Urophysiotherapy, or how to regain a comfortable life after prostate removal. Episode 107

Kamila Grabek
It is very common for men to fall into some kind of depressive state afterwards, because, after all, they associate this erection with masculinity. We must also remember that such a recovery after surgery is up to two years. More and more doctors are suggesting that before the operation, a specialist such as myself, in other words a urogynaecological physiotherapist, should be consulted to discuss the causes of urinary incontinence and erectile dysfunction, because sometimes we can actually work on this very often, as our pelvic floor muscles are involved. We should certainly pay attention to how our urine flows, whether it flows in a strong stream or a very thin one, yes?

Monika Rachtan
And which one should he fly?

Kamila Grabek
Strong. It should be firm, yes? There shouldn't be any dribbling. Male incontinence is simply not talked about.

Monika Rachtan
Hi Monika Rachtan, I welcome you very warmly to the next episode of the programme. First of all, the patient. A few months ago, I received a letter from a patient who accused me of not telling the whole truth in my programme because I did not talk about what complications can affect patients undergoing surgery for prostate cancer. Today, I would like to correct this and that is why I have invited Kamila Grabek to my programme. Hi, Kamila.

Kamila Grabek
Hi.

Monika Rachtan
Which you already had the opportunity to see in the programme a few weeks ago. We'll talk about what you can do to combat complications after prostate surgery. But first we'll start by saying that you are a urophysiotherapist and that urophysiotherapy doesn't only apply to women. As we discussed in the last episode of the programme, but also guys can come to you. What are the most common problems men come to you with?

Kamila Grabek
Honestly? It is those after various types of surgery. Prostatectomy can be associated with the risk of subsequent incontinence, erectile dysfunction and sometimes even inguinal hernia. Nevertheless, patients are often not informed of this, or perhaps they simply do not want to know. On the other hand, we know that this problem with the prostate is already affecting younger and younger men, so really young men are already undergoing prostatectomy, i.e. removal of the prostate, and it is known that they want to continue to be sexually active. And of course they want to hold their urine, simply.

Monika Rachtan
Going back to that letter I received. You know, it was a bit of a cry for help and a bit of such a regret that nobody told this gentleman about the fact that he had just written to me that he was going to lose his manhood. And I was also at a conference some time ago, the European Cancer Patients' Conference, one gentleman, probably from Germany or France, also just came forward to speak and said that men in his country are being cheated because they don't get information from their doctor that they will have erectile dysfunction, that they will have problems in the form of incontinence. And is your experience the same, that really these patients are not informed about these complications. Because on the other hand, you know, I think to myself, verbal information is one thing, and what you sign in the documents, well let's not kid ourselves, patients just don't read it.

Kamila Grabek
This is true. That is why I said that perhaps patients sometimes do not want what the doctor says to be true to turn out to be true. On the other hand, I honestly can't answer the question of why doctors don't report such complications, because these are quite common complications. At the moment, more and more robotic surgeries are being performed, which are indeed more precise and less fraught with the risk of complications. However, such complications still occur. Whether erectile dysfunction or incontinence occurs also depends on what type of cancer we were dealing with and how extensive the operation had to be. So indeed, prostatectomy surgery alone does not equal incontinence or erectile dysfunction. It may indeed be the case that at the very beginning, immediately after the operation, these disorders do occur. However, with time, after the operation, everything returns to normal. Sometimes it returns, sometimes it does not. This is why more and more doctors are suggesting to see a specialist such as myself, i.e. a urogynaecological physiotherapist, before the operation, in order to discuss the causes of urinary incontinence. What do these erectile dysfunctions come from? Because sometimes, in fact really often, we can work on it because our pelvic floor muscles are involved.

Monika Rachtan
So you mean to tell me that a patient who has an incontinence problem that is a consequence of a prostatectomy can regain normality, comfort, quality of life, if they contact a urophysiotherapist and start working.

