Pelvic floor muscle training (PFMT) represents the first-line conservative therapy of postprostatectomy incontinence but its value remains questioned [1]. The role of the pelvic floor muscles (PFM) in male urinary continence has been studied and there is increasing evidence that with reference to urinary continence selective recruitment of the bulbospongiosus (BS), striated urethral sphincter (SUS) and ischiocavernosus (IC) muscles seem to be of high importance [2]. Thus training should not predominantly focus on activation of the puborectalis (PR) muscle. It has been demonstrated that selectivity of PFM activation in the male population can be examined with perineal ultrasound imaging [3].
In this pilot study we wanted to investigate PFM function and activity patterns in male patients with persistent urinary incontinence postprostatectomy. We were particularly interested to detect specific recruitment patterns in patients who received PFM rehabilitation. We also looked at selectivity of muscle recruitment patients perform with standardized instructions. We hypothesized that the patterns of PFM function male patients learn in rehabilitation are inhomogeneous and might not address selective recruitment of BS, SUS, and IC muscles.

Based on existing research a standardized protocol for assessment of selective Pelvic Floor Muscle Function (PFMF) was compiled and used in routine follow-up postprostatectomy screening. A convenient sample of 15 men who had performed non standardized post-prostatectomy PFMT by different physiotherapists was screened. 2-D perineal ultrasound was performed using a convex abdominal transducer 3.0 to 6.0 MHz. Voluntary activity of PFM was observed during standardized verbal instruction as “activate PFM as learned”, “stop urine”, “shorten the penis”, “tighten around the anus” and “elevate the bladder”. Specific activity (timing and predominance) of PFM, particularly of the PR, SUS, BS and IC muscles were observed.

Patients showed different activity patterns when instructed “activate as learned”. All patients were familiar with the instruction “tighten around the anus”. With this instruction we observed the contraction of the PR in all patients (15) and coordinated activity of the SUS and BS in 11 of them. In 9 men the same muscle pattern was observed during the instruction “elevate the bladder”. 11 patients had learned the instruction “shorten the penis”. With this instruction we were able to assess the activity of the SUS and BS but the activation of the IC was observed only in 3 patients. The same pattern occurred with the instruction “stop urine”. These two instructions (shorten the penis; stop urine flow) also showed co-activation with PR in 7 patients, but in a different timing and intensity of activation than with the other instructions. SUS, BS and IC were recruited first and PR activity was less dominant. That pattern seems to significantly contribute to the ventral displacement of the basis of urethra bladder neck and closure as well as angulations of lower urethra (membranous to bulbar).

With this pilot study we demonstrated that perineal ultrasound is a feasible tool to assess pelvic floor (PF) activity in postprostatectomy men in a routine screening. The activation patterns identified were not homogenous. Recruitment of the PR muscle was predominantly seen, indicating that most muscle training programs focus on instructions for PR activation patterns. During the instruction “shorten the penis” and “stop urine flow” we could best assess the activity of the SUS, BS, IC and also coordinated recruitment of the PR muscle. This pattern seems to support closure and stability of the bladder neck and thus contribute highly to urinary continence. Therefore we stress the concept of a standardized training and standardized instructions focusing on the pattern of BS, SUS, IC muscle recruitment. Regular screening with ultrasound imaging techniques can lead to early detection of failure in specific muscle recruitment competency and could help to develop individually tailored rehabilitation programs in postprostatectomy PFM rehabilitation.

Perineal ultrasound imaging allows dynamic evaluation of PFM functions and can be used to control and counsel postprostatectomy incontinent men. PFMT should use specific instructions and give feedback using perineal ultrasound early in rehabilitation to guarantee selectivity of PFM control.

Anderson, C.A., Omar, M.I., Campbell, S.E., Hunter, K.F., Cody, J.D., Glazener,  C.M.A. (2015). Conservative management for postprostatectomy urinary incontinence. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD001843. DOI: 10.1002/14651858.CD001843.pub5.
Stafford, R.E., van den Hoorn, W., Coughlin, G., Hodges, P.W. (2018) Postprostatectomy incontinence is related to pelvic floor displacements observed with trans-perineal ultrasound imaging. Neurourol.& Urodyn. 37:658–665. https://doi.org/10.1002/nau.23371
Stafford,R.E., Ashton-Miller, J.A., Consantinou, C.E., Hodges, .P.W. (2013) A New Method to Quantify Male Pelvic Floor Displacement From 2D Transperineal Ultrasound Images; Urology, Volume 81, Issue 3 , 685 – 689