Physiotherapy procedures in the management of the patient with prostate cancer

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The physiotherapist, from his assessment, can also help the patient with PCa in the presurgi-cal period in which the exercises for the pelvic floor and for the respiration that will be performed in the post-surgical period can be learned early by the patient. Moreover, the knowledge and the perception of the muscles of the pelvic floor by the patient will be very important. As these muscles are located inside the pelvis, they are considered a continence muscle group giving structural support for the pelvic organs and the pelvic sphincters (urethra and anus, for exemple in men). Based on urethral continence maintained by muscles of the pelvic floor, the procedures of the physiotherapy of this muscle group can retake the control of the urinary continence or maximize it, also by nerve stimulation, according to the consensus, which can inhibit the detrusor muscle, increasing the quality of life of patients with Pca [20-26].

Patient assessment by the physiotherapist is accomplished through the anamnesis, voiding diary, pad test, data collection of the urodynamic study and/or other complementary examinations, if any, physical examination and specific maneuvers to assess urine leakage [24].

In the interview, beyond identifying the main complaint and history of the patient, issues inherent in urination are of utmost importance to be addressed. The voiding diary is a useful tool because it allows the physiotherapist to objectively quantify the volume of urine loss, as well as the frequency of the urination. As the voiding diary is fully performed by the patient over a period of about two to three days, with notes of drinking water, the type of the drink, volume voided, urgency severity, quantification of loss and its association to carry out some activity at the time,he is leding to observe his behavior voiding, generating his self-knowledge [20-26].

The completion of the pad test lasts one hour, and after that the pad is weighed, depicting the severity of UI. When the weigth is less than 3g, the UI is considered light. The UI is moderated to 3 up to 10 g, and over 10g is considered severe incontinence [20-26].

Urodynamic investigations involve the evaluation of the dynamic function of the lower urinary tract. The urodynamic study, an examination of the gold standard, evaluates the morphology, pressure (urethral, vesical and abdominal under static and dynamic conditions), physiology and hydrodynamic transport urine of the voiding mechanism, thus detailing the stages of filling and emptying as well as the sphincter behavior. Common urodynamic findings in post-RP patients are (a) internal sphincter deficiency and (b) bladder dysfunction (detrusor instability and decreased compliance) [20-26].

On physical examination is evaluated the strength and the tone of the pelvic floor muscles through the anal sphincter, perineal sensation and bulb-cavernosum reflex. Maneuver effort, such as coughing, can evaluate the sphincter function, which can be performed with the patient standing, with the bladder full, and where he is asked to simulate cough. From this assessment is given the goal of treatment [20-23].

One of the objectives of the intervention of the physiotherapy is to re-train the muscles of the pelvis by improving the active retention strength of the striated muscles of the pelvic floor in order to overcome the insufficiency of the injured sphincters and improve the continence of men with PCa. This level includes the awareness of the pelvic floor musculature and the coordination of the contraction-relaxation process to improve the control and the quality of the muscle contraction. Specific attention is given to the muscles of the deep plane of the pelvic floor [5, 24, 25].

To facilitate the perception of the muscles of the pelvic floor, electrotherapy is often used. This technique beyond to guide the patient to correct the contraction of muscles, depending on the type of electrical current, it also can be used other responses. Two types of electrodes can be used in the electrotherapy; internal (anal) and external electrodes [20-26].

In the case of functional electrical stimulation, which is an alternating current of low frequency, it generates muscle contractions and an increase of muscle function. In the pelvic floor muscles, electrode stimulation in the perineal body, the contraction is perceived by the patient and the physiotherapist with the apparent anal contraction. This contraction also acts by stimulating the sacral nerve roots, or specifically the pelvic and pudendal nerves, suppressing the (hyper) detrusor activity [24]

In figure 4, a patient that is undergone electrotherapy with external electrodes is shown. A correct frequency is choosen, following international studies and the intensity of electric current is selected considering the sensibility of the patient.

