Effectiveness of Pelvic Floor Muscle Training Alone and in Combination With Biofeedback, Electrical Stimulation, or Both Compared to Control for Urinary Incontinence in Men Following Prostatectomy: Systematic Review and Meta-Analysis

Retzius sparing robot-assisted radical prostatectomy: optimizing functional results

PURPOSE

The aim of this study is to critically evaluate the existing body of evidence regarding the efficacy of Retzius-sparing radical prostatectomy (RS-RARP) in achieving improved functional outcomes. Moreover, we explored possible strategies to further optimize functional outcomes.

METHODS

Following PRISMA guidelines, a systematic review (PROSPERO ID CRD42024539915) was performed on 9th September 2023 on PubMed, Scopus, and Web of Science. Only original articles in the English language reporting functional outcomes after RS-RARP were included.

RESULTS

Overall, the search string yielded 99 results on PubMed, 122 on Scopus, and 120 on Web Of Science. After duplicate exclusion, initial screening and eligibility evaluation, a total of 47 studies were included in the qualitative analysis, corresponding to a cohort of 13.196 patients. All studies reported continence recovery. RS-RARP appeared to achieve better and faster continence recovery compared to S-RARP. However, it should be noted that continence definition was heterogeneous and not based on validated condition-specific questionnaires. Seven (15%) studies provided for any sort of rehabilitation for urinary incontinence after RS-RARP. 22 studies analyzed potency recovery rates, showing no difference between RS-RARP and S-RARP. The evaluation of this outcome poses a great challenge due to the lack of standardized assessment tools and reporting methods. Only two studies reported on the consistent use of post-operative PDE5i as penile rehabilitation.

CONCLUSIONS

The current review highlights the satisfactory functional results of Retzius-sparing robot assisted radical prostatectomy, which holds true irrespective of disease stage and prostate volume, with promising results even in patients previously treated for BPH or in the salvage setting. How can we optimize those results? The answer does not probably lie in further refinement of the surgical technique, but in giving greater attention to patient counselling and rehabilitation strategies in order to minimize regret and maximize satisfaction.

Effects of different treatment frequencies of electromagnetic stimulation for urinary incontinence in women: study protocol for a randomized controlled trial

BACKGROUND

Urinary incontinence is highly prevalent in women while pelvic floor muscle training is recommended as the first-line therapy. However, the exact treatment regimen is poorly understood. Also, patients with pelvic floor muscle damage may have decreased muscle proprioception and cannot contract their muscles properly. Other conservative treatments including electromagnetic stimulation are suggested by several guidelines. Thus, the present study aims to compare the effectiveness of electromagnetic stimulation combined with pelvic floor muscle training as a conjunct treatment for urinary incontinence and different treatment frequencies will be investigated.

METHODS/DESIGN

This is a randomized, controlled clinical trial. We will include 165 patients with urinary incontinence from the outpatient center. Participants who meet the inclusion criteria will be randomly allocated to three groups: the pelvic floor muscle training group (active control group), the low-frequency electromagnetic stimulation group (group 1), and the high-frequency electromagnetic stimulation group (group 2). Both group 1 and group 2 will receive ten sessions of electromagnetic stimulation. Group 1 will be treated twice per week for 5 weeks while group 2 will receive 10 days of continuous treatment. The primary outcome is the change in International Consultation on Incontinence Questionnaire-Short Form cores after the ten sessions of the treatment, while the secondary outcomes include a 3-day bladder diary, pelvic floor muscle function, pelvic organ prolapse quantification, and quality of life assessed by SF-12. All the measurements will be assessed at baseline, after the intervention, and after 3 months of follow-up.

DISCUSSION

The present trial is designed to investigate the effects of a conjunct physiotherapy program for urinary incontinence in women. We hypothesize that this strategy is more effective than pelvic floor muscle training alone, and high-frequency electromagnetic stimulation will be superior to the low-frequency magnetic stimulation group.

Effect of transcranial direct current stimulation combined with pelvic muscle training in women: Randomized, controlled, double-blind, and clinical trial

BACKGROUND

Pelvic floor muscle training (PFMT) is widely used for pelvic floor muscle (PFM) weakness in women; however, it has no prolonged effects.

OBJECTIVE

To evaluate the effect of Transcranial Direct Current Stimulation (tDCS) associated with PFMT on PFM contraction, sexual function and quality of life (QoL) in healthy women.

STUDY DESIGN

32 nulliparous women, aged 22.7 ± 0.42 years, were randomized into two groups: G1 (active tDCS combined with PFMT) and G2 (sham tDCS combined with PFMT). The treatment was performed three times a week for 4 weeks, totaling 12 sessions. PFM function was assessed using the PERFECT scheme (P = power, E = endurance, R = repetitions, F = rapid contractions, ECT = each timed contraction) and the perineometer (cmH2O). Sexual function was assessed by The Female Sexual Function Index, and QoL by the SF-36 questionnaire. These assessments were performed before and after the 12nd treatment session and after 30-day follow-up.

RESULTS

There was a significant increase (p = 0.037) in the power of G2 compared to G1; repetitions and fast contraction increased in the G1 group, and the resistance increased in both groups, however, without statistical difference between the groups. ECT increased in the G1 group (p = 0.0).

CONCLUSION

Active tDCS combined with PFMT did not potentiate the effect of the PFMT to increase the PFM function, QoL, and sexual function in healthy women. However, adjunctive tDCS to PFMT improved the time of contractions, maintaining it during follow-up.

