The nuts and bolts of prostatectomy
Thu 06, Nov 2014
Australian men on average die 4.3 years earlier than women, yet men’s health receives four times less expenditure - at 35th place, just before parasites. There are 22,000 new prostate cancer cases a year compared to 15,000 new breast cancer cases. This in addition to 78 per cent of men being overweight or obese, 58 per cent not exercising regularly and 79 per cent consuming alcohol most days of the week.
However, if prostate cancer is caught early, 94 per cent can expect to live five years and 92 per cent 10 years, so the opportunity to ”make good’’ should not be underestimated.
Surgery - no matter what kind - is the gold standard treatment for localised prostate cancer, and caught early, the options for improved outcomes are excellent.
Indeed, many post-prostatectomy patients I see today are neither incontinent nor impotent following treatment, despite the expectations.
In 2004, this would have been a miracle. Ten years later, it’s a daily presentation in my physiotherapy clinic. But it takes a lot of work and a team approach.
Although the jury’s still out and research hasn’t quite yet recommended a particular type of surgery over another - open, keyhole or robotic - there are some definite points to consider. Treat your prostate diagnosis like you would research for a new car. Look. Read. Talk. Ask questions. Seek a second opinion. An experienced surgeon should have no qualms about advising you on their number of cases, success and failure rates.
Ask too, before your surgery, if you can have pre-operative pelvic floor muscle training, as it is well established that this makes a significant difference to continence recovery.
Lift nuts to guts - pelvic floor muscle training for men
1. Find yourself a comfortable position; sitting, standing or lying. Let go of all the tension in your belly and shoulders by taking a couple of deep breaths.
2. Focus your attention on your urinary sphincter, the one that starts and stops flow when you urinate. Think of the holding on feeling before a wee or during sex.
3. Forget about squeezing or pulling up your back passage (anal sphincter) or holding your breath. Instead feel the lifting of the scrotum and testicles and then feel a “let go” as they drop. Repeat a few times to get the feeling of letting go. Keep breathing throughout.
4. You may need some biofeedback from a physiotherapist using real-time ultrasound to confirm the correct technique. Meanwhile, stand naked in front of a mirror and you should see your penis retract and scrotum lift slightly with each lift. No six-pack, hip thrusts or breath-holding required!
A combination of fast-twitch (quick, one second) and slow-twitch (long, 2-10 seconds) pelvic floor muscle lifts are essential to help with everyday tasks.
To avoid leakage when coughing, sneezing or for sit-to-stand actions, try a strong, fast-twitch lift before and during the task, then let go.
Long holds are recommended to train for endurance tasks, such as holding on and walking without leakage, but there are no set formulas. Start gently with perhaps three sets per day of five fast-twitch lifts, then five slow-twitch lifts, with an equal rest time between each before gradually building up.
It is generally accepted that following a radical prostatectomy - no matter whether the surgery is open, robotic or keyhole - most men will endure between six and 12 weeks of urinary incontinence, with about 2 per cent requiring reconstructive surgery a year later.
In the initial weeks, your pelvic floor muscles are on a steep learning curve. Removal of the prostate results in a major anatomical rearrangement, and all previous automatic bladder- emptying functions are now manual. This takes time, practice, a few mishaps and some boundary-testing.
No two prostates or patients are the same but in general, most men will follow the same overall pattern of recovery.
Achieving dryness will happen at night first, then when sitting, standing and walking, before gradually improving over a day as the pelvic floor muscle endurance increases. It should take no longer than three to six months to be completely pad-free.
Erectile function recovery
Despite recent advances in outcomes, sexual function is expected to take at least two to four years to improve, with current evidence suggesting only 30 per cent of men will regain pre-operative function. This is because the delicate neurovascular bundles that supply blood flow are either stretched, bruised or removed during surgery.
Today, however, just like early pelvic floor training for incontinence, your urologist should commence penile rehabilitation as soon as possible after surgery.
This typically involves the use of medications (such as Cialis and PDE5 inhibitors) and regular use of a vacuum compression device to stimulate blood flow.
Shortening of the penis (by up to 2cm), urinary leakage during orgasm, infertility and absence of ejaculate fluid are also common and expected side effects you may not be warned about, so ask your urologist or GP for guidance on all of the above. Remember, sex need not only be about penetration, but touch and conversation.
Talk and walk into the future
A prostate cancer diagnosis need not be an end, but a new beginning and an opportunity for the strengthening of relationships and mateship, and a time to invest in your own long-term health.
Although you may feel reluctant, a prostate cancer diagnosis is an important conversation to share with your partner, family and friends. Linking up with a “prostate mate’’ is also a good idea. Your local prostate support group is a great start.
A daily 30 to 45-minute walk will encourage weight loss, strengthen your pelvic floor, clear your head, improve your circulation and increase your general fitness. It will also be a measure of your progress.
But walking with your life partner is my favourite tip. You may find you have so much more to share and blood flow anywhere will help blood flow everywhere.
Jo Milios is a Perth-based physiotherapist who specialises in men’s health. She recently established PROST! Exercise4 Prostate Cancer Inc., a not-for profit organisation that provides exercise and peer support. For further information go to menshealthphysiotherapy.com.au