Episode 1738 - Urinary incontinence in the older male

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses the management of urinary incontinence in the older male, implications for function, and quality of life.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

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CHRISTINA PREVETT Hello everybody and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of our lead faculty in our geriatric division and today I am hoping to talk a little bit about urinary incontinence in the older male. A lot of times we focus a lot of our conversations around pelvic health on the female side of the sex spectrum. But today I really want to talk about males. We talk a lot in MMOA, especially in our Level 2 course where we do an entire segment on pelvic health for the older adult. around how every clinician is a pelvic floor clinician. And the reason why we say that is because if you're interacting with hip and low back pain, then you're interacting with the pelvic floor as part of our core canister. And urinary incontinence is a leading cause of institutionalization and a very big reason why some people may not want to engage in the dosage of exercise that they need in order for them to gain the independence that they're hoping to gain. And so we really want to make sure that we are at least doing our due diligence in screening. When we are working with individuals, we wanna know if there's any urinary incontinence on board. And then we wanna talk about what is going on with respect to the male aging pelvis and how that interacts with signs and symptoms like urinary incontinence. So the biggest, biggest, getting bigger area of the male pelvis where there's a lot of conversations around its impact with age is the prostate. So we do know that there is an enlarging of the prostate that occurs with age. And the main roles of the prostate is to create seminal fluid and help with propulsion of ejaculation of that seminal fluid when mixed with the sperm when achieving orgasm. And what we recognize is that as individuals age, there is a growing of the prostate, an enlargement of the prostate that occurs. that is called benign prostatic hyperplasia. Now this is non-cancerous. This is not a malignancy. This is a part of aging physiology in the pelvis. And what we recognize is that there's also a lot of discrepancies of if this is something that we need to worry about or not. So enlargement of the prostate happens in almost every human with a penis. And it can be associated with lower urinary tract symptoms. In the literature, sometimes it's called BPE, benign prostatic enlargement. If it is associated with symptoms, that is not always consistently done, but there is screening that can happen. And then that enlargement, if it does have cancerous tissues in it, now we're thinking prostate cancer and individuals are going for screens for malignancy in the prostate, and then leading to potentially intervention, including radiation and, or radical prostatectomy. And I've done podcast episodes on radical prostatectomy before. When we're thinking about lower urinary tract symptoms, that can include stress urinary incontinence. And oftentimes in males, because of the length of the urethra, the level of incontinence is significantly less than in the female pelvis. So only about 5% of individuals over the age of 65 have incontinence. And usually it is as a consequence of conditions like radical prostatectomy. So it can be radical prostatectomy. Individuals can have pelvic fracture trauma. Some neurodegenerative conditions can also have a urinary condition associated with it. And so usually there's a precipitating event, not always, but most of the time there is some sort of precipitating event that has happened around the pelvis that has led to urinary incontinence. For example, when you have a radical prostatectomy, the prostate is removed. That includes the areas around the external anal sphincter. The urethra is then pulled up to reconnect to the bladder, which can disrupt the pelvic floor, the deep pelvic floor muscles that are responsible for kinking that hose of the urethra in order for a stress urinary incontinence not to occur. And so it makes sense why there's a disruption to that longer urethra can lead to things like stress urinary incontinence. When you have an older adult with stress urinary incontinence, I know it doesn't sound that, that surgery doesn't sound that great, but it is minimally invasive and people do respond pretty well to it, but we have podcast episodes on the, the surgical art of radical frost detective and what we can expect postoperatively. So when we're working with individuals, urinary incontinence is something that we may be managing and we have a big role to play in helping with post-operative or the new development of urinary incontinence. And so when we're thinking about management, we have kind of our conservative buckets, and then we have surgical management. If you are a person who's had a radical prostatectomy, the natural physiology is that many symptoms resolve within a year. So usually we are not doing any follow-up, or your urologist is not doing any follow-up surgical intervention around the pelvis until a year post-operatively with individuals post-radical prostatectomy. But we do have conservative methods that we can use in the shorter term, and hopefully to try and avoid a subsequent surgical management. And so those buckets are pelvic floor muscle training, penile clamps, and surgical intervention. And so the first and go-to knee-jerk reaction is always going to be conservative management, especially if initiated pre-operatively or pre-event, where individuals who are males get an awareness of the pelvic floor system. Because incontinence and pelvic floor issues in the male pelvis are not as common, many times education around the pelvic floor is not as widespread, individuals are not having these conversations as frequently, and then recognizing how to contract and relax the pelvic floor muscles can be something, especially if there is a training effect that we are doing with appropriate dosing, can help with mild to moderate urinary incontinence post pelvic event in the older male. When we are thinking about pelvic floor muscle training, we are trying to cue the pelvis either to stop the flow of urine, or to try and shorten the base of the penis. Those are the two cues that have been shown in research to have the highest EMG activation of the pelvic floor when trying to teach the pelvic floor contraction in an older male, and trying to get a strengthening effect with appropriate dosage. And there's some protocols in the post-radical prostatectomy world that tries to accumulate 20, 30, 40 reps. It's a bit variable, but we wanna make sure that we are getting a training effect based on where individual's baseline status is. initiating pelvic floor muscle training, seeking a pelvic floor physical therapist, or if you're okay with palpating externally, you can go kind of medial to the sits bones and see if there's a contraction of those pelvic floor muscles in the male. If you are a non-internal pelvic floor physical therapist, then you can work on some of that coordination and contraction in individuals who this is a barrier for them going out into the house. So that's kind of our first option. Our second option is a penile clamp. And so if you're aware, in the female pelvic space, we have a device called a pessary, which is inserted intravaginally, and basically what it does is it kinks off