Erectile dysfunction and urinary and faecal incontinence are not topics normally discussed by men. However, it is important to know that the most common cancer experienced by men is prostate cancer and more than 1.2 million cases a year are diagnosed worldwide annually.
Rehabilitation is readily available to lessen these quality of life burdens but the what, where and how are the concerns for most men suddenly thrust into the world of cancer. A toolbox of skills should be mandatory for surviving well beyond treatment and, fortunately, good progress is being made.
Treatment for prostate cancer, if detected early, often results in a normal lifespan for most men diagnosed, but many side effects can be ongoing. Historically, however, men have been reluctant to seek testing which traditionally involved a digital rectal exam and confusing messages from GPs, as recommendations for PSA testing have long been controversial.
Conversation around the topic has also been relatively taboo, with most men reluctant to open up to their peers about problems in the bedroom or their private parts.
However, a new era is evolving in men’s health. With technology improving drastically over the past 15 years – including ultra-sensitive blood tests, multiparametric MRI scans, transperineal targeted biopsies (vs rectal approaches) robotic surgeries and sophisticated Cyberknife (surgical radiation) options – the opportunity to receive less invasive assessment and treatment has never been better.
This, coupled with improvements in drug therapy, exercise prescription and a better understanding of the psychological impacts of prostate cancer, means men should expect and receive better preparation, treatment and rehabilitation programs.
Rehabilitation should start with prehabilitation at the point of diagnosis. This can include improving fitness, weight loss and male pelvic floor exercises, particularly between biopsy and treatment. As most treatments – radical prostatectomy surgery or radiation therapy – will typically result in urinary incontinence and erectile dysfunction, learning how to perform contractions of the urinary sphincter and sexual muscles within the pelvic floor is imperative to minimising long-term leakage and impotency.
For patients receiving radiotherapy bowel issues are also commonplace but tend to occur after treatment has finished, which often comes as a surprise. Radiation may cause rectal bleeding, faecal incontinence and bowel leakage with flatulence. These side effects can be despairing for men, who may feel they have ‘beaten’ the cancer only to find one to three years later, issues they never expected impact their every day. Pelvic floor exercises also greatly assist in the rehabilitation of bowel incontinence, with contraction of the rectal sphincter the focus of treatment.
But there are gaps in knowledge.
Fortunately, research in prostate cancer has been prolific in the past decade with a strong focus on improving quality of life outcomes. A recent RCT in WA showed that 74% of men performing six sets of PFM exercises a day in standing were fully continent (i.e., no pads or urine leakage) within 12 weeks of surgery if they completed a five-week ‘prehabilitation’ program before surgery. Of the 100 men in the study, one in six were never incontinent and had much faster recovery times with erectile function and return to sexual activity within three months of treatment.
With less incontinence, a faster return of sexual desire and confidence led to quicker commencement of penile rehabilitation strategies. This aspect of rehabilitation includes the use of medications, vacuum compression pumps and penile injections to improve blood flow and penis length which, if left untreated can lead to fibrosis and scar tissue development.
A little-known fact is that 16% of men following surgery and 12% following radiation will experience a penile deformity known as Peyronie’s disease. Penile pain, curvature and plaque formation tend to occur due to damage of erectile nerves that surround the prostate and, over many months, reduced blood flow results in tissue change. Early intervention can minimise this.
‘Exercise is medicine’ is the new mantra in cancer care and programs such as PROST! Exercise 4 Prostate Cancer.inc are providing professional, evidence-based programs in the community for men with prostate cancer.
Research shows 150 minutes per week of low intensity exercise such as walking and three hours of more vigorous exercise per week such as gym sessions that include cardio and resistance work can do much to enhance survivorship in cancer patients.
By exercising in peer support groups, the mood, muscle and mateship of men improves, ultimately reducing distress. For those in need, psychological support is available, but men’s health specialists are rare. Meanwhile, online resources, support groups and podcasts are helping to fill the rehabilitation toolbox.
Key messages
- Urinary incontinence and erectile dysfunction after treatment for prostate cancer can be reduced
- Rehabilitation starts at time of diagnosis
- Exercise, both general and pelvic floor, is a key component.
Author competing interests- nil