Episode 1794 - PT post-op prostatectomy: unique considerations

Dr. April Dominick // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member April Dominick discusses 4 topics to cover early in rehab for an individual who had a prostatectomy surgery in order to promote optimal physical and mental recovery!

Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog.

If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

EPISODE TRANSCRIPTION

APRIL DOMINICKPost-op prostatectomy, unique considerations for the PT. Let's talk about them. Today on the podcast, we'll talk about four topics that are unique to post-op appointments when it comes to treating someone with a, or after a prostatectomy. Overall, we address the person who comes in for prostatectomy care with similar basic foundations that we would any other post-op person, like rotator cuff repair, post-op knee replacement. We do this in regards to respecting general tissue healing guidelines and timelines, restoring mobility and function, as well as using those progressive overload principles in order to achieve those goals. Don't let the prostate piece scare you. It's basically the same, except for a few considerations that we'll talk about today. You are the musculoskeletal expert, and you can use what you already know for these general post-op sessions. The post-op PT eval will be, like I said, similar to the pre-prostatectomy eval that I talked about in my previous episode, number 1765. In that episode, I outlined some basic education on prostatectomy, options for surgery. I go into detail about what a rehab session would look like from the subjective to the objective to the treatment and, uh, week over the most common complaints, which are urinary leakage and erectile dysfunction. So the biggest takeaway from that episodes besides how to outline your eval and session is that pelvic floor muscle training prior to a prostatectomy is key for having incredible impacts on improving health-related quality of life post-op. So again, the outline of a prehab evaluation for someone prior to their prostatectomy will be very similar to the post-op. So I just wanted to take out some key pieces or topics to focus on today that are unique to someone who had a prostatectomy. So we'll talk about how to educate, intervene, and I'll give you some tools for four different branches of our post-prostatectomy tree. The first branch we'll talk about is surgery specifics and general pelvic floor knowledge. The second thing we'll talk about is bladder function. Then we'll go into sexual function. And our fourth branch is the psychosocial piece. So let's dive in. SURGICAL CONSIDERATONS Branch number one, surgical considerations to ask the patient. So the patient comes in, they've had their prostatectomy. What do we need to know about their surgery? Well, first off, we need to know which type of surgery did they have. And we're today talking about a full prostatectomy, so removal of the prostate and some seminal vesicles. So which type of surgery was used? Was it open, meaning they had much larger incisions in the abdomen in order to get to the prostate? which is gonna have a huge effect on rehab. Number two, is it a laparoscopy? And that's gonna be a lot smaller incisions on the abdomen, or was it robotic assisted? Generally speaking, those are smaller incisions. They have less trauma and much shorter hospital stays. Another important question to ask is how long was their catheter in? And on average, it's about one to two weeks. If it's longer, there is a big potential to impact short-term bladder function, like urgency, frequency, leakage, and there is a greater risk for UTIs. And then if they know about this, a lot of times they don't really know about this, but if they know about it, any information about how much nerve sparing was achieved during the surgery. We know now the greater the nerve sparing, the likely that there is better function from a bladder side of things, as well as sexual function. So that's just some general surgery considerations. Now we'll dive into pelvic specific education that we can give. In terms of the pelvic floor, most people don't know what the pelvic floor is and don't know how it's related to the surgery they just did. So ensuring that the individual has some visual models or pictures of the pelvic floor itself and how these muscles relate to bladder, bowel, sexual function, supports, and things like that. Then making sure that they know, hey, this is the surgery that you had. Here's what happened, if they're okay with you talking about it. That way they understand why they're experiencing certain side effects. And then asking them, very much understanding what is it that they need in terms of lifting? Do they have a toddler at home? Do they have a grandchild that they're lifting or a caregiver? What are their job duties? Does their work require that they lift? And making sure that we have those in mind so that we can prioritize those with their rehab goals. Still under our pelvic branch, we can also get some objective measurements from them, outcome measures that are really helpful for this population. From a bladder side of things, the International Prostate Symptom Score is helpful. They also ask about nocturia or nighttime leakage. And then the NIH chronic