27 August 2020: Celebrating the benefits of pelvic floor physiotherapy with the wonderful Hester van Aswegen. Her specialist training and simple direct manner are helping me go beyond the basic penile rehabilitation and pelvic floor physio work previously described. Now we are working together on:

  • Going to the loo less frequently: rebuilding my bladder capacity;
  • Mobilising the deep tissues in my abdomen and groin to avoid the risk of dangerous adhesions;
  • Working pelvic floor muscles while moving and in different overall body positions;
  • Getting the penile rehab working in situations where it really counts (in the bedroom).

It is already six months since my radical prostatectomy surgery and yet today was only my third visit to Hester. I now know I should have started with her already before my operation.

I am glad my surgeon has committed to referring his future patients for physiotherapy before and after he operates. Once again we are learning from my wife, who has just come home with excellent pre-op physiotherapy exercises for her pending knee replacement operation.

Over-using the loo shrinks bladder capacity

Since being diagnosed with prostate cancer I have often joked that “now I am an older man” I need to pee more often. After all, who hasn’t seen men over 60 or 70 running to the loo the minute they get out of a car, or pre-emptively before going on even a shortish journey?

The nerve signalling that says “time to pee” is fairly separate from the actual sphincter muscle that controls urine flow. And typical bladder capacity is about 500 ml (nearly a pint). My bladder is sending over-anxious signals to pee long before it is actually anywhere near its physical limits.

Going to the loo every hour “trains” the bladder to expect to be emptied when it is less than a quarter full.

How to stretch out the time between loo visits

What Hester taught me is this. Men like me who have regained some urine control after prostate surgery can retrain our bladders back to full capacity. Now that I have conscious control over my urine flow, I can retrain it back to the full 500 ml, at least at night.

On Hester’s advice, I have been measuring the flow with a plastic bottle and creating a rudimentary “pee diary”.

At first, I found I was not able to store more than about 200 ml – my bladder had “forgotten” more than half of its true capacity! She warned me that without retraining, this loss will become permanent. Now after 6 weeks of Hester’s treatment, I am celebrating that at times I get up to 450 ml before that “gotta go” signal becomes overwhelming.

After regaining continence, my new mission is to retrain my bladder to do the storage job it was designed for. Here are some helpful tips for bladder capacity retraining. I am over 60 but I no longer have to get up several times in the night to go to the loo.

Tissue adhesions after prostate surgery: a serious risk

From my very first session with Hester, she has been deeply mobilising the tissues of my abdomen to avoid painful and highly dangerous tissue adhesions. She starts at the surface level, which has the added benefit of reducing the visible scarring. Then she works gently and firmly deeper down into the layers of fascia between muscles and surrounding internal organs.

The deep tissue massage treatment is mildly uncomfortable, but worthwhile. I understand now why we need to restore the smooth natural gliding motion between the different layers of our internal tissues and organs. Without this there is serious risk that post-operative scarring can develop into a stuckness that impairs core body functions and puts my life at risk. There are tissue adhesion risks after both surgical and radiation treatment.

I personally know at least two prostate cancer survivors, one of them a relative, who had to be rushed into emergency surgery in the weeks after their radical prostatectomies. In both cases this was due to complications resulting from internal tissue adhesions. I also read that small bowel obstruction and abdominal pain due to such adhesions are actually statistically more frequent in the year after after robotic-assisted laparoscopic surgery than old-fashioned “open” surgery.

Practicing pelvic floor exercises and penile rehab where it counts

Both urine continence and erectile function are typically challenged most while our bodies are in motion.

So Hester points out that all my diligent pelvic floor and penile rehab exercises are convenient – but only partially useful – in the “laboratory” environment where I lie still on her massage table or my own bed.

It took a physiotherapist to make me realise this. I have to exercise muscles in the scenarios where I need them, not just while stationary in one fixed position. “Context is everything” is an adage I know from my professional work. Now I see it also applies to physical rehab and it is a real challenge to me.

Homework to anchor benefits of pelvic floor physiotherapy

Here’s what Hester challenged me to do at home. She was able to give me great guidance at least on the first two!

  • Practice both pelvic floor muscle contraction and relaxation exercises in a variety of positions. That includes sitting, standing, and lying down on back, sides and front;
  • Practice the same exercises while in motion: getting up, sitting down, walking and lifting objects;
  • Do penile rehabilitation exercises with (at least partial) erections.

This last one is a paradox. I have to do penile rehab to support erections. But for effective rehab, I need  to somehow find the very erections my body is unable to produce! Definitely a “chicken and egg” situation. The journey continues.