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Physiotherapy for Male Continence Problems
Male, incontinence, lower urinary tract symptoms, physiotherapy.
The purpose of this descriptive survey was t o ascertain the number of physiotherapists who t r e a t men with continence problems and to describe t h e various physiotherapeutic techniques which can be used t o treat lower urinary tract symptoms in men.
Summary
Literature Search
A survey was sent to the total (531) membership of two British organisations of physiotherapists who treat patients with urinary continence problems. They were asked about aspects of current physiotherapy treatment of male urinary incontinence. Replies were received from 319, giving a response rate of 60%. Twenty-six physiotherapists did not treat continence patients. Female continence problems were treated by 293 respondents; of these only 81 treated male continence problems. In the 12 months prior to the survey, the respondents had treated only 390 male patients. Most post-prostatectomy out patients (70%) were taught pelvic floor exercises. Many (50% of all patients) were given bladder training, few (20% in the department and 8% at home) received electrical stimulation and even fewer (7%) received biofeedback. Most patients were given advice on fluid intake (68%), caffeine products (69%), alcohol intake (55%) a n d bulbar massage (32%). The main problems identified were lack of referrals and lack of training.
I n order t o identify t h e prevalence of male u r i n a r y incontinence, incidence of postprostatectomy incontinence, anatomy, a n d the benefits of physiotherapy treatment for male lower urinary tract symptoms (LUTS), an extensive literature search was undertaken. The search was undertaken from computerised searches w r i t t e n i n English on MEDLINE, other MEDLARS databases, Embase - Physical Medicine and Rehabilitation and the Physiotherapy Index Database from 1990 t o d a t e u s i n g t h e key words male, prevalence, incontinence, then post prostatectomy, incontinence, t h e n male, incontinence, exercise, t h e n male, incontinence, electrical, then male, urgency, nocturia, frequency and finally the key words male, bladder training. Manual searches were made from t h e references of t h i s literature, by a m a n u a l review of t h e proceedings of t h e International Continence Society meetings from 1982 to date, and from the proceedings of the First International Conference for Nurses and Allied Health Care Professionals on Benign Prostatic Hyperplasia, 1997, i n Paris. These searches revealed 27 papers by urologists, urology nurses, continence advisers and physiotherapists which mentioned physiotherapeutic techniques, b u t they included only seven research papers using physiotherapy for male LUTS (Burgio et al, 1989; Ceresoli et al, 1993, 1995; Jackson et a l , 1996; Salinas et al, 1996; Moore, 1997; Paterson et al, 1997).
Grace Dorey Key Words
Introduction In Britain, physiotherapy has been used widely for female urinary incontinence (Bo, 19951, while treatment of male urinary incontinence h a s been more commonly u n d e r t a k e n by continence advisers and urology nurses. This is because most women with continence problems consult a n d a r e referred for physiotherapy treatment by gynaecologists (Mantle and Versi, 1991) whereas men consult urologists who often refer t o urology n u r s e s . Over t h e y e a r s , physiotherapists have worked closely with gynaecologists, whereas physiotherapists and urologists do n o t have t h e s a m e historic relationship although a small but increasing number of physiotherapists are now treating men with continence problems. Physiotherapists and nurses have recognised that best practice in continence care depends on collaboration. Although no research is published on t h e i r respective roles, recent l a n d m a r k meetings have been held to discuss t h e collaboration of urology nurses, continence advisers and physiotherapists, and to explore each profession's individual strength and areas of overlap (Consensus Forum, 1998; Lancaster Suite Consensus Statement, 1998).
