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Tienforti et al. report results of their well-designed trial demonstrating that preoperative pelvic floor muscle training (PFMT) produced clinically and statistically significant differences on validated outcome instruments (ICIQ-UI, UCLA-PCI, and ICIQ-OAB), as well as traditional measures (incontinence episodes on diary and pad counts). This trial adds to a considerable body of evidence (Table 1[1–5]) that peri-operative PFMT for all men undergoing radical prostatectomy improves continence outcomes.

Table 1.  Summary of adequately powered randomized controlled trials of peri-operative PFMT for prevention of post-prostatectomy incontinence
Study N InterventionDefinition of continencePercent continent: intervention vs control group
3 months6 months1 year
  • *

    Clinically and statistically significant results of intervention.

Positive Studies *
Filocamo et al., 2005 [1]300PFMT on physical exam in three postoperative sessions, home exercises, bladder control strategies vs usual careDry on ICS-Male Questionnaire23% vs 14%77% vs 32%89% vs 68%
Burgio et al., 2006 [2]125Single session of preoperative biofeedback-assisted PFMT and home exercises vs usual careNo leakage on Bladder Diary48% vs 32%68% vs 48%6-month study
Mariotti et al., 2009 [3]60PFMT via biofeedback and electrical stimulation twice a week for 6 weeks postoperatively vs usual care≤2 grams on 24 hour pad test and no pad use.80% vs 33%97% vs 67%97% vs 97%
Ribeiro et al., 2010 [4]73Biofeedback-assisted PFMT weekly plus home exercises x 3 months or until continent vs brief verbal instructionsNo pads73% vs 39%88% vs 64%96% vs 75%
Tienforti et al. 201232Preoperative biofeedback-assisted PFMT, monthly postoperative biofeedback-assisted PFMT vs verbal and written instructions for home exercisesScore of 0 on the ICIQ-SF50% vs 6%63% vs 6%6-month study
Negative Study
Bales et al. 2000 [5]100Single session of preoperative biofeedback-assisted PFMT vs verbal and written instruction. Both groups encouraged to practise home exercises.≤1 pad per day57% vs 62%94% vs 96%6-month study

Research questions do still remain, particularly regarding the intensity of peri-operative therapy necessary. Varying levels of technologies were used in these trials – biofeedback, biofeedback augmented with electrical stimulation, and no technologies – simply PFMT on physical examination –all demonstrated considerable benefit. The negative trial by Bales et al. [5] showed that biofeedback did not improve the results of verbal and written instruction with encouragement to do home exercises. The message for practice is that even low-tech peri-operative PFMT, combined with home exercises, can improve continence outcomes.

Most men who choose radical prostatectomy are relatively healthy otherwise. The diagnosis of cancer followed by postoperative incontinence can be life-changing – enough to cause some experts to discourage routine PSA testing for men. Regaining continence months sooner is a highly desirable outcome for these men.

As the evidence has mounted, urology practices have begun to include various levels of PFMT for men undergoing radical prostatectomy; however, translation from research to practice has not been optimum. Most men undergoing radical prostatectomy do not receive PFMT. It is time to change practice and implement PFMT into routine peri-operative care for all men undergoing radical prostatectomy.

REFERENCES

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  2. REFERENCES
  • 1
    Filocamo MT, Li Marzi V, Del Popolo G, Cecconi F, Marzocco M, Tosto A, Nicita G. Effectiveness of Early Pelvic Floor Rehabilitation treatment for Post-Prostatectomy Incontinence. European Urology 2005; 48: 7348
  • 2
    Burgio KL, Goode PS, Urban D, Umlauf M, Locher J, Bueschen A, Redden DT. Preoperative Biofeedback Assisted Behavioral Training to Decrease Post-Prostatectomy Incontinence: A Randomized, Controlled Trial. J Urology 2006; 175: 196201
  • 3
    Mariotti G, Sciarra A, Gentilucci A, Salciccia S, Alfarone A, Di Pierro G, Gentile V. Early Recovery of Urinary Continence After Radical Prostatectomy Using Early Pelvic Floor Electrical Stimulation and Biofeedback Associated Treatment. Journal of Urology 2009; 181: 178893
  • 4
    Ribeiro L, Prota C, Gomes C, Bessa J, Boldarine M, Dall'Oglio M, Bruschini H, Srougi M. Long-Term Effect of Early Postoperative Pelvic Floor Biofeedback on Continence in Men Undergoing Radical Prostatectomy: A Prospective, Randomized, Controlled Trial. J Urol 2010; 184: 10349
  • 5
    Bales GT, Gerber GS, Minor TX, Mhoon DA, McFarland JM, Kim HL, Brendler CB. Effect of Preoperative Biofeedback/Pelvic Floor Training on Continence in Men Undergoing Radical Prostatectomy. Urology 2000; 56: 62730