Kamila Grabek
Exactly. Now, as if I had to briefly explain like this, what these incontinences, these disorders stem from in the first place, it's like I already explained in the previous podcast we have two sphincters, yes? The bladder works in such a way that at the moment when the internal sphincter fills, it is tightened. The moment we want to empty the bladder, the sphincters relax, the muscle on the bladder displaces the bladder, displaces the urine from the bladder. The moment we have we undergo prostatectomy surgery. Men undergo a prostatectomy procedure. The prostate is removed, but along with the prostate the internal sphincter of the urethra is also removed. That is, we can now only rely on one sphincter. The one that depends on our willpower, which is what we can exercise by exercising the pelvic floor muscles. If these muscles are not fit, if they do not work properly, if we do not know how to tighten them properly, how to relax them properly, then unfortunately, incontinence can occur.

Monika Rachtan
Kamila and now I am thinking and looking at such a classic, standard patient who undergoes a tectomy. This is a gentleman aged, let's say, 60+, I think to myself, mostly physically inactive, struggling with obesity here or overweight. So, as if the likelihood of something going wrong with the prostatectomy is almost certain, there will be an incontinence problem after all.

Kamila Grabek
It is definitely bigger, of course. This is also due to the fact that in obese patients it is sometimes not possible to perform laparoscopic surgery, but it is necessary, for example, to perform this procedure through the perineum. As a result, it is as if the damage to the tissues is greater, because laparoscopy involves making a few small holes through which instruments are inserted; surgeons insert instruments, not me, of course. With a key access, however, the tissue trauma is bound to be greater, there will be a much larger scar, which may also interfere with the normal functioning of the tissues. And all of this together can affect later incontinence.

Monika Rachtan
If you found our conversation interesting and are looking for more valuable content, subscribe to us on YouTube and Spotify. Monika Rachtan. Invite. Why before such simplicity? Who her. A man should see a physiotherapist. Do you help choose the right surgical treatment. In the sense you talk about these complications and compare. Or does the patient already learn at this first visit what exercises he should do to avoid this incontinence problem later on?

Kamila Grabek
We rather work with the pelvic floor, as this is my area, and when it comes to the selection of surgical techniques, I absolutely cannot interfere, as I simply do not have the knowledge and competence to advise the patient. However, of course, we discuss how such an operation goes, more or less, what the patient can expect after such an operation. And we already discuss the first exercises that the patient will be able to do immediately after the operation, in fact.

Monika Rachtan
And tell me what percentage of patients in your practice are men?

Kamila Grabek
Very small for now, to be honest.

Monika Rachtan
Well, that's right. Well, because, you know, I'm imagining this 70 or 60 year old man again now. Where, Grazyna just has to get him out, to get him to go to the doctor and see that urologist at all. The very visit to the urologist for many men causes stress, is uncomfortable and breaking through to see a urologist is one thing. Besides, we women are used to the gynaecological examination, because we de facto go to the gynaecologist. Well, if, let's say, since the age of 16 regularly already and this examination is once a year. We are used to it, we know that we do it for ourselves, and the guy, however, has this first contact with the examination at the urologist, usually at the age of 40, if he takes care of himself, and if not, he meets for the first time. When there are problems with urination, there are problems with erection. And now coming back to this, which is my question, that as I'm thinking to myself, you know, this comfort zone to go to this urologist at all is already going to be broken, now how would I still find out if I were in my dad's place, for example, that I'm supposed to go to such a Kamila in her 20s, who's going to talk to me about how I should exercise my sphincters. This is in general, no way. It's kind of in the consciousness of Polish men. It's not doable.

Kamila Grabek
Well that is still a big wall to jump over, I would say, and a big awareness to build in patients. On the other hand, I think that these erectile problems motivate patients a little more than incontinence problems, because, after all, men still want to feel desirable and they still want to feel sexually active. And, above all, they have female partners with whom they want to have intercourse. Yes?

