Dan Kirges PT Pelvic PT distance journal club Jan 6,2016
Purpose: Examine
the effectiveness of conservative management of post-prostatectomy
incontinence. Multiple intervention
options were investigated including pelvic floor muscle training with or
without biofeedback, e-stim, extra-corporeal magnetic innervation, compression
clamps and lifestyle changes.
Aim: Answer the question “Does conservative
management improve urinary incontinence post-prostatectomy within the first 12
months compared to time alone.”
Our journal club will
only focus on post-prostatectomy and not post-TURP at this time. Recording of journal club discussion included input from the Male Study group of the pelvic PT distance journal club consensus document. Recording can be accessed here. https://fccdl.in/w9RareCWK
Search:
·
Reference search considered up to date on 2/5/14
·
Years included within search and reference list
Jan 1982-Feb 2014
·
Included studies:
o
RCTs of conservative management to prevent or
treat urinary incontinence after prostatectomy.
o
Any single or multi-modal intervention plan
Participants:
·
Adult men with urinary incontinence (UI)
following prostatectomy
Types of interventions:
·
PFMT alone
·
PFMT (with or without biofeedback)
o
Verbal or machine mediated
·
E-stim (external with sticky patch, anal probe,
TENS)
·
Life-style adjustment
·
External penis compression device
Comparison group: no
treatment group, sham treatment, verbal or written instructions, or compared to
each other
Primary Outcomes:
·
Number of men reporting UI after 12 months
post-prostatectomy
·
ICIQ scores
·
Number of men reporting adverse effects
Secondary Outcomes:
·
Participant reported observations
·
Quantification of symptoms – including pad tests
·
Clinician reported UI outcome measures
·
Quality of life
Main results:
·
96 reports reviewed from the 50 studies for
qualitative analysis
·
59 reports reviewed from 27 studies for
quantitative analysis
·
Total (Prostatectomy+TURP) men studied = 4717
o
2736 had an active conservative intervention
Surgery
·
Specifics for type of prostatectomy not
identified
Timing of Recruitment
·
Varied greatly among the trials
o
Pre-op, Post-op, both
o
Within days or 2 weeks or several months post-op
Comparison 1: (9 trials)
Post-op PFMT plus or minus
biofeedback vs no treatment or sham treatment or verbal instruction
·
Low to moderate quality
·
Highly variable with:
o
Definition of UI (pad test, diary, pad use, etc)
o
PFMT exercise prescription/dosage
o
Start of PFMT (pre-op, post-op: days to 1 yr
post)
o
Outcome measures (pad use, quality of life)
·
Overall no significant differences noted at any
time period in the UI rates up to 12 months
o
Some individual studies favored treatment group
and others not
Comparison 6: (10 trials)
Pre-op PFMT (+/- biofeedback)
treatments vs no treatment or sham or verbal instruction
·
Very low to moderate quality
·
Highly variable with:
o
Definition of UI (pad test, diary, pad use, etc)
o
PFMT exercise prescription/dosage
o
Biofeedback set up (sticker pads, internal
sensor)
o
Outcome measures (pad use, quality of life)
·
Overall no significant differences noted at any
time period in the UI rates up to 12 months
o
Some individual studies favored treatment group
and others not
Comparison 4: (2 trials)
Post-op Combination of
treatments vs no treatment or sham
·
Very low to low quality
·
PFMT and E-stim+Biofeedback
·
1 study reported adverse effects of anal pain
post-stimulation
·
Overall no significant differences noted at any
time period in the UI rates up to 12 months
o
Some individual studies favored treatment group
and others not
Comparison 9: (1 trial)
Pre-op Combination of treatments
vs no treatment or sham
·
Low quality
·
PFMT with E-stim + biofeedback
·
A significant difference was noted in treatment
group for continence recovery in 6-12 months, 24 hr pad test and number of
incontinent men vs control group
Comparison 5: (9 trials)
Post-op One active treatment vs
another active treatment
·
Very low to low quality
·
Mostly PFMT alone vs adjunctive treatment
(E-stim, biofeedback)
·
1 study showed biofeedback group had higher
quality of life score vs PFMT alone
·
Overall no significant differences noted at any
time period in the UI rates up to 12 months
o
Some individual studies favored one treatment
group and others not
Comparison 10: (8 trials)
Pre-op One active treatment vs
another active treatment
·
Moderate quality
·
Mostly PFMT alone vs adjunctive treatment
(E-stim, biofeedback)
o
1 study used PFMT + penile vibration without
difference
o
1 study showed significance with general
exercise + PFMT beneficial in 1st 6 months
·
Some individual studies favored E-stim and
biofeedback with PFMT and others not
Comparison 7: (1 trial)
Pre-op E-stim vs no treatment or
sham
·
Very low quality
·
No significant difference noted
Comparison 2: (4 trials)
Post-op E-stim vs no treatment
or sham
·
Low to moderate quality
·
Overall no significant differences noted at any
time period in the UI rates up to 12 months
o
Some individual studies favored treatment group
and others not
·
1 study reported adverse effects of anal pain
post-stimulation
Comparison 3: (0 trials)
Post-op Lifestyle adjustment vs
no treatment or sham
Comparison 8: (0 trials)
Pre-op Lifestyle adjustment vs
no treatment or sham
Comparison 21: (1 trials)
External compression device
(penile clamp) vs no treatment or sham
·
3 different clamps compared
o
Cunningham clamp
o
U-Tex Male Adujustable Tension Band
o
C3 penile compression device
·
All devices reduced UI, but none eliminated UI
·
Cunningham clamp most favored by men, but
potential safety issue with blood flow
·
Pads were most highly rated overall in
protection, but clamp less restrictive with clothing
Main Findings
Amongst trials of conservative treatment for all men after
radical prostatectomy, aimed at both treatment and prevention, there was
moderate evidence of an overall benefit from pelvic floor muscle training
versus control management in terms of reduction of urinary incontinence.
However, this finding was not supported by other data from pad tests. The
findings should be treated with caution because the risk of bias assessment
showed methodological limitations.
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