By Dr Jo Milios (PhD), Men’s Health & Research Physiotherapist (MACP)
In 2005, in pursuit of acquiring some post-graduate education in men’s health as a physiotherapist and keen to upskill in prostate cancer management, I was shocked to find I had nowhere to go for basic information. At the request of my brother — a urologist who was pioneering the laparoscopic radical prostatectomy (RP) approach in Western Australia — my directive was to develop a men’s health service for patients likely to acquire urinary incontinence (UI) following surgery, utilising pelvic floor muscle training (PFMT). Initially, this was to form part of a post-op rehabilitation program, with a focus on continence management. Hence, patients were not assessed or screened by me prior to surgery, only after the fact. Without an academic training course available, my knowledge, therefore, evolved from observing urologists at work in theatre, seeking out international experts and delving into the limited research published in my chosen field1. However, I soon discovered that the gurus I would learn most from were, in fact, the very men sitting before me. There were so many gaps to fill as patient after patient (there have now been >4000) taught me the nuts and bolts of life after a diagnosis of prostate cancer.
Having observed scores of men who had the opportunity to prepare with me prior to surgery in comparison to those that didn’t, I quickly ascertained that a man’s rehabilitation should actually start with prehabilitation at the point of diagnosis. The huge disparity, despair and dire volumes of leakage between the “prepared’’ and the ‘’not’’ was too obvious to ignore, so we quickly changed practise. The opportunity to meet with men prior to surgery enabled me to physically prepare them for the expected side effects and, more importantly, develop trust, rapport and an understanding that I was part of their wider support team. The goal, I explain from the outset, is to achieve FULL continence within three months of surgery, with many achieving dryness much faster and just a few, a little longer than that. But only if the prep work is done.
The three focuses of prehabilitation
- To improve overall fitness to assist physical recovery, a one-hour daily walk is highly recommended. Any extra gym/cycle/swim or attendance at a dedicated program such as Prost is a huge bonus. The fitter, the better!
- To lose 5-10kg weight to assist surgical precision for improved oncological outcomes and reduced load on the pelvic floor
- To commence pelvic floor exercises specific to male anatomy under the supervision of an experienced pelvic health physiotherapist or urology nurse.
Most men are often shocked and unprepared for a cancer diagnosis, and this trio of tasks will usually provide a man with a positive focus and empowerment during a very uncertain time. Regrettably, there is 70% increased risk of suicide in men diagnosed with prostate cancer2. Physical applications can do much to alleviate the mental health and quality-of-life implications3.
What prehabilitation involves
Prostate removal will typically result in urinary incontinence and erectile dysfunction (ED), so it’s essential to learn how to perform contractions of the three major pelvic floor muscles (PFM) that control these functions — the external urethral sphincter (EUS), bulbocavernosus (BC) and puborectalis (PR)4. However, given that most men I’ve met in our initial consultation don’t even know they have a pelvic floor, getting the technique and language right has had its own challenges.
Today, I guide men to focus on the sensation of “stopping the flow of urine” at the same time as relaxing their belly and buttock muscles to activate the urinary sphincter (EUS). Men can practice this during urination. Next, “drawing in or retracting the penis’’ and “lifting the testicles’’ activates the remaining PFMs (BC, PR) to compress the bulb of the urethra responsible for urinary continence control. All three muscles simultaneously work together on the inside of the pelvis, easily visualised with real-time ultrasound techniques. For home practise I encourage men to stand naked in front of a mirror and to observe their penis retracting and testes rising, without bracing their abdominals. Doing this action “gently” as opposed to with “gusto’’ is the key. My favourite cue — which men seem to best relate to — is to think of “lifting the nuts to the guts’’. Men can perform these exercises anywhere, any time and a high-intensity interval training (HIIT) protocol is now recommended as best practice.
Benefits of prehabiliation
Unfortunately, research in men’s pelvic health has been lacking for many years and so the benefits of PFM prehabilitation have been difficult to prove. However, keen to mirror the positive results seen clinically, our recently published randomised control trial showed 74% of men who averaged five weeks of pre-op training with high-intensity PFM exercise were pad-free and fully continent within 12 weeks of surgery5. Specifically, the intervention program consisted of six sets of PFM exercises per day performed in a standing posture and included both fast (10 x 1 sec) and slow (10 x 10 sec) twitch PFM fibre training to a total of 120 exercises per day. This was contrasted to a standard care program recommended for women, consisting of the sets of slow-twitch PFM (10 sec holds x 10) in either sitting, standing or lying positions.
When comparing the intervention versus control groups post-operatively, 1 in 6 were never incontinent from the outset, there was 50% less leakage and pad use (100g leakage vs 200g per 24 hours) and the duration of time to complete continence control was significantly faster (74% vs 43% at 12 weeks).
Fortunately, more research is now emerging with a recently published systematic review highly recommending prehabilitation6,7 in alignment with our own findings.
Who can help?
The good news is everyone can help with guiding patients to a prehabilitation program. GPs and specialists can refer to physiotherapists with a special interest in men’s health via APA’s Find a Physio listings. Additionally, dedicated prostate cancer nurses can be accessed in person or via telehealth through the Prostate Cancer Foundation (PCFA) and the Continence Foundation of Australia (CFA).
My take-home message, however, is that it’s never too soon or too late to refer a patient for PFMT. Continence and sexual function can be addressed and improved by a program personalised to the individual at any time. No two men are ever the same and if a man understands there’s a starting point and an end point, with work and effort required along the way, he too should thrive. Fusing research and reality, however, capitalising on the recommended six-week time frame between biopsy/diagnosis and surgery, is the critical difference. Prehabilitation works and we shouldn’t waste a minute.
The Prostate Cancer Foundation
Continence Foundation of Australia
Australian Physiotherapy Association
PROST! Exercise 4 Prostate Cancer
Read more: Prostate cancer
 Anderson CA, Omar MI, Campbell SE, Hunter KF, Cody JD, Glazener CM. 2015. Conservative management for post-prostatectomy urinary incontinence. The Cochrane Database of Systematic Reviews
 Smith DP, Calopedos R, Bang A, et al. 2018. Increased risk of suicide in New South Wales men with prostate cancer: Analysis of linked population-wide data. PloS One
 Avery JC, Stocks NP, Braunack-Mayer A, Taylor A, Goldney R, MacLennan A. 2013. Identifying the quality of life effects of urinary incontinence with depression in an Australian population. BMC Urol
 Stafford RE, Ashton-Miller JA, Constantinou CE, Hodges PW. 2012. Novel insight into the dynamics of male pelvic floor contractions through transperineal ultrasound imaging. J Urol
 Milios, J.E., Ackland, T.R. & Green, D.J. 2019. Pelvic floor muscle training in radical prostatectomy: a randomized controlled trial of the impacts on pelvic floor muscle function and urinary incontinence. BMC Urol https://doi.org/10.1186/s12894-019-0546-5
 Goonewardene SS, Gillatt D, Persad R. 2018. A systematic review of PFE pre-prostatectomy. J of Robotic Surg
 Nahon I. 2021. Physiotherapy management of incontinence in men. J Physiotherapy