Incontinence Following Radical Prostatectomy Reduced
by Behavioral Therapy Program
Editorial writers ask if limited benefits are worth
the patient and clinician time and effort;
researchers say 'yes' do to significant, durable improvement in
incontinence and quality of life,
Jan. 12, 2011 - Men who
suffered with incontinence – lack of bowel control - for at least one
year following radical prostatectomy, achieved a significant reduction
in the number of incontinence episodes after participating in a behavioral
training program that included pelvic floor muscle training, bladder
control strategies and fluid management.
The researchers also
found that the addition of biofeedback and pelvic floor electrical
stimulation provided no additional benefit, according to the report in
the January 12 issue of the Journal of the American Medical Association
(JAMA).
Men in the United States
have a 1 in 6 chance of having prostate cancer. Although survival is
excellent, urinary incontinence (involuntary leakage of urine) is a
significant problem following radical prostatectomy, which is often the
treatment of choice for localized prostate cancer.
“Patient surveys
indicate that as many as 65 percent of men continue to experience
incontinence up to 5 years after surgery. Loss of bladder control can be
a physical, emotional, psychosocial, and economic burden for men who
experience it," according the background information in the article.
"Although behavioral
therapy has been shown to improve postoperative recovery of continence,
there have been no controlled trials of behavioral therapy for
post-prostatectomy incontinence persisting more than 1 year."
Also, biofeedback, which
assists patients to properly contract pelvic floor muscles, and pelvic
floor electrical stimulation, which produces a maximal pelvic floor
contraction and improves urethral closure pressure, are often used
together in practice and are thought to enhance the effectiveness of
behavioral therapy, but empirical evidence of a benefit has been
lacking.
A study to evaluate the
effectiveness of behavioral therapy for reducing persistent
post-prostatectomy incontinence and to determine whether the
technologies of biofeedback and electrical stimulation enhance its
effectiveness was conducted by Patricia S. Goode, M.S.N., M.D., of the
University of Alabama at Birmingham, and colleagues conducted
The randomized
controlled trial, which involved 208 community-dwelling men ages 51
through 84 years with incontinence persisting 1 to 17 years after
radical prostatectomy, was conducted from 2003 - 2008 and included a
1-year follow-up after active treatment.
Twenty-four percent of
the men were African American; 75 percent, white.
After stratification by
type and frequency of incontinence, participants were randomized to 1 of
3 groups:
1. eight (8) weeks of behavioral therapy (pelvic floor muscle training and
bladder control strategies);
2. behavioral therapy plus in-office, dual-channel electromyograph
biofeedback and daily home pelvic floor electrical stimulation (behavior
plus); or
3. delayed treatment, which served as the control group.
Participants completed
7-day bladder diaries.
The researchers found
that at 8 weeks, those in the behavioral therapy group had an average
reduction of incontinence episodes of 55 percent (from 28 to 13 episodes
per week), which was a significantly greater percent reduction than that
reported by the control group (average reduction of 24 percent; from 25
to 21 episodes per week).
Those in the
behavior-plus group experienced an average reduction of 51 percent (from
26 to 12 episodes per week), indicating that the addition of biofeedback
and electrical stimulation did not improve 8-week results compared with
behavioral therapy alone.
"Improvements were
durable to 12 months in the active treatment groups: 50 percent
reduction (13.5 episodes per week) in the behavioral group and 59
percent reduction (9.1 episodes per week) in the behavior plus group,"
the authors write.
At the end of the 8-week
treatment period, 15.7 percent of men in the behavior therapy group,
17.1 percent in the behavior-plus group, and 5.9 percent in the
control
group achieved complete continence, reporting no incontinence episodes
in their 7-day bladder diaries.
Behavioral therapy also
improved the effects of incontinence on daily activities and
condition-specific quality of life.
"Based on the
significant decrease in incontinence frequency and the small number
needed to treat (10) to achieve complete continence with behavioral
therapy, these findings have important implications for urologists,
primary care providers, and their patients," the researchers write.
"Behavioral therapy
should be offered to men with persistent post-prostatectomy incontinence
because it can yield significant, durable improvement in incontinence
and quality of life, even years after radical prostatectomy."
Editorial: Treatment for Post-prostatectomy
Incontinence - Is This as Good as It Gets?