Contribution of pudendal nerve injury to stress urinary incontinence in a male rat model

Urinary incontinence is a common complication following radical prostatectomy, as the surgery disturbs critical anatomical structures. This study explored how pudendal nerve (PN) injury affects urinary continence in male rats. In an acute study, leak point pressure (LPP) and external urethral sphincter electromyography (EMG) were performed on six male rats with an intact urethra, the urethra exposed (UE), the PN exposed (NE), and after PN transection (PNT). In a chronic study, LPP and EMG were tested in 67 rats 4 days, 3 weeks, or 6 weeks after sham PN injury, PN crush (PNC), or PNT. Urethras were assessed histologically. Acute PNT caused a significant decrease in LPP and EMG amplitude and firing rate compared to other groups. PNC resulted in a significant reduction in LPP and EMG firing rate 4 days, 3 weeks, and 6 weeks later. EMG amplitude was also significantly reduced 4 days and 6 weeks after PNC. Neuromuscular junctions were less organized and less innervated after PNC or PNT at all timepoints compared to sham injured animals. Collagen infiltration was significantly increased after PNC and PNT compared to sham at all timepoints. This rat model could facilitate preclinical testing of neuroregenerative therapies for post-prostatectomy incontinence.

Six-Month Prostate Cancer Empowerment Program (PC-PEP) Improves Urinary Function: A Randomized Trial

Purpose: This is a secondary analysis examining a six-month home-based Prostate Cancer-Patient Empowerment Program (PC-PEP) on patient-reported urinary, bowel, sexual, and hormonal function in men with curative prostate cancer (PC) against standard of care. Methods: In a crossover clinical trial, 128 men scheduled for PC surgery (n = 62) or radiotherapy with/without hormones (n = 66) were randomized to PC-PEP (n = 66) or waitlist-control and received the standard of care for 6 months, and then PC-PEP to the end of the year. PC-PEP included daily emails with video instructions, aerobic and strength training, dietary guidance, stress management, and social support, with an initial PFMT nurse consultation. Over 6 months, participants in the PC-PEP received optional text alerts (up to three times daily) reminding them to follow the PFMT video program, encompassing relaxation, quick-twitch, and endurance exercises; compliance was assessed weekly. Participants completed baseline, 6, and 12-month International Prostate Symptom Score (IPSS) and Expanded Prostate Cancer Index Composite (EPIC) questionnaires. Results: At 6 months, men in the PC-PEP reported improved urinary bother (IPSS, p = 0.004), continence (EPIC, p < 0.001), and irritation/obstruction function (p = 0.008) compared to controls, with sustained urinary continence benefits at 12 months (p = 0.002). Surgery patients in the waitlist-control group had 3.5 (95% CI: 1.2, 10, p = 0.024) times and 2.3 (95% CI: 0.82, 6.7, p = 0.11) times higher odds of moderate to severe urinary problems compared to PC-PEP at 6 and 12 months, respectively. Conclusions: PC-PEP significantly improves lower urinary tract symptoms, affirming its suitability for clinical integration alongside established mental health benefits in men with curative prostate cancer.

The added value of devices to pelvic floor muscle training in radical post-prostatectomy stress urinary incontinence: A systematic review with metanalysis

PURPOSE

To investigate the role of pelvic floor devices (e.g., biofeedback, electrical stimulation, magnetic stimulation, or their combination) as adjunctive treatments in pelvic floor muscle training (PFMT) in stress urinary incontinence (SUI) after radical prostatectomy.

MATERIALS AND METHODS

A systematic review with meta-analysis. We searched for randomised controlled trials (RCTs) and prospective non-randomised studies investigating the effectiveness of pelvic floor devices as an adjunctive treatment for SUI symptoms assessed with weight pad-test or standardised questionnaires. To assess the risk of bias (RoB) and overall certainty of evidence, the RoB 2.0 or the ROBINS-I, and the GRADE approach were used.

RESULTS

Eleven RCTs met our eligibility criteria. One was at a 'low' RoB, one had 'some concerns', while nine were at a 'high' RoB. Two meta-analyses were conducted to analyse the pooled results of six RCTs included. Specifically, two RCTs reported at week 4 with a 1h pad test a mean difference of 0.64 (95% CI = [-13.09, 14.36]), and four RCTs reported at week 12 with a 24h pad test a mean difference of -47.75 (95% CI = [-104.18, 8.69]). The heterogeneity was high in both analyses (I2 = 80.0%; I2 = 80.6%). The overall level of certainty was very low.

CONCLUSIONS

In line with our results, we cannot conclude whether pelvic floor devices add any value as adjunctive treatment in the management of SUI after radical prostatectomy. Future studies require more comprehensive and standardised approaches to understand whether these devices are effective.

Pelvic Floor Muscle Training for Urinary Incontinence After Radical Prostatectomy: A Narrative Review

Rehabilitative treatment of urinary incontinence after prostatectomy has showed, on the basis of recent published evidence, encouraging results. At first, clinician applied evaluation and treatment approach suggested based on the studies and rationale of female stress urinary incontinence, but although long term literature suggested no evidence of benefits. Recent studies that have shown the real control mechanisms in male continence through the use of trans-perineal ultrasound, demonstrated that it is not appropriate to transfer the rehabilitation techniques applied in female stress incontinence to male incontinence after prostatectomy. Even that pathophysiology of urinary incontinence after prostatectomy is not fully understood, it's in part attributable to a urethral or bladder source. In particular, however, urethral sphincter dysfunction is predominant, secondary to surgical damage and to the partly organic and partly functional dysfunction of the external urethral sphincter; complementary action of all the muscles capable of contributing to the maintenance of urethral resistance is therefore important. As for rehabilitative approach to post-prostatectomy incontinence, the primary objective is to quantify the residual capacity of the muscular function that must replace the sphincter function, often compromised by surgery. Than a multimodal approach, comprising exercise and instrumental therapies, is needed. The present paper's aim was to overview current urinary dysfunction knowledge for male with radical prostatectomy, and to describe practical issue of evaluation and conservative treatment.