Figure 4. Patient after prostate cancer surgery undergoing electrotherapy

Physiotherapy also assists with postoperative respiratory recovery, early mobilization, lym-phoedema prevention, education and garments if required, as well as the later management of pelvic floor re-education, continence advice and lymphoedema treatment if necessary. Men undergoing RP under a general anaesthetic will be off work for about 6 weeks. Moerover, they will stay in hospital for 5-7 days and have a urinary catheter for 2 weeks. The sphincter "valve" has gone and the urine leaks without control, day and night until the patient has learned again to use his muscles of the pelvic floor to regain his continence. Concerning ED, when a man wakes up from a RP he will almost certainly have ED initially. If there is going to be a recovery of erectile function, it may take 18-24 months to occur. Approximately 30% of men will recover erectile function and medication (Viagra or Cialis) will usually boost this recovery. However, physiotherapy procedures could be another suitable option without contraindications. In figure 3 is possible to see a man that has previously been submitted to RP and is undergoing external electrotherapy. In addition, the patient that has learned about the exercises involving the muscles of the pelvic floor can start these exercises immediately just after the surgery or after the catheter removal [20-26, 52, 53].

In the figure 5 are shown men doing exercises using a ball to increase the perception of the pelvic floor muscles, as well as to work these muscles.

In figure 5.a, the man relaxed and in 6.b, he has raising the hips and contracting the pelvic floor muscles. In figure 5.c, the man is sitting on the ball to increase the perception of the pelvic floor muscles and in 6.d, the man puts the hands together and begins to lift up the hands and feeling the contraction of the pelvic floor muscles to upward movement.

Beneficial effects of pre- and postoperative pelvic floor re-education are clear, since both the duration and degree of UI after RP can be distinguishably decreased [5, 43, 51].

Physiotherapy has responded to the improved outcomes and patient demand for quality of life improvements by instituting new treatments and education, such as informing about the possible importance of the sunlight in the prevention of the PCa and the equal need to pro-

tect against the harmful effects of the ultraviolet radiation, or about the options of physiotherapy for rehabilitation and re-integration to normal life [5, 6, 8, 9].

Figure 5. Men doing exercises with a ball to perception and to work the pelvic floor muscles.

Alternative and complementary techniques have also been considered as an option to be used for treating ED. One of these techniques that is related to the physiotherapy is the acupuncture. Acupuncture is safe and involves the insertion of thin needles into different areas of the body known as acupuncture points. Traditionally, acupuncture has been often used to restore and maintain health through the stimulation of these specific points on the body. As this stimulation could modulate the NO, it is possible to consider that acupuncture might be effective for treating ED. Although, in some studies the acupuncture has been used successfully to treat ED, there is sufficient evidence that acupuncture is an effective intervention for treating ED [55].

Mechanical vacuum devices cause erection by creating a partial vacuum, which draws blood into the penis, engorging and expanding it. The devices have three components. A plastic cylinder, into which the penis is placed; a pump, which draws air out of the cylinder; and an elastic band, which is placed around the base of the penis to maintain the erection after the cylinder is removed and during intercourse by preventing blood from flowing back into the body.One variation of the vacuum device involves a semirigid rubber sheath that is placed on the penis and remains there after erection is attained and during intercourse [27, 28, 50].

In general, physiotherapy management in the area of oncology have relevant contributions to patient care, including: (i) Decreasing length of stay in acute facilities (early discharge planning, outpatient follow up and education, involvement in palliative care facilities and physiotherapy services in home care); (ii) Improving functional capacity (early mobilization, management of complications of surgery, convenient manipulations of the areas submitted to RT and other treatments, as treating lymphoedema and scars); (iii) Improving lymphoe-dema management that has lead to decreased hospital admissions for cellulitis (a feature of poorly controlled lymphoedema and/or orientation of the patient) and decreased need for costly and at times uncomfortable pressure garments; (iv) Improving local and general exercise capacity (prevention of loss of body weight and managing the side effects of the disease, medication and surgery); (v) Shortening the period of time of UI after RP; and (vi) Affecting quality of life factors for all patients with cancer and their carers and families. These all provide examples where physiotherapy intervention contributes considerably to the health care provision and demonstrate how the various disciplines allied to medicine are working together to either bring the now healthy individual back to normal life and re-integration to the society, or improve the quality of life of patients that have to live with cancer as a chronic disorder and those that are in the terminal stages of the disease and life [5-7, 43, 53].

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