Male_pelvic_floor.powe point presentation

Pelvic floor

1. Pumping the male pelvic floor
to perfection
Bury 2011Bury 2011
Professor Grace Dorey PhD FCSPProfessor Grace Dorey PhD FCSP

2. Deep pelvic floor musclesDeep pelvic floor muscles
PubococcygeusPubococcygeus maintains continencemaintains continence
Iliococcygeus Iliococcygeus maintains maintains
continencecontinence
Ischiococcygeus Ischiococcygeus stabilises levator anistabilises levator ani
PuborectalisPuborectalis ano-rectal angleano-rectal angle

3. Superficial pelvic floor musclesSuperficial pelvic floor muscles
IshiocavernosusIshiocavernosus penile rigiditypenile rigidity
BulbocavernosusBulbocavernosus penile rigidity penile rigidity
pumps ejaculate pumps ejaculate
prevents PMD prevents PMD
Anal sphincterAnal sphincter controls faecescontrols faeces

4. Prostatic problemsProstatic problems
Benign prostatic hyperplasiaBenign prostatic hyperplasia Affects 40% Affects 40%
of men over 70 Impaired blood supply of men over 70 Impaired blood supply Berger Berger
et al 2005et al 2005 Causes urethral obstruction Causes urethral obstruction
Disposing factors Age & testosteroneDisposing factors Age & testosterone
Prostate cancerProstate cancer Affects 14% of Affects 14% of
50 year olds 50 year olds
Almost all 80 year oldsAlmost all 80 year olds
Prostatitis Prostatitis Acute or Acute or
chronic chronic
Men under 50Men under 50

5. Prostatitis categoriesProstatitis categories
I I Acute bacterialAcute bacterial
II II Chronic bacterialChronic bacterial
III III Chronic pelvic pain syndromeChronic pelvic pain syndrome
IIIA IIIA InflammatoryInflammatory
IIIB IIIB Non-bacterial (prostatodynia)Non-bacterial (prostatodynia)
IV IV Asymptomatic inflammatoryAsymptomatic inflammatory

6. Voiding symptomsVoiding symptoms
HesitationHesitation
StrainingStraining
Weak streamWeak stream
Intermittent streamIntermittent stream
Terminal dribbleTerminal dribble
Incomplete emptyingIncomplete emptying

7. Filling symptomsFilling symptoms
FrequencyFrequency
NocturiaNocturia
UrgencyUrgency
Urge incontinenceUrge incontinence

8. MAPS trial MAPS trial Glazener et al 2010Glazener et al 2010
65% of TURPs wet at 6 weeks post op65% of TURPs wet at 6 weeks post op

9. MAPS trial MAPS trial Glazener et al 2011Glazener et al 2011
89% of Radicals wet at 6 weeks post op89% of Radicals wet at 6 weeks post op

10. Predictor of Post Prostatectomy Predictor of Post Prostatectomy
IncontinenceIncontinence
Pre-op erectile dysfunction p=0.024Pre-op erectile dysfunction p=0.024
Age Age p=0.759p=0.759
Nerve sparing Nerve sparing p=0.504p=0.504
Wille et al 2007Wille et al 2007

11. Types of urinary incontinenceTypes of urinary incontinence
Urge incontinence Urge incontinence
Infection Bladder cancer Bladder stonesInfection Bladder cancer Bladder stones
Idiopathic detrusor overactivity Dysfunction Idiopathic detrusor overactivity Dysfunction
of prefrontal cortex or limbic (emotion) system of prefrontal cortex or limbic (emotion) system
Griffiths & Tadic 2008Griffiths & Tadic 2008
Stress Stress
Post prostatectomyPost prostatectomy
Weak pelvic floor musclesWeak pelvic floor muscles
Mixed Mixed
Stress & Urge incontinenceStress & Urge incontinence

12. Types of urinary incontinenceTypes of urinary incontinence
Overflow incontinence Overflow incontinence
Blockage Blockage
Impaired nerve supply Impaired nerve supply
Atonic bladderAtonic bladder
ContinualContinual
Extra-urethralExtra-urethral

13. Types of urinary incontinenceTypes of urinary incontinence
Post-micturition dribble Post-micturition dribble
Bulbocavernosus fails to emptyBulbocavernosus fails to empty
Uncategorised Uncategorised
FunctionalFunctional

14. Subjective assessmentSubjective assessment
Personal detailsPersonal details
Duration and severity of symptomsDuration and severity of symptoms
Amount and frequency of leakageAmount and frequency of leakage
Appliances or padsAppliances or pads
Medical and Surgical historyMedical and Surgical history
Neurological problemsNeurological problems
Bowel activityBowel activity
Sexual dysfunctionSexual dysfunction
Motivation and functional factorsMotivation and functional factors