Conservative interventions for managing urinary incontinence after prostate surgery

BACKGROUND

Men may need to undergo prostate surgery to treat prostate cancer or benign prostatic hyperplasia. After these surgeries, men may experience urinary incontinence (UI). Conservative treatments such as pelvic floor muscle training (PFMT), electrical stimulation and lifestyle changes can be undertaken to help manage the symptoms of UI.

OBJECTIVES

To assess the effects of conservative interventions for managing urinary incontinence after prostate surgery.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearched journals and conference proceedings (searched 22 April 2022). We also searched the reference lists of relevant articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of adult men (aged 18 or over) with UI following prostate surgery for treating prostate cancer or LUTS/BPO. We excluded cross-over and cluster-RCTs. We investigated the following key comparisons: PFMT plus biofeedback versus no treatment; sham treatment or verbal/written instructions; combinations of conservative treatments versus no treatment, sham treatment or verbal/written instructions; and electrical or magnetic stimulation versus no treatment, sham treatment or verbal/written instructions.

DATA COLLECTION AND ANALYSIS

We extracted data using a pre-piloted form and assessed risk of bias using the Cochrane risk of bias tool. We used the GRADE approach to assess the certainty of outcomes and comparisons included in the summary of findings tables. We used an adapted version of GRADE to assess certainty in results where there was no single effect measurement available.

MAIN RESULTS

We identified 25 studies including a total of 3079 participants. Twenty-three studies assessed men who had previously undergone radical prostatectomy or radical retropubic prostatectomy, while only one study assessed men who had undergone transurethral resection of the prostate. One study did not report on previous surgery. Most studies were at high risk of bias for at least one domain. The certainty of evidence assessed using GRADE was mixed. PFMT plus biofeedback versus no treatment, sham treatment or verbal/written instructions Four studies reported on this comparison. PFMT plus biofeedback may result in greater subjective cure of incontinence from 6 to 12 months (1 study; n = 102; low-certainty evidence). However, men undertaking PFMT and biofeedback may be less likely to be objectively cured at from 6 to 12 months (2 studies; n = 269; low-certainty evidence). It is uncertain whether undertaking PFMT and biofeedback has an effect on surface or skin-related adverse events (1 study; n = 205; very low-certainty evidence) or muscle-related adverse events (1 study; n = 205; very low-certainty evidence). Condition-specific quality of life, participant adherence to the intervention and general quality of life were not reported by any study for this comparison. Combinations of conservative treatments versus no treatment, sham treatment or verbal/written instructions Eleven studies assessed this comparison. Combinations of conservative treatments may lead to little difference in the number of men being subjectively cured or improved of incontinence between 6 and 12 months (RR 0.97, 95% CI 0.79 to 1.19; 2 studies; n = 788; low-certainty evidence; in absolute terms: no treatment or sham arm: 307 per 1000 and intervention arm: 297 per 1000). Combinations of conservative treatments probably lead to little difference in condition-specific quality of life (MD -0.28, 95% CI -0.86 to 0.29; 2 studies; n = 788; moderate-certainty evidence) and probably little difference in general quality of life between 6 and 12 months (MD -0.01, 95% CI -0.04 to 0.02; 2 studies; n = 742; moderate-certainty evidence). There is little difference between combinations of conservative treatments and control in terms of objective cure or improvement of incontinence between 6 and 12 months (MD 0.18, 95% CI -0.24 to 0.60; 2 studies; n = 565; high-certainty evidence). However, it is uncertain whether participant adherence to the intervention between 6 and 12 months is increased for those undertaking combinations of conservative treatments (RR 2.08, 95% CI 0.78 to 5.56; 2 studies; n = 763; very low-certainty evidence; in absolute terms: no intervention or sham arm: 172 per 1000 and intervention arm: 358 per 1000). There is probably no difference between combinations and control in terms of the number of men experiencing surface or skin-related adverse events (2 studies; n = 853; moderate-certainty evidence), but it is uncertain whether combinations of treatments lead to more men experiencing muscle-related adverse events (RR 2.92, 95% CI 0.31 to 27.41; 2 studies; n = 136; very low-certainty evidence; in absolute terms: 0 per 1000 for both arms). Electrical or magnetic stimulation versus no treatment, sham treatment or verbal/written instructions We did not identify any studies for this comparison that reported on our key outcomes of interest.

AUTHORS' CONCLUSIONS

Despite a total of 25 trials, the value of conservative interventions for urinary incontinence following prostate surgery alone, or in combination, remains uncertain. Existing trials are typically small with methodological flaws. These issues are compounded by a lack of standardisation of the PFMT technique and marked variations in protocol concerning combinations of conservative treatments. Adverse events following conservative treatment are often poorly documented and incompletely described. Hence, there is a need for large, high-quality, adequately powered, randomised control trials with robust methodology to address this subject.

Effect of pelvic floor muscle training on urinary incontinence after radical prostatectomy: An umbrella review of meta-analysis and systematic review

OBJECTIVE

To analyse the specific exercise effects of pelvic floor muscle training (PFMT) with or without biofeedback or electrical stimulation on urinary incontinence rehabilitation after radical prostatectomy.

DATA SOURCES

We searched PubMed, Embase, Cochrane Database of Systematic Reviews, Web of Science and Scopus databases for systematic reviews and meta-analyses on PFMT for urinary incontinence after radical prostatectomy from inception to 3 October 2022.

