Pelvic floor electrical stimulation for postprostatectomy urinary incontinence: a meta-analysis

Pelvic floor rehabilitation in cancer survivorship: an umbrella review

PURPOSE

This umbrella review aimed to identify, critically appraise, and summarize current systematic reviews with meta-analyses on the role of pelvic floor rehabilitation in cancer survivorship.

METHODS

Four bibliographic databases were searched from inception to August 1, 2024. Two independent reviewers screened the titles and abstracts of 379 records and retrieved 24 full-text systematic reviews. Assessing the Methodological Quality of Systematic Reviews-2 was used for quality assessment. Qualitative syntheses were performed to compile the effects of pelvic floor rehabilitation on bladder function, bowel function, quality of life, and other outcomes. Measures of effect sizes of these outcomes in each meta-analysis were extracted and summarized.

RESULTS

Seventeen systematic reviews with meta-analyses published between 2012 and 2024 were included in this umbrella review, containing a total of 92 primary studies. For quality assessment, four studies were evaluated as moderate quality, five as low, and eight as critically low. Populations with prostate, colorectal, and gynecological cancer were studied. Effects of pelvic floor rehabilitation on bladder, bowel, sexual function, and quality of life were reported and synthesized.

CONCLUSIONS

Pelvic floor rehabilitation is an essential component of cancer survivorship, including following prostate, colorectal, and gynecological cancer surgery. Further high-quality primary studies with adequate sample sizes are needed to inform clinical practice and research endeavors.

IMPLICATIONS FOR CANCER SURVIVORS

This umbrella review highlights the therapeutic potential of pelvic floor rehabilitation, underscores the need for its broader implementation in survivorship care, and guides future research directions to optimize outcomes for cancer survivors.

Conservative interventions for managing urinary incontinence after prostate surgery

BACKGROUND

Men may need to undergo prostate surgery to treat prostate cancer or benign prostatic hyperplasia. After these surgeries, men may experience urinary incontinence (UI). Conservative treatments such as pelvic floor muscle training (PFMT), electrical stimulation and lifestyle changes can be undertaken to help manage the symptoms of UI.

OBJECTIVES

To assess the effects of conservative interventions for managing urinary incontinence after prostate surgery.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearched journals and conference proceedings (searched 22 April 2022). We also searched the reference lists of relevant articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of adult men (aged 18 or over) with UI following prostate surgery for treating prostate cancer or LUTS/BPO. We excluded cross-over and cluster-RCTs. We investigated the following key comparisons: PFMT plus biofeedback versus no treatment; sham treatment or verbal/written instructions; combinations of conservative treatments versus no treatment, sham treatment or verbal/written instructions; and electrical or magnetic stimulation versus no treatment, sham treatment or verbal/written instructions.

DATA COLLECTION AND ANALYSIS

We extracted data using a pre-piloted form and assessed risk of bias using the Cochrane risk of bias tool. We used the GRADE approach to assess the certainty of outcomes and comparisons included in the summary of findings tables. We used an adapted version of GRADE to assess certainty in results where there was no single effect measurement available.

