Preoperative pelvic floor muscle exercise for early continence after holmium laser enucleation of the prostate: a randomized controlled study

Benign Prostatic Hyperplasia (BPH) is a common condition in elderly males and affects over half of all men aged > 60 years [1]. Holmium laser enucleation of the prostate (HoLEP) is widely used as a minimally invasive surgical procedure because it can be performed in patients with large-sized prostatic hyperplasia and is associated with lower volumetric blood loss and shorter periods of indwelling catheterization and hospitalization than transurethral resection of the prostate (TURP) [2]. However, postoperative transient urinary incontinence has been reported as a bothersome complication of HoLEP in 16–44% patients within 3 months [3‐5]. Postoperative urinary incontinence remains a representative complication of HoLEP and can have a negative influence on the patient’s quality of life (QOL) [5].

Pelvic floor muscle exercise (PFME) is one of the physiotherapies used for recovery of continence after prostate surgery. Although the efficacy of PFME for urinary incontinence after prostate surgery remains controversial [6‐11], some recent studies demonstrated that PFME started preoperatively and continued postoperatively was associated with better outcomes than PFME started only postoperatively [6‐8]. We herein present the first randomized clinical trial to compare the effects of preoperatively started PFME with postoperatively started PFME for early recovery of continence after HoLEP.

A total of 70 patients were randomized into groups A (PFME started preoperatively and continued thereafter, n = 35) and B (PFME postoperatively only, n = 35) for final analysis (Fig. 1). Among the patient and perioperative background characteristics, there were no differences in age, BMI, IPSS, OABSS, ICIQ-SF score, prostate volume, operation time, enucleate prostate weight, diabetes mellitus status, and G8 score between the two groups (Table 1). The postoperative urinary incontinence rate was significantly lower in group A than in group B at 3 months postoperatively (3% vs. 26%; P = 0.01); however, there were no significant differences in the urinary incontinence rate between groups A and B at 3 days (40% vs. 54%; P = 0.34), 1 month (37% vs. 51%; P = 0.34), and 6 months (0% vs. 3%; P = 1.00) postoperatively (Fig. 2). Furthermore, the postoperative ICIQ-SF score was not significantly different between groups A and B at 1 month (5.4 ± 4.9 vs. 5.6 ± 4.9; P = 0.89), 3 months (2.9 ± 3.4 vs. 3.8 ± 4.6; P = 0.80), and 6 months (1.5 ± 2.0 vs. 1.5 ± 2.4; P = 0.83) postoperatively.

We investigated the predictive factors for urinary incontinence at 3 days and 1, 3, and 6 months after HoLEP. As shown in Table 2, by univariate and multivariate analyses, preoperative PFME was a significant predictive factor for urinary incontinence at 3 months after HoLEP [odds ratio (OR), 0.08; P = 0.01 (univariate), OR, 0.10; P = 0.01(multivariate)]. At 3 days and 1 month after HoLEP, there were no significant predictive factors for urinary incontinence. At 6 months postoperatively, predictive factors could not be evaluated and were thus not included in Table 2 because there remained only one case with urinary incontinence in 70 cases. In univariate analysis, patients who performed preoperative PFME had a 0.56-fold lower risk of being incontinent 1 month after HoLEP and a 0.08-fold lower risk of being incontinent 3 months after HoLEP (Table 2).

Regarding the urodynamic examination results, there were no differences between groups A and B in terms of the maximum detrusor pressure (76 ± 33 cmH₂O vs. 73 ± 29 cmH₂O; P = 0.85), detrusor overactivity (18% vs. 12%; P = 0.73), volume at the first desire to void (274 ± 118 ml vs. 288 ± 145 ml; P = 0.79), maximum cystometric capacity (422 ± 171 ml vs. 366 ± 180 ml; P = 0.12), and residual volume (127 ± 145 ml vs. 135 ± 178 ml; P = 0.91). We also investigated the predictive factors for postoperative urinary incontinence among the factors obtained on urodynamic examination, and no significant predictive factors were found at 3 days, 1 month, 3 months, and 6 months after HoLEP.