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Background to the Study The prevalence of reported urinary incontinence in men increases with age and ranges between between 3.6% in men 45 years old to 28.2% in men 90 years or older (Britton et al, 1990; Brocklehurst, 1993; Thomas et a l , 1980; Malmsten et al, 1997). Milne et a1 (1972) found that in men aged 62-90 years in the USA, urgency, frequency a n d nocturia were p r e s e n t i n 50%. T h e prevalence of LUTS a n d o t h e r urological conditions in Spanish men, based on a survey of 2,002 men 50 years and older, revealed 30.4%
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(609 men) with moderate or severe symptoms which increased with age (Hunter et al, 1996). In the UK, one in three men over the age of 50 y e a r s h a d symptoms of bladder outlet obstruction usually due to benign prostatic hyperplasia (Garraway et al, 1991). Kirby (1993) reported that 40,000 transurethral resections of‘ prostate (TURP) were performed in the UK in 1993. Incontinence i n men may occur from sphincter damage after T U R P o r from radical prostatectomy f o r cancer of t h e p r o s t a t e (Donnellan et al, 1997; Emberton et al, 1996; Rudy et a l , 1984) or it may be t h e result of detrusor dysfunction.
Lower Urinary Tract Symptoms Urethral obstruction may cause a variety of bladder changes and may result in new LUTS or exacerbate existing ones. There is, however, no significant relationship between prostate size and symptoms (Simpson et al, 1996). LUTS are not necessarily related to urodynamically proven bladder outlet obstruction (BOO) or histologically proven BPH (Abrams, 1995) and may be equally evident in an age-matched female population (Lepor and Grace, 1993). LUTS in men may be divided into voiding a n d filling symptoms (Abrams, 1994) - see table 2.
Anatomy and Physiology According t o Dixon and Gosling (19941, slow twitch fibres of the levator ani are continuously tonic to maintain pelvic floor tone and visceral s u p p o r t a n d fast twitch fibres a r e mainly activated d u r i n g activities which increase abdominal pressure. A rectal examination may be performed t o determine the strength and integrity of both the slow and fast twitch fibres of the pelvic floor muscles (Dixon et al, 1997). There is controversy about the voluntary control of the external urinary sphincter. The key t o bladder control may be in the external urethral sphincter ‘guarding reflex’ identified in cats (Garry et al, 1959). Pelvic floor exercises may affect continence by neuromuscular reinforcement of the guarding reflex (Park et a l , 1997). The lower urinary tract of men differs from women by a longer urethra (18 to 20 cm in men, 3 t o 4 cm in women), the absence of the vagina perforating t h e pelvic floor a n d t h e presence of the prostate gland. The prostate gradually enlarges with age (table 1) in the presence of androgens, especially dihydrotestosterone causing benign prostatic hyperplasia (BPH) which may lead t o symptoms of urethral obstruction (Sant and Long, 1994). Prostate can-cer is a separate condition and occurs as a result of a primary tumour in the majority of can case (Gray, 1992). As the tumour increases, it can cause enlargement of the prostate gland and symptoms of bladder obstruction. Table 1 : The prevalence of clinical benign prostatic hyperplasia and symptoms with ageing (Neal, 1997) Age (years) 35-44 45-54 55-64 65-74 75-84 >85
Microscopic
1“/9, 8 23 42 71 82 88
Gross (%) 2 8 21 35 44 53
Severe symptoms (“A) 0 0 2-5 8-15 15-20 20-30
Table 2: Bladder filling and voiding symptoms in men (Abrams, 1994) Filing symptoms
Voiding symptoms
Frequency Urgericy Urge incontinence Nocturia
Hesitancy Poor stream Straining Incomplete emptying lntermittency Terminal dribble
When the urethral obstruction is removed by either transurethral resection of the prostate or radical prostatectomy, incontinence may ensue. The cause may be sphincteric incompetence (Foote et al, 19911, filling symptoms (urgency, urge incontinence, frequency and nocturia), or a combination of both. Physiotherapy h a s the potential to be effective in alleviating postprostatectomy urinary incontinence.