REVIEW METHODS

Two authors independently extracted key data from the included studies. The methodological quality of the included studies was assessed using the A Measure Tool to Assess Systematic Reviews-2 checklist. Grading of Recommendations Assessment Development and Evaluation was used to evaluate the quality of the outcomes.

RESULTS

A total of 18 studies with 29,925 patients were included, all of which were of critically low methodological quality. Biofeedback therapy seemed to show additional benefits compared to PFMT alone; however, the adjunctive role of electrical stimulation remained more controversial due to the lack of strong evidence. Preoperative PFMT sometimes, but not always, showed the potential to improve urinary incontinence. PFMT with the guidance of a therapist could bring some benefits to the patient and was more acceptable to the patient, but consumed some medical resources.

CONCLUSIONS

PFMT has a good effect on improving post-radical prostatectomy incontinence in men, and biofeedback can have an additional beneficial effect on patients, especially in the short-term and medium-term. However, there is insufficient evidence to suggest that electrical stimulation is beneficial for patients with urinary incontinence.

Physiotherapy as an Effective Method to Support the Treatment of Male Urinary Incontinence: A Systematic Review

Urinary incontinence (UI) is a serious health issue that affects both women and men. The risk of UI increases in men with age and after treatment for prostate cancer and affects up to 32% of men. Furthermore, UI may affect up to 69% of men after prostatectomy. Considering such a high incidence, it is critical to search for effective methods to mitigate this issue. Hence, the present review aims to provide an overview of physiotherapeutic methods and evaluate their effectiveness in treating UI in men. This systematic review was performed using articles included in PubMed, Embase, WoS, and PEDro databases. A total of 6965 relevant articles were found. However, after a risk of bias assessment, 39 studies met the inclusion criteria and were included in the review. The research showed that the available physiotherapeutic methods for treating men with UI, including those after prostatectomy, involve pelvic floor muscle training (PFMT) alone or in combination with biofeedback (BF) and/or electrostimulation (ES), vibrations, and traditional activity. In conclusion, PFMT is the gold standard of UI therapy, but it may be complemented by other techniques to provide a personalized treatment plan for patients. The effectiveness of the physiotherapeutic methods varies from study to study, and large methodological differences make it difficult to accurately compare individual results and draw unequivocal conclusions.

Latest Evidence on Post-Prostatectomy Urinary Incontinence

A radical prostatectomy is frequently used as the first-line treatment for men with prostate cancer. Persistent urinary incontinence after surgery is one of the most severe adverse events. We report the results of a comprehensive literature search focused on post-prostatectomy urinary incontinence (PPI), performed by a panel of experts on non-neurogenic lower urinary tract symptoms. The data on the prevalence and timing of PPI are very heterogeneous. The etiology of PPI can be multifactorial and mainly dependent on patient characteristics, lower urinary tract function or surgical issues. The medical history with a physical examination, the use of validated questionnaires with a voiding diary and pad tests are determinants in identifying the contributing factors and choosing the right treatment. Lifestyle intervention and urinary containment are the most frequently used strategies for the conservative management of PPI, while antimuscarinics, beta-3 agonists and duloxetine (off-label) are drugs indicated to manage PPI with a concomitant overactive bladder. Surgical therapies for the management of post-prostatectomy SUI include non-adjustable trans-obturator slings in men with mild-to-moderate incontinence and an artificial urinary sphincter in men with moderate-to-severe incontinence.

Efficacy of perineal electrical stimulation in men with urinary incontinence after radical prostatectomy. A prospective randomized controlled trial

OBJECTIVE

To evaluate the efficacy of perineal electrical stimulation (ES) on anxiety, depression, incontinence-related quality of life (QoL), and clinical parameters in men with urinary incontinence (UI) after radical prostatectomy (RP).

METHODS

Fifty-eight men with UI after RP were randomized into two groups using the random numbers generator as follows: Group 1 received perineal ES (n:29), and Group 2 no treatment (n:29). Perineal ES was performed in lithotomy position via a stimulation device (Enraf Myomed 632) with surface electrodes, 3 days a week, 20 min a day, for a total of 24 sessions for 8 weeks. Men were evaluated in terms of continence rates (primary outcome), incontinence severity (24 h-pad test), incontinence episodes (3-day bladder diary), anxiety-depression (HADS), QoL (IIQ-7), and improvement rates and treatment satisfaction (Likert scale) at the baseline and the end of treatment (8th week).

RESULTS

A statistically significant improvement was found in all parameters except depression in Group 1, in the severity of incontinence and QoL parameters in Group 2 at the 8th week compared to the baseline values (p < 0.05). At the end of treatment; the severity of incontinence, incontinence episodes, QoL, and anxiety were significantly improved in Group 1 compared to Group 2 (p < 0.05). No difference was found between the two groups in terms of depression (p > 0.05). The continence and improvement rates and treatment satisfaction were significantly higher in Group 1 than in Group 2 (p < 0.05).

CONCLUSION

Perineal ES is more effective than no treatment in men with UI after RP as an alternative ES option that is well tolerated and does not produce serious adverse events. Clinical Trial Registration: This study was registered with ClinicalTrials.gov number, NCT05236140.

Efficacy of various forms of acupuncture for the treatment of urinary incontinence in women: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Evidence regarding the efficacy of various forms of acupuncture for the treatment of urinary incontinence (UI) in women is outdated and inconclusive. This review aims to determine the efficacy of different forms of acupuncture for the treatment of UI in women.

METHODS

Multiple databases were searched from inception to June 2020. Randomized controlled trials that compared various forms of acupuncture to control were included.

