VOL: 103, ISSUE: 26, PAGE NO: 40
Grace Dorey, PhD, FCSP, is consultant physiotherapist, The Somerset Nuffield Hospital, SomersetMale pelvic floor muscles may be divided into a deep supportive layer forming the urogenital diaphragm and a superf...
Male pelvic floor muscles may be divided into a deep supportive layer forming the urogenital diaphragm and a superficial layer, which is relevant to sexual function. These muscles have diverse functions - they help to maintain the storage of urine and faeces, support the abdominal contents when standing and are active during breathing. They actively increase local blood supply and are important for normal erectile function.
THE EVIDENCE FOR IMPROVING FUNCTION WITH PELVIC FLOOR MUSCLE EXERCISES
Stress urinary incontinence
Five level-II (strong evidence from at least one properly designed RCT of appropriate size) RCTs used PFM exercises to treat urinary incontinence before and after radical prostatectomy (Burgio et al, 2006; Parekh et al, 2003; Sueppel et al, 2001; Bales et al, 2000; Mathewson-Chapman, 1997). Of these, two RCTs identified a significant difference to the continence outcomes between the treatment and control groups following surgery (Burgio et al, 2006; Sueppel et al, 2001).
Five level-II RCTs looked at the efficacy of using PFM exercises to treat urinary incontinence after radical prostatectomy (Filocamo et al, 2005; Franke et al, 2000; Joseph and Chang, 2000; Van Kampen et al, 2000; Moore et al, 1999). Of these, two found a significant difference in continence outcomes of the treatment and control groups (Filocamo et al, 2005; Van Kampen et al, 2000).
One level-II RCT has been identified which used PFM exercises before and after transurethral resection of prostate (TURP) compared with a control group (Porru et al, 2001). Three weeks after TURP there were significantly fewer episodes of urinary incontinence in the exercise group.
Two level-II RCTs have compared PFM exercises with a control group for men with post-micturition dribble (Dorey et al, 2004a; Paterson et al, 1997). Both showed a significant improvement in the active group. Of these, one RCT advised a strong post-void pelvic floor muscle contraction to empty the bulbar urethra (Dorey et al, 2004a).
Two level-II RCTs have used PFM exercises to treat erectile dysfunction (Dorey et al, 2004b; Sommer et al, 2002). Both showed a significant return to normal erectile function in the active group.
HOW TO PERFORM PFM EXERCISES
PFM exercises should be taught by a specialist to make sure they are performed correctly. The progress of the muscle strength and endurance should be monitored. Before an exercise programme can begin, an anal assessment is performed to grade the strength, endurance and speed of the anal sphincter and the puborectalis muscle (Dorey, 2006).
PFM exercises are individually taught to ensure they are performed correctly. They can be described as 'tightening and lifting the pelvic floor muscles as in the control of wind' and can be practised in front of a mirror in order to observe a movement of the base of the penis into the body and a lift of the testicles. Maximum effort should be used when tightening these muscles as the exercises aim to increase muscle strength and bulk. To achieve muscle endurance some contractions require sub-maximum effort.
The therapist will prescribe home exercises detailing the number of contractions to be performed and the length of time in seconds to hold them. Some exercises can begin with a slow build-up of power and some can start with a fast contraction (Box 1). Fast muscle work is needed during times of increased intra-abdominal pressure. Exercises should be practised every day and each contraction should be held for the length of time specific to the individual but no longer than 10 seconds. This should be followed by a 10-second rest. The quality of contraction is more important than the quantity. There should be an attempt to contract the pelvic floor muscles to 50% of maximum strength while walking to encourage them to work with activity. In addition, the muscles should be tightened before and during activities that increase intra-abdominal pressure such as coughing, sneezing, shouting, laughing, rising from sitting, and lifting. This technique is termed 'the knack' (Miller et al, 1996).
Clinical trials show that those who are motivated, practise their exercises and adhere to the advice are more likely to have a successful outcome.
Level-II evidence supports the use of PFM exercises in the management of urinary continence and erectile dysfunction. These exercises may also be performed to prevent pelvic floor dysfunction. PFM exercises should include maximum contractions to increase muscle strength as well as sub-maximal exercises to increase muscle endurance.