May 21, 2017
Kegel exercises pre and post-prostate surgery + Peter Dorman exercises
“PFMT with or without biofeedback enhancement hastens the return to continence more than no PFMT in men with UI after RP. ” [Source]
Start 4 to 6 weeks prior to surgery to get into the habit of incorporating them into routine activities such as exercising. Practising even one day before surgery is beneficial.
I developed a program to treat incontinence. This involved, basically, designing a strong exercise program for the pelvic floor muscles which were progressively overloaded by integrating the abdominal muscles, as well as developing a super-fit neuromuscular reflex circuitry. My experience led me to write a book outlining the program – “Conquering Incontinence” (see “books” on my website). [Source]
NO EXERCISES WHILE CATHETER IS STILL IN
Doing pelvic floor muscle exercises after surgery (whilst a urinary catheter is in place) can irritate the bladder and cause discomfort. It is therefore recommended that you do not do any exercises during this time. However, once the catheter is removed you may start the pelvic floor exercises straight away.
IMMEDIATELY UPON REMOVAL OF CATHETER
When the catheter comes out and you empty your bladder for the first time, reconnect with
your ‘flow stop’ muscles and actually try to stop your urine flow. Overdoing the pelvic floor exercises after surgery may cause pelvic floor muscle fatigue or pain. Rest the muscles completely when
you are sitting or lying.
NOTE: Do the exercises lying down initially as this exerts the least pressure on the pelvic floor. When an improvement is noticed do them sitting or standing. [Source]
FIRST WEEK AFTER REMOVAL OF CATHETER
Do two sets of five-second contractions in the first three weeks after catheter removal. [Source]
SECOND WEEK AFTER REMOVAL OF CATHETER
The second week after the catheter is removed, increase the amount of time you contract the sphincter for 4 seconds. [Source]
THIRD WEEK AFTER REMOVAL OF CATHETER
The third week and beyond, increase the time of contraction to 5 to 10 seconds. [Source]
“Started in supine, then sitting, standing and during ADLs” [Source] – basically, start when lying down. Then move on to sitting exercises. Finally during walking, etc.
As your muscles get stronger, increase the length of time that you tighten and
hold the muscles to 10 seconds.
As the muscles get stronger, try to do 20 or more contractions at a time. Do them a few times a day. [Source]
The more PFME that can be performed on a daily basis, the better. Urologists generally recommend a hundred or more a day. Studies have demonstrated significant decreases in the time to continence in men performing such exercises after surgery. In fact, randomized studies demonstrated that 74-88% of men regularly performing PFME were dry 3 months after prostatectomy as opposed to only 30-56% of men who did not perform the exercises. [source]
This table shows the significant variation in prescription by different physiotherapists:
PRACTICAL EXPERIENCE OF ONE PATIENT
“Here are the exercise my therapist gave me:
- One month after surgery. Seated. Squeeze 5 seconds, relax 15. 15 times, 2–3 times a day. Remembering to squeeze before coughing, laughing, sneezing, or lifting.
- One month later. Seated. Squeeze 7 seconds, relax 15. 15–20 times 2–3 a day. Also. Seated. Squeeze 2 seconds, relax 4. 10 times twice a day.
- One month later. Standing. Squeeze 7 seconds, relax 10. 10–15 times twice a day. Standing. Squeeze 2 seconds, relax 4. 10 times 1–2 times a day.” [Source]
BENEFIT OF THESE EXERCISES
Incontinence will usually improve with time but by learning how to control the pelvic floor muscles, you can speed up the recovery process and reduce the leakage faster. If you don’t strengthen these muscles, the leakage may persist. [Source]
“One man who commenced pelvic floor exercises a year after radical prostatectomy kept a chart
of his monthly urinary leakage” [Grace Dorey – Pelvic Dysfunction in Men]
HOW TO DO THESE EXERCISES
Identifying your pelvic floor muscles: The first step in performing pelvic floor muscle exercises is to identify the correct muscles. There are several ways to identify them.
- When you go to the toilet, try to stop or slow the flow of urine midway through emptying your bladder. If you are able to do this you are squeezing the correct muscles. Do not do this repetitively. This is not an exercise, but a way to identify the correct muscles. In the early stages after prostate surgery this will be easiest during the night when the flow is likely to be strongest.
- You can do the exercise lying down, sitting, or standing with your legs apart, but make sure your thighs, bottom and stomach muscles are relaxed.
