THE "NEW" PROSTATE CANCER INFOLINK

An article published this week in the Journal of the American Medical Association has documented the value of Kegel exercises (with or without biofeedback and pelvic floor electrical stimulation) on recovery of continence after a radical prostatectomy (RP) — in men with persistent incontinence post-surgery. Our first reaction to the article was, “Didn’t these patients get advised to do Kegel exercises immediately following their surgery (and ideally before it too)?”

According to Goode et al., despite the fact that behavioral therapy is known to improve the recovery of continence after an RP, there have been no controlled trials of this type  of therapy for post-RP incontinence that lasts for more than 1 year. Their study was designed to address this issue.

The authors report data from a prospective, three-arm, randomized clinical trial. Eligible patients were stratified by type and degree of incontinence and then randomized to receive one of the following forms of management:

• Group A: 8 weeks of behavioral therapy (pelvic floor muscle training and bladder control strategies)
• Group B: Behavioral therapy plus in-office, dual-channel electromyograph biofeedback and daily home pelvic floor electrical stimulation at 20 Hz
• Group C: Delayed treatment, i.e., the control group

The trial enrolled a total of 208 patients aged between 51 and 84 years, and 24 percent of the men were African-Americans. Patients all had post-RP incontinence that had lasted for at least 1 year. One patient’s incontinence had lasted for as long as 17 years. The patients were all enrolled and managed at one university and 2 Veterans Affairs continence clinics between 2003 and 2008. There was a 1-year follow-up period after the active treatment. The primary outcome assessed was the reduction in number of episodes of incontinence after 8 weeks of treatment (which was documented through the use of 7-day bladder diaries).

Thew key findings of this study were as follows:  

• Among men in Group A and Group B, the average (mean) number of episodes of incontinence decreased significantly
  • From 28 to 13 per week (a 55 percent reduction) in Group A
  • From 26 to 12 per week (a 51 per cent reduction) in Group B
• Among men in Group C, the average (men) number of episodes of incontinence decreased from from 25 to 21 (a 24 percent reduction).
• There was no significant difference in incontinence reduction between patinets in Group A and Group B (the two active treatment groups).
• Improvements in continence were durable for at least 12 months in the two active treatment groups.
  • 13.5 episodes per week (a 50 percent reduction) for patients in Group A
  • 9.1 episodes per week (a 59 percent reduction) for patients in Group B

The authors conclude that for men who have continued incontinence for at least 1 year post-RP, 8 weeks of behavioral therapy, compared to delayed treatment, resulted in significantly fewer episodes of incontinence but that the addition of biofeedback and pelvic floor electrical stimulation did not improve the overall outcome.

This study has also been discussed in some detail on The Wall Street Journal Health Blog. That article includes a couple of important additional points.

First, in an editorial published in association with this study, Dr. David Penson, a recognized expert on prostate cancer outcomes and quality of life apparently notes, with accuracy, that “prevention” (of the incontinence) might well be better than “a cure.” In other words, at least a percentage of these patients might have been better managed with active surveillance or watchful waiting, and therefore no had no risk for post-RP incontinence at all.

Second, even though the patients in Group B did no better than the patients in Group A overall, Dr. Goode is attributed with the observation that the biofeedback and electrostimulation technique still “has value for people who can’t contract their muscles on their own.”

Some additional information is available on line in a media release from the University of Alabama at Birmingham.

At the end of the day, however, it would seem to The “New” Prostate Cancer InfoLink that there is a fundamental obligation either on the surgeon who carries out the radical prostatectomy or on the physician who has primary responsibility for post-surgical follow-up. That obligation is to ensure that, post-RP, every patient follows a rigorous process of behavioral therapy using Kegel exercises (and biofeedback with electrostimulation if necessary) to optimize continence as fast as possible after his surgery. And in fact there is evidence from at least one well-conducted study to suggest that starting Kegel exercises prior to surgery will also assist in the recovery of continence.

Filed under: Living with Prostate Cancer, Management, Treatment | Tagged: continence, exercise, Kegel, outcome, radical prostatectomy |