Biofeedback For Urinary Incontinence after Prostate Surgery

Urinary incontinence that develops after prostatectomy surgery for prostate cancer, prostatitis or BPH is a significant problem. As many as 65 percent of men who have undergone prostatectomy for prostate cancer continue to suffer with urinary incontinence up to five years postsurgery. (Penson 2005) Finding effective ways to treat this distressing and often embarrassing condition has been a challenge, but there is evidence that biofeedback for urinary incontinence after prostatectomy and even before can be beneficial.

Among the many approaches available to manage male urinary incontinence are medications (e.g., anticholinergics, 5-alpha reductase inhibitors, tricyclic antidepressants, alpha-1 adrenergic blocking agents), catheters, pads, penile clamps and rings, collagen injections, behavior therapy (e.g., biofeedback, bladder retraining, pelvic floor muscle exercises [Kegel]), neuromuscular electrical stimulation, diet modifications, artificial urinary sphincters, and male suburethral slings. Of these options, biofeedback combined with pelvic floor muscle training and/or electrical stimulation has been the subject of a number of studies and deserves a closer look.

Biofeedback therapy for urinary incontinence involves being trained in controlling certain bodily functions that are normally involuntary, such as heart rate, blood pressure, and some types of muscle tension. With the help of a biofeedback therapist and a monitoring device, individuals can learn how to make voluntary changes that affect their muscles, for example, while getting feedback from electrodes associated with a monitoring instrument, and then gradually achieve the same responses without using the device.

Biofeedback Before Prostate Surgery

Could practicing biofeedback assisted behavioral therapy before undergoing prostatectomy reduce the severity of urinary incontinence? That was the question a research team from Alabama tackled using a prospective, randomized, controlled trial. The volunteers included 125 men ages 53 to 68 years who had elected to undergo radical prostatectomy for prostate cancer.

All the men were randomly assigned to one of two groups: a control group that was given simple postoperative instructions on how to interrupt their urinary stream while voiding, or to a group in which the men received one preoperative biofeedback session plus daily home exercises.

The men who received the preoperative biofeedback training regained urinary continence at a median of 3.5 months while those in the instructions only group took longer than six months. Six months postsurgery, 5.9 percent of men in the biofeedback training group still had severe/continual leakage compared with 19.6 percent in the instructions group. Men in the instructions-only group also experienced significantly more urine loss when coughing, sneezing, and getting up from lying down than did men in the biofeedback group.

These findings led the researchers to conclude that offering biofeedback for urinary incontinence before prostatectomy can speed up the recovery of urine control and reduce the severity of urinary incontinence after prostatectomy. (Burgio 2006)

Post Prostate Surgery Biofeedback Studies

Studies of the use of biofeedback along with pelvic floor muscle exercises and/or electrical stimulation have yielded some mixed results. In one study, a total of 73 men who had undergone radical prostatectomy were randomly assigned to receive either biofeedback and pelvic floor muscle training once a week for 3 months along with home exercises (36 men), or to a control group (37). Each biofeedback session lasted 30 minutes and included the use of an electromyographic device, which measures muscle activity such as contractions. Treatment involved placing a surface electrode into the anus and a reference electrode on the left lateral malleolus (the bump on your ankle). The men practiced various pelvic floor exercises while viewing a computer monitor.

All the men in the study were evaluated at 1, 3, 6, and 12 months postsurgery using the International Continence Society male Short Form questionnaire and the Incontinence Impact Questionnaire. Of the 73 patients, 54 (26 in the biofeedback group and 28 controls) completed the study.

At the 12-month evaluation, 96.15 percent of the patients in the biofeedback group and 75.0 percent of controls were continent. The duration of incontinence was shorter in the treatment group. The researchers concluded that “early biofeedback-pelvic floor muscle training not only hastens the recovery or urinary continence after radical prostatectomy but allows for significant improvements in the severity of incontinence, voiding symptoms and pelvic floor muscle strength 12 months postoperatively.” (Ribeiro 2010)

Another positive study was reported by Italian researchers in 2009 after they analyzed the benefit of biofeedback for urinary incontinence combined with functional pelvic floor electrical stimulation in men who had undergone radical prostatectomy.  The 60 men were randomly assigned either to a control group or to treatment with pelvic floor electrical stimulation plus biofeedback that started seven days after catheter removal, and treatment continued twice weekly for six weeks. Each treatment session included 15 minutes of biofeedback followed by 20 minutes of pelvic floor electrical stimulation.

An evaluation of urinary continence was done at baseline and at 2 and 4 weeks, and then again at 2, 3, 4, 5, and 6 months during a follow-up period. Compared with the men in the control group, those who received early biofeedback and electrical stimulation treatment showed significantly less leakage starting at 4 weeks into the treatment and lasting until 6 months of follow-up. Overall, the median time to regain continence was 4 weeks in the treatment group and 16 in the control group.

At six months, continence was achieved in 96.7 percent of treated patients compared with 66.7 percent of controls, leading the authors to conclude that early treatment with biofeedback and pelvic floor electrical stimulation has a significant effect on early recovery of urinary continence in men who undergo radical prostatectomy. (Mariotti 2009)

Neutral Biofeedback Study

Not all studies of biofeedback and urinary incontinence have shown positive results, suggesting that researchers need to identify why some men respond while others do not. One example of a study that provided neutral results was conducted at the University of Alabama Birmingham. Researchers there evaluated 208 men aged 51 through 84 years who had suffered with urinary incontinence for 1 to 17 years after they had undergone radical prostatectomy. The men were randomly assigned to one of three groups: 8 weeks of behavioral therapy (pelvic floor muscle training plus bladder control techniques), behavioral therapy plus in-office, electromyography biofeedback along with daily pelvic floor electrical stimulation, or delayed treatment (the control group).

At the end of the study period, the mean number of incontinence episodes declined from 28 to 13 per week (55% reduction) among men in the behavioral therapy group and from 26 to 12 (51% reduction) among men in the behavior plus biofeedback group. Among the controls, the reduction was less impressive: from 25 to 21 (24%). When the men were revisited at 12 months, the reduction in urinary incontinence was 50 percent in the behavioral group and 59 percent in the behavior plus biofeedback group.  Overall, the addition of biofeedback and pelvic floor electrical stimulation did not result in better improvement in urinary incontinence. (Goode 2011)

Overall, biofeedback plus kegel, pelvic floor muscle exercises and/or electrical stimulation speeds up recovery of urinary continence in some men after they undergo radical prostatectomy. Biofeedback should be a treatment option men discuss with their healthcare providers when urinary incontinence develops or when it is anticipated to be problem following prostatectomy, surgery for BPH, or radiation therapy.

Sources

Burgio KL et al. Preoperative biofeedback assisted behavioral training to decrease post-prostatectomy incontinence: a randomized, controlled trial. J Urol 2006 Jan; 175: 196-201

Goode PL et al. Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for persistent postprostatectomy incontinence: a randomized controlled trial. JAMA 2011 Jan 12; 305(2): 151

Mariotti G et al. Early recovery of urinary continence after radical prostatectomy using early pelvic floor electrical stimulation and biofeedback associated treatment. J Urol 2009 Apr; 181: 1788-93

Penson DF et al. 5-year urinary and sexual outcomes after radical prostatectomy: results from the prostate cancer outcomes study. J Urol 2005; 173(5): 1701-5

Ribeiro LHS et al. Long-term effect of early postoperative pelvic floor biofeedback on continence in men undergoing radical prostatectomy: a prospective, randomized, controlled trial. J Urol 2010 Sep; 184:1034-39