Benefits of Physiotherapy Physiotherapy f o r t h e t r e a t m e n t of female urinary incontinence is known t o be effective (Bg, 1995). The benefits i n men a r e not so well researched although in non-randomised a n d non-controlled t r i a l s , t h e r e s u l t s a r e encouraging (Burgio et a l , 1989; Flynn et al, 1994; Jackson et al, 1996; Paterson et al, 1997; Salinas et a l , 1996; Sueppel, 1998). Methods which have been used effectively in women have also been successful in men. Pelvic floor muscle exercises, biofeedback, bladder retraining, electrical stimulation and behavioural strategies have all been used for men with u r i n a r y incontinence. However, the studies are limited by small sample sizes and lack of control groups. This paucity of research literature which could support evidence-based practice led t o a n exploration of t h e c u r r e n t physiotherapy undertaken for the relief of male lower urinary tract symptoms as part of a MSc by independent study.
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Aims This survey w a s u n d e r t a k e n i n order t o ascertain the number of physiotherapists who t r e a t men with continence problems and to describe the physiotherapeutic techniques which c a n be used to t r e a t lower u r i n a r y tract symptoms for men.
A ‘Physiotherapy for Male Continence Problems Questionnaire’ was designed t o identify the physiotherapeutic techniques currently being used to treat male lower urinary tract problems in Britain.
Methodology Questionnaire Design The survey was carried out by means of a questionnaire. This started with questions such as the following: Do you treat patients for urinary continence problems?
Have you ever been requested to treat male continence problems? Do you only treat female urinary continence problems?
These were designed to investigate the number of physiotherapists who treated male patients. The following questions asked for : The numbers of male pre- and post-prostatectomy in-patients and out-patients treated by the respondent in the last 12 months. 0
The modalities (out of a given list of physiotherapy modalities) used in the last 12 months for male patients.
0
0 The number of patients in the last 12 months for each modality. 0
Other modalities used.
Other advice given. Modalities used in the last 12 months for each urinary symptom.
0 0
0
Other symptoms treated.
The type of pelvic floor examination undertaken at assessment.
0
0 Contact name for help and/or expert advice in the field of male incontinence.
Association of Chartered Physiotherapists in Women’s Health (ACPWH) and/or of Chartered Physiotherapists Promoting Continence (CPPC). The specialist subgroups were the target of the questionnaires. The questionnaires were mailed on March 24, 1997, t o 465 ACPWH members and 66 CPPC members who were not members of ACPWH (531 in total), with a pre-paid envelope for a reply. The questionnaire was not coded. Participants had the option of disclosing their names and addresses o r remaining anonymous. No reminders were sent and no deadline was given. A l e t t e r was included to each member explaining t h a t t h e investigator was undertaking her MSc at the University of East London, with Jill Mantle as her specialist tutor.
Analysis The answers to the questionnaire were analysed and collated and descriptive statistics were produced.
Results By April 30, 1997, a total of 319 responses had been received (60% response r a t e ) a n d t h e research was closed. No replies were invalid although many respondents chose t o remain anonymous. All t h e physiotherapists were female. Twenty-six respondents were retired and/or not treating continence problems so were excluded from the analysis. Of the remaining 293 respondents, 81 (25%) treated female and male continence problems a n d 212 physiot h e r a p i s t s t r e a t e d only female continence problems.
Physiotherapists Treating Only Female Urinary Incontinence Problems A substantial number of physiotherapists, 155 out of 293 (53%), had never been asked to treat male patients and surprisingly, a further 59 out of 293 (20%) physiotherapists had been requested to treat men but only treated women. The following reasons for not treating male patients were given: Lack of male referrals (8).
Pilot Questionnaire On January 21, 1997 a pilot questionnaire was s e n t to eight selected professionals - three physiotherapists, two urologists, two urology nurses and a continence adviser. Using feedback from the pilot group, it was further developed for clarity, relevance and unambiguity. Sample Of the 26,000 chartered physiotherapists in the UK in 1997, there were 531 members of the ~
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I treated men some years ago, not recently (5). I only treat females at the moment (3).