MAIN RESULTS

We identified 25 studies including a total of 3079 participants. Twenty-three studies assessed men who had previously undergone radical prostatectomy or radical retropubic prostatectomy, while only one study assessed men who had undergone transurethral resection of the prostate. One study did not report on previous surgery. Most studies were at high risk of bias for at least one domain. The certainty of evidence assessed using GRADE was mixed. PFMT plus biofeedback versus no treatment, sham treatment or verbal/written instructions Four studies reported on this comparison. PFMT plus biofeedback may result in greater subjective cure of incontinence from 6 to 12 months (1 study; n = 102; low-certainty evidence). However, men undertaking PFMT and biofeedback may be less likely to be objectively cured at from 6 to 12 months (2 studies; n = 269; low-certainty evidence). It is uncertain whether undertaking PFMT and biofeedback has an effect on surface or skin-related adverse events (1 study; n = 205; very low-certainty evidence) or muscle-related adverse events (1 study; n = 205; very low-certainty evidence). Condition-specific quality of life, participant adherence to the intervention and general quality of life were not reported by any study for this comparison. Combinations of conservative treatments versus no treatment, sham treatment or verbal/written instructions Eleven studies assessed this comparison. Combinations of conservative treatments may lead to little difference in the number of men being subjectively cured or improved of incontinence between 6 and 12 months (RR 0.97, 95% CI 0.79 to 1.19; 2 studies; n = 788; low-certainty evidence; in absolute terms: no treatment or sham arm: 307 per 1000 and intervention arm: 297 per 1000). Combinations of conservative treatments probably lead to little difference in condition-specific quality of life (MD -0.28, 95% CI -0.86 to 0.29; 2 studies; n = 788; moderate-certainty evidence) and probably little difference in general quality of life between 6 and 12 months (MD -0.01, 95% CI -0.04 to 0.02; 2 studies; n = 742; moderate-certainty evidence). There is little difference between combinations of conservative treatments and control in terms of objective cure or improvement of incontinence between 6 and 12 months (MD 0.18, 95% CI -0.24 to 0.60; 2 studies; n = 565; high-certainty evidence). However, it is uncertain whether participant adherence to the intervention between 6 and 12 months is increased for those undertaking combinations of conservative treatments (RR 2.08, 95% CI 0.78 to 5.56; 2 studies; n = 763; very low-certainty evidence; in absolute terms: no intervention or sham arm: 172 per 1000 and intervention arm: 358 per 1000). There is probably no difference between combinations and control in terms of the number of men experiencing surface or skin-related adverse events (2 studies; n = 853; moderate-certainty evidence), but it is uncertain whether combinations of treatments lead to more men experiencing muscle-related adverse events (RR 2.92, 95% CI 0.31 to 27.41; 2 studies; n = 136; very low-certainty evidence; in absolute terms: 0 per 1000 for both arms). Electrical or magnetic stimulation versus no treatment, sham treatment or verbal/written instructions We did not identify any studies for this comparison that reported on our key outcomes of interest.

AUTHORS' CONCLUSIONS

Despite a total of 25 trials, the value of conservative interventions for urinary incontinence following prostate surgery alone, or in combination, remains uncertain. Existing trials are typically small with methodological flaws. These issues are compounded by a lack of standardisation of the PFMT technique and marked variations in protocol concerning combinations of conservative treatments. Adverse events following conservative treatment are often poorly documented and incompletely described. Hence, there is a need for large, high-quality, adequately powered, randomised control trials with robust methodology to address this subject.

Physiotherapy as an Effective Method to Support the Treatment of Male Urinary Incontinence: A Systematic Review

Urinary incontinence (UI) is a serious health issue that affects both women and men. The risk of UI increases in men with age and after treatment for prostate cancer and affects up to 32% of men. Furthermore, UI may affect up to 69% of men after prostatectomy. Considering such a high incidence, it is critical to search for effective methods to mitigate this issue. Hence, the present review aims to provide an overview of physiotherapeutic methods and evaluate their effectiveness in treating UI in men. This systematic review was performed using articles included in PubMed, Embase, WoS, and PEDro databases. A total of 6965 relevant articles were found. However, after a risk of bias assessment, 39 studies met the inclusion criteria and were included in the review. The research showed that the available physiotherapeutic methods for treating men with UI, including those after prostatectomy, involve pelvic floor muscle training (PFMT) alone or in combination with biofeedback (BF) and/or electrostimulation (ES), vibrations, and traditional activity. In conclusion, PFMT is the gold standard of UI therapy, but it may be complemented by other techniques to provide a personalized treatment plan for patients. The effectiveness of the physiotherapeutic methods varies from study to study, and large methodological differences make it difficult to accurately compare individual results and draw unequivocal conclusions.

