Undergoing your prostate cancer journey is surely a daunting one. With the prospect of cancer, having to undergo a prostatectomy and what the recovery might look like is often an afterthought. Unfortunately, recovery from a prostatectomy is no easy feat and there are some complications that come from having prostate surgery: incontinence and erectile dysfunction. These can be longstanding, with continence taking up to 12 months to recover and have a significant impact on quality of life post operatively. That’s where we come in! A men’s health physiotherapist will assist and guide you along your journey with recovery from incontinence and ED.
Incontinence after prostatectomy
Incontinence is pretty much a given after prostatectomy. Some blokes recover really quickly, others unfortunately, not so much. The good news is that about 97% of men recover their continence within one year. With most men recovering quite well from prostate surgery, we can start to turn our attention to how quickly men recover and can return to life without limitations from leaking and restoring their quality of life.
- A younger age <70 years
- A lower cancer stage (stage 1)
- Lower BMI
- Smaller prostate volume (<40cc)
- Higher SHIM score (Sexual Health Inventory for Men questionnaire)
Patients who meet these criteria typically recover their continence within three months post prostatectomy.
Intra op & pathological:
The following factors are associated with a poorer time to return to continence.
- A longer operative time
- Higher estimated blood loss during surgery
- Having a higher Gleason score
Predicting time to being pad free after the operation
After the procedure, there are a few objective ways we can measure your estimated time to recovery which involve analysing how much you are leaking: how many pads you use over the course of the few days after catheter removal; or how the amount of urine lost the day after catheter removal (this involves weighing your pads to determine how much urine you have leaked).
Analysing the number of pads used
The number of pads used between days 4 and 7 can be used to predict time to recovery. The median time to recovery for men using three pads per day was 73 days; two pads, the median time to recovery was 42 days; and one pad, the median time to recovery was 35 days. This gives us a rough estimate of how long we might expect it to take for continence to recover. As we see in Figure 1, at around 90 days, 85% of patients using 1 and two pads per day between days 4 and 7 of catheter removal have restored their continence. This takes around 250 days to achieve for those who require three or more pads.
Analysing pad weight
Another common method used to predict time to recovery is 24 hour pad weight on the first day of catheter removal. To measure this, over the course of the first 24 hours after the catheter is removed, pads are weighed before being worn + a plastic bag, and after changing (with the same plastic bag). This will give us the amount of urine in grams that has been absorbed by the pad (which is equivalent to mL). The amount of urine leaked in the first 24 hours is used to predict recovery timeframes. The recovery timeframes are shown in table 1 below.
Amount of urine leaked on day 1 post catheter removal
Days to achieving continence (no need for pad use)
Improving continence after prostatectomy
It is important to see a men’s health physiotherapist throughout your prostatectomy journey to help you achieve the best continence outcomes faster. This all starts pre-operatively with pelvic floor prehab. With a physiotherapist, you will engage in training your pelvic floor muscles. These muscles are crucial for controlling your voiding and the flow of urine. Studies show that outcomes are better for those who engage in pelvic floor muscle training (PFMT) prior to surgery. Seeing a physio pre op is also beneficial as it gives you another point of contact to voice your concerns, ask any questions that you may have some uncertainty about, and it expands your support network. Post operatively, rehab from prostatectomy will heavily involve PFMT, education around managing your incontinence, and providing support around the impacts that incontinence can bring. Learn more about your pelvic floor here.
Erectile Dysfunction post prostatectomy
Just like incontinence, erectile dysfunction (ED) is also a given after prostatectomy. To achieve an erection, a few things need to fall into place. There needs to be a psychological and emotional arousal, there needs to be communication from the brain to the erectile tissue, adequate blood flow and dilation of blood vessels to allow blood to engorge the erectile tissue, and it needs to be kept there by local blood pressure changes and muscular activity.
