Peter Dornan method to achieve continence

INCONTINENCE: An aggressive approach to treatment by Peter Dornan

Peter Dornan is a Brisbane physiotherapist who has a special interest in prostate cancer.

He is currently leader of the Brisbane Prostate Cancer Support Network.

STANDARD TREATMENT OPTIONS

  1. Behavioural Intervention
  • Pelvic floor exercises
  • Biofeedback/electrical stimulation
  • Modifications in diet and fluid intake
  • Bladder training
  1. Pharmacological intervention
  2. Surgical

 

NEW APPROACH

The working hypothesis of this program centers on expanding the philosophy involved with Behavioural Intervention  particularly in relation to pelvic floor activity, based on the role of the pelvic

floor in providing bladder neck support and supplementary urethral closure

pressure. (DeLancey 1990, Gosling et al 198I).

Fig 1 Male Pelvis showing location of Pelvic Floor Muscles

 

The prime focus is to develop a highly efficient (super fit) neuromuscular and vascular system which controls all of the structures which form the pelvic and abdominal cavities, including pelvic floor muscles.

Fig 2 Detail of Pelvic Floor Muscles

Further, as there are seven command centers which control bladder voidance and continence, it is essential that a specific intense system of exercises be undertaken to improve all reflex

circuitry relating to this control.

For incontinence involving nerve damage, and I refer particularly here to the “nerve-sparing” operation for men who have undergone a radical prostatectomy, any nerve damage in this instance should be a neuropraxia (compression or stretching of the nerve), and the pathway should reactivate by nine months to two years. However, recent evidence suggests that the main damage during surgery is probably to the blood vessels supplying the nerves, and this may be one reason for long-term neural deficiency (R.Appell,1999). In view of this speculation, the extended hypothesis of this program is to dynamically and functionally retrain elements of the local vascular, muscular and neural system to the extent that a collateral circulation may be introduced, therefore leading to a more normal bladder control situation. (This is not unreasonable. An average man can increase the width of his iliac artery from 6mm to 12mm by dedicated aerobic training).

The program aims to achieve these goals at four levels.

1.To gain control, strength, power, endurance and speed of muscle contraction of the pelvic floor muscles.

2.To dynamically and functionally retrain and integrate the pelvic floor muscles with the abdominal muscles.

3.To dynamically and functionally retrain components of the reflex circuitry mechanism involved with continence.

4.To aerobically condition elements of the local vascular system supplying neural and other structures in the pelvic region.

PROGRAM

FIRST LEVEL:

Pelvic Floor Exercises:

These are standard but specific exercises regularly prescribed for incontinence management, Initially the patient is directed to learn to correctly identify the muscles that need to be exercised.

Exercise 1:

Imagine you are at a party and you are trying desperately to prevent passing wind from the bowel. Contract the muscles around the anal sphincter which surrounds the back passage. Learn to tighten them and relax them.

Exercise 2:

Imagine you are passing urine. Now envisage trying to stop the flow of urine. Image you are releasing and then preventing the flow. Do not do this exercise while you are actually passing urine, except for a test.

Exercise 3:

Locate the perineal area (perineum) between your anus and vagina (or testicles). Imagine you are holding a red-hot needle which you aim at this region. Try to pull your perineum back inside your body and away from the needle,

Exercise 4:

When you have mastered the above exercises, try and contract the muscles involved in the above three exercises together; as if you are trying desperately not to lose any urinary or faecal matter.

The Exercise Routine

Before actually starting the exercises, it is important to understand we are trying to train the muscles for both speed of contraction and endurance+Therefore, these pelvic floor contractions need to be practiced at a fast rate and then a slow rate. (Keep in mind the pelvic floor muscles are composed predominately of slow twitch or endurance fibres).

Fast:  contractions should be performed as quickly as possible, ensuring each one is a full strong contraction: Contract – Relax, Contract- Relax (5 repetitions)

Slow: contractions are sustained for as long as five seconds: Contract -two-three-four-five, relax (5 repetitions)

Be aware that the muscles may tire quickly. As soon as you can achieve an efficient contraction of the first three exercises working together (i.e. Exercise No. 4) it is not necessary to do them individually

again -simply do exercise No.4 only.

Regularity: A reasonable goal in the early stages is to try and complete the full program twice a day. As you achieve fitness, add one or two more sessions.

Do not have unrealistic goals; for instance, attempting ten sessions a day may lead to boredom and probably non?compliance. The bottom line, however, is you must never give up; YOU MUST

PERSIST.