15. Objective assessmentObjective assessment
Informed consentInformed consent
ChaperoneChaperone
Supine lying & knees bent with paper sheet Supine lying & knees bent with paper sheet
Skin condition infection, abnormalitiesSkin condition infection, abnormalities
Ability to tighten anusAbility to tighten anus
Perform penile retraction and scrotal liftPerform penile retraction and scrotal lift
Leakage on coughingLeakage on coughing
Able to prevent leakage on coughingAble to prevent leakage on coughing

16. Objective assessmentObjective assessment
Palpation Palpation
Sensation Sensation
Pain Pain
ReflexesReflexes
Digital anal examination Digital anal examination
Strength Strength
Endurance Endurance
Fast fibres Fast fibres
PuborectalisPuborectalis

17. Assessment of PFM strength Assessment of PFM strength
Dorey 2003Dorey 2003
0 = nil0 = nil
1 = flicker1 = flicker
2 = weak2 = weak
3 = moderate 3 = moderate Movement of PR muscleMovement of PR muscle
4 = good 4 = good PRPR resistanceresistance
5 = strong 5 = strong Strong PR resistanceStrong PR resistance
6 = v strong 6 = v strong Unable to withdraw fingerUnable to withdraw finger

18. Treatment for stress Treatment for stress
incontinenceincontinence
Patient education Patient education Model of male pelvisModel of male pelvis
Patient specific pelvic floor muscle exercisePatient specific pelvic floor muscle exercise
The knackThe knack
BiofeedbackBiofeedback
Quantity of fluid adviceQuantity of fluid advice

19. Fluid Advice Fluid Advice Malone-Lee 2010Malone-Lee 2010
Thirst is the most accurate judge of fluid Thirst is the most accurate judge of fluid
balance and cannot be betteredbalance and cannot be bettered
Pushing fluids dilutes natural antibodies Pushing fluids dilutes natural antibodies
and natural antibioticsand natural antibiotics
Drinking too little does not allow filling of Drinking too little does not allow filling of
300-400ml for optimum emptying300-400ml for optimum emptying

20. Pelvic floor muscle exercisesPelvic floor muscle exercises
Strong contraction to gain elevation of Strong contraction to gain elevation of
testicles and slight penile retractiontesticles and slight penile retraction
SittingSitting StandingStanding LyingLying
3 strong holds of 10 seconds twice a day3 strong holds of 10 seconds twice a day
Slight lift whilst walkingSlight lift whilst walking
The knackThe knack
Strong pelvic floor muscle contraction Strong pelvic floor muscle contraction
after voiding urineafter voiding urine

21. Treatment for urge incontinenceTreatment for urge incontinence
Patient education Patient education Model of male pelvisModel of male pelvis
Lifestyle modifications Lifestyle modifications
Type and timing of fluids Diet Type and timing of fluids Diet
Cranberry juice Cranberry juice Not with RhA & gastric ulcersNot with RhA & gastric ulcers

Smoking Smoking Haidinger et al 2000Haidinger et al 2000
Patient specific pelvic floor muscle exercisePatient specific pelvic floor muscle exercise
Urge suppression techniquesUrge suppression techniques
AnticholinergicsAnticholinergics

22. Urge Suppression techniquesUrge Suppression techniques
Keep calmKeep calm
Relax abdominal musclesRelax abdominal muscles
Stand still or sit downStand still or sit down
Wait 1 minute until urge disappearsWait 1 minute until urge disappears
NEVER RUSH TO TOILET MID-URGENEVER RUSH TO TOILET MID-URGE
Continue activities or visit bathroomContinue activities or visit bathroom

23. Treatment for post-micturition Treatment for post-micturition
dribble dribble Paterson et al 1997Paterson et al 1997
Pelvic floor muscle exercises Pelvic floor muscle exercises Twice as Twice as
effective as bulbar massage effective as bulbar massage
Bulbar massage Bulbar massage Instant Instant
self helpself help
Counselling Counselling No No
improvementimprovement
Strong PFM contraction after voidingStrong PFM contraction after voiding
Dorey et al 2004Dorey et al 2004

24. Treatment for overflow Treatment for overflow
incontinenceincontinence
Relief of obstruction Relief of obstruction
Medication to relax prostate muscle Medication to relax prostate muscle
Medication to reduce size of prostate Medication to reduce size of prostate
TURP TURP
Surgery for stricture Surgery for stricture
Self intermittent catheterisationSelf intermittent catheterisation

25. Treatment for functional Treatment for functional
incontinenceincontinence
Alterations to clothingAlterations to clothing
Environmental changesEnvironmental changes
Position for urinationPosition for urination
Containment productsContainment products
Social careSocial care

