Assessment & diagnosis
- GP or specialist imaging, biopsy, and PSA results
- Current bladder habits and any changes
- Bladder and pelvic floor ultrasound
- Pelvic floor muscle activation and co-ordination
Before and after prostate surgery
Physiotherapy before and after prostate surgery to protect and rebuild bladder control and support the return of erectile function. Prehab before surgery and rehab afterwards give the best long-term outcomes.
Understanding prostate surgery
Prostate cancer is the second-most commonly diagnosed cancer and the fifth leading cause of cancer-related death in men worldwide, with Australia and New Zealand among the highest incidence rates alongside the USA and Northern Europe. That said, detection and treatment technologies have improved over the last decade, so men who choose either conservative or surgical treatment have better outcomes than ever before.
Because of the prostate's anatomy and its close proximity to the bladder and urethra, surgical and radiotherapy techniques to remove all or part of it can cause trauma to the bladder and urethra, resulting in incontinence or difficulty maintaining bladder control. Depending on the degree of nerve and lymphatic involvement, it can also affect sensation and erectile function of the penis and change bowel habits. Your urologist and surgical team will discuss the degree of involvement and the post-operative risks when you are considering surgery, and will often refer you to physiotherapy for pre-surgical rehabilitation to optimise your long-term outcomes.
What men often notice after surgery
- A catheter for usually two weeks, during which you let the pelvic floor and bladder rest and recover. You might notice some rosy-coloured urine in the first few days after the catheter comes out (this is normal and settles within a few days)
- Difficulty holding urine and not getting to the toilet in time
- Urinary frequency, needing to go often, and not feeling fully empty
- Spotting on the underwear, and the anxiety around small accidents
- Erectile dysfunction and sensory changes to the penis that can take months to return
The surgery and recovery
After the surgery you'll usually stay in hospital for one or two nights, depending on how extensive it was and whether you need monitoring. You'll have a catheter in for 7 to 14 days (also depending on the level of invasiveness and whether anything was done directly to the bladder or urethra), and while you might feel some spasms of the muscles around the bladder or urethra, these are normal and usually managed easily with the basic painkillers your surgeon prescribes or recommends. Some people get a swollen scrotum for a few days, which is also normal, often painless, and settles within a few days of going home.
Types of prostatectomy
There are a few different prostatectomy techniques. They don't hugely change the rehabilitation outcomes, though some have a slightly longer recovery than others:
- TURP (transurethral resection of the prostate)
- RALP (robot-assisted laparoscopic prostatectomy)
- TUNA (transurethral needle ablation)
- Green laser prostate surgery
- Open prostatectomy
- Perineal-approach prostatectomy
- TUIP (transurethral incision of the prostate)
Physiotherapy starts before surgery with pelvic floor assessment and strengthening (and in some cases both strengthening and improving co-ordination and relaxation, as increased pressure from the prostate can make the pelvic floor a strange mix of overactive but still under-useful). After surgery, I wait until the catheter is removed to reassess the strength and co-ordination of the pelvic floor, including using ultrasound to see the muscles and gauge how they are working to support the pelvis, kink the urethra, and control urine flow. I then use that to work out how best to strengthen and control the pelvic floor, alongside bladder and toilet-timing strategies.
In many cases you'll use underwear liners or pull-up pants to catch leakage, and I'll get you to weigh the used pads (and note how many you use per day) to monitor how much leakage is happening and how it improves, so you can use fewer through the day or have periods without them, depending on your bladder control.
It might not sound glamorous, but the rehabilitation is all about quality of life - making any bladder or pelvic floor issues less intrusive on day-to-day life, ideally to the point they are no longer there, and helping you regain social confidence and, in many cases, sexual function (though in some cases this may not be possible if the nerves that travel to the penis to control erectile function could not be spared during surgery).
How I support your recovery
Treatment techniques
- Bladder diaries and fluid balance charts
- Pelvic floor activation, timing, and co-ordination
- Pelvic floor strengthening in different positions and activities
- Progressing underwear liner use and timing
- Blood flow optimisation, including penis pumps
- Weisner clamps in some cases to help bladder training
Your home program
- Pelvic floor activation and relaxation exercises
- Optimising fluid, fibre, and caffeine intake
- Micturition (voiding) reflex training
- Building the capacity to "hold on" longer
- Erectile function redevelopment
Your first visit
During your first visit, I'll go through what has brought you in, the history and timeline of the prostate changes, and, if you haven't already had surgery, when it is planned. I'll also ask about other factors that can affect urinary function beyond the prostate (fluid and caffeine intake, awareness of the pelvic floor, and so on), what you do for work and socially, and any additional stressors or triggers that can bring symptoms on.
To diagnose accurately and build a treatment plan, I'll assess the bladder and pelvic floor. While the urologist often performs a urodynamic study that measures the residual urine in the bladder after you go to the toilet, ultrasound in physiotherapy looks at how you contract the muscles around the pelvic floor and bladder to control your ability to hold on. I'll also look at how you contract the muscles externally around the base of the penis and behind the scrotum, where they can be seen and felt, so you can co-ordinate them at home. In most cases there is no need for an internal examination, but ultrasound of the deep pelvic muscles through the perineum (the probe resting on the gooch) can add information if there are concerns around the colon or rectum as well as the prostate.
After the examination, treatment usually begins in the same session and often involves training the pelvic floor muscles in some way - activation or co-ordination if they are hard to feel working, or relaxation and down-training if they are overactive from the pressure of the prostate on the bladder, urethra, or surrounding structures. I'll also discuss whether penis pumps to assist blood flow into the penis are needed, along with any changes to your fluid intake, volume and timing and how they affect your toileting. Toileting habits are a big part of rehab after surgery and the potential incontinence, so you'll get familiar with measuring and timing them very quickly.
All of this is packaged into a plan to continue at home between sessions, where I monitor your progress, increase the intensity or complexity of the exercises, and adjust the bladder training as you improve.
Consent is ongoing, specific, and yours to withdraw at any time.
Common questions about prostate surgery recovery
When should I start pelvic floor physiotherapy after surgery?
Ideally you'll start physiotherapy at least 3 weeks before surgery, and preferably 6 weeks before, to strengthen and better co-ordinate the pelvic floor and make the post-op outcomes better and quicker. After surgery, you won't do much with the rehabilitation until the catheter is removed 7 to 14 days later, at which point you can get back in touch to either start the process or reassess how things are since surgery and adjust the plan for returning to dryness, regular life, and potentially sexual activity (which typically takes a few months to return).
Will my continence come back?
In many cases, yes, though the caveat is the timeline. Men with fewer symptoms and less invasive surgery often recover quicker than those who had more intensive surgery, because of the amount of tissue moved or removed and the trauma to the muscles, nerves and other structures. Roughly 65% of men achieve continence (dryness) within the first three months, and close to 80% within the first 12 months. Improvement continues beyond 12 months, though some factors can slow recovery, such as smoking, uncontrolled diabetes, heart disease, uncontrolled high cholesterol, erectile dysfunction before surgery, and obesity.
Can physiotherapy help with erections after prostate surgery?
Yes. While it is not the primary goal in the early stages after surgery, working towards normal sexual function usually starts after the first 8 to 12 weeks, once continence is improving and the surgical site has properly recovered. The recovery is not hugely different from treating erectile dysfunction unrelated to prostate surgery, so you can read about what is involved on the erectile dysfunction and premature ejaculation page.
Book an assessment
Not sure if I'm who you need? Ask me and I'll let you know if physiotherapy is the right fit, or point you to who is.