Monika Rachtan
And I also remember the very man who was speaking at the conference I mentioned, how he said that he had been maimed, that he had become an invalid, that he had become depressed, because he had gone from being a man, and he was a slender man, such a nice grandfather, who says that he had gone from being a man who cared about his emotions, about his relationship, about his woman, to having no clue that when he left the hospital he would be deprived of an erection and that he would no longer be able to coexist with his wife. That his whole life had fallen apart because she said - hey man, you don't love me anymore or what's the matter? Like you know. Well, because when you're not mentally ready for it and suddenly your husband comes back. And let's agree this doesn't apply to 30 year olds, Where can they educate themselves, what suddenly happened? I don't know. He met some beautiful nurse there and he doesn't love me anymore.

Kamila Grabek
Well, that is why I am saying here there is a lot to do in terms of education simply. But I think not only in terms of educating men, but also their female partners.

Monika Rachtan
Because we are the ones dragging our Stas to go to the doctor.

Kamila Grabek
And the partner can be such a source of knowledge for the partner here. Exactly as you say, she can just enlist him a little by force, but also, above all, present him with the possibilities. Well, if the doctor fails here somewhere, and unfortunately he doesn't.

Monika Rachtan
Kamila, I think that it is also a problem that urologists, but the fact that we said that they do not inform about complications is one thing. We are not in these surgeries, so we cannot make any judgements here either. On the other hand, could they perhaps do more to encourage these men to see a specialist such as yourself?

Kamila Grabek
I think they could, especially as the reaction time is also important here. Well, because at the moment when the erection does not take place, these tissues also start to change, they start to stiffen and then it may be more and more difficult to rebuild sexual functions with time, so that is why we encourage consultation before the operation, at least a month beforehand, so that we can really discuss all these aspects, practice, prepare the patient mentally, because, as you say, very often men later fall into some depressive states, because, despite everything, they associate an erection with masculinity.

Monika Rachtan
Well, yes. And is it possible to go to a physiotherapist in Poland on the National Health Fund?

Kamila Grabek
There are already places where you actually can. There are specific hospitals, specific urology departments that actually provide patients with such access. However, this is unfortunately still not such a standard in every hospital and in every department, which is a pity.

Monika Rachtan
In Poland at the moment, the health service is not very accessible as far as patients are concerned, and I think that to get an appointment with a urologist at the National Health Fund is something of a miracle. And then there's the other miracle, where you have to be very lucky to get to see a urofiotherapist and also to get into a ward where a urofiotherapist works. So most people take the easier route and go private. Tell me, what is the order of magnitude of the costs that a patient has to assume if they want to come to a specialist like you? Is it one visit or is it usually going to be several visits for him to learn to do these exercises. What costs does he have to reckon with? Because even though this procedure is being done in younger and younger men, the fact is that it tends to apply to people who are retired and can't always afford such expenses.

Kamila Grabek
If I were to give a rough estimate of the cost of a single visit, I think with most specialists it would be between, say, £150-£250. So let's average out that it will be 200 zł per visit. Unfortunately, it doesn't usually stop at one visit. On the other hand, we also teach patients what they can do at home, so that they don't actually have to come to us for this therapy. All the time, we can apply electrostimulation treatments, for example, and this is also something that can be more costly for patients. However, this is why I always recommend buying a home device as well, which means that we carry out the diagnosis in the clinic, select the parameters, then the patient does the work on their device at home for a month or a month and a half and only then comes back to me for another check-up. Yes, we check for ourselves what progress has been made in that pelvic floor, whether anything has changed there, whether anything has moved forward at all. And with this new information that I gather in the office, I readjust the device. The patient continues to work at home again. So it is also not the case that the patient has to come to me once a week or, for example, a couple of times a week. How does this compare to orthopaedic rehabilitation, where the frequency of visits is actually much more frequent. Here I often work with patients on a monthly basis.

