Urinary incontinence is common after robotic-assisted laparoscopic prostatectomy (RALP). Post-prostatectomy incontinence (PPI) rates vary considerably in the literature and can be as high as 80% depending on the definition of continence and timing of evaluation [1]. Pelvic floor muscle exercises (PFMEs) represent the most commonly employed non-invasive management strategy for PPI [2]. However, studies provide inconsistent findings regarding its efficacy. Noncompliance has been postulated to be one of the possible reasons that can decrease the success rate of PFMEs in enhancing recovery of continence following RALP. Our objective was to identify barriers to PFME compliance in patients with PPI.

The sample included 28 men diagnosed with localized prostate cancer and elected to undergo RALP between August 2019 and December 2019. The setting for this quality improvement study was a University Hospital-based clinic in the US. Patients with end-stage renal disease, urinary diversion, or those who were visually or cognitively impaired were excluded from the study.  
At the one-week post-RALP visit, the nurse practitioner (NP), who had more than 10 years of experience in the field of Urology, removed the indwelling Foley catheter and provided patients with verbal instruction and illustration of three PFMEs. Patients were then asked to do 10 repetitions each exercise 3 times daily at home. Those who exercised exactly as advised were considered as being compliant and those who did not as noncompliant.  
During the one-month visit following catheter removal, the barriers influencing PFME compliance were evaluated by the same NP via administration of the 10-item PFME Barrier Questionnaire, which was created based on the data gathered out of the relevant literature and the input accumulated throughout the years from the patients who were advised to do PFMEs after RALP. 
Content validity of the questionnaire was obtained by review of experts in the field of lower urinary tract dysfunction including urologists, physical therapists, and urology nurses. The questionnaire was solely composed of yes-no questions and did not take longer than 5 minutes to complete. None of the patients had asked for supervision or help from a healthcare provider while answering the questions.

The barriers to PFME compliance, which were identified based on the responses given to the questionnaire items, have been summarized in Figure 1. A total of 10 patients (35.7%) responded that “body soreness” was the reason for noncompliance in performing PFMEs. Seven patients (25%) indicated that the fear of “damaging the site of surgery” was the reason as to why they did not do the exercises as instructed. In contrast, no patients responded “yes” to the possible barriers of “being too busy” or “urinary leakage”.  
Regarding the distribution of barriers with respect to the frequency of PFMEs (Figure 2); only 4 patients (14.3%) exercised 3 times a day exactly as instructed. These patients were not devoid of postoperative problems, with “body soreness” being the most commonly reported one. However, they were able to overcome these potential barriers and comply with the recommendations.
Four other patients (14.3%) reported performing PFMEs 4 or 5 times a day. Among these patients; “body soreness” and the fear of “damaging the site of surgery” seemed to be equally contributing to PFME noncompliance. 
One fourth of the patients reported less than 2 PFME sessions per day. “Body soreness” and loss of the educative brochure were the leading reasons for PFME noncompliance within this subgroup.
The largest group of noncompliant patients (n= 13, 46.5%) repeated PFMEs twice daily and they specified “body soreness” (n= 4, 14.3%) and the fear of “damaging the site of surgery” (n= 3, 10.7%) as the main barriers to PFME compliance.

Pain and perceived possible damage to the surgical site were the main barriers to PFME compliance in 35.7% and 25% of the patients with PPI, respectively. Only 14% of the patients repeated the PFMEs exactly as instructed. Pain was the most prevalent barrier across all PFME daily frequency subgroups. Thus, identification and better management of the factors contributing to postoperative pain is crucial in promoting compliance with PFME.
Nurses play an essential role in this respect, as they are actively involved in the postoperative counselling of these patients regarding pain prevention and treatment strategies [3].  Moreover, the input they provide to the patients regarding relevant anatomical landmarks and what to expect in the surgical site while doing PFMEs would possibly further motivate the patient towards compliant behavior.

Pain and perceived possible damage to the surgical site are the main reasons underlying PFME noncompliance in patients with urinary incontinence following RALP. Optimizing postoperative pain management and relaying information regarding possible surgical site changes that can be encountered while training the pelvic floor (in addition to routine exercise descriptions) might potentially improve compliance with PFMEs.

Borello-France, D., Burgio, K., Goode, P., Markland, A., Kenton, K., Balasubramanyam, A., & Stoddard, A. (2010).   Urinary incontinence treatment network, adherence to behavioral interventions for urge incontinence when combined with drug therapy: adherence rates, barriers, and predictors. Physical Therapy, 90 (10), 1493–1505. https://doi-org.proxy.cc.uic.edu/10.2522/ptj.20080387
Campbell, S.E., Glazener C., Hunter, K.F., Cody, J.D., & Moore, N. (2012). 	Conservative management for postprostatectomy urinary incontinence. Cochrane 	Database Systemic 	Review, 1: CD001843. doi: 	10.1002/14651858.CD001843.pub4.
Ene, K. W., Nordberg, G., Sjöström, B., & Bergh, I. (2008). Prediction of postoperative pain after radical prostatectomy. BMC Nursing, 7 (14), 7-14. Retrieved from https://doi.org/10.1186/1472-6955-7-14.