence, mobility, and confidence more quickly.

If you or a loved one is preparing for or recovering from prostatectomy, consult one of the qualified physical therapists from Physical Therapy Your Way to develop a personalized care plan. Investing in physical therapy is an investment in your health, comfort, and long-term well-being.

Every week, I see men who have been told that they have prostatitis. Naturally, they think there’s something wrong with their prostate gland that’s making it inflamed – bacterial infection, injury, autoimmune disorder. After all, “itis” is a suffix that means “inflammation,” and “prostate” means, well, “prostate.” Arthritis is inflammation of the joints. Colitis is inflammation of the colon. Bronchitis is inflammation of the lungs. But often prostatitis isn’t inflammation of the prostate. It’s tightness or dysfunction of the pelvic floor muscles that lie beneath the prostate. 

When the pelvic floor muscles dysfunction, it may cause pain in the lower abdomen, back, perineum, scrotum, testicles, or anus. It may cause painful or frequent urination. It may cause erectile dysfunction or make orgasm painful. These symptoms are typical of actual inflammation of the prostate, hence the confusion. Unfortunately, many who seek help for these symptoms are prescribed round after round of antibiotics without even being tested for bacterial infection. The antibiotics don’t solve the problem because bacterial infection isn’t causing them. 

Pelvic floor physical therapy is among the treatments that are helpful in decreasing symptoms of “nonbacterial prostatitis” because the symptoms aren’t coming from the prostate, they’re coming from the pelvic floor!

Pelvic Organ Prolapse

My inspiration for this post is that on the evening of September 24th, my amazing colleague, Dr Nadia Wahid, will be giving a talk on pelvic organ prolapse. If you want to get a head start on the topic, please read on . . .

Definition

Pelvic organ prolapse occurs when an internal organ presses into the vagina. It may create a sensation of pressure in the lower abdomen, back, or perineum, or make it feel as if something is bulging out of the vagina. If prolapse is severe enough, a pelvic organ may actually bulge out of the vagina.

Risk Factors

There are several risk factors for pelvic organ prolapse including pregnancy, childbirth, obesity, frequent coughing or sneezing, lifting heavy weights with poor breathing techniques, or participating in high-impact exercise without proper shock absorption from your legs, and hypermobility such as in connective tissue disorders such as Ehlers Danlos Syndrome, and laxity of body tissues due to menopause and aging.

Types

Organs in the pelvis that are capable of prolapsing include the urethra, bladder, uterus, vaginal vault, intestines, or rectum. Here is a brief description of each type of prolapse:

• Urethracele: Prolapse of the urethra.
• Cystocele: Prolapse of the bladder.
• Cystourethracele: Prolapse of both urethra and bladder.
• Uterine Prolapse: Prolapse of the uterus.
• Vaginal Vault Prolapse: May occur after hysterectomy. Prolapse of the proximal vagina, the part of that was closest to the uterus before the uterus was surgically removed.
• Enterocele: Prolapse of the small intestine. 
• Rectocele: Prolapse of the rectum into the posterior wall of the vagina.
• Rectal Prolapse: Prolapse of the rectum coming out of the anus. 

Grading

Pelvic organ prolapse is graded by severity, with zero indicating that there is no evidence of prolapse and 4 being complete eversion. In stage 4, the organ slips entirely outside the vaginal opening.

Because of the effects of gravity, the severity of pelvic organ prolapse changes based on time of day and activity level. Often, prolapse is less pronounced in the morning, because most people lie down to sleep and have had many hours without gravity pulling the prolapsed organ toward the vaginal opening. Prolapse is typically more pronounced at the end of the day, after vigorous exercise, or after repeated coughing or other increases in abdominal pressure pushing down onto the pelvic organs. It’s very possible for one of your healthcare providers to diagnose you with a grade 1 prolapse and another to say you’re a grade 2. It will all depend on the time of day that you are tested, what your activity level has been like that day, the position in which you are tested, and whether you are asked to cough or bear down during testing. If you are tested in the morning and tested lying down on your back without coughing, you will likely not be graded with as severe a prolapse as you would have been if you had seen your provider in the evening, after an active day, were tested standing up in a wide squat, and asked to cough. 