RESULTS

Ten trials were included in this review. The pooled analysis demonstrated that an increased proportion of women with stress UI (SUI) reported fewer UI episodes (1.73 [95% CI 1.46, 2.04]; p < 0.00001) in the electroacupuncture group than in the sham group. The meta-analysis also revealed a significantly increased number of women who reported the complete cure of SUI in the electroacupuncture combined with pelvic floor muscle training group than in the medication group (RR 2.67 [95% CI 1.51, 4.71]; p = 0.0007). Body and laser acupuncture caused significant decreases in the number of urge accidents (-2.70 [95% CI -4.86, -0.54]; p = 0.01) and the occurrence of urgency symptoms (-3.60[95% CI -5.34, -1.86]; p < 0.0001), compared with sham acupuncture.

CONCLUSIONS

Based on the findings of this review, electroacupuncture may be able to improve SUI in women in clinical settings. This review also identified evidence supporting the use of body, electro,- and laser acupuncture for the treatment of urge UI; however, these results were obtained from single studies, and further research remains necessary to confirm the effects of these interventions on the treatment of urge UI in women.

European Association of Urology Guidelines on Male Urinary Incontinence

CONTEXT

Urinary incontinence (UI) is a common condition in elderly men causing a severe worsening of quality of life, and a significant cost for both patients and health systems.

OBJECTIVE

To report a practical, evidence-based, guideline on definitions, pathophysiology, diagnostic workup, and treatment options for men with different forms of UI.

EVIDENCE ACQUISITION

A comprehensive literature search, limited to studies representing high levels of evidence and published in the English language, was performed. Databases searched included Medline, EMBASE, and the Cochrane Libraries. A level of evidence and a grade of recommendation were assigned.

EVIDENCE SYNTHESIS

UI can be classified into stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence. A detailed description of the pathophysiology and diagnostic workup has been reported. Simple clinical interventions, behavioural and physical modifications, and pharmacological treatments comprise the initial management for all kinds of UI. Surgery for SUI includes bulking agents, male sling, and compression devices. Surgery for UUI includes bladder wall injection of botulinum toxin A, sacral nerve stimulation, and cystoplasty/urinary diversion.

CONCLUSIONS

This 2022 European Association of Urology guideline summary provides updated information on definition, pathophysiology, diagnosis, and treatment of male UI.

PATIENT SUMMARY

Male urinary incontinence comprises a broad subject area, much of which has been covered for the first time in the literature in a single manuscript. The European Association of Urology Non-neurogenic Male Lower Urinary Tract Symptoms Guideline Panel has released this new guidance, with the aim to provide updated information for urologists to be able to follow diagnostic and therapeutic indications for optimising patient care.

Effectiveness of ultrasound-guided pelvic floor muscle training in improving prolonged urinary incontinence after robot-assisted radical prostatectomy

Persistence of urinary incontinence (UI) after robot-assisted radical prostatectomy (RARP) is a bothersome problem because of its negative effect on the patient's quality of life (QOL). This study aimed to evaluate the effect of transperineal ultrasound (TPUS)-guided pelvic floor muscle training (PFMT) on prolonged UI after RARP. Thirty men with stress UI persisting for > 1 year after RARP underwent biofeedback PFMT using TPUS once every 2-3 weeks for 3 months. The frequency and duration of sustaining pelvic floor muscle (PFM) contractions were assessed using ultrasound imaging. The severity of UI and UI-related QOL were evaluated using a 24-hour pad test and the incontinence quality of life (I-QOL) questionnaire. Twenty-four men (mean age, 72.2 years) completed the TPUS-guided PFMT. The mean duration from RARP to PFMT was 1,228.9 days. The mean cumulative session and the total duration of TPUS-guided PFMT were 4.6 times and 73.3 days, respectively. Compared with the data before TPUS-guided PFMT, the frequency of PFM contractions and duration of sustaining contraction significantly improved after TPUS-guided PFMT (p < 0.05). Additionally, the total amount of urinary leakage after TPUS-guided PFMT was reduced significantly (248.6 ± 280.6 g vs. 397.0 ± 427.0 g, p = 0.024). The I-QOL score was significantly increased after TPUS-guided PFMT (72.1 ± 16.8 vs. 61.0 ± 19.0, p < 0.001). TPUS-guided PFMT may be effective in improving prolonged UI occurring > 1 year after RARP.

Effects of therapeutic exercise on disease severity, balance, and functional Independence among individuals with cerebellar ataxia: A systematic review with meta-analysis

BACKGROUND

Balance impairments are common in cerebellar ataxia. Exercises are beneficial in this population.

OBJECTIVE

Explore the benefits of therapeutic exercises on disease severity, balance and functional independence in cerebellar ataxia.

METHODS

Databases were searched from inception until July 2021. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale and the Newcastle-Ottawa Scale (NOS); and quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool.

RESULTS

Twenty-six studies were included and eight studies of low to high PEDro methodological quality were meta-analyzed. 'Low' to 'moderate' GRADE quality evidence supports the use of therapeutic exercises to reduce disease severity, assessed using the Scale for the Assessment and Rating of Ataxia [weighted mean difference (WMD): -3.3; 95% confidence interval (95%CI): -3.7, -2.8; p < .01]; and improve balance, assessed using the Berg Balance Scale (WMD: 2.6; 95%CI: 1.1, 4.2; p < .01). The effect of therapeutic exercises on functional independence was insignificant (WMD: 1.6; 95%CI: -1.5, 4.6; p = .31).

CONCLUSION

Low to moderate evidence from studies of low to high methodological quality provides some support for therapeutic exercises for reducing disease severity among non-hereditary degenerative cerebellar ataxia and improving balance among acquired cerebellar ataxia. Exercises did not benefit functional independence. Additional studies of large sample size and high methodological quality are necessary to substantiate these findings.

