Patients who undergo a radical prostatectomy – have their prostate surgically removed – often experience urinary incontinence, which can sometimes linger for many months, and even years. Those whose incontinence problems continue for over 12 months responded well to a behavioral training program which included bladder control strategies, fluid intake management and pelvic floor muscle training, researchers from the University of Alabama at Birmingham wrote in JAMA (Journal of the American Medical Association).

Adding pelvic floor electrical stimulation and biofeedback to their program did not add to the benefit, the authors revealed.

The investigators wrote:

“Men in the United States have a 1 in 6 lifetime prevalence of prostate cancer. Although survival is excellent, urinary incontinence is a significant morbidity following radical prostatectomy, often the treatment of choice for localized prostate cancer. Patient surveys indicate that as many as 65 percent of men continue to experience incontinence up to 5 years after surgery.

Loss of bladder control can be a physical, emotional, psychosocial, and economic burden for men who experience it. Although behavioral therapy has been shown to improve postoperative recovery of continence, there have been no controlled trials of behavioral therapy for postprostatectomy incontinence persisting more than 1 year.”

The researchers explained that empirical evidence of the benefits of biofeedback and electrical stimulation is lacking. Biofeedback is thought to help patients contract their pelvic floor muscles properly, resulting in improved pelvic floor contractions and more urethral closure pressure.

Patricia S. Goode, M.S.N., M.D., and team set out to determine how effective behavioral therapy might be in reducing incontinence among patients who had undergone a radical prostatectomy. They also aimed to determine whether adding biofeedback and electrical stimulation might help further.

They carried out a randomized, control trial with 208 males aged between 51 and 84 years. They all had persistent urinary incontinence of 1 to 17 years. They were monitored for up to 1 year after active treatment. 75% of the patients were Caucasians and 24% were African-Americans.

The participants were randomly selected into three groups, with the following results:

  • Behavioral therapy group – they received pelvic floor muscle training and bladder control strategies.
    They had an average reduction of incontinence episodes of 55% at 8 weeks
  • Behavioral therapy plus in-office dual channel electromyography biofeedback group – they received the same therapy as the group above, plus biofeedback and electrical stimulation
    They had an average reduction of incontinence episodes of 51%
  • Control group – they received no special therapy.
    They had an average reduction of incontinence episodes of 24%

They all had to fill in 7-day bladder diaries.

The authors concluded that adding the electrical stimulation and biofeedback to behavioral therapy did not provide better results at 8 weeks than just behavioral therapy.

They wrote:

“Improvements were durable to 12 months in the active treatment groups: 50 percent reduction (13.5 episodes per week) in the behavioral group and 59 percent reduction (9.1 episodes per week) in the behavior plus group.

15.7% of those in the behavior therapy group achieved complete continence at the end of the 8-week treatment period, compared to 5.9% in the control group and 17.1% in the behavior-plus group.

The researchers wrote:

“Based on the significant decrease in incontinence frequency and the small number needed to treat (n=10) to achieve complete continence with behavioral therapy, these findings have important implications for urologists, primary care providers, and their patients. Behavioral therapy should be offered to men with persistent postprostatectomy incontinence because it can yield significant, durable improvement in incontinence and quality of life, even years after radical prostatectomy.”

In an Accompanying Editorial, David F. Penson, M.D., M.P.H., of Vanderbilt University and VA Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC), Nashville, Tenn., wrote:

“Is it behavioral therapy, which likely re¬quires considerable patient and clinician time and effort to implement and is associated with limited benefit? Is it sur¬gical implantation of an artificial urinary sphincter (a structure, or a circular muscle, that relaxes or tightens to open or close a passage or opening in the body) that works, but requires another surgical procedure?

Or is it applica¬tion of new technologies at the time of prostatectomy that purport to result in better patient-reported outcomes but still appear to be associated with a significant incidence of postprostatectomy urinary incontinence? Perhaps none of these is ideal. A better strategy would be primary preven¬tion: increased utilization of active surveillance among pa¬tients with lower-risk disease and selective application of aggressive interventions in patients with worse prognostic variables.”

“Behavioral Therapy With or Without Biofeedback and Pelvic Floor Electrical Stimulation for Persistent Postprostatectomy Incontinence – A Randomized Controlled Trial”
Patricia S. Goode, MSN, MD; Kathryn L. Burgio, PhD; Theodore M. Johnson II, MD, MPH; Olivio J. Clay, PhD; David L. Roth, PhD; Alayne D. Markland, DO, MSc; Jeffrey H. Burkhardt, PhD; Muta M. Issa, MD, MBA; L. Keith Lloyd, MD
JAMA 2011;305(2):151-159. doi: 10.1001/jama.2010.1972

Written by Christian Nordqvist