SECOND LEVEL

Integration of pelvic floor muscle activity with abdominal muscle activity

Once the patient has gained control of the pelvic floor muscles, then all muscles involved with pelvic and trunk stability should be dynamically and functionally retrained. At this stage it is important to gain strength, speed and endurance of the abdominal muscles, particularly the rotators (Fig 3), the transversus (Fig 4) and multifidis muscles.

Fig 3: The Abdominal Muscles highlighting The Rotators

 

Recent research has shown a strong link between abdominal muscle activity and pelvic floor activity.

Obliciuus Externus, Obliquus lnternus and Transversus Abdominis contraction has been shown to occur automatically during a maximal pelvic floor contraction.(Sapsford, Hodges, Richardson et al, 2001).

In another study (Saps ford and Hodges 2001), it was found that pelvic floor activity preceded abdominal muscle activity. This was viewed as the pelvic floor being activated as part of the motor

program in normal activation of the abdominals.

To train this integrated mechanism effectively, it is important to ensure that, during exercise, the abdominal muscles are deliberatelyactivated at the same time as the pelvic floor muscles, (that is, while performing the fourth pelvic floor exercise).

There are many variations and levels of abdominal exercises. The patient’s fitness status will determine this. Generally I prefer to start with the traditional “crunch” exercise.

  • Lie on your back with your knees bent, feet flat on the floor, hands behind your head.
  • Brace your abdominal muscles as if you are about to be dealt a blow to them (Le. flatten your navel to the floor)
  • Co-activate your pelvic floor muscles -(pull them all on together)
  • With your hands balancing your head, raise your head and shoulders as in a half sit-up (or “crunch”), while holding the pelvic floor contractions on, then lower your head and shoulders
  • If you need more resistance, hold a weight behind your head.

If you are grossly unfit, start with three repetitions

As you get fitter, you can build up to the “bicycle manoeuvre”.

  • Lie on your back, with your hands behind your head
  • Prepare by co-contracting your braced abdominal and pelvic floors. Use a pedalling motion to “crunch” your left knee to your right elbow, then alternate sides, as in a cycling action.

Over weeks, or months, try and accumulate a combined session total of all abdominal exercises-, to reach at least 200 repetitions. (Elle does 400 a day – it would be nice to secretly aim for that).

THIRD LEVEL

To dynamically and functionally retrain components of the reflex circuitry mechanism involved with

continence.

This entails activities which stresses and trains the pelvic floor muscles while carrying out functional activities. Firstly, the aim is to contract the pelvic floor muscles during walking, building through to jogging, then up to hard running, eventually over hilly tracks. It is important to increase the effect of heel impact by varying the degree of difficulty of the terrain – hard, uneven surfaces. The intention here is to “joggle” the internal systems about in an attempt to stimulate, retrain and strengthen bladder control reflex circuitry.

Secondly, the patient is educated to voluntarily contract the pelvic floor muscles during other dynamic activities such as lifting, coughing, and changing postures.

FOURTH LEVEL

To aerobically condition elements of the local vascular system supplying neural and other structures of the pelvic region.

Ultimately, this involves an aerobic training program, such as cycling or running, while functionally co- activating the pelvic floor muscles. The aim is to create an enhanced (or collateral) vascular system supplying any damaged nerves in the urogenital area.

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Tests needed before urethroplasty

Uroflowmetry: Testing the urine flow rate

This is the first step.  “The normal urinary flow rate in young and middle aged men is generally greater than 15?ml/second and the flow pattern a bell shaped curve. ” “In those who have a urethral stricture the peak flow rate is typically low but the flow pattern is characteristically flat” [Source]

“With a flow rate of less than 5?ml/second, abnormalities such as those listed above are much more likely and the patient is potentially at risk of acute retention, although this is a lot less common than one would expect from the severity of the narrowing of the urethra that is seen in such a situation. In these patients treatment is advisable even if symptoms of voiding difficulty are not troublesome.” [Source] (Sanjeev: I’m having pain while voiding)

Urethrogram

Both “RUG/VCUG is costly and some-times logistically difficult to perform, and exposes men to radiation” [Source] These tests “show the exact site and length of the stricture and most of its potential complications” [Source]

Retrograde urethrogram (RUG)

See Wikipedia entry.

The penis is postioned at approximately the 10 o’clock position. The round opaque structure in the distal penis is the inflated Foley balloon. The Foley catheter tip is faintly radiopaque, but can be better seen as a filling defect after administration of contrast.  [Source]

Voiding cystourethrogram (VCUG)

See Wikipedia entry.