Acupuncture for prostatectomy incontinence: study protocol for a multicenter single-blind randomized parallel controlled trial

BACKGROUND

Urinary incontinence is a common complication post radical prostatectomy. Acupuncture is considered an effective treatment for post-prostatectomy incontinence (PPI), but the evidence is still limited. We propose to evaluate the effectiveness of acupuncture in a rigorously conducted trial.

METHODS

Twenty hospitals will recruit 340 participants with urinary incontinence after radical prostatectomy in China from April 2021 to April 2022. Participants will be randomly allocated to acupuncture or sham acupuncture with a 1:1 ratio using computerized simple random sampling. The study plan consists of 1-week baseline, 6-week treatment, and 18-week follow-up. Eighteen 30-min sessions of acupuncture or sham acupuncture treatment will be provided between weeks 1 and 6. The primary outcome is the change in the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF) score at the week 6 from the baseline. Secondary outcomes include the change in volume of urine leakage at weeks 4 and 6 from a baseline measured using the 1-h pad test; 72-h incontinence episode frequency based on a 72-h voiding diary; change in the Expanded prostate cancer Index Composite scale (EPIC-26); change in the Self-Rating Anxiety Scale; weekly consumption of pads; and the severity of urinary incontinence based on a 72-h bladder diary and self-assessment of the therapeutic effect. The safety of acupuncture will also be assessed.

DISCUSSION

This trial will help to identify whether acupuncture is effective for PPI, and, if so, whether it exerts a therapeutic rather than a placebo effect.

TRIAL REGISTRATION

www.Chictr.org.cn ChiCTR2100042500 . Retrospectively registered on 22 January 2021.

A systematic review of treatment options for post-prostatectomy incontinence

PURPOSE

Urinary incontinence remains common in men after prostatectomy. Current guidance suggests early corrective surgery to those that are still incontinent after trying Pelvic Floor Muscle Therapy, however, other treatments are now available. This review aims to evaluate all currently available treatment options for men with post-prostatectomy incontinence (PPI).

METHODS

A search of MEDLINE and CENTRAL databases on 2/2/2021 produced 879 articles. Any study evaluating incontinence before and after a treatment protocol was eligible for inclusion. After screening, 17 randomized control trials were included, and pre-defined data points were collected. Due to heterogeneity, pooled analysis was not possible, and a descriptive synthesis was produced in accordance with PRISMA guidelines. Cochrane Risk of Bias (RoB) tool was used to evaluate all studies. The search protocol and methods for this study was registered on the PROSPERO database before the search began, ID:(CRD42021229749).

RESULTS

3/17(18%) of studies focussed on pharmacotherapy, 2/17(12%) on vibration therapies, 8/17(47%) on pelvic floor muscle therapy (PFMT), 3/17(18%) on electrical stimulation (ES), and 1/17 (6%) on extracorporeal magnetic innervation (ExMI) as their main intervention. The use of Duloxetine, Solifenacin, PFMT, ES, and ExMI all show effective reduction in incontinence in men suffering from PPI. No study in this review evaluated surgical managements for PPI.

CONCLUSION

A large number of treatments are available for PPI using an array of different methods. For this reason, a variety of treatments could be considered before early invasive procedures, to prevent unnecessary surgery and its associated negative complications.

Randomized-Controlled Trial Examining the Effect of Pelvic Floor Muscle Training in the Treatment of Stress Urinary Incontinence in Men after a Laparoscopic Radical Prostatectomy Pilot Study

AIM

The aim of this study was to assess the impact of pelvic floor muscle training (PMFT) in the treatment of stress urinary incontinence (SUI) in men after they received radical prostatectomy (RP).

METHODS

From November 2018 to September 2019, patients who underwent radical prostatectomy were assessed for eligibility. A total of 37 men were then randomly assigned to the experimental group (EG) and the control group (CG). The EG group received supervised exercise twice a week for 12 weeks, and the CG did not receive any intervention. To objectify the results obtained in both groups before and after the intervention, the authors assessed myostatin concentration. Moreover, the Expanded Prostate Cancer Index Composite (EPIC-26) was applied to assess the quality of life, and Beck's Depression Inventory (BDI-II) was used to measure depression severity.

RESULTS

Study results demonstrated a statistically significant reduction of myostatin concentration in the EG following the treatment and no statistically significant differences in this parameter in the CG. In addition, a comparison of the EPIC-26 scores in the EG at the initial and final assessments revealed a statistically significant improvement in the quality of life in each domain. A comparison of the EPIC-26 scores in the CG at the initial and final assessments showed there is a statistically significant decline in quality of life in the "overall urinary problem" and "sexual" domain. A comparison of the BDI-II scores at the initial and final assessments showed a statistically significant decline in depressive symptoms in the EG and no statistically significant differences in the CG.

CONCLUSIONS

PFMT is an effective treatment for urinary incontinence (UI) in men who received radical prostatectomy.

Analysis of conventional versus advanced pelvic floor muscle training in the management of urinary incontinence after radical prostatectomy: a systematic review and meta-analysis of randomized controlled trials

Background

The underutilization of additional supportive muscles is one of the potential reasons for suboptimal efficacy of conventional pelvic floor muscle training (CPFMT). The present study concentrates on any advantage of advanced pelvic floor muscle training (APFMT) in patients with urinary incontinence (UI) after radical prostatectomy (RP).

Methods

Literature search was conducted on PubMed, Embase, Cochrane Library and Web of Science from database inception to February 2020. The data analysis was performed by the Cochrane Collaboration's software RevMan 5.3.