prostatitis symptom index, it talks about impacts of symptoms and their quality of life. From a sexual function standpoint, the erectile hardness scale and then the international index of erectile function, those basically have them rate their erections and the quality of those. And then psychosocially, there is a prostate cancer specific index cancer patients and it measures health-related quality of life, physical function, as well as emotional well-being. So those are some outcome measures that you can track changes of with your patients. And then still on the objective side of things for the pelvic floor, we want to get a general orthopedic assessment and pelvic floor specific assessment. And during that pelvic floor assessment, we are looking at hyper or hypotenicity. We are understanding what their awareness is of their pelvic floor, their connection, coordination, strength, so many different things that we can look at. And you can do an external visual palpation of the pelvic floor. And you can do an internal a digital rectal exam. However, that's only going to be once they are cleared by the physician around six to eight weeks. So that was all the surgery considerations that we want to ask, then the pelvic floor, just kind of like things that we want to go over, objective measures. BLADDER FUNCTION Now we're going to move into the bladder function and talk about education, exercise, and some general tools and resources for that branch. So education wise, we want to be educating these individuals that urinary incontinence is extremely common in this population. It can be significant and very much improve. We usually see most improvements within the year. Clinically, I've seen a lot of improvements in that first three to six months, especially if they're able to come in for PT. And then we want to be telling them about, hey, here's some education on pads, how you can use the weight of the pad to be a specific measurement for whether or not they're improving in their urinary leakage. So weighing the pads is a lot more objective of a measurement than asking, How many paths do you go through? And then teaching them, hey, there's different levels of absorbency of the pads. That could be another measure. If you need one that has a much lighter absorbency, then that can be another sign that you're improving. And then from a daughter's side of things, educating them on taking note of your daytime leakage and nighttime leakage. Reminding them that, hey, if you After the surgery, once you become more and more active, you may notice at first some more urinary leakage and we expect that. for some people. And as they do therapy, we also expect that to get better. So also being mindful for these tracking changes and suggestions. Some individuals may have a lot of anxiety with tracking these changes. So being careful with who it is that you actually recommend being very diligent about tracking. And then from an exercise standpoint to help with bladder leakage, we're always going to start with pelvic floor muscle training. And that can be isolated at the very, very beginning. And then, and we can start that as soon as the catheter is removed. There aren't any solid research-based protocols on how many reps exactly and how often and whatnot, but we generally want to be starting with isolated pelvic floor muscle contractions and then pairing that with functional movements pretty much right off the get-go. I'm gonna say sit-to-stands are one of the biggest and most common ADLs that someone post-op will have leakage with and because think about how many times we stand up to during our day as well. So really harping on mechanics and breathing and bracing strategies to help limit the urinary leakage with that. And then of course lifting, walking, returning to specific sports or job duties is going to be how we also want to pair our functional activities. our pelvic floor muscle training. Then we want to be teaching about breath mechanics and bracing strategies. So really leaning into, hey, there is a spectrum of breath mechanics like using an open glottis versus using a closed glottis. That's going to be a lot more intraabdominal pressure. And really teaching them how to gauge that pressure at the beginning to reduce the strain that they have with activities like standing up. Also ensuring that, hey, when they are lifting, they are not straining. They are not, as we like to say in the pelvic division, going down to the basement. And because that is going to increase unnecessary pressure on the area that is healing. And then progressively building up to increasing intra-abdominal pressures as well as external loads as they return to lifting or impact or return to their sport. From a bladder side of things, the tools that we can use, a penile clamp would be a tool that lightly puts pressure around the mid-shaft and then in doing so it kinks the urethra and that's going to over time increase bladder capacity and help them if they are struggling quite a bit with urinary leakage. All right, so that was the bladder branch. SEXUAL FUNCTION Now we're onto the sexual function branch. The sexual function piece, often the most distressing post-op change. Education-wise, we want to make sure that they understand, hey, there is no longer going to be wet