- Stand in front of the mirror (with no clothes on) and tighten your pelvic floor muscles. If you are tightening the right muscles, you should see the base of the penis draw in and scrotum lift up. The back passage will tighten too but it is not the focus of the exercise. When you relax your muscles you should feel a sensation of ‘letting go’.
Correct technique is very important when doing pelvic floor muscle exercises. You should feel a ‘lift and a squeeze’ inside your pelvis. The lower abdomen may flatten slightly, but try to keep everything above the belly button relaxed, and breathe normally.
Men can be encouraged to tighten and lift the pelvic floor muscles as in the control of flatus and the prevention of urine flow and can practise in front of a mirror to observe a visible retraction of the base of the penis into the body and a testicular lift. The testicular lift may be sluggish initially. In some men with weak pelvic floor muscles only one testicle might rise initially. As the pelvic floor muscles strengthen both testicles will lift more quickly to a higher level. … The intensity of the contraction is more important
than the frequency as maximum voluntary effort causes muscle hypertrophy and increased muscle strength.
Men can be taught to lift their pelvic floor slightly whilst walking. Instruction to tighten the anal sphincter about 50 % of maximum whilst walking will achieve this supportive lift which can become part of good posture and way of carrying oneself. [Grace Dorey – Pelvic Dysfunction in Men]
Walking UI is particularly disturbing to men. It was discussed that asking a patient to maintain tension for extended periods of time is not realistic or accepted with concern of hip muscle dysfunction. However it may be helpful to ask for a low level, submaximal contraction to be held for 5 to 10 steps to restore the ability of the muscle to hold under these circumstances. [Source]
“Craig teaches his patients palpation of the PFM contraction externally lateral to the base of the
penis at the perineal body. Others have men watch the penis move upward in the mirror or just
by looking down. One PT uses a video camera aimed at the rectal sphincter to show men the
inwards movement.” [Source]
Pelvic floor muscle training: Once you master the art of contracting your pelvic floor muscles, try holding the inward squeeze for longer (up to 10 seconds) before relaxing. If you feel comfortable doing this, repeat it up to 10 times. This can be done three times a day. Make sure you continue to breathe normally while you squeeze in.
Putting the pelvic floor into action: Every time the pressure in your abdomen increases you are potentially pushing urine out of the bladder. Identify the activities that cause urine to spurt out such as coughing, standing up or lifting, and tighten your muscles first to prevent urine escaping. Practice this control until it is automatic. This is called ‘the knack’. You should also try to use your pelvic floor muscles throughout the day. Some examples of when you could use them are:
- Whilst walking – try lifting your pelvic floor about 50% of maximum squeeze.
- When you feel the urge to pass urine – squeeze your pelvic floor to hold on until you get to the toilet.
- After you have passed urine – tighten your pelvic floor, which may help prevent the embarrassment of an after-dribble leak of urine as the squeeze expels the last few drops of urine from the urethra.
- After opening your bowels – tighten around your back passage.
Once you identify your pelvic floor then start working on ‘the knack’. Also identify 2 to 3 regular times in a day when you can concentrate and spend 5–10 minutes working on your muscles. It is important that you give your muscles time to recover when getting back into a regular routine. Do this by making sure you ‘rest’ for as long as you ‘hold’. For example, if you hold for 5 seconds make sure you rest for 5 seconds. When your muscles get tired, give them a full minute rest.
As doing the exercises gets easier you can try doing them in progressively more challenging positions: from sitting to standing and on to walking. Over time you may only be leaking when you exert yourself.
By identifying the activities that cause you to leak, you can learn to tighten your muscles to try and prevent it using ‘the knack’. If it happens during your chosen sport you may need to practice the movement involved so that tightening your pelvic floor muscles becomes automatic.
During Kegel exercise the abdominal muscles must be totally relaxed otherwise they will push the organs from inside causing significant injury. In the first few weeks after surgery avoid doing these muscle activities while standing to minimise the pressure on the bladder while it is healing. At https://youtu.be/YkMcA6iDkMk the physio shows how these should be done lying down initially but after sleeping continence is achieved, then only while standing. Do not do excessive exercises as they will harm. Do not hold your breath while doing this exercises. Each time you get up hold your pelvic muscles. If you forget do this then do it five times till it is embedded in your head. That’s how you develop the knack.
How long will I need to keep doing the exercises? Your pelvic floor will remain a weak spot for life. It is therefore important that you keep exercising it for life. If you become sick with the flu and cough a lot you may start leaking again. This does not have to be permanent however, so revisit a pelvic floor training regimen once you recover.