I only treat men with faecal incontinence (2). My colleague treats the men (2). Men go to Urology and to the continence adviser (1). I only give men advice (1). No facilities for men (1). I have no experience with male incontinence (1). No one has any experience in the treatment of males (1).
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Physiotherapists Treating Male Urinary Incontinence Problems Forty out of 81 (49%) respondents stated that in t h e l a s t 12 months they h a d t r e a t e d male patients who had not undergone a prostatectomy a n d 64 out of 81 (79%) respondents had treated post-prostatectomy patients in a n o u t - p a t i e n t s e t t i n g ( t a b l e 3). T h u s t h e majority of respondents h a d t r e a t e d men following prostatectomy as out-patients. Some of the respondents may have treated the same pre- and post-prostatectomy patients. Table 3: Number of patients treated by respondents in previous 12 months
Type of patient
No of respondents
Post prostatectomy out-patients (165) Post prostatectomy in-patients (131) Outpatients (no prostatectomy) (77) Pre-prostatectomy in-patients (17) ~
Average (range) per physiotherapist
64
2 (1-16)
11
12 (1-50)
40
2 (1-12)
9
2 (1-2)
~
In the 12 months prior t o the survey 242 outpatients and 148 in-patients (total 390) were treated by 81 respondents. The number of male p a t i e n t s t r e a t e d by each physiotherapist averaged only five (range 1-16) in the previous year. They indicated t h a t they had used a variety of modalities t o treat men with continence problems (table 4). Table 4: Physiotherapy modalities used on 390 patients in past 12 months
Modality
No of patients
Pre-operative exercises pelvic floor urinary sphincter anal sphincter
44 3 4
Post-operative exercises pelvic floor sphincter anal sphincter
274 147 93
Electrical stimulation in department with surface (patch) electrodes with rectal electrode for home use with surface electrodes with rectal electrode Biofeedback with surface electrodes with rectal electrode
63 17 18 12 5 23
Bladder re-education
196
Timed voiding
100
Advice about amount of fluid intake caffeine intake alcohol intake diuretics bulbar massage
264 268 216 87 124
Modalities Pelvic floor exercises: Respondents indicated that in the last 12 months they had treated with pelvic floor exercises 44 out of 94 (47%)men who had not undergone a prostatectomy and 274 out of 296 (93%) post-prostatectomy patients. Three out of 94 of these patients (3%) who had not had a prostatectomy and 147 out of 296 (50%) postprostatectomy had also been given specific ‘urinary sphincter exercises’ even though five other physiotherapists considered there was no difference between these and voluntary pelvic floor muscle exercise. Four out of 94 male patients (4%) who had not had a prostatectomy and 93 out of 296 (31%) post-prostatectomy had also been given anal sphincter exercises. Electrical stimulation was not a frequently employed modality. The types of machine used and output were not specified. Respondents reported that they had treated 63 out of 390 (16%) patients in the department with surface (sticky patch) electrodes and 17 out of 390 (4%) with a rectal electrode. In addition, 18 out of 390 (5%) patients used a home unit with surface electrodes and 12 out of 390 (3%) with a rectal electrode. The majority of physiotherapists used surface electrodes in preference to a rectal electrode. Biofeedback: Respondents reported t h a t biofeedback was used for only five out of 390 (1%)patients using surface EMG electrodes and 23 out of 390 (6%)using a rectal electrode. Bladder re-education: Respondents reported that bladder training was taught t o 196 out of 390 (50%)patients and timed voiding to 100 out of 390 (26%) patients. Some of the patients were advised on both. Other modalities: One physiotherapist reported using acupuncture for men with urgency and one physiotherapist added reflextherapy for low back pain and relaxation. Advice: It was claimed that the majority of the men, 264 out of 390 (68%), had been given advice on fluid intake and 268 out of 390 (69%) received advice on caffeine intake, whereas only 216 out of 390 (55%)had been given advice on alcohol consumption. Some of these patients, 87 out of 390 (22%) had also been advised about diuretics. Advice about bulbar massage was given to 124 out of 390 (32%)patients. Twenty respondents indicated further advice given in the areas of prevention of constipation (3), defaecation techniques (11, bladder diary (l), cranberry juice (31, l i t e r a t u r e (2), m a n u a l handling (21, continence products (3), general fitness (l),functional activities (l),and double
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t h e r a p i s t s who were t r e a t i n g male p a t i e n t s did n o t know whom t h e y could c o n t a c t for help or advice. Their comments included:
voiding for post micturition dribble (1).Patients were referred t o a continence adviser (11, a sexual psychologist (11, and a diabetic patient to the GP (1).
