Postprostatectomy Incontinence Reduced by Behavioral Therapy Program

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For men with incontinence for at least one year following radical prostatectomy, participation in a behavioral training program can result in a significant reduction in the number of incontinence episodes, according to a study in the January 12 issue of The Journal of the American Medical Association.

Components of the behavioral training included pelvic floor muscle training, bladder control strategies such as keeping a diary, and fluid management.

Men in the United States have a 1 in 6 lifetime prevalence of prostate cancer. Incontinence is a known risk of prostate removal surgery, and as many as 65% of men will still have some degree of incontinence up to five years after the surgery. Loss of bladder control can be a physical, emotional, psychosocial, and economic burden for men who experience it.

Postprostatectomy incontinence has been attributed to intrinsic sphincter deficiency and/or detrusor dysfunction, leading to stress and/or urgency incontinence, respectively. Surgical interventions for incontinence are quite effective but are usually reserved for moderate to severe incontinence, and many prostate cancer survivors are reluctant to undergo another surgery.

Previous studies have shown the value of behavioral therapy in postoperative recovery of continence, there none have looked at the issue for postprostatectomy incontinence persisting more than 1 year.

Patricia S. Goode, M.S.N., M.D., of the University of Alabama at Birmingham, and colleagues conducted a study to evaluate the effectiveness of behavioral therapy for reducing persistent postprostatectomy incontinence and to determine whether the technologies of biofeedback and electrical stimulation enhance its effectiveness.

The researchers conducted a prospective randomized controlled trial involving 208 community-dwelling men aged 51 through 84 years with incontinence persisting 1 to 17 years after radical prostatectomy at a university and 2 Veterans Affairs continence clinics (2003-2008) and included a 1-year follow-up after active treatment. Of the participants, 24% were African American; 75%, white.

After stratification by type and frequency of incontinence, participants were randomized to 1 of 3 groups: 8 weeks of behavioral therapy (pelvic floor muscle training and bladder control strategies); behavioral therapy plus in-office, dual-channel electromyograph biofeedback and daily home pelvic floor electrical stimulation (behavior plus); or delayed treatment, which served as the control group. Participants completed 7-day bladder diaries.

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The researchers found that at 8 weeks, those in the behavioral therapy group had more than double the average reduction of incontinence episodes compared to the control group [55% (from 28 to 13 episodes per week) and 24% (25 to 21 episodes per week) respectively].

Those in the behavior-plus group experienced an average reduction of 51% (from 26 to 12 episodes per week), indicating that the addition of biofeedback and electrical stimulation did not improve 8-week results compared with behavioral therapy alone.

The improvements were noted to be durable to 12 months in the active treatment groups: 50% reduction (13.5 episodes per week) in the behavioral group and 59% reduction (9.1 episodes per week) in the behavior plus group.

At the end of the 8-week treatment period, 15.7% of men in the behavior therapy group, 17.1% in the behavior-plus group, and 5.9% in the control group achieved complete continence, reporting no incontinence episodes in their 7-day bladder diaries.

Behavioral therapy also improved the effects of incontinence on daily activities and condition-specific quality of life.

In an accompanying editorial, David F. Penson, M.D., M.P.H., of Vanderbilt University and VA Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC), Nash­ville, Tenn., writes that questions remain regarding the optimal way to address postprostatectomy uri­nary incontinence.

"Is it behavioral therapy, which likely re­quires considerable patient and clinician time and effort to implement and is associated with limited benefit? Is it sur­gical implantation of an artificial urinary sphincter [a structure, or a circular muscle, that relaxes or tightens to open or close a passage or opening in the body] that works, but requires another surgical procedure? Or is it applica­tion of new technologies at the time of prostatectomy that purport to result in better patient-reported outcomes but still appear to be associated with a significant incidence of postprostatectomy urinary incontinence? Perhaps none of these is ideal. A better strategy would be primary preven­tion: increased utilization of active surveillance among pa­tients with lower-risk disease and selective application of aggressive interventions in patients with worse prognostic variables."

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Source
Behavioral Therapy With or Without Biofeedback and Pelvic Floor Electrical Stimulation for Persistent Postprostatectomy Incontinence: A Randomized Controlled Trial; Goode PS, Burgio KL, Johnson II TM, Clay OJ, Roth DL, Markland AD, Burkhardt JH, Issa MM, LK; JAMA 2011;305(2):151-159; doi:10.1001/jama.2010.1972

Treatment for Postprostatectomy Incontinence: Is This as Good as It Gets?; David F. Penson; JAMA. 2011;305(2):197-198.doi:10.1001/jama.2010.1984

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