Long-Term Effect of Early Post-operative Transcutaneous Electrical Stimulation on Voiding Function After Radical Hysterectomy: A Multicenter, Randomized, Controlled Trial

Introduction: Post-radical-hysterectomy (RH) patients suffer from a series of problems resulting from neurovascular injury, such as bladder dysfunction, which reduce their quality of life. We have designed this study to evaluate the efficacy of transcutaneous electrical stimulation (TENS) on patient rehabilitation after RH for early cervical cancer.

Materials and methods: A total of 97 patients were enrolled in a randomized-controlled trial (from January 2015 to December 2019) involving 7 medical centers nationwide. Patients were assigned to either the intervention group (n = 46), or the control group (n = 51). TENS was given to patients in the intervention group from the 7^th day after surgery for a total of 14–21 days. The control group received no TENS. Primary outcomes were measured for residual urine volume and recovery of urination function. Secondary outcomes were measures for urodynamics (UDS), pelvic floor electromyography function examination (PFEmF), and quality of life (QoL).

Results: Residual urine volume and improvement in the rate of urination were found to show no significant differences on the 14^th, 21^st, and 28^th days after surgery. The maximum flow rate (Qmax) in the intervention group was significantly higher than that in the control group on the 28^th day, but there were no significant differences in average flow rate, voiding time, time to Qmax, muscle fiber strength, muscle fiber fatigue, and the abnormal rate of A3 reflection on the 28^th day and the 3^rd mo., as well as in the QoL at 3^rd mo., 6^th mo., and 12^th mo. after surgery.

Conclusion: Our study showed no sufficient evidence to prove that TENS under the trialed parameters could improve the subject's voiding function, PFEmF, and QOL after RH. This has provided valuable data for rehabilitation after RH.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02492542.

Analysis of conventional versus advanced pelvic floor muscle training in the management of urinary incontinence after radical prostatectomy: a systematic review and meta-analysis of randomized controlled trials

Background

The underutilization of additional supportive muscles is one of the potential reasons for suboptimal efficacy of conventional pelvic floor muscle training (CPFMT). The present study concentrates on any advantage of advanced pelvic floor muscle training (APFMT) in patients with urinary incontinence (UI) after radical prostatectomy (RP).

Methods

Literature search was conducted on PubMed, Embase, Cochrane Library and Web of Science from database inception to February 2020. The data analysis was performed by the Cochrane Collaboration's software RevMan 5.3.

Results

Both APFMT and CPFMT groups indicates superiority over baseline in terms of pad number, the International Consultation on Incontinence Questionnaire—Short Form (ICIQ-SF) score, pad weight at short-term follow-up, and PFME and PFMS at intermediate-term follow-up. No adverse events were reported in all included studies. Patients receiving APFMT had a similar attrition rate to those receiving CPFMT (18/236 vs. 22/282, P=0.61). Compared to CPFMT group, APFMT group provided intermediate-term advantages in terms of pad number (MD: −0.75, 95% CI: −1.36 to −0.14; P=0.02), ICIQ-SF score (MD: −3.79, 95% CI: −5.89 to −1.69; P=0.0004), PFME (MD: 1.93, 95% CI: 0.99 to 2.87; P<0.0001) and pad weight (MD: −1.40, 95% CI: −1.70 to −1.00; P<0.00001).

Conclusions

Current evidence indicated that APFMT might facilitate the recovery of UI after RP according to intermediate-term advantages over CPFMT in terms of pad number, ICIQ-SF score, PFME and pad weight. Further standardized, physiotherapist-guided and well-designed clinical trials conducted by large multicenter and experienced multidisciplinary clinicians are still warranted.