Urinary incontinence is one of the common complications after prostate surgeries such as radical prostatectomy (RP) for prostate cancer and TURP as well as HoLEP for BPH. Urinary incontinence after surgery is a challenging complication that may discourage patients from seeking surgery and reduces patient QOL [5]. PFME, which was shown to be effective primarily in females with stress urinary incontinence [15], is one of the physiotherapy approaches used for recovery of continence after prostate surgery. However, to the best of our knowledge, no study has examined the effects of PFME on urinary continence after HoLEP. Although the period is relatively short in most patients, postoperative urinary incontinence seriously decreases the postoperative QOL not only after HoLEP but also other prostate surgeries.

The current study demonstrated that preoperatively started PFME promoted early recovery of continence after HoLEP. We started PFME preoperatively to promote early recovery of continence after HoLEP based on several recent studies demonstrating that preoperatively started PFME was associated with improved outcomes compared with postoperatively started PFME in patients undergoing RP [6‐8]. A recent meta-analysis showed that preoperatively started PFME significantly reduced the risk of postoperative urinary incontinence by 36% at 3 months after RP [8]. Conversely, the same meta-analysis also showed that there were no differences in long-term outcomes beyond the first 6 months postoperatively, suggesting that preoperatively started PFME might aid in early recovery of short-term continence and not long-term continence [8]. These results regarding preoperatively started PFME in RP are consistent with our findings which show that preoperatively started PFME promoted early recovery of continence at 3 months after HoLEP but did not have an effect on long-term continence.

The mechanism underlying the effect of preoperatively started PFME on urinary incontinence after HoLEP is unclear. One potential explanation is that PFME requires a certain time period to exhibit the beneficial effect. One study previously reported that a minimum of 1 month was required for the increase in the contraction strength of the pelvic floor muscle after PFME [9]. We considered that PFME affected postoperative urinary incontinence after at least 1 month from the start of PFME. Therefore, in the group that underwent preoperative PFME from 1 month before HoLEP, a significant effect on postoperative urinary incontinence was observed 1–3 months after HoLEP. In this study, only at 3 months after HoLEP, there was a significant difference in the urinary incontinence rate between the two groups. The same rationale might also underlie the disappearance of the beneficial effect of PFME by 6 months postoperatively. However, the study sample size was small; therefore, further randomized studies involving larger groups of patients are necessary. Another possibility underlying the benefit of preoperatively started PFME for postoperative urinary incontinence is the additional instruction timing  provided to the patients by the nurses, which might have allowed for improved acquisition of appropriate PFME techniques. Therefore, it is critical for the patients to learn to perform PFME appropriately [16], as noted by several reports emphasizing the importance of repeated education [16, 17].

Several studies examined the effect of PFME on postoperative urinary incontinence in TURP, a standard surgery for BPH, as well as HoLEP. The efficacy of PFME for urinary incontinence after TURP continues to be a topic of debate [9‐11]. Chang et al. reported that patients performed postoperative PFME showed improvement in urinary continence at 3 and 4 weeks after TURP compared with patients who did not receive the intervention [9]. Conversely, Glazener et al. reported that PFME started 6 weeks after TURP did not lead to an improvement in urinary continence at 3, 6, 9, or 12 months after TURP [10]. One study investigating preoperatively started PFME found that preoperatively started PFME was not associated with an improvement in urinary continence after TURP compared with the control group [11], which is not consistent with the finding of the current study. Although the initiation time and duration of preoperative PFME were not described in that report, one potential reason for the discrepant finding is short or insufficient exercise duration for the emergence of the beneficial effect of preoperatively started PFME. Another possibility is that patients might have recovered from postoperative urinary incontinence after TURP relatively early; the number of patients with postoperative urinary incontinence in that case would be too low to detect any significant differences regardless of preoperative PFME.

There are several limitations to this study. First, the number of cases was small. Second, we did not investigate the severity, type, or continuation of incontinence using objective tests, such as the pad test. However, we believe that preoperative PFME contributed to the improvement of early urinary continence after HoLEP because the current study was conducted as a prospective randomized trial including two groups with no differences in patient background characteristics. Additionally, the multivariate analysis showed that preoperative PFME was the only significant predictive factor for early recovery of continence at 3 months after HoLEP (Table 2). Nonetheless, larger randomized prospective studies that investigate the efficacy of preoperatively started PFME will be beneficial to further elucidate definitive treatment strategies of PFME for recovery of continence after HoLEP.

Preoperatively started PFME may promote early recovery of continence at 3 months after HoLEP. Preoperative PFME is a costless and minimally invasive treatment that can be adapted to individuals attempting to recover urinary continence. However, the study sample size was small; therefore, further randomized studies involving larger groups of patients are necessary.