Physical Therapy Treatment

A pelvic floor physical therapist will grade your prolapse, test your muscle function, assess your posture and work with you to develop a plan to decrease symptoms associated with pelvic organ prolapse. Typical symptoms include feelings of heaviness or pressure, difficulty initiating urination or defecation, difficulty completely emptying the bowel or bladder, urinary or fecal incontinence, constipation, and urinary urgency or frequency among others. 

Physical therapy is effective in decreasing symptoms associated with grade 1 and 2 prolapse. Therapy may include muscle strengthening or stretching, exercise, visceral manipulation, breath control, posture corrections, practicing lifting and carrying objects with good form, and training in exercise modifications. Therapy will include whatever treatments are most appropriate to your specific symptoms, concerns, priorities, and lifestyle.

If you don’t get enough symptom relief from physical therapy alone for a grade 1 or 2 prolapse, or if you have a grade 3 or 4 prolapse, your therapist may suggest use of a vaginal pessary.  

Pessaries

A pessary is a device that provides support for the pelvic organs much like a bra provides support for the breasts.

If you and your therapist think a pessary may be a good option for you, you may want to start with an over-the-counter product. The Revive pessary is inserted much like a large tampon. This silicone bladder support may be cleaned and reused for up to a month. Another over-the-counter is the Poise Impressa. It’s also inserted like a tampon, but it is disposable. It comes in three sizes. Size 1 is the smallest and size 3 is the largest. You should start at the smallest size and gradually size up as needed to further improve your symptoms. 

While the above options may help, many women find it is even better to have their therapist fit them for a pessary. These fitted pessaries provide much more customization than do the over-the-counter options. They may be used for many years before being replaced so long as they are worn, removed, cleaned, and stored property. Below is an example of some pessary shapes. There are even more shapes and sizes than those shown. Your pelvic health physical therapist will help you find the one that is best for you. 

Pessaries are often a helpful supplement to pelvic floor physical therapy for non-surgical treatment of pelvic organ prolapse. When used as part of a comprehensive treatment plan that also addresses posture, breathing, muscle training, and activity modification, the pessary may be useful in decreasing bowel, bladder, sexual, or pelvic pain problems caused by prolapse. 

Summary

There are effective non-surgical treatments for pelvic organ prolapse. Please attend the Physical Therapy Your Way virtual community event on 9/24/24 at 7pm. 

Click Here to Register for this free informative event: https://form.jotform.com/83005883557160

Physical Therapy Your Way blog by

Dr. Brauna Carl, PT, DPT

Women’s Health Clinical Specialist (WCS)

Pelvic Rehabilitation Practitioner Certification (PRPC)

Got Biofeedback?

“Do you have biofeedback?” If I had a nickel for every time somebody asked me that question, I’d have a few dollars, at least.

I get why people ask it. Some have been to a doctor who tells them they need a therapist who “has” biofeedback. Others read about biofeedback on the internet. The question drives me a little nuts because biofeedback isn’t a specific thing to have. There’s no special equipment that IS biofeedback. Sometimes specialized equipment helps, and we have that equipment at Physical Therapy Your Way. But at its essence biofeedback is the process of providing conscious awareness of a normally unconscious body movement or action. 

Low-Tech Biofeedback: words, touch, a mirror

Sometimes really simple tools are all that’s needed for biofeedback. Here’s an orthopedic example:

I ask someone to raise their right arm until it’s parallel to the floor. They try, but it’s not quite right. I then tell them to lift a little higher or lower until they achieve the desired position. That’s biofeedback. They weren’t aware of where their arm was in space. My verbal cueing made them aware and allowed them to correct it. 