26. Treatment of pelvic painTreatment of pelvic pain
Assess the spineAssess the spine
Relaxation for hypertonic muscles using BFBRelaxation for hypertonic muscles using BFB
Trigger point pressure & relaxationTrigger point pressure & relaxation
Relax PFMs whilst walking & activitiesRelax PFMs whilst walking & activities

27. General informationGeneral information
Men pass urine better when standingMen pass urine better when standing
Pads are preferable to a leg bagPads are preferable to a leg bag
Semen may enter bladder after TURPSemen may enter bladder after TURP
Dry orgasm after radical prostatectomy Dry orgasm after radical prostatectomy
Erection Orgasm Ejaculation are separate eventsErection Orgasm Ejaculation are separate events

28. When to refer to UrologistWhen to refer to Urologist
Blood in urine – bladder cancer?Blood in urine – bladder cancer?
Blood in semen – Blood in semen – inflammation inflammation infection infection
blockage seminal vesicles?blockage seminal vesicles?
Retention of urine – blockage BPH or prostate CaRetention of urine – blockage BPH or prostate Ca
Severe urgency – bladder cancer?Severe urgency – bladder cancer?
Family member with prostate cancerFamily member with prostate cancer

29. Post radical prostatectomy PFMEsPost radical prostatectomy PFMEs
RCT 102 menRCT 102 men
PFME group PFME group 95% continent at 4 months95% continent at 4 months
Treated once a week until dry Treated once a week until dry
Van Kampen et al 2000Van Kampen et al 2000
RCT 300 menRCT 300 men
PFME group PFME group 19% continent at 1 month19% continent at 1 month
94.6% continent at 6 months94.6% continent at 6 months
Filocamo et al 2005Filocamo et al 2005

30. Post radical prostatectomy PFMEsPost radical prostatectomy PFMEs
OvergOvergåård et al 2008rd et al 2008
42 PFE group & 43 controls with PFE info42 PFE group & 43 controls with PFE info
PFE group treated once a week until dryPFE group treated once a week until dry
Dry at 1 yearDry at 1 year
92% in intervention group92% in intervention group
72% controls 72% controls
p=0.028p=0.028

31. MAPS study MAPS study Glazener et al 2011Glazener et al 2011
Large multicentred RCT for Men After Large multicentred RCT for Men After
Prostate Surgery (MAPS) Prostate Surgery (MAPS)
4 PFMEs & urge suppression treatments 4 PFMEs & urge suppression treatments
for urinary incontinencefor urinary incontinence
Trained physiotherapists and nurses in 34 Trained physiotherapists and nurses in 34
centres in UK centres in UK
205 men after radical prostatectomy (RP)205 men after radical prostatectomy (RP)
220 men after TURP220 men after TURP

32. MAPS Results MAPS Results Glazener et al 2011Glazener et al 2011
Age: RP men 62 years TURP men 68 years Age: RP men 62 years TURP men 68 years
RP men reported more SUI than UUIRP men reported more SUI than UUI
TURP men reported more UUI than SUITURP men reported more UUI than SUI
(36% of TURPs had pre-op incontinence)(36% of TURPs had pre-op incontinence)
PFM strength increasedPFM strength increased over 3 monthsover 3 months
SUI UUI & PMD reduced in RP and TURPSUI UUI & PMD reduced in RP and TURP
Control groups showed similar improvementControl groups showed similar improvement

33. Why MAPS failed?Why MAPS failed?
All men in trial knew about PFMEsAll men in trial knew about PFMEs
Some of control group had PFMEs as part of Some of control group had PFMEs as part of
standard carestandard care
Only 85% of RP men & 72% of TURP men Only 85% of RP men & 72% of TURP men
attended 4 appointments in 3 monthsattended 4 appointments in 3 months
Few therapists experienced in treating menFew therapists experienced in treating men
At 1 year 50% radical controls & 20% of TURP At 1 year 50% radical controls & 20% of TURP
controls were performing PFMEscontrols were performing PFMEs

34. Pre radical prostatectomy PFMEsPre radical prostatectomy PFMEs

RCT 16 men received PFMEsRCT 16 men received PFMEs
Sueppel et al 2001Sueppel et al 2001
RCT 125 men had BFB & behavioral trainingRCT 125 men had BFB & behavioral training
Burgio et al 2006Burgio et al 2006
Both RCTs showed significant improvementBoth RCTs showed significant improvement