Results

Both APFMT and CPFMT groups indicates superiority over baseline in terms of pad number, the International Consultation on Incontinence Questionnaire—Short Form (ICIQ-SF) score, pad weight at short-term follow-up, and PFME and PFMS at intermediate-term follow-up. No adverse events were reported in all included studies. Patients receiving APFMT had a similar attrition rate to those receiving CPFMT (18/236 vs. 22/282, P=0.61). Compared to CPFMT group, APFMT group provided intermediate-term advantages in terms of pad number (MD: −0.75, 95% CI: −1.36 to −0.14; P=0.02), ICIQ-SF score (MD: −3.79, 95% CI: −5.89 to −1.69; P=0.0004), PFME (MD: 1.93, 95% CI: 0.99 to 2.87; P<0.0001) and pad weight (MD: −1.40, 95% CI: −1.70 to −1.00; P<0.00001).

Conclusions

Current evidence indicated that APFMT might facilitate the recovery of UI after RP according to intermediate-term advantages over CPFMT in terms of pad number, ICIQ-SF score, PFME and pad weight. Further standardized, physiotherapist-guided and well-designed clinical trials conducted by large multicenter and experienced multidisciplinary clinicians are still warranted.

Pelvic Floor Muscle Training in Radical Prostatectomy and Recent Understanding of the Male Continence Mechanism: A Review

OBJECTIVE

Pelvic floor muscle training (PFMT) is recommended as part of supportive care for patients with prostate cancer. It can assist in reducing treatment-related symptoms such as urinary incontinence. This literature review aims to discuss recent innovative findings on the pathophysiology of the male continence mechanism and implications for PFMT in radical prostatectomy.

DATA SOURCES

CINAHL, Embase, Web of Science, Emcare and PsycINFO were searched until January 2020.

CONCLUSION

Nurses providing supportive care for patients undergoing radical prostatectomy can engage in-clinic in the instruction and recommendation of pre- and postoperative PFMT and delivering guidance on home-based programs to promote motor learning.

IMPLICATIONS FOR NURSING PRACTICE

Optimal postoperative urinary incontinence outcomes are suggested to be promoted by preoperative PFMT. Training focused on the urethral and anterior pelvic floor muscle complex has been shown to facilitate mid urethral occlusion required for continence. Prescription of PFMT should be individualised, focusing on skill acquisition and motor learning, which is in line with recent knowledge developments in male pelvic floor anatomy.

OUTLET OBSTRUCTED CONSTIPATION AND FECAL INCONTINENCE: IS REHABILITATION TREATMENT THE WAY? MYTH OR REALITY

Pelvic floor rehabilitation aims to address perineal functional and anatomic alterations as well as thoraco-abdominal mechanic dysfunctions leading to procto-urologic diseases like constipation, fecal and urinary incontinence, and pelvic pain. They require a multidimensional approach, with a significant impact on patients quality of life. An exhaustive clinical and instrumental protocol to assess defecation disorders should include clinical and instrumental evaluation as well as several clinical/physiatric parameters. All these parameters must be considered in order to recognize and define any potential factor playing a role in the functional aspects of incontinence, constipation and pelvic pain. After such evaluation, having precisely identified any thoraco-abdomino-perineal anatomic and functional alterations, a pelvi-perineal rehabilitation program can be carried out to correct the abovementioned alterations and to obtain clinical improvement. The success of the rehabilitative process is linked to several factors such as a careful evaluation of the patient, aimed to select the most appropriate and specific targeted rehabilitative therapy, the therapist's scrupulous hard work, especially as regards the patient's emotional and psychic state, and finally the patient's compliance in undertaking the therapy itself, especially at home. These factors may deeply influence the overall outcomes of the rehabilitative therapies, ranging from "real" success to illusion "myth".

Do features of randomized controlled trials of pelvic floor muscle training for postprostatectomy urinary incontinence differentiate successful from unsuccessful patient outcomes? A systematic review with a series of meta-analyses

AIMS

Efficacy of pelvic floor muscle training (PFMT) for postprostatectomy incontinence (PPI) differs between randomized clinical trials (RCT). This might be explained by variation in content/delivery of PFMT (eg, biofeedback, muscles targeted, and time of commencement of training). This review investigated whether outcome of meta-analysis differs based on presence or not of specific RCT features.

METHODS

PubMed, CINAHL, EMBASE, Physiotherapy Evidence Database (PEDro), and Cochrane were searched for RCTs that investigated efficacy of PFMT on PPI. PFMT details and outcomes were extracted. Methodological quality and comprehensiveness of PFMT reporting was assessed using the PEDro scale and Consensus on Reporting Template, respectively. Effect size and 95% confidence intervals were calculated for incontinence rate at 3 months. To identify features that influenced efficacy, separate meta-analyses were performed for studies with and without specific features.

RESULTS

Twenty-two trials were included, and 15 were used for meta-analysis of 3-month outcomes. Overall, meta-analysis showed reduced incontinence with PFMT (risk ratio [RR] = 0.85; I² = 55%; P = .005). Meta-analyses showed better outcomes for PFMT than control groups when the study included preoperative PFMT (RR = 0.76; I² = 30%; P = .006), biofeedback (RR = 0.73; I² = 58%; P = .006), instruction to contract around the urethra (RR = 0.9; I² = 43%; P = .009), a control group without PFMT instruction (RR = 0.85; I² = 69%; P = .05), inclusion of all men irrespective of continence status (RR = 0.84; I² = 30%; P = .003) and continence defined as no leakage (RR = 0.85; I² = 48%; P = .05).