‘I don’t know.’
Modalities used for different symptoms: Table 5 shows t h e purpose for which physiotherapy modalities were used. Pelvic floor exercises were most commonly used for stress incontinence while bladder re-education with pelvic floor exercises were most commonlv used for urgency ” a n d urge incontinence. Bulbar massage was mostfrequently advised for post micturition dribble.
‘That’s a problem.’ ‘1 don’t know anyone. 1 wish 1 did,’ ‘Don,t know anyone who specialises in males,, ‘I would contact a female expert and ask if they would give me a name.’ ‘I am very interested to seek further information and guidance and would be grateful for contact names.’ ‘Fortunately I’ve never had to ask.’
Table 5: Number (percentage) of respondents identifying modalities used for specific symptoms (N = 81)
PFE Electrical Biofeedback Bladder re-education Fluid advice Advice
Sress and poor sphincter
Urgency, irequency, urge incontinence nocturia
No PA)
No (%A)
62 (77) 26 (32)
(6)
42 (51) 27 (33) 3 (4)
4 3 1
(5)
53 (65)
14
5 4
-
-
Acupuncture Relaxation Advice on enuresis alarm Double void Daily living Bulbar massage
5 1
(6) (1)
-
Poor compliance
Hyperreflexia
No (%A)
No (“A)
___
(4)
1
-
(1)
Identification of Mentors I n t h e section requesting a contact name for help or advice, J o Laycock was identified 24 times, followed by Jeanette Haslam (9), Grace Dorey ( 8 ) , Jill Mantle (3) and Margaret Barr (2). Fifteen other physiotherapists were mentioned once as were four continence advisers, three urologists, a urotherapy nurse a n d a clinical n u r s e specialist. The Clinical Interest Group ACPWH w a s m e n t i o n e d five t i m e s a n d t h e support group CPPC was mentioned twice. Some physiotherapists (48 out of 81) listed up to three m e n t o r s w h i l e t h e r e m a i n i n g 33 physio~~
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(5) (4) (1) (17)
1
-
(1)
-
Pelvic Floor Assessment When asked whether the levator ani muscles were palpated during a n assessment, 28 out of 81 physiotherapists answered ‘always’, 25 ‘sometimes’ and 23 ‘never’. Five physiotherapists did not answer this question. However, when asked whether a rectal examination was performed, only 19 out of 81 answered ‘always’, 22 ‘sometimes’ a n d 38 ‘never’. Two physiotherapists did not answer this question.
~
Post void dribble No (%h)
-
10 (12) 2 (2) 3
Enuresis No (“h)
I
-
Discussion Survey By using a postal questionnaire, a large number of respondents was contacted i n a relatively short time with minimal expense (Depoy and Gitlin, 1994). Multiple data were gained from 319 out of 531 physiotherapists (60% response). The 60% response rate was considered adequate a s it was felt that those physiotherapists with a special interest in continence would readily reply. At the time of the survey, the membership list of ACPWH did not separate members with a special i n t e r e s t i n continence from t h o s e members with a special interest in obstetrics and gynaecology. Many of the 40% who did not reply could have been in the latter group. T h e outcomes of t h e s u r v e y m a y a l e r t t h e profession to the few physiotherapists who are treating male lower urinary tract problems and identify the type of treatments undertaken. It may also underline a training need and the need t o collaborate w i t h urologists, GPs, urology n u r s e s a n d continence a d v i s e r s t o provide
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a service as part of a multi-disciplinary team. The researcher had an obligation t o feed back results t o the respondents and share the information gained, and an ethical responsibility t o maintain confidentiality and anonymity of the informants (Colquhoun and Kellehear, 1993). The mentors identified by the respondents gave consent to the publication of their names. The members of ACPWH and CPPC used in this sample are not the only ones who treat male continence problems. There may be physiotherapists who are not members of either organisation who are currently undertaking these treatments as well as some of t h e 212 nonrespondents. In-patients are usually treated by generalist in-patient physiotherapists.