ejaculate post-op due to the removal of the seminal vesicles. You may have a loss of penis length, Expect that. And then also reminding them that, hey, there may be some changes in your erection and orgasm, such as delayed onset or reduced intensity, maybe some increased pain or reduced sensation, but that is why you're working with me. We'll work together on some of those pieces. and then from an exercise or modality perspective for sexual function. Obviously, pelvic floor muscle training is going to be really helpful, making sure that they have an understanding and awareness of which muscles or where they need to be working if there are restrictions to the pelvic floor. So we can teach them some self-mobilization techniques, not only at the pelvic floor, but also globally at the hips and abdominals as well. And this is going to help promote local blood flow, which is what we need for sexual function and for interaction. And then modalities like dry needling plus stim are helpful for local and global blood flow. And then of course, regular aerobic exercise, 150 minutes a week, that is going to 100% improve their blood flow and just overall physical health in general. Other non-musculoskeletal tools that they can use to help with sexual function, penile pumps that can help with erectile function by increasing the local blood flow and maintaining penile length. There are various protocols for using these. And then a lot of folks are also recommended to use medication like phosphodiesterase to help with post-prostatectomy and sexual function. PSYCHOSOCIAL CONSIDERATIONS And then our third branch, the psychosocial branch. While this surgery removes something physically, we cannot forget the ricochet effects it has on the person's mental and emotional well-being. exercise levels pre and post-op, let's use this as an opportunity to create lifestyle change, to increase their aerobic and resistance exercise frequency so that they're not leading that sedentary lifestyle post-op that maybe they did pre-op. This is going to obviously improve mental health and the physical effects post-prostatectomy. While the surgery does affect the client, it also affects their social life. Say leaking or wearing a diaper, going out to happy hour, not a great look. And then also it includes the romantic partners or maybe even caregivers. So ensuring that we are addressing not only the individual who was affected from the surgery, but others in their life. And then tools wise, the Prostate Cancer Foundation, it's a great resource for finding providers, treatment centers, support groups, and there's a space for caregivers. So I really liked that website. Then there's the Mojo app, and that focuses on the psychological side of sexual function for erectile dysfunction. So it's created by a psychotherapist and pelvic floor physical therapist. There's lots of different exercises, little modules that they can go through. A support group is also included. It is not prostatectomy specific, but I think it's a great resource from the psychosocial side of things. And then of course, mental health providers are huge, especially those that are versed in pelvic conditions or even someone who's a sex therapist. SUMMARY Okay, in summary, we know that prehab is vital for these prostatectomy patients in order to improve their outcomes post-op. Post-op prostatectomy, the general guidelines of tissue healing are very similar in how we would use progressive overload principles, very similar as any other kind of operation or post-op. There's just those unique considerations that we talked about. We talked about that tree with some different branches, so making sure that surgically we asked them about specific questions like what was the type of surgery, how long did they have their catheter in from a bladder function branch. We talked about education of the pelvic floor itself and anatomy so that they understand why leakage is happening. We talked about breathing and bracing strategies and using those to up or down ramp the pressure to affect urinary leakage. And then we talked about pairing the isolated pelvic floor muscle contractions and coordination work with whole body strengthening and functional activities. Definitely focusing on sit to stands as they have the greatest urinary leakage. And then we talked about sexual function, ensuring that they know there are changes in their penis, like the erection, orgasm. They can do self-limbalizations to help with restricted areas. They can use the Mojo app, the penile pump, to assist in erectile function. And then from the psychosocial piece or branch, we talked about resources like the Prostate Cancer Foundation, mental health providers for both the client and the caregiver. So our next online cohorts, if you all are interested in pelvic classes through ICE, Our next online level one cohort starts September 9th. Level two starts October 21st, and that's where we really deep dive into post-op considerations. And we also talk more in depth about prostatectomies. Our next live courses are in Hendersonville, September 7th and 8th, Milwaukee, September 14th and 15th, and Galesbury, Connecticut, September 21st and 22nd. Thank y'all so much for listening, and I will catch you next time.

OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.