The voiding urethrogram evaluates the posterior urethra. The Foley balloon is advanced into the bladder and contrast is instilled until the bladder is dilated. The bladder should be so dilated, that the patient “feels like he absolutely needs to pull off to the side of the road so he can urinate”. The Foley is then removed and the patient is encourage to urinate. Images are obtained of the open posterior urethra. As this is not a dedicated cystogram, imaging the bladder is a secondary concern. [Source]

AUGMENTED URETHROPLASTY

“If the stricture is long and/or located in the penis, the stricture may be open or removed and the area is more commonly patched or less commonly replaced with a tube, made from surrounding tissues, such as nearby skin or from tissue removed from other areas in the body such as from the inside of the cheek (buccal mucosa). ” [Source]

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Aged care issues

My FB post.

THE UNDERBELLY OF AUSTRALIA: SEVERE MARKET FAILURE IN AGED CARE
I wasn’t aware of how badly run the aged care sector is in Australia. There is moral hazard at its most acute. And zero accountability.
 
 
Middle aged children who do not have the time (or capacity) to look after their parents send them to aged care homes. But these “homes” are run by extremely immoral owners whose goal is simple: rip off (a) whatever savings the family had accumulated, and (b) taxpayers. And provide zero care.
ADDENDUM
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Monitoring of urine flow rate

Average rates across the world:

Ages 14 to 45 — The average flow rate for males is 21 mL/sec. The average flow rate for females is 18 mL/sec.

Ages 46 to 65 — The average flow rate for males is 12 mL/sec. The average flow rate for females is 18 mL/sec. [Source]  SEE ALSO: http://www.malcolmfrazer.com.au/pdf/Publications/Liverpool%20Nomograms.pdf

AND THIS: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2808647/

MY MEASUREMENTS post urethrotomy

Final closure to the issue: urine flow test on 6 February 2018. This was considered OK, with average rate of 17.5 ml/sec – which is broadly consistent with my readings in November. The surgery has been a success.

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Dealing with sub-meatal urethral stricture: meatoplasty and dilation (related: fossa navicularis strictures)

Note: my surgery was for Rigid Cystoscopy and Optical Urethrotomy (direct visual internal urethrotomy – DVIU).

EVEN IF MY SURGEON HAD DONE A DVIU DURING RADICAL PROSTATECTOMY, THIS ISSUE WOULD HAVE REMAINED A LIFELONG ISSUE

When urethral strictures are identified at the time of catheter placement for another surgical procedure, assessment of the need for catheterization should be made. [Source: Male Urethral Stricture: American Urological Association Guideline] 

Urethral strictures may be dilated in this setting [when a stricture is suspected during surgery]to allow catheter insertion, and dilation over a guidewire is recommended to prevent false passage formation or rectal injury. Alternatively, DVIU may be performed, particularly if the stricture is too dense to be adequately dilated. SP cystotomy may also be performed to provide urinary drainage at the time of surgery if these initial maneuvers are unsuccessful, or when subsequent definitive treatment for urethral stricture is planned in the near future. [Source: Male Urethral Stricture: American Urological Association Guideline]

[Sanjeev: My surgeon felt something blocking the catheter during the prep for the prostatectomy. He did not do dilation or DVIU at that stage but moved on with the prostatectomy. I understand that using a large cathether is essential for such a surgery. In my case the goal of fixing the bigger issue – cancer – led to a secondary injury that is going to remain with me lifelong. EVEN IF HE HAD CONDUCTED A DVIU AT THAT STAGE, THE SITUATION I NOW HAVE WOULD HAVE BEEN UNCHANGED. Therefore, there was NO WAY to avoid what I’ve now got.]

URETHROTOMY IS GUARANTEED TO FAIL

After 1 urethrotomy Pansadoro and Emiliozzi found a 5-year stricture-free survival rate of 6%, which closely matched our 5-year stricture-free survival rate of 7%. Treatment eventually failed in all 7% of the patients by 79 months. [Source] – i.e. 100 PER CENT RECURRENCE WITHIN FIVE YEARS, WITH MOST RECURRING WITHIN 3-6 MONTHS.

The stricture-free rate after the first urethrotomy was 8% with a median time to recurrence of 7 months. For the second urethrotomy stricture-free rate was 6% with a median time to recurrence of 9 months. For the third urethrotomy stricture-free rate was 9% with a median time to recurrence of 3 months. For procedures 4 and 5 stricture-free rate was 0% with a median time to recurrence of 20 and 8 months, respectively. [Source]

RECOMMENDATION: NO MORE THAN ONE URETHROTOMY

“During the last 30 years urethroplasty has improved in efficacy and safety, while urethrotomy is increasingly considered neither cost-efficient nor effective in the long term. Urethroplasty is reported to have lifetime success rates ranging from 75% to 100%. Repeat and unsuccessful urethrotomies impose costs to the patients in the form of lost wages, unnecessary health care expenditures, decreased quality of life and unnecessary anesthesia. The fact that urethrotomy has a low success rate is a strong argument for opting for the more effective urethroplasty instead of a less effective urethrotomy.” [Source]

NOTE: THIS ISSUE IS NOT STENOSIS!