CONCLUSIONS

Preoperative PFMT, biofeedback, urethral instructions, no PFMT instruction for controls, inclusion of all men, and continence defined as no leakage are features associated with successful patient outcomes. Future studies should consider these features in design of interventions and pooling data for meta-analysis.

The effect of a comprehensive care and rehabilitation program on enhancing pelvic floor muscle functions and preventing postpartum stress urinary incontinence

This study was to investigate the incidence and the risk factors of postpartum stress urinary incontinence (SUI), and the effect of comprehensive care and rehabilitation program (CCRP) on preventing postpartum SUI.In stage I, 479 puerperae were recruited within 1 week postpartum, then the postpartum SUI incidence at 8th week and its risk factors were investigated. In stage II, 240 vaginal delivery puerperae were enrolled within 1 week postpartum and randomly assigned to CCRP group or control group as 1:1 ratio. The postpartum SUI incidence and pelvic floor muscle function indexes were evaluated at 8th week.In stage I, the postpartum SUI incidence was 25.7%, and SUI puerperae presented with higher body mass index (BMI), vaginal delivery rate, newborn weight, and larger newborn head diameter compared with non-SUI puerperae. Besides, the vaginal delivery, the elevated age and BMI were independent risk factors for postpartum SUI. In stage II, the postpartum SUI incidence in CCRP group was decreased compared with control group, and the vaginal resting pressure, vaginal squeezing pressure, and vaginal contraction duration were increased in CCRP group compared to control group at 8th week postpartum.The incidence of postpartum SUI is 25.7%, and the vaginal delivery, increased age, and BMI are independent risk factors for postpartum SUI. More importantly, CCRP strengthens pelvic floor muscle functions and decreases postpartum SUI incidence in puerperae.

Traditional Biofeedback vs. Pelvic Floor Physical Therapy-Is One Clearly Superior?

PURPOSE OF REVIEW

Pelvic floor physical therapy is a worldwide accepted therapy that has been exclusively used to manage many pelvic floor disorders in adults and children. The aim of this review is to suggest to clinicians an updated understanding of this therapeutic approach in management of children with non-neuropathic voiding dysfunction.

RECENT FINDINGS

Today, pelvic floor muscle training through biofeedback is widely used as a part of a voiding retraining program aiming to help children with voiding dysfunction which is caused by pelvic floor overactivity. Biofeedback on its own, without a pelvic floor training component, is not an effective treatment. Biofeedback is an adjunct to the pelvic floor training. In the current review, we develop the role of pelvic floor physical therapy in management of children with non-neuropathic voiding dysfunction and compare it with biofeedback therapy alone.

Electrical Stimulation Activates Fibroblasts through the Elevation of Intracellular Free Ca2+: Potential Mechanism of Pelvic Electrical Stimulation Therapy

Ca²⁺ is an important ion in response to electrical stimulation (ES) and acts as second messenger in the regulation of various physiological processes. Pelvic floor electrical stimulation (PES) is a low-voltage clinical application, available for urinary incontinence (UI) treatment. Fibroblasts, as the main cellular component of vaginal wall and pelvic ligament, play an important role in the maintenance of pelvic health. We studied the effect of ES on fibroblasts in this study. ES was conducted with electrotaxis chambers on L929 fibroblast and the ES parameter was 100 mV/mm×2h. The results showed that ES increased intracellular Ca²⁺ concentration, promoted the expression of PCNA, CyclinB1, and CyclinD1, and increased the proportion of cells in S and G2 phages. After ES, fibroblasts get activated and proliferated. Besides, BAPTA-AM, a membrane permeated chelator for intracellular free Ca²⁺, partially inhibited the effect of ES on fibroblasts activation and proliferation promotion. Furthermore, we elucidated that Ca²⁺, as a second messenger and upstream signal for Smads and Akt signaling, regulated ES-induced nuclear translocation of smad2/3, phosphorylation of smad2/3, Akt, and GSK3β. Finally, we validated the effect of ES on PES mouse model. The results indicated that PES promoted the activation and proliferation of fibroblasts in vivo. In conclusion, we verify that ES can elevate the concentration of intracellular Ca²⁺ and activate its downstream signaling and then promote the activation of fibroblasts, which may be one of the mechanisms of PES therapy.

Uroflow stop test with electromyography: a novel index of urinary continence recovery after RARP

PURPOSE

Urinary incontinence (UI) is one of the most bothersome surgical side effects after robot-assisted radical prostatectomy (RARP). Alteration of both smooth and striate urethral sphincter occurs after RARP. Since the contraction of perineal muscles is involved in the complex mechanism of urinary continence, the uroflow stop test (UST) seems to predict early continence recovery after RARP. The UST was added of perineal surface electromyography (EMG) evaluation to evaluate the latency time (LT) between muscular contraction and the complete stop of urine flow. Our aim was to present UST-EMG as a new tool in the investigation of UI, implying pelvic floor integrity, and to evaluate whether an early return (≤ 3 months) to preoperative LT could be associated with early recovery of UC (≤ 3 months).

METHODS

After prospectively enrolling 137 patients who underwent RARP with a minimum follow-up of 6 months, we identified two groups: Group 1 (93 patients) with early (≤ 3 months) pre-surgical LT recovery and Group 2 (44 patients) with late > 3 months or not able to reach pre-surgical LT recovery.

RESULTS

Between the two groups, there were significant differences in terms of different surgical technique (nerve-sparing versus non-nerve-sparing) and pads use at 3 and 6 months after RARP (p < 0.05). No differences were recorded neither in postoperative maximum flow-rate, nor in postoperative symptoms score.

CONCLUSIONS

UST with EMG can be considered as a noninvasive, reproducible and easily performable tool. LT is applicable in the clinical evaluation to predict urinary continence recovery after RARP.