Monika Rachtan
We urge patients, men, to see a urophysiotherapist, but we didn't talk at all about what such a first visit is like. Well, because we said it's a taboo subject and that it's hard to get together. But once I get myself together, I say I'm manly and go to the urophysiotherapist to fight for my manhood. So what should I expect at this practice of yours?

Kamila Grabek
First of all, an extensive interview and such quite intimate questions. I also always ask patients, if they have undergone any surgical procedures, to take their discharge notes to me so that I know exactly what was done during the procedure. Yes, because it is important to me how extensive the operation was. For example, were the neurovascular bundles removed? If so, well that erection may simply not be recoverable. However, if I know that the vascular bundles are intact, then this is where we can work. We examine male patients through the anus, of course. We can examine the pelvic floor not only with our finger, but also with various biofeedback devices, that is, with a probe that we place in the anus. We check the tension on the pelvic floor, we check how the muscles work, whether the patient can tighten them, whether they can relax them. It is also possible to check the pelvic floor externally, i.e. with a transrectal ultrasound. If the physiotherapist has access to an ultrasound and knows how to use it, it is possible to examine the pelvic floor in this way. And I think that this can sometimes be less stressful for patients. However, the per rectum examination itself, i.e. examination through the rectum, should not hurt. If it hurts, it is very possible that we may still have a problem with some dysfunction, usually proctological, that is, for example, some large haemorrhoids or, for example, an anal fissure. And then this examination can indeed cause great discomfort. However, if everything is ok there proctologically, this examination absolutely does not hurt and the patient has nothing to fear.

Monika Rachtan
Is it possible to come to such a study with your wife?

Kamila Grabek
Yes, as much as possible.

Monika Rachtan
What does it look like from your side? You probably have more contact with women on a daily basis and when a man suddenly turns up, you see in your schedule that a man is turning up, you have a bit of that stress that you're a young girl after all and you don't know who's coming to you because you don't know the man and some thoughts occur to you that maybe this visit from a man isn't the most comfortable for you after all.

Kamila Grabek
You know what, no, no. In the clinic as I work now, not anymore. Indeed, before I graduated, I worked as a massage therapist and then the situations were unfortunately different. Exactly. This is in general a topic for a separate podcast, But not now, absolutely not. I just know that these patients come to me with a specific problem and I also know how stressed they are by the visit, so I think they are more stressed than me. I always approach it in such a way that I am more curious about what the patient is coming with.

Monika Rachtan
And do you have any patients of whom you can say that, as a result of them joining this physiotherapy, they managed to regain an erection? Because I'm asking about erection a little bit more, because as you said, this incontinence is somehow still manageable. But when you lose sexual function and you're not mentally prepared for it, well it's a very stressful situation.

Kamila Grabek
Unfortunately, it's like I say, it's not all down to me and the physiotherapy either, because even if these bundles have not been removed, it's sometimes possible that they have simply been damaged in some way. We also have to remember that such a return to full fitness after surgery is up to two years, yes? So here we do not expect quick results, that the patient will come in for one visit and after a month he or she is just there laughing as before. We also have to take into account his concomitant diseases and, in general, how this erection looked before. That is, if the patient has diabetes, has some neurological disease. This erection was already incomplete before, it was hard to maintain. So here, this return to fitness after prostatectomy may be even more difficult than, for example, in a young patient who was previously healthy, without any accompanying diseases.

Monika Rachtan
I will repeat my question and ask if you actually have a patient that you can say, yes, we achieved a really super result, that this gentleman came to you and said Mrs Kamila, there it is, we did it! My wife and I had a super night. It may not have been like 20 years ago, but it was better than a year ago. Thanks. You are extra. Do you have a patient like that?