35. Pre radical prostatectomy PFMEsPre radical prostatectomy PFMEs
Centemero et al 2009Centemero et al 2009
100 men100 men
Group A PFMEs 30 or 15 days Pre op & Post opGroup A PFMEs 30 or 15 days Pre op & Post op
Group B Post op PFMEs onlyGroup B Post op PFMEs only
At 3 monthsAt 3 months
Group A Pre-op & Post op PFMEsGroup A Pre-op & Post op PFMEs 62% dry62% dry
Group B Post op PFMEs Group B Post op PFMEs 38% dry38% dry
p=0.033p=0.033

36. Evaluation ofEvaluation of
pelvic floor muscle exercisespelvic floor muscle exercises
and manometric biofeedbackand manometric biofeedback
in the management ofin the management of
erectile dysfunctionerectile dysfunction
Dorey et al 2004Dorey et al 2004

37. RCTRCT
Group 1 Pelvic floor muscle exercisesGroup 1 Pelvic floor muscle exercises
Biofeedback Lifestyle changes Biofeedback Lifestyle changes
Group 2 Lifestyle changesGroup 2 Lifestyle changes
5 weekly sessions5 weekly sessions
Evaluated Initially 3 months 6 months Evaluated Initially 3 months 6 months
IIEF PIIEF ED-EQoL Blind assessment IIEF PIIEF ED-EQoL Blind assessment

38. SampleSample
55 men with erectile dysfunction55 men with erectile dysfunction
Hormone AssayHormone Assay
20 years and over20 years and over
Not had previous surgery (except TURP)Not had previous surgery (except TURP)
No congenital venous abnormalitiesNo congenital venous abnormalities
Not cognitively impairedNot cognitively impaired
Spoke EnglishSpoke English

39. Performing pelvic floor Performing pelvic floor
exercisesexercises
Pretend to prevent wind escapingPretend to prevent wind escaping
Pretend to stop flow of urinePretend to stop flow of urine
Tighten as strongly as possibleTighten as strongly as possible
Gain penile retraction and scrotal lift Gain penile retraction and scrotal lift

40. Pelvic floor muscle exercisesPelvic floor muscle exercises
3 contractions in standing 3 contractions in standing
3 contractions in sitting3 contractions in sitting
3 contractions in lying 3 contractions in lying
holding for 10 seconds twice a dayholding for 10 seconds twice a day
Slight lift whilst walkingSlight lift whilst walking
strong post-void pelvic floor contractionstrong post-void pelvic floor contraction

41. International Index of Erectile International Index of Erectile
FunctionFunction
IIEF 15 questionsIIEF 15 questions75 points75 points
Erectile function Erectile function
Orgasmic functionOrgasmic function
Sexual desireSexual desire
Intercourse satisfactionIntercourse satisfaction
Overall satisfaction Overall satisfaction Ranked 0-5 almost Ranked 0-5 almost
never few times sometimes never few times sometimes most times most times
almost always almost always

42. Erectile Function domain of IIEFErectile Function domain of IIEF
Ability to attain erectionAbility to attain erection
Hard enough for penetrationHard enough for penetration
Ability to penetrate partnerAbility to penetrate partner
Maintain erection after penetrationMaintain erection after penetration
Maintain erection to completionMaintain erection to completion
Confidence in maintaining erectionConfidence in maintaining erection

Clinical improvement 6 points Total 30Clinical improvement 6 points Total 30

43. Analysis of RCTAnalysis of RCT
Erectile function domain of IIEF at 3 months Erectile function domain of IIEF at 3 months
using parametric independent t-testusing parametric independent t-test
p = 0.001p = 0.001
Clinical shift of 6 points on erectile function Clinical shift of 6 points on erectile function
domain of IIEFdomain of IIEF6.74 points6.74 points

44. Analysis of Cross-over armAnalysis of Cross-over arm
3 months and 6 months3 months and 6 months
Erectile function domain Erectile function domain
paired Wilcoxon Signed Ranks Test paired Wilcoxon Signed Ranks Test
p < 0.001p < 0.001
Erectile function domain clinical shift Erectile function domain clinical shift
10.73 points10.73 points

45. Final blind assessmentFinal blind assessment
for both groups for both groups
including drop outsincluding drop outs
40% 40% normal erectile functionnormal erectile function
34.5% 34.5% improvedimproved
25.5% 25.5% no improvementno improvement

46. Reasons for failuresReasons for failures
Cardiovascular problemsCardiovascular problems44
Diabetes mellitusDiabetes mellitus44
Bilateral orchidectomiesBilateral orchidectomies11
Peyronie’s diseasePeyronie’s disease11
Severe low back painSevere low back pain11
High alcohol intakeHigh alcohol intake22
Bicycle racing for 17 yearsBicycle racing for 17 years11 Anal Anal
pressure <100 cmHpressure <100 cmH22OO44

47. www.yourpelvicfloor.co.ukwww.yourpelvicfloor.co.uk