It is hard to get information on this issue from the internet. First thing to note is that it is quite different to meatal stenosis, which is a narrowing of the opening (this is how it looks). “Meatal stenosis is a common complication of circumcision.” Curing stenosis is relatively easy and is done through a surgical procedure called meatotomy during which the meatus is crushed with a straight mosquito hemostat and then divided with fine-tipped scissors. (here is a video of how it is done]

WHAT A MEATAL (or fossa navicularis) STRICTURE LOOKS LIKE?

What it looks like – picture.

Causes

It appears this issue was very common with prostatectomies in the past (Some Common Complications After Prostatectomy, J. Cosbie Ross and L. F. Tinckler, The British Medical Journal, Vol. 2, No. 5153 (Oct. 10, 1959). The issue still occurs in around 2 per cent of the patients.

Male Urethral Stricture: American Urological Association Guideline (2017)

Male Urethral Stricture: American Urological Association Guideline (full guideline needs online journal access) says that uncomplicated urethral stricture confined to the meatus or fossa navicularis should be treated with simple dilation or meatotomy, with or without guidewire placement.

However, urethroplasty is needed for to patients with recurrent meatal or fossa navi­cularis strictures. Meatal and fossa navicularis strictures refractory (i.e. stubborn to) to endoscopic procedures are unlikely to respond to further endoscopic treatments (e.g. Urethrotomy).

Patients who opt for repeat endoscopic treatments or intermittent self-dilation in lieu of more definitive treatment, such as ure­throplasty should be advised that success of a sub­sequent reconstructive procedure may be lower when following a plan of repeated endoscopic surgery and/ or intermittent self-dilation. Similar to other types of stricture, exact delineation of length and etiology is important for guiding treatment.

Dilation is a bad idea. In my case, when the stricture recurs, I should undergo urethroplasty (or whatever the term is called).

TREATMENT OPTION 1: DILATION [not recommended]

Pictures of Dilation of the Urethral Meatal Stricture

INTERMITTENT SELF MEATAL DILATATION – AN INFORMATION LEAFLET, January 2017

What are the Treatments for Meatal Stricture / Meatal Stenosis? [Sanjeev: these are quite different things]

  • Intermittent self meatal dilatation – In some men it is possible that the narrowing of your urethra may re-occur. To reduce this risk you may be taught how to perform intermittent self meatal dilatation. [Sanjeev: it appears it will recur in almost all cases, and instead, aggravate things.]

What is Meatal Dilatation? Meatal Dilatation is a procedure which involves you passing a short catheter into the end of your urethra. The catheter is passed beyond the narrow section and this helps to keep the urethra open.

What Are The Alternatives?

  • Meatal dilatation – If your urethra is not too narrow, it can be dilated or stretched in theatre under local anaesthetic or a general anaesthetic (when you are put completely to sleep) using catheters (soft, hollow plastic tubes) which are graduated in size.
  • Meatotomy – A small operation to stretch or cut through the narrow tissue in your urethra may be necessary. This is called a ‘meatotomy’. Occasionally an additional procedure called circumcision (removal of the foreskin) may be necessary if repeated infections and inflammation (balanitis) at the tip of the penis has resulted in a tight foreskin. [Sanjeev: this is – as described – ONLY meant for a stenosis; not applicable in my case]

What are the risks of Meatal Dilatation?

  • Pain. At first it may be a little painful or uncomfortable to pass the catheter, especially if you have had recent surgery. This, however, should improve with time and most men are able to tolerate the procedure with little discomfort.
  • Bleeding. You may see a little blood on the end of the catheter after performing the procedure or experience a little bleeding from the urethra. This is nothing to worry about and should soon stop. If the bleeding becomes heavy and prolonged then contact your healthcare professional. [Sanjeev: actually bleeding is a BAD thing during dilation, as it will simply aggravate scarring]
  • Infection. It is important to wash your hands and penis before performing meatal dilatation so that no bugs are passed up into the bladder. However, if you experience pain or burning when passing urine, notice that your urine is cloudy or smelly or, especially, if you start to feel unwell (i.e. high temperature, abdominal pain or flu like symptoms), contact your GP or healthcare professional immediately as you may have a urine infection.
  • Recurrent Stricture If you notice a reduction in your flow of urine or if it becomes difficult to pass the catheter into the urethra, it may be because the narrowing has re-occurred. If this happens seek advice from you healthcare professional. [Sanjeev: This is STUPID. The advice should be provided upfront, including discussion of all risks]

General Advice

  • For how long and how often should I perform Meatal Dilatation? As everyone is different, a personalised regime will be agreed between yourself and your healthcare professional as to how often and for how long you should perform the procedure.