Data Produced From the survey it was shown that in Britain in the year before the survey that out of the 293 respondents only 81 treated male patients with LUTS. It appears that they treated very few men (242 out-patients a n d 148 in-patients). The reason so few physiotherapists treat men may be due t o embarrassment, inadequate training, or lack of referrals. There may be a role for male physiotherapists in the treatment of men with LUTS. I t must be borne in mind that urology nurses and continence advisers undertake much of the work in this area and that this is by no means the total number of patients treated with physiotherapeutic techniques. Respondents used a variety of modalities for t r e a t i n g male LUTS. Most physiotherapists (93%) used pelvic floor exercises for men with post-prostatectomy urinary incontinence. Four physiotherapists reported using bladder training for stress urinary incontinence, a therapy which is more effective for urgency. This response may reflect a lack of clarity in the question o r a misunderstanding of the theory behind bladder retraining. Respondents reported t h a t biofeedback was used for only 7% of patients. This may be due t o the fact that specially designed incontinence biofeedback equipment is very expensive. Physiotherapists using electrical stimulation i n their departments showed a preference for using surface electrodes (63 out of 390 treatments) as opposed to using a rectal electrode (17 out of 390 treatments) which may be due to the lack of availability of electrical e q u i p m e n t a n d electrodes due to t h e c o s t . However, 18 out of 390 treatments used home electrical s t i m u l a t i o n u n i t s with surface electrodes as opposed t o 12 out of 390 treatments using rectal electrodes, which may again indicate the type of equipment available or the physiotherapists’ preferences. -
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Physiotherapists varied widely in the advice they offered. The lack of research in this area and the lack of formal training in male urinary incontinence may result in care being based on experience rather than on evidence-based practice. Many physiotherapists (38) did not undertake a rectal examination. This may be due to lack of training. Sadly, as many as 33 out of 81 physiotherapists did not know the name of an expert t o whom to turn for help. This may be because many of t h e recognised expert physiotherapists i n incontinence t r e a t only women. Physiotherapists are in a unique position, based on their treatment of women with continence problems, t o provide skills of muscle r e education, electrical s t i m u l a t i o n a n d biofeedback with p a t i e n t specific advice to provide a service for men patients with LUTS as part of a multi-disciplinary team.
Conclusion The respondents reported that only 81 out of 293 surveyed physiotherapists treat male continence problems. The survey identified only 390 men receiving physiotherapy for continence problems in Britain in the 12 months before the survey; a n average of five patients per respondent. Considering t h a t 2.4 million men in the UK suffer urinary symptoms associated with benign prostatic hyperplasia (Garraway et a l , 1991), there are many men who would benefit from what physiotherapy has to offer. All t h e physiotherapists were female. The majority of respondents (212) t r e a t e d only female patients. Many of the physiotherapists (33 out of 81 (41%) treating men did not know whom to turn to for help. Thirty-eight out of 81 (47%) physiotherapists did not undertake a rectal examination indicating a possible training need. The main problems identified in the survey are the lack of referrals and lack of training. Physiotherapists have a wide variety of modalities and advice to use in order to treat men with LUTS. Many treatments are the same as those used for women. Respondents h a d taught most post-prostatectomy patients pelvic floor exercises (93%),and many men were given bladder training (50%), but few had electrical stimulation (28%), and fewer had used biofeedback (7%). Advice was given to most patients on fluid intake (68%), caffeine products (69%) and alcohol intake (55%), and 32% of men were taught bulbar massage. ~
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Recommendations Further clinical research would enable evidencebased practice to evolve for physiotherapy for men with lower urinary tract symptoms. A further survey could discover the reasons why many p h y s i o t h e r a p i s t s who t r e a t women with continence problems do not t r e a t men with similar problems. A training need may have been identified and could be addressed. If t h e reason is a lack of r e f e r r a l s , t h e n physiotherapists may benefit by collaboration w i t h continence advisers, urology n u r s e s , urologists and GPs in order to offer a service for their male patients equivalent to the service they provide for women.