With prostatectomy, the innervation (the nerve supply) to the erectile tissue is impaired as well as possibly the pelvic floor muscle function that helps keep the blood there. This is due to the proximity of the cavernous nerves to the prostate. The cavernous nerves innervate the erectile tissue of the penis. During a prostatectomy, the nerves have to be shifted out of the way and are ‘shocked’ during the operation, causing poor function after the surgery. As a result the erectile tissue of the penis lacks oxygenation, the small blood vessels don’t function as well due to poorer function of the smooth muscle function within them, and the connective tissue within the penis can become stiff. Normally, this is preserved due to men normally having nocturnal erections which helps bring blood into the penis. After a prostatectomy, this doesn’t happen.
Improving erectile function after prostatectomy
Erectile function recovers slowly over time, but in some men, erectile function doesn’t return. We can try our best to stimulate the erectile tissue in order to regain function sooner. Again, this is where a men’s health physiotherapist is your friend. There are a few things you can do to help improve your erections after prostate surgery:
Vacuum Device Therapy
- As the name suggests, vacuum erection devices (VED) create a vacuum around the penis which increases blood flow to engorge the erectile tissues of the penis. Regular use of VEDs aims to preserve the smooth muscle function (of blood vessels), reduce fibrosis (thickening or scarring) of connective tissues within the penis and increase oxygenation of the erectile tissue. This can be done in conjunction with a physiotherapist to guide you on how to use a VED, how often you should be engaging in VED therapy, how long and intense VED therapy should be and help work with you to make it suit your needs. Learn more about VED & penile rehab post prostatectomy here.
Medication (PDE-5 inhibitors)
- VED typically is and should be done in conjunction with PDE-5 inhibitors such as Viagra or Cialis. These medications help maintain dilation of blood vessels, to increase blood flow to erectile tissue. The aim with penile rehabilitation is similar to above, to preserve smooth muscle function and the tissues within the penis. VED rehab alone, typically doesn’t yield effective results and the research has shown that outcomes are much better with it used in conjunction with the use of PDE-5 inhibitors, typically a 5mg dose of tadalafil (Cialis).
Pelvic floor muscle training (PFMT)
- Pelvic floor muscle function also plays a role in improving erectile function. Contraction of these muscles (this ischiocavernosus in particular), contribute to increased intracavernous (within the erectile tissue) blood pressures, which helps build and maintain rigidity in the erect penis. Training the pelvic floor is an important and generally done routinely following prostatectomy to improve continence but this cross over with erectile function is important to note.
Recovery time frame for erectile function
As mentioned above, the recovery time frame for erectile function is quite a bit longer than continence recovery after prostate surgery. It can take up to two years - about 40-50% of men who recover do so within the first year, and about 30-60% recover within two years. There are many factors that contribute to the speed of recovery such as preoperative erectile function, age, level of physical fitness, the surgery itself, the level of nerve sparing achieved during the surgery and the grade of cancer in the prostate.
The main three factors
The primary three to consider are: preoperative erectile function, age and level of nerve sparing during the procedure. At three years post op, 76% of men younger than 60 years of age who had full erections pre operatively, who had bilateral nerve sparing would be expected to regain erections sufficient for intercourse. Compared to younger men, who also had full erections pre-op and bilateral nerve sparing; those 60-65 years of age had an expected chance to recover erections of 56%, and those 65+ were 47%.
Patients with recently diminished erections had a 63% chance to recover erections, and patients with pre-existing erectile dysfunction had a 47% chance of recovery.
Resection of one neurovascular bundle reduced the chance of erection recovery to 25% compared to bilateral nerve sparing.
Preoperative erectile function
Likelihood to recover erections
Prostatectomy can be a frustrating surgery to recover from due to the significant impacts that incontinence and sexual dysfunction has on our lives. Understandably, there is a lot of focus on the cancer itself after diagnosis and leading up to the procedure, however, this leaves a lot of uncertainty around when things might recover and what you might expect life to be like after having the procedure. With success rates of prostate cancer interventions being so high, and detection of prostate cancer being improved, allowing faster outcomes, mortality from prostate cancer is lower. With this, we can start to shift our focus more towards quality of life after prostate cancer and prostate interventions.
Get in touch with our Men’s Health physiotherapists if you are undergoing or have undergone prostate cancer intervention to have the right guidance to achieve the quality of life you want. Click here for more information on men’s health physiotherapy.