[Physiotherapy of pelvic floor for incontinence].

UNLABELLED: The rate of urinary incontinence after prostatectomy, as reported in several studies, varies between 0 and 88%. In the last years, pelvic floor rehabilitation in the women stress incontinence has been strengthened, with a great amount of clinical studies and results. Recently, the rehabilitation treatment has been studied in men who underwent a radical prostatectomy. The Cochrane Database of Systematic Reviews recently published the "Conservative management for post prostatectomy incontinence". The aim of this study was to determine the effects of conservative management in post prostatectomy urinary incontinence. Randomized or almost-randomized trials were analyzed up to January 1999; five studies were included, with the following results: 1. Pelvic floor muscle training versus no active treatment. Two trials compared pelvic floor muscle training with patients in a control group. In both groups there was a clinical improvement, especially in the first months after prostatectomy. The results of the two studies suggest a benefit in the treated group, even if not statistically significant, mainly in the first months after surgery. 2. Pelvic floor muscle training + biofeedback versus no active treatment. The treated group regained continence in shorter time, with decrease of incontinence episodes, of urinary frequency, of the quantity of urine loss; these data were not statistically significant. 3. Pelvic floor muscle training + rectal electrical stimulation versus no active treatment No detectable differences among the two groups, either in number of men still incontinent, and in Pad-test results. 4. Pelvic floor muscle training + rectal electrical stimulation + biofeedback versus no active treatment. Pad-test evaluation was similar in the treated and in the control group; no other outcomes were described. 5. Pelvic floor muscle training + rectal electrical stimulation versus pelvic floor muscle training. There was a progressive improvement in three months of rehabilitation, even if not statistically significant. All the studies showed improvement of urinary incontinence in men, independent of their trial allocation (treatment or control group). After an initial period of rapid improvement, continence improves even after the first three months, so that only 15-20% was still incontinent by six to twelve months.

IN CONCLUSION: in the post-operative period, a supportive and educative approach is recommended to reduce the duration and the degree of urinary incontinence. Spontaneous recovering occurs particularly in the first three months: it is maintainable a delayed rehabilitation management, with intensive rehabilitation treatment for men with persistent urinary incontinence. Rehabilitation seems to be more effective in the first four months after surgery. Even the AHCPR Guideline recommends a behavioural, rehabilitative and pharmacological treatment. Research must be improved. Limits of the studies are: small sample sizes, incomplete randomisation--necessary to avoid sample "contamination"--, definition of the best timing for treatment; trials could be restricted to men with persistent urinary incontinence, or could compare early treatment with delayed more selective treatment. This management is intensive and resource-dependent; it may be difficult to justify it, unless it proves evidently effective. In our clinical-therapeutical experience, patients undergo a physiatrist examination within 10 days after catheter removal. The clinical examination includes: full history, self-evaluation questionnaire, strength (PC test: 0-5 by digital anal control), perianal sensibility, anal sphincter tone, presence of muscle synergies. The rehabilitation team immediately enrolls the patient, with an educative-behavioural and rehabilitative approach: men are asked to fill a voiding diary, and have a bladder training and a first pelvic floor muscle training, with written instructions. Patients must know and share the therapeutical project. A second clinical evaluation occurs after three months: if urinary incontinence persists, the patient is submitted to complete rehabilitation: *Urinary incontinence + absence of muscle contraction (PC = 0/1): pelvic floor muscle training and rectal electrical stimulation; *Urinary incontinence with PC test > 1: pelvic floor muscle training and even biofeedback (for those with poor self muscle consciousness). Frequency of treatment: 2-3 times a week. The aim of the treatment is to enable consciousness of pelvic muscles and to strengthen perineal function.