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Re: Pelvic Floor Muscle Training in Radical Prostatectomy: A Randomized Controlled Trial of the Impacts on Pelvic Floor Muscle Function and Urinary Incontinence.

available at http://www.ncbi.nlm.nih.gov/pubmed/31729959 Editorial Comment: This group looked at facilitation of the return of post-radical prostatectomy continence in a somewhat different way. Five weeks before undergoing surgery participants were randomized to an intervention or usual care group. Both groups received initial physiotherapy directed pelvic floor muscle (PFM) instructions over 2 sessions of 30 minutes and were then prescribed a daily training program. This program differed in mode and intensity, depending on randomization. The usual care group was instructed to do 3 sets of exercises per day with 10 contractions per set, aiming to hold the contractions for a duration of 10 seconds with an equal rest time, providing a total of 30 contractions. Exercise sets were performed once each in the supine, sitting and standing positions. The intervention group was believed to have both slow and fast twitch muscle fibers targeted. Six sets of PFM exercises per day were performed, with each set consisting of 10 fast and 10 slow contractions with an equal rest time, providing a total of 120 contractions per day. All exercises in this group were performed in the standing posture. Postoperatively training recommenced following catheter removal. The interventions continued through the 12-week assessment period. No participants were incontinent before undergoing surgery. Of 101 participants 97 completed the study. Dryness (no pads or 0 gm net pad weight) was achieved in 14% of the intervention group vs 4% of the control group at 2 weeks, 32% vs 11% at 6 weeks and 74% vs 43% at 12 weeks. Pad weights were significantly different as well, although these data were provided only in the form of graph representations. The differences do look clinically significant. There was a statistically significant difference in International Prostate Symptom Score at 6 weeks but not at 2 weeks or 12 weeks, and the differences in all cases looked to be less than 3 points. The authors used a health related quality of life measure for men following treatment, which revealed statistically significant differences at 2 weeks but not at 6 or 12 weeks. The authors conclude, “Whilst some studies reported positive results and concluded an important role for PFM training, others, including a prominent and large clinical trial and a Cochrane review which included it, suggested that an active intervention did not substantially accelerate the degree of spontaneous recovery. Our findings demonstrated a benefit of the prehabilitation intervention performed at a higher intensity, but we also observed evidence for spontaneous post-op recovery in the control group.” It is unfortunate that the various parameters of continence and quality of life were not recorded at 6 and 12 months. Certainly preoperative intensive training 1) does no harm, 2) doesn’t sound as though it takes much time to teach and 3) is inexpensive. However, it does require a compliant patient. An interesting aspect of the article is whether the 2 types of exercises selected for the intervention group really do activate or strengthen fast and slow twitch periurethral striated musculature. Alan J. Wein, MD, PhD (hon), FACS References 1. Wang W, Huang QM, Liu FP et al: Effectiveness of preoperative pelvic floor muscle training for urinary incontinence after radical prostatectomy: a metaanalysis. BMC Urol 2014; 14: 99. 2. Patel MI, Yao J, Hirschhorn AD et al: Preoperative pelvic floor physiotherapy improves continence after radical retropubic prostatectomy. Int J Urol 2013; 20: 986. 3. Stafford RE, Ashton-Miller JA, Constantinou C et al: Pattern of activation of pelvic floor muscles in men differs with verbal instructions. Neurourol Urodyn 2016; 35: 457.