Tactile cueing is also biofeedback. To provide tactile biofeedback, I might physically adjust the person’s arm until it’s parallel to the floor or ask them to lift their arm until it touches an object I set to their shoulder height.  It would also be biofeedback if I ask them to look in a mirror. They’d get visual feedback as to where their arm is, could make adjustments, and see the results of those adjustments in the mirror. 

Sometimes verbal cueing, tactile cueing, or mirror training is the best biofeedback for a pelvic health patient. If we are trying to get a patient to contract her pelvic floor muscles, for example, we may cue her to use the muscles that stop the flow of urine and then provide verbal feedback on how to use them more effectively. Or for tactile biofeedback, we may insert a finger vaginally to give the patient something to squeeze her muscles around. For visual biofeedback, we may give the patient a mirror so she can see her perineum move. 

Electromyographic Biofeedback

What most people are referring to when they ask if we have biofeedback is electromyography. We do, but it’s not always necessary or even helpful to use. In electromyography (EMG), an internal vaginal or rectal electrode or external electrodes over the skin measure the electrical signals nerves send to muscles. The amplitude of those electrical signals is then displayed on a monitor, providing visual feedback to the user. Some units simply show a number, others light up, and still others allow users to essentially play games by either contracting or relaxing their pelvic floor muscles. 

The trouble with EMG is that the electrodes, whether internal or external, pick up electrical signals not only from the target muscles but also from those around them. Let’s say we place surface electrodes near the anus, as is often done in pelvic floor biofeedback. Those electrodes will also detect nerve signals coming from the glutes. It takes a skilled therapist to ensure the visual biofeedback that the EMG unit displays is actually reflecting the desired motion rather than a cheat or compensation. 

EMG is really great for making sure muscles stay relaxed because you can’t cheat relaxation. What EMG can’t detect, though, is an electrically silent short and tight muscle. Let’s say for example your pelvic floor muscles are really short but the nerves are not actively trying to contract the muscle. EMG won’t detect that. Internal palpation will. 

So, in other words, EMG biofeedback is a useful tool, but it’s not the only way to provide biofeedback, and if it’s not interpreted by a knowledgeable practitioner, the feedback it provides may be unreliable.

Real-Time Ultrasound Biofeedback

The same goes for real-time ultrasound biofeedback. If it’s not interpreted by a knowledgeable therapist, it may provide misleading information. Now don’t get me wrong, I love my ultrasound. I use it every day. It’s super cool because it allows us to see inside the body, to see what muscles are doing as they’re doing it, to see organs move as we breathe. Love, love, love.

If you don’t know what you’re doing with ultrasound, though, you might misinterpret the results. 

Let’s say for example, you want to use ultrasound biofeedback to see if a patient can bulge his pelvic floor and allow it to lengthen toward his feet.  You might use this motion if you have feces that’s stuck halfway out the anus and you want to give it a push so it comes all the way out. Or you might bulge the pelvic floor if you’re pushing to deliver a baby. To correctly bulge, the breathing diaphragm and abdominal muscles contract to increase pressure in the abdomen and pelvis while the pelvic floor muscles relax and passively lengthen in response to the increased pressure. 

Ultrasound over the abdomen will show the net result of your bulging efforts. It’ll show if the pelvic floor is lifting up toward your head or expanding downward toward your feet. What it won’t show is if your pelvic floor muscles are helping or hindering this overall effort. It’s entirely possible for the pelvic floor to appear to bulge even though the pelvic floor muscles are contracting. The pelvic floor muscles may be doing the wrong thing, but the ab muscles are still overpowering them, so the net result looks correct even though it really isn’t. 

Summary

So you can see that “having biofeedback” isn’t really enough. You don’t need a certain technology to gain awareness of your body. Instead, you need to be sure whatever method you’re using is being applied correctly. Besides, the end goal of biofeedback is to stop using it — to stop relying on external tools, to tune into your body rather than tuning into a display screen.

“You must’ve been a strange kid.” That was my patient’s comment as I held a plastic model of a pelvis and paused for a moment as I was explaining pelvic anatomy and what I’d be checking during her exam.

