Rehabilitation After Prostate Cancer Treatment

Complications of Rehabilitation After Prostate Cancer Treatment
Urinary Incontinence
Treatment of Urinary Incontinence
Erectile Dysfunction
Urinary Incontinence and Erectile Dysfunction
Emotional Support and Counselling

Why is Rehabilitation after Prostate Cancer Treatment important?

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Prostate cancer is one of the most commonly treated malignancies in Western society. Attempts at curing prostate cancer may involve surgery, radiotherapy or high intensity focused ultrasound. The aims of any prostate cancer treatments are to achieve cure of the cancer, preserve urinary control and preserve erectile function. Unfortunately, and notwithstanding increasing treatment sophistication and therapeutic diligence, very significant morbidity is associated with prostate cancer therapy especially with regards to urinary incontinence and erectile dysfunction. During the recovery period after prostate cancer treatment, the patient must be offered a comprehensive rehabilitation plan whilst concurrently being provided with appropriate emotional and psychological support. A multi disciplinary approach is preferable involving a urologist, a physiotherapist experienced in the management of male urinary incontinence and finally a psychologist adept at couples, cancer and sexual dysfunction counselling. Please click here to view information on the male urogenital system.

Urinary Incontinence

Urinary Incontinence results from damage to the distal urethral sphincter mechanism during radical prostatectomy surgery. Regardless of how experienced the surgeon severe urinary incontinence will occur in at least 3% of cases. This is regardless of whether the surgery was performed with an open retro-pubic technique, laparoscopically or with robot assisted laparoscopic surgery. Post radical prostatectomy incontinence is predominantly sphincter weakness in type. A diagnostic urodynamic study should be performed where detrusor instability or bladder overactivity is suspected on the basis of symptoms relating to urgency.

Treatment of Urinary Incontinence

Intensive Pelvic Floor Training

It is normal for the majority of men to experience a degree of sphincter weakness incontinence once the urinary catheter is removed. Men should immediately commence pelvic floor training having been trained in the correct technique by an appropriate physiotherapist specialising in this area. With daily training and the passage of time many men over a three-month period re-gain very good bladder control. Many men do not immediately identify their Pelvic Floor Muscles and tend to strain abdominally in an inappropriate fashion. Correct tuition is critical.

Invance Male Sling

The invance male sling is appropriate for men with mild to moderate stress urinary incontinence that has not responded to conservative measures. The Invance sling is a polypropylene mesh material that is inserted via a small perineal incision. The patient is operated on a day stay basis. For cases of moderate to severe urinary incontinence the inflatable artificial urinary sphincter is the standard of care. The artificial urinary sphincter is constructed of biocompatible silicon and is primed with a normal saline solution. It consists of a reservoir of fluid placed intra-abdominally, an inflatable and deflatable cuff that surrounds the urethra and a deflate mechanism that is situated beneath the scrotal skin. The artificial sphincter is inserted via a small transverse scrotal incision and the patient discharged after an overnight stay in hospital. After a six week settling in period the device is activated and the patient taught the simple technique of manipulating the small scrotal pump to relax the cuff in order to facilitate voiding. In difficult cases involving urethral fibrosis such as after external beam radiotherapy, a double cuff system may be implanted to ensure restoration of urinary control. Rehabilitation After Prostate Cancer Treatment

Uro-Lume Urethral Prosthesis

Radio-fibrotic urethral stricture disease may occur with either external beam radiotherapy or with brachytherapy. Should these strictures not respond to urethrotomy or stricture incision a Uro-Lume Urethral Prosthesis may be endoscopically placed in an attempt to allow urethral healing without stricturing.

Erectile Dysfunction

Surgeons attempt to maintain post-operative erectile function by preserving the cavernosal nerves during radical prostatectomy. Unfortunately claims of potency preservation are often unrealistically presented and erectile dysfunction remains a significant ongoing morbidity related to prostate cancer surgery. Similarly, 50% of pre-treatment potent men have significant erectile dysfunction at two years after radiotherapeutic intervention. This erectile dysfunction is due to corporal fibrosis of the erectile tissue.

Penile Injection Therapy

It is very important that penile injection therapy be commenced four to six weeks following radical prostatectomy surgery. The patient is taught by an experienced nurse the technique of self injection into the side of the penis. Vaso-active combinations of drugs are used, most commonly combinations of Prostaglandin, Papaverine and Phentolamine. Early introduction of penile injection therapy after surgery is critical in order to prevent permanent atrophy of the erectile mechanism. Appropriate warnings are given to the patient in order that priapism prevented, and if it occurs treated promptly.

PDE-5 Inhibitors

PDE-5 Inhibitors will only work when a degree of cavernosal nerve function exists. For men who have had successful cavernosal nerve preservation, it is frequently the case that due to neurapraxia the nerves do not function even partially for at least three months. It is therefore appropriate to introduce oral therapy for erectile dysfunction at three months post operatively. These compounds are safe, the absolute contraindication to their use is in combination with nitrate compounds.

Penile Prosthetic Surgery

The implantation of an implantable penile prosthesis is the gold standard in terms of permanent restoration of quality erectile function. Should the patient be impotent pre-operatively or should potency not return post-operatively the patient should be counselled with respect to penile prosthetic surgery in terms of adequate long-term management. The inflatable penile prosthesis is inserted through a small transverse incision and comprises and intra abdominal reservoir of normal saline, inflatable cylinders within the penis and an inflate and deflate pump mechanism located within the scrotum. Surgery is performed on a twenty-four hour hospital stay basis.

Rehabilitation After Prostate Cancer Treatment

The great popularity of the penile prosthesis is the restoration of spontaneous and therefore romantic lovemaking as well as elimination of performance anxiety.

Urinary Incontinence and Erectile Dysfunction

Unfortunately some men experience both erectile dysfunction and urinary incontinence. Both conditions can be successfully treated by the concurrent placement of a penile prosthesis with either an artificial urinary sphincter or in cases of mild urinary incontinence, an Invance male sling.

Emotional Support and Counselling

The prostate cancer patient and his wife are suddenly forced to deal with a number of very major life stresses. There is the diagnosis of cancer, the prospect of radical surgery or radiotherapy, the fear of urinary incontinence and the concern about ongoing erectile function. These concerns are best anticipated and dealt with in a multi-disciplinary approach involving a partnership between the patient, his wife, the urologist, physiotherapist and psychologist. In this way successful rehabilitation of the patient to a normal quality life is assured. (Article kindly contributed by Dr P M Katelaris, Consultant Urologist, Director Prostate Cancer Foundation of Australia, Director Prostate Cancer Research Division of the Institute of Magnetic Resonance Research and Director of the Prostate Cancer Rehabilitation Centre.)