Pelvic floor muscle training and electrical stimulation as rehabilitation after radical prostatectomy: a randomized controlled trial

[Purpose] To investigate the effect of electrical stimulation and pelvic floor muscle training on muscle strength, urinary incontinence and erectile function in men with prostate cancer treated by radical prostatectomy. [Subjects and Methods] One hundred twenty-three males were randomized into 3 groups 1 month after RP: (G1, n=40) control; (G2, n=41) guideline: patients were instructed to perform three types of home exercises to strengthen the pelvic floor and (G3, n=42) electrical stimulation: patients in this group were also instructed to perform exercises as group G2, and also received anal electro-stimulation therapy, twice a week for 7 weeks. The primary outcome assessment was based on the measurement of the recovery of pelvic floor muscle strength between groups. Secondary outcomes were: 1 hour Pad Test, ICIQ-SF, IIEF-5 and IPSS. Data were obtained preoperatively and at 1, 3 and 6 months after surgery. [Results] There was no significant difference in the demographic data among groups. Greater urinary leakage and pelvic floor muscle weakness in the first month compared to pre treatment improved after 3 and 6 months postoperative, without difference among groups. [Conclusion] The muscle strength recovery occurs independently of the therapy employed. Pelvic floor exercises or electrical stimulation also did not have an impact on the recovery of urinary continence and erectile function in our study.

Literature review of factors affecting continence after radical prostatectomy

Radical prostatectomy (RP) is the most common cause of stress urinary incontinence (UI) in men. Several anatomic structures affect or may affect urinary continence - urethral sphincter, levator ani muscle, puboprostatic ligaments, bladder neck, endopelvic fascia, neurovascular bundle - and understanding of the anatomy of pelvic floor and urethra is crucial for satisfactory functional outcome of the procedure. Surgical techniques implemented to improve continence rates include nerve-sparing procedure, bladder neck preservation/plication, urethral length preservation, musculofascial reconstruction, puboprostatic ligaments preservation or seminal vesicle preservation. Perioperative (preoperative and postoperative) pelvic floor muscle training (PFMT) aims to shorten the duration of postoperative UI and thus, improve early continence rates postoperatively. In the review, complex information regarding anatomical, intra- and perioperative factors affecting urinary continence after RP is provided, including description of important anatomical structures, possible implications for surgical technique and evaluation of different PFMT strategies in perioperative period.

Pelvic floor muscle exercises with or without electric stimulation and post-prostectomy urinary incontinence: a systematic review

Abstract Introduction: Urinary incontinence (UI) after prostatectomy is difficult to treat and causes profound adverse impacts on the individual's quality of life. The main clinical treatments available for post-prostatectomy UI consist of behavioral techniques and physical therapy techniques, such as exercises, electrical stimulation and biofeedback for pelvic floor muscles (PFMs). Objective: To investigate the effectiveness of PFM exercises with or without electrical stimulation for reducing post-prostatectomy UI. Methods: We included only randomized controlled trials (RCTs) which used PFM exercises with or without electrical stimulation. The search was conducted in August of 2013 in the databases of the U.S. National Library of Medicine (MEDLINE), Scientific Electronic Library Online (SciELO), Physiotherapy Evidence Database (PEDro) and Virtual Health Library (VHL). We searched for RCTs published between 1999 and 2013. As keywords for our search, we used the following descriptors from the Health Sciences Descriptors (DeCS): urinary incontinence, pelvic diaphragm, prostatectomy, pelvic floor exercises, electrostimulation and electrical stimulation. We also used the following descriptors from the Medical Subject Headings (MeSH): electrical stimulation, pelvic floor, urinary incontinence, prostatectomy, physiotherapy and exercise therapy. Results: Of the 59 RCTs found, 26 were excluded as duplicates, and 28 were excluded for not displaying a minimum score of 5.0 on the PEDro Scale, which left us with five RCTs. Conclusion: PFM exercises can be effective for treating UI after radical prostatectomy, especially if begun soon after surgery. Associating electrical stimulation with PFM exercises did not show additional benefit for treating urinary incontinence. However, the selected studies presented some methodological weaknesses that may have compromised their internal validity.