Colquhoun, D and Kellehear, A (1993). 'Politicians, bureaucrats and the doctors' in Health Research in Practice: Political, ethical and methodological issues, Chapman and Hall, London, pages 14-15. Consensus Forum (1 998). 'Nurses and physiotherapists working in continence care', March 5, at the King's Fund, Cavendish Square, London. Depoy, E and Gitlin, L N (1994). lntroduction to Research: Multiple strategies for health and human services, Mosby-Year Book Inc, St Louis, USA, page 117. Dixon, J, Dorey, G, Eve, B, Simonds, K and Taylor, V (1997). 'Post-prostatectomy incontinence', Journal of the Association of Chartered Physiotherapists in Women's Health, 80, 35-38. Dixon, J and Gosling, J (1994). 'Histomorphology of pelvic floor muscle' in: Shussler, B, Laycock, J, Norton, P and Stanton, S (eds), Pelvic Floor Re-education Principles and Practice, Springer-Verlag, New York, page 31.
Acknowledgments
Donnellan, S M, Duncan, H J, MacGregor, R J and Russell, J M (1997). 'Prospective assessment of incontinence after radical retropubic prostatectomy: Objective and subjective analysis', Adult Urology, 49, 2, 225-230.
My thanks are due to Jill Mantle BA FCSP DipTP, research physiotherapist at King's College Hospital and specialist tutor to Grace Dorey at the University of East London, for giving a considerable amount of time to reviewing this article.
Emberton, M, Neal, D E, Black, N, Fordham, M, Harrison, M, McBrien, M P, Williams, R E, McPherson, K and Devlin, H 6 (1996). 'The effect of prostatectomy on symptom severity and quality of life', British Journal of Urology, 77, 2, 233-247.
I am also grateful to Katherine Moore PhD RN, post doctoral Fellow in nursing, King's College, for her help, expertise and encouragement.
Flynn, L, Cell, P and Luisi, E (1994). 'Effectiveness of pelvic muscle exercises in reducing urge incontinence among community residing elders', Journal of Gerontological Nursing, 20, 5, 23-7.
Author
Foote, J, Yun, S, and Leach, G E (1991). 'Post-prostatectomy incontinence: Pathophysiology, evaluation, and management', Urologic Clinics of North America, 18, 229-241.
Grace Dorey MCSP is a specialist continence physiotherapist at BUPA Hospital Bushey and is currently undertaking study leading to an MSc at the University of East London. This article was received on March 20, 1998, and accepted on July 3, 1998.
Address for Correspondence Mrs G Dorey, Old Hill Farm, Portmore, Barnstaple, Devon EX32 OHR.