Questions remain
regarding the optimal way to address post-prostatectomy urinary
incontinence, according to an editorial by David F. Penson, M.D.,
M.P.H., of Vanderbilt University and VA Tennessee Valley Geriatric
Research, Education, and Clinical Center (GRECC), Nashville, Tenn.
They write, "Is it
behavioral therapy, which likely requires considerable patient and
clinician time and effort to implement and is associated with limited
benefit?
“Is it surgical
implantation of an artificial urinary sphincter [a structure, or a
circular muscle, that relaxes or tightens to open or close a passage or
opening in the body] that works, but requires another surgical
procedure?
“Or is it application of
new technologies at the time of prostatectomy that purport to result in
better patient-reported outcomes but still appear to be associated with
a significant incidence of post-prostatectomy urinary incontinence?
“Perhaps none of these
is ideal. A better strategy would be primary prevention: increased
utilization of active surveillance among patients with lower-risk
disease and selective application of aggressive interventions in
patients with worse prognostic variables."
About Urinary Incontinence(Also called, ‘Overactive bladder’)
While it may happen to anyone, urinary incontinence
is more common in older people. Women are more likely than men to have
incontinence. If this problem is happening to you, there is help.
Incontinence can often be cured or controlled. Talk to your doctor about
what you can do.
Causes of Incontinence
Incontinence is often seen as part of aging. But it
can occur for many other reasons. For example, urinary tract infections,
vaginal infection or irritation, constipation, and some medicines can
cause bladder control problems that last a short time. When incontinence
lasts longer, it may be due to:
● weak bladder muscles
● overactive bladder muscles
● damage to nerves that control the bladder from diseases such as
multiple sclerosis or Parkinson’s disease
● diseases such as arthritis that may make it difficult to get to the
bathroom in time
● blockage from an enlarged prostate in men
Bladder Control
The body stores urine in the bladder. During
urination, muscles in the bladder tighten to move urine into a tube
called the urethra. At the same time, the muscles around the urethra
relax and let the urine pass out of the body. Incontinence occurs if the
muscles tighten or relax without warning.
Diagnosis
The first step in treating incontinence is to see a
doctor. He or she will give you a physical exam and take your medical
history. The doctor will ask about your symptoms and the medicines you
use. He or she will want to know if you have been sick recently or had
surgery. Your doctor also may do a number of tests. These might include:
● urine and blood tests
● tests that measure how well you empty your bladder
In addition, your doctor may ask you to keep a
daily diary of when you urinate and when you leak urine.
Types of Incontinence
There are different types of urinary incontinence:
●
Stress incontinence happens when urine leaks as pressure
is put on the bladder, for example, during exercise, coughing, sneezing,
laughing, or lifting heavy objects. It’s the most common type of bladder
control problem in younger and middle-age women. It may also begin
around the time of menopause.
● Urge
incontinence happens when people have a sudden need to
urinate and aren’t able to hold their urine long enough to get to the
toilet in time. It is often, but not only, a problem for people who have
diabetes, Alzheimer’s disease, Parkinson’s disease, multiple sclerosis,
or stroke.
●
Overflow incontinence happens when small amounts of
urine leak from a bladder that is always full. A man can have trouble
emptying his bladder if an enlarged prostate is blocking the urethra.
Diabetes and spinal cord injury can also cause this type of
incontinence.
●
Functional incontinence happens in many older people who
have normal bladder control. They just have a problem getting to the
toilet because of arthritis or other disorders that make it hard to move
quickly.
Treatment
Today, there are more treatments for urinary
incontinence than ever before. The choice of treatment depends on the
type of bladder control problem you have, how serious it is, and what
best fits your lifestyle. As a general rule, the simplest and safest
treatments should be tried first.
Researchers studied almost 6,000 senior citizens,
suggest patients be informed about the differences and similarities in
expected outcomes, make treatment decisions with an experienced surgeon
-
Feb. 22, 2010
Androgen-deprivation therapy (ADT) may increase
cardiovascular risk, but unclear whether it’s linked to increased death
from heart disease - Feb. 3, 2010
MIRP, especially with robotic assistance, increased from 1% to 40% of radical prostatectomies from 2001 to
2006,despite limited data on outcomes and costs
Sarcosine is better indicator of advancing disease
than traditional prostate specific antigen test (PSA); it is detected in
urine, researchers hopeful simple urine test can be used