Kamila Grabek
I haven't had any such patients myself yet, because, as I say, at the moment not many people just report it to me. And if they do come forward, well, at the moment they are still just out of therapy. In the courses we often have very patients who just come to us so that we can learn from them. And that's where we actually often have these patients where this progression can be seen. I remember on a course there was a gentleman in his 60s who had very severe urinary incontinence and an erectile dysfunction. Well, and here I can honestly say that such a pleasant story half and half, because the incontinence was managed practically in 100%, while the erectile incontinence has not returned to this day. Why? No one knows. Perhaps there is simply some damage there. Also, no one here can ever give a 100 per cent guarantee.

Monika Rachtan
But it is worth trying. I think it's worth highlighting. I'm asking you about those good stories because, for example, when someone tells me that they went to a hairdresser and she did super for them, I want to go to that hairdresser too. And sort of you know, and I think in men, looking at this problem of going to a specialist like that at all, there's a big need to give these good examples. And what's it like with incontinence of continence, in terms of that kind of social aspect, because it's also the kind of problem that lack of erection doesn't show. Incontinence, on the other hand, is the different situations that these men are in. It is an environment that may not accept, for example, that someone is not holding their urine. What kind of stories do patients come to you with here? Is it common for them to have such difficult stories to tell?

Kamila Grabek
They have. I think it's still just a taboo subject. However, somewhere it might sound so unladylike, but women are used to wearing incontinence pads and it's ok, yes? Because somehow it's so established that after pregnancy incontinence can happen and it's normal. Of course, it is not, but it is somewhere so established in our social space in Poland. On the other hand, incontinence in men is simply not talked about. There is little of this knowledge, rather on TV, in podcasts nobody talks about it. On the other hand, there are more and more podcasts for women and indeed patients are very much embarrassed. Just what you mentioned. They don't feel this masculinity of theirs, they feel bad about themselves, they feel cheated.

Monika Rachtan
If such a patient, who now knows that he is a candidate for prostatectomy, or if he knows what type of operation he is going to have, because now there are operations such as the traditional method, laparoscopic operations and we have robotic operations, well, in which one, in which of these methods as it were, is there the greatest likelihood that he should use a physiotherapist at all, because it is known that it can be very bad.

Kamila Grabek
Certainly with robotic surgery, this risk of something going wrong there is the least. Perhaps in this way, but it is absolutely not zero. I believe that every patient, regardless of the method they will be operated on, should simply attend such a consultation as a precautionary measure.

Monika Rachtan
And can patients who undergo radiotherapy for prostate cancer also expect incontinence and erectile dysfunction?

Kamila Grabek
As much as possible. Here, this can occur by a slightly different mechanism. However, radiotherapy has the effect of causing tissue stiffening and fibrosis. Such complications may also occur here.

Monika Rachtan
Well. Often male patients who opt for radiotherapy say that they have been informed about these symptoms associated with surgery, with surgical treatment, and that is why they do not opt for surgery, because they are afraid of all these complications and opt for radiotherapy. And then again there is this disappointment that also with radiotherapy there is tissue damage. That, however, this radiation therapy is not indifferent to our body and that it can cause similar effects to surgical treatment. And in the case of radiotherapy, can we also reverse this process?

Kamila Grabek
Here, to be honest, I am not sure that we are able to reverse it completely. We also have to bear in mind that if we already decide to have radiotherapy, it is very possible that a prostatectomy will no longer be possible precisely because of this tissue fibrosis. So usually a prostatectomy is performed first and only later, if we are not sure that all these foci have been excised, can the patient be additionally irradiated. And that's how I see it most often in patients.

Monika Rachtan
You say there's a lot of podcasts aimed at women, so I think we get a little bit of girls of all ages listening here too. How do you convince Husband, Dad, Grandad to go and see a nice girl like you. I for one think it's terribly difficult and maybe you have a formula, some recipe for that?

Kamila Grabek
Oh, I would say that the topic is a tough one. Indeed, men are very difficult to persuade and I think that you cannot do more than educate, because it really has to be the decision of the patient and the willingness of the patient to take the treatment and to go to such a consultation. We can't do anything by force.