References Abrams, P (1994). 'New words for old: Lower urinary tract symptoms for "prostatism"', British Medical Journal, 308, 929-930. Abrams, P (1995). 'The unstable bladder' in: Fitzpatrick, J M and Krane, R J (eds), The Bladder, Churchill Livingstone, Edinburgh, pages 221 -227. 60, K (1995). 'Pelvic floor muscle exercise for the treatment of stress urinary incontinence: An exercise physiology perspective', lnternational Urogynecology Journal, 6, 282-291 . Britton, J P, Dowell, A C and Whelan, P (1990). 'Prevalence of urinary symptoms in men aged over 60', British Journal of Urology, 66, 175-176. Brocklehurst, J C (1993). 'Urinary incontinence in the community-analysis of a MORl poll', British Medical Journal, 306, 832-834. Burgio, K L, Stutzman, R E and Engel, B T (1989). 'Behavioral training for post-prostatectomy urinary incontinence', Journal of Urology, 141, 303-306. Ceresoli, A, Seveso, M, Zanetti, G, Meligrana, C, Trinchieri, A, Guarneri, A, Tzoumas, S and Austoni, E (1993). 'Treatment of urinary incontinence in the patient operated on for benign prostatic hyperplasia' (abstract), Archivo ltaliano di Urologia Andrologia, 65, 5, 555-558. Ceresoli, A, Zanetti, G, Trinchieri, A, Seveso, M, Del Nero, A, Meligrana, C, Serrago, M and Pisani, E (1995). 'Stress urinary incontinence after perineal radical prostatectomy' (abstract), Archivo ltaliano di Urologia Andrologia, 67, 3, 207-210.
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Garraway, W M, Collins, G N and Lee, R J (1991). 'High prevalence of benign prostatic hypertrophy in the community', Lancet, 338, 469-471. Garry, R C, Roberts, T D M and Todd, J K (1959). 'Reflexes involving the external urethral sphincter in the cat', Journal of Physiology, 149, 635-665. Gray, M (1992). Genitourinary Cancer, Mosby's Clincal Nursing Series, Mosby-Year Book Inc, St Louis, pages 233-234. Hunter, D J, Berra-Unamuno, A, and Martin-Gordo, A (1996). 'Prevalence of urinary symptoms and other urological conditions in Spanish men 50 years old or older', Journal of Urology, 155, 6, 1965-70. Jackson, J, Emerson, L, Johnston, 6 ,Wilson, J and Morales, A (1996). 'Biofeedback: A non-invasive treatment for incontinence after radical prostatectomy', Urologic Nursing, 16, 2, 50-54. Kirby, R S (1994). 'Are the days of transurethral resection of prostate for benign prostatic hyperplasia numbered? Urologists must grasp the future', British Medical Journal, 309, 716-718. Lancaster Suite consensus statement: The contribution of nursing to continence care (1998). April 16, at The Lancaster Suite, Mayday University Hospital, Croydon, South London. Lepor, H and Grace, M (1993). 'Comparison of AUA symptom index in unselected males and females between 55 and 79 years of age', Urology, 42, 36-40. Malmsten, U G H, Milsom, I, Molander, U, and Norlen, L J (1 997). 'Urinary incontinence and lower urinary tract symptoms: An epidemiological study of men aged 45 to 99 years', Journal of Urology, 158, 1733-37. Mantle, J and Versi, E (1991). 'Physiotherapy for stress urinary incontinence: A national survey', British Medical Journal, 302, 753-755. Milne, J S , Williamson, J and Maule, M M (1972). 'Urinary symptoms in older people', Modern Geriatrics, 2, 198-212. Neal, D E (1997). 'The National Prostatectomy Audit', British Journal of Urology, 79, 2, 69-75. Park, J M, Bloom, D A and McGuire, E J (1997). 'The guarding reflex revisited', British Journal of Urology, 80, 940-945.
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Simpson, R J, Fisher, W, Lee, A J, Russell, E B A W and Garraway, M (1996). ‘Benign prostatic hyperplasia in an unselected community-based population: A survey of urinary symptoms, bothersomeness and prostatic enlargement‘, British Journal of Urology, 77, 186-191. Sueppel, C (1998). ‘Timing of pelvic floor muscle strengthening exercises and return of continence in post-prostatectomy patients’, Conference Proceedings, 4th National Multi-Specialty Nursing Conference on Urinary Continence, Florida. Thomas, T M, Plymat, K R and Blannin, J (1980). ‘The prevalence of urinary incontinence’, British Medical Journal, 281, 1243-45.
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