Dilatation catheters
These are usually sterile hydrophilic coated single use catheters with NO drainage eyes. They are used for keeping the urethra patent in patients with strictures or who have had surgery to the urethra. Dilatation catheters will not drain the bladder. Shorter length meatal dilators are available for men who need only to dilate the meatus to avoid meatal stenosis, or to dilate a sub-meatal stricture. If the stricture is higher in the urethra then a full length dilatation catheter (40cm) will be needed. [Source: Trust Guideline for the Management of Teaching Clean Intermittent Self-catheterisation (CISC)]

DILATION IS NOT A GREAT IDEA

Treatment approach to pre-TURP urethral strictures:

– Meatal/sub-meatal stricuture: Do a formal meatotomy instead of excess dilation

Source: Common Urologic Problems: Benign Prostatic Hyperplasia By Sujata Patwardhan

NOT RECOMMENDED

“For urethral strictures in the penile urethra to the bulbar urethra, dilation is not recommended.” [Source]

CAN DILATION WORK IN SOME CASES? – UNLIKELY

It is said in the Male Urethral Stricture: American Urological Association Guideline that stricture recurrence is significantly lower among patients performing self-catheterization. Data suggests that performing self-catheterization for greater than four months after DVIU reduced recurrence rates compared to performing self-catheterization for less than three months. [Sanjeev: I find this hard to believe – given the study which showed that RECURRENCE IS GUARANTEED WITH DVIU – see this study].

TREATMENT OPTION 2: MEATOPLASTY/ URETHROPLASTY – fixes 90 per cent of the time

URETHROPLASTY CAN FAIL IF YOUR SURGEON IS NOT EXTRAORDINARLY COMPETENT

” the success of open urethroplasty is very dependent on the surgical technique and the expertise of the surgeon. When urethral surgery is not properly performed, early recurrence of the stricture is a very common complication. … Although stricture recurrence is always a possibility, even when the surgery is performed by a qualified experienced specialist, recurrences more commonly occur when surgery is performed by urologists not exclusively specialized in male urethral and penile reconstructive surgery. When the surgery is not properly performed, failure is an expected outcome.” [Source]

NOTES

Note that this is different from the ear meatoplasty! And note that is is not meatotomy, although some doctors use the terms interchangeably.

ONE-STAGE MEATOPLASTY IS POTENTIALLY AN OPTION IN MY CASE

SUB-MEATAL STRICTURE SOMETIMES REQUIRES TWO STAGE SURGERY

“For the most complex strictures of the anterior urethra, including the urethral meatus, a staged surgical approach is adopted, removing the stricture then placing a graft in the open space. This is allowed to heal open to the air for a period of 6-12 months, before it is “re-tubularized” into a urethra. This is usually reserved for individuals with strictures in the pendulous urethra, very scarred strictures, repeated failures, and very long strictures.” [Source]

A TEN PERCENT RECURRENCE RATE EXISTS EVEN FOR URETHROPLASTY

“Like all surgical procedures, the results of urethroplasty are not 100%. A recurrence urethral stricture rate of 10 % can be expected long-term. Patients with pelvic fracture associated urethral stricture and prostate involvement associated strictures have the highest recurrence rate.” [Source]

The surgical technique of Meatoplasty is generally suggested in patients with meatal urethral stricturesThere are three basic types of Meatoplasty [Source] This is perhaps the best description.

  • Meatoplasty using skin flapUsing this technique, the urethral meatus is augmented using a penile skin flap (figure 1).

  • Meatoplasty with oral mucosal graft. Using this technique, the urethral meatus is augmented by a transplant of an oral graft (figure 2).

  • Meatoplasty with skin graft. Using this technique, the urethral meatus  is augmented by a transplant of a skin graft.

Jordan Flap Meatoplasty – a lot of details here.

DETAILS – IN A PAPER: Meatoplasty using double buccal mucosal graft technique – Apul Goel, Anuj Goel, Diwakar Dalela, Satya N. Sankhwar, International Urology and Nephrology, December 2009, Volume 41, Issue 4, pp 885–887

Glanular/meatal stricture can be seen as an isolated problem or as part of more extensive urethral stricture disease. Various treatment options are available, including penile flap and buccal mucosa, for the treatment of stricture at this location

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