Monika Rachtan
We have talked a lot today about prostatectomy and this procedure, which affects many men in Poland. But are there any other medical conditions that can be associated with incontinence in a man? And is this also where your help, the help of other female urophysiotherapists or urophysiotherapists can be effective?

Kamila Grabek
By all means. Here it could simply be classic muscle weakness, such even just related somewhere to age, to a change in the concentration of our hormones. Male hormones will also have an impact on their tissue quality. Again, unfortunately, age does not play in our favour, either in men or women, so here as well. Of such associated diseases, diseases such as diabetes would also need to be addressed here.

Monika Rachtan
So can they also predispose a man to develop incontinence?

Kamila Grabek
Yes, exactly. For all sorts of bladder-related disorders. When it comes to diabetes mellitus, it is most often incontinence from overflow, that is, the patient simply does not feel this bladder filling. And as the bladder is overfilled, there is an increase in bladder pressure, a decrease in urethral pressure and then this urine leakage can occur. Of course, neurological diseases, here we are not always able to prevent this incontinence so fully, because of course the patient for my therapy, for urogynaecological therapy, must be in full verbal and logical contact. That is, I must be able to communicate with him. He must be able to understand the instructions, remember them and then carry them out at home. Also, with neurological problems this is simply not always possible. However, I would also like to warn you straight away that it is worth paying attention to bladder problems and erectile dysfunction, because they can very often herald other diseases, such as cardiovascular diseases, and very often erectile dysfunction is the first symptom of cardiovascular diseases. For example, we don't have an erectile dysfunction, and only in a few years we find out that we have atherosclerosis, for example.

Monika Rachtan
But what you've said about, it also requires like such a big sensitivity from Primary Care doctors. Because again, I see this difficulty that you go to your doctor, what, a month in there to get hypertension tablets you go, you go, you go, you go and suddenly you imagine. Mr Stanislaw comes in and says to his doctor Kasia, Ms Kasia, and I'm the one with the erectile dysfunction right now and it's like what can we do about it? And, you know, it's kind of a taboo subject in Poland all the time too, that it's not talked about, that in general how do you go to a woman, a doctor and tell her that you have an erectile dysfunction, that it's so terribly difficult.

Kamila Grabek
But patients don't talk about it either, because I see in the practice that they don't know what the norm is.

Monika Rachtan
And what is the norm?

Kamila Grabek
We just don't observe this, this body of ours very much at all. Certainly, patients should be concerned about urinary problems, such as waking up several times a night to go to the toilet. Some kind of disturbance, such as difficulty in starting micturition. That is, the patient has to stand over the toilet for a while to pass urine, or has to sit down to pass urine. This can also indicate the development of some sort of sub-bladder obstruction. And here we do not have to mean immediately the development of some prostate cancer, but we may simply have hypertrophy of the gland or some inflammation. We should certainly pay attention to how our urine flows. Does it flow in a strong stream, or is it very thin, yes?

Monika Rachtan
And which one should he fly?

Kamila Grabek
Strong, it should be firm. There should not be any dribbling. That urine should not stop in the middle of itself. We should not urinate even when coughing or sneezing, yes? This is not a situation that should naturally occur. It is always an indication of some disorder, whether in the pelvic floor or just somewhere higher up in the pelvis.

Monika Rachtan
It turns out, gentlemen, that the way you pee, the way you urinate, can really indicate what state of health your body is in. Importantly, you should not be ashamed of your problems and your disorders. If you have so far only talked about it with your wife, today is the day when you should think about seeing a urophysiotherapist in order to help yourself get back to a quality life without erectile incontinence. And this is what I urge you to do. And today my guest was Kamila Grabek. Thank you very much Kamila for our conversation today.

Kamila Grabek
Thank you very much also.

Monika Rachtan
Kamila is a urophysiotherapist and my name is Monika Rachtan. This was the First Patient programme. I warmly invite you to follow me on my social media. See you there.