“Why would you say that?” I asked, truly bewildered.

“Because you do this for a living,” she said.

I remember my next thought – a sarcastic comment I kept to myself – but I don’t remember what I said. Maybe I laughed awkwardly, or changed the subject. I don’t know.

It’s not strange to be a pelvic health physical therapist or to want to be one! What’s strange, or maybe just unfortunate, is to ignore parts of our bodies because it’s socially taboo to discuss them. I’ve met adult women who don’t know their clitoris from their urethra and adult men who don’t know that they too have a pelvic floor.

The blogger as an 8-year-old, eating her sister’s birthday cake – yum!

Physical therapy graduate programs are beginning to add pelvic health into their curricula, but barely. My program had a guest lecturer on the subject, but if I remember correctly, it was one lecture out of 3 years of school.

My first introduction to pelvic health physical therapy was at the clinic I ultimately would fall in love with – Back in Motion Physical Therapy. I was fortunate to be placed at Back in Motion for both part-time and full-time clinical experiences during grad school. Once I graduated and passed my national board certification exam, I started working at the clinic. In 2018, Back in Motion moved pelvic health to our sister practice, Physical Therapy Your Way Advanced and Specialty Care.

It makes perfect sense to have therapists trained in rehabilitation (and prehabilitation) of the pelvic floor! The pelvic floor is responsible for so many important life functions: bowel and bladder control, core stability, organ support, fluid movement, sexual function. If something goes wrong with an area of the body that’s so vital, why wouldn’t we rehab it? Or, even better, why wouldn’t we get routine pelvic health checkups to help prevent anything from going wrong?

I’m not going to argue that traditional orthopedic physical therapy isn’t important. It is. But think about this . . . If someone twists his ankle and tears a ligament playing basketball, we rehab that ankle. If someone tears her pelvic floor delivering a 10-pound baby, we should rehab that too. The pelvic floor is made up of muscles, nerves, connective tissues, all the structures physical therapists work on. We shouldn’t ignore the pelvic floor just because the body parts there are private.

The main nerve to skeletal muscle in the pelvic floor is called the pudendal nerve. The name comes from the Latin “pudenda,” which translates roughly to “shameful.” Really? We need to stop perpetuating the idea that there’s anything shameful about the pelvic floor, or about our bowel, bladder, or sexual functions. And, I’d argue, there’s nothing weird about specializing in helping people maintain continence, decrease pain, or improve sexual function. In fact, it’s really quite rewarding.

I love what I do. The human body is endlessly fascinating. I’m continually studying anatomy and physiology, listening to pelvic health podcasts, attending webinars, going to in-person continuing education courses and seminars, and practicing therapy techniques. I’ll talk about sexual function just as readily and easily as I’ll talk about shoulder function. It’s not shameful. It’s important. If that makes me strange, then I guess I’m strange.

The blogger now, Dr. Brauna Carl, PT, DPT.

Great question! In 2019, three Pelvic Floor therapists developed return to running guidelines and established certain benchmarks for post-partum women. While research is still lacking in this area, these guidelines and benchmarks are a collection of the best practice information we have at the moment. ..

A few take-away’s:

Running is a high-impact activity is associated with a sudden rise in intra-abdominal pressure and; therefore, a lot of that pressure and forces are transmitted through the pelvic floor. It highlights the importance of having a strong pelvic floor musculature and to be able to address the increased load on the muscles of the pelvis.

• • Return to running is not advisable if any of the following subjective issues are identified during screening: Urinary or fecal leakage prior to or while running, pressure/bulge/dragging of the vagina prior to and/or during running, ongoing vaginal bleeding not related to menstrual cycle during or after attempted low impact or high impact exercise, or other musculoskeletal pain (i.e. pelvic pain prior to or during the commencement of running.
  • Aim to return to running between 3-6 months part-partum provided that you can pass the criteria listed below for both:1. load and impact management and 2. strength testing.

Lisa Pan, PT, DPT
Staff Physical Therapist
Pelvic Therapy Your Way