University of Queensland researchers are working to change the way physiotherapists provide treatment for prostate cancer patients experiencing incontinence after prostatectomy.

In the first international work of its kind, Professor Paul Hodges, a physiotherapist and National Health and Medical Research Council (NHMRC) Principal Research Fellow, is leading a team of researchers who have identified a new way to assess and train men’s pelvic floor muscles.

“Several years ago, we realised not only do men have a very high prevalence of incontinence after prostate cancer, but in the research world the understanding about how men actually recover continence after they have surgery is far from complete,” he says.

“The problem is - you’ve got cancer in the prostate, they remove the prostate and varying amounts of the structures that normally control continence. Basically you lose a lot of the mechanism that helps to automatically keep the urine in the bladder.

“Normally your continence is controlled automatically, your nervous system just does it. These muscles automatically contract and stop the urine from leaving your bladder.

“Surgery to remove the prostate interferes with much of that mechanism and all of a sudden - how are you going to keep continence?”

Professor Hodges says their research shows men have a series of other muscles which can also control continence, but men have to train to use them in a new way.

It’s also been challenging for physiotherapists to assess whether men are using the right muscles.

About five years ago, a Cochrane Review publication argued physiotherapy treatments for men with incontinence after a prostatectomy were unsuccessful.

UQ researchers believe their studies reveal why the treatments were not working – older studies have been using assessments that measure the wrong muscles, those designed for fecal continence not urine continence.

“Men and women have a series of other muscles that are available to help contribute to maintaining urine in the bladder,” he says.

“Our research shows that these muscles normally help to control continence in challenging situations like coughing. You can also voluntarily contract these muscles, you can turn them on.

“What we’ve identified is that these muscles are really important for controlling continence in demanding situations.

“What we propose is that if we train men to use these muscles differently after prostate removal, that is, aiming to get men to use these muscles to be active much of the time, this may be able to improve recovery of continence.”

In the past five years, the research team has been releasing new evidence showing how men can control continence using the right pelvic floor muscles, and how to best evaluate and train those muscles.

“What we are providing is a basis for changing the way that we do exercise for incontinence after prostatectomy,” Professor Hodges says.

“There’s been a new review published by the Cochrane collaboration. Although it shows some evidence that physiotherapy treatments can make a difference, they’re still not optimal because they’re still training the wrong muscles.

“What we’re proposing is that we can make a big difference if we focus on training the right muscles in the right way in these men.

“Our research is providing a strong foundation to argue for that.”

Professor Hodges says physiotherapists need to change the instructions they use to train men in how to use their pelvic floor muscles.

“Instructions that focus on the muscles that are best for controlling continence include - stop the flow of urine, shorten the penis.

“We’ve done experiments that show that those instructions actually make the right muscles contract.”

The researchers found that physiotherapists can use a non-invasive method of ultrasound imaging in clinical practice to test whether men are exercising the right pelvic floor muscles.

“We can place the transducer onto the pelvic floor between the legs…and then we can view the muscles in the ultrasound image and watch the muscles contracting,” he says.

“We can actually observe whether the man is contracting or not and whether he’s contracting the right muscles or not.

“Many of our experiments show that what you see on the image tells us important information about how the system works and this is something physiotherapists can use.

“There’s an increasing number of physiotherapists who have access to ultrasound imaging in their practice and this is a way that we can actually assess these muscles and make sure that we’re having the right effect.”

Professor Hodges says exercising the right pelvic floor muscles is unlikely to be the answer for every patient with incontinence after a prostatectomy, but it is likely to be effective for many. If exercise treatments fail, other options are available including surgery and devices.

“We think this is really an appropriate first line strategy,” he says.

“What we’re asking men to do is not difficult. The assessment is actually not that confronting and it provides very useful information to work out whether they’re contracting the right muscles and then teaching them some instructions that they can put into practice on day one.

“We can teach them how to contract the right muscles and then we can teach them how to use them to control continence when they function.”

The research team is planning a clinical trial that compares the new physiotherapy treatment with conventional treatment for incontinence.

* Professor Hodges will speak about his research into continence exercises for prostate cancer patients at the Australian Physiotherapy Association’s CONNECT 2015 national conference being held on the Gold Coast from October 3-6