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Evaluation of a Video Pelvic Floor Muscle Exercise Model Prior To Radical Prostatectomy.

Prostate cancer is the most common cancer diagnosis in men, with approximately 18,000 men diagnosed each year in Australia (Australian Institue of Health & Welfare [AIHW], 2017). Typically, men diagnosed with localized prostate cancer requiring treatment are offered two potentially curative treatment options: radical prostatectomy (RP) or radiation therapy. Both treatments have the potential for morbidity related to erectile dysfunction (ED) and urinary incontinence (UI). In general, the majority of men will experience some level of UI for the first few weeks to months post-RP (Capogrosso et al., 2016). Commencing pelvic floor muscle (PFM) exercises preoperatively can improve post-prostatectomy urinary incontinence (PPI) (Chang, Lam, & Patel, 2016; Dorey, 2005; Fernandez et al., 2015; MacDonald, Fink, Huckabay, Monga, & Wilt, 2007; Moul, 1994; Nahon, Waddington, Dorey, & Adams, 2009; Overgard, Angelsen, Lydersen, & Morkved, 2008; Parekh et al., 2003; Tienforti et al., 2012; Xie & Sandhu, 2013). However, men may experience difficulty in correctly performing these exercises, with difficulty isolating and correctly contracting the PFM (MacDonald et al., 2007). For example, of 52 healthy young men receiving verbal instruction about PFM exercises, only one-third were able to correctly perform these exercises in both the standing and lying positions (Scott, Osmotherly, & Chiarelli, 2013). This supports the need for individual PFM exercise instruction and assessment, and investigation of alternative means of providing this information to ensure participants have mastered the technique prior to RP.

Literature Review

Urinary Incontinence Following Radical Prostatectomy

The reported prevalence of incontinence after RP varies widely, ranging from 2% to 60%, albeit at varying times after the operation (Milsom et al., 2009). Factors affecting the variations in reported rates of PPI include how UI was defined, how and when it was assessed, and the reporting procedure (Nahon, Waddington et al., 2009; Robinson, 2000). UI following RP typically affects participants immediately after removal of the urinary catheter at 1 to 3 weeks following surgery, and improves with time (Khoder, Trottmann, Stuber, Stief, & Becker, 2013; Parekh et al., 2003; Robinson, 2000; Yu Ko & Sawatzky, 2008). PPI can have a significant negative impact on quality of life (QoL) and men's self-esteem (Butler, DowneWamboldt, Marsh, Bell, & Jarvi, 2001; McCallum, Moore, & Griffiths, 2001; Nahon, Dorey, Waddington, & Adams, 2009; Robinson, 2000). The most common cause of PPI is thought to be intrinsic sphincter deficiency, when the urethral closure pressures are insufficient to prevent leakage (Giannantoni et al., 2008; Stafford, Mazzone, Ashton-Miller, Constantinou, & Hodges, 2014). Typically, this happens when men get up from a chair, or when they are walking, bending, and coughing (Stafford, Ashton-Miller, Sapsford, & Hodges, 2012).

The Male Continence Mechanism and PFM Exercises

Male continence is thought to be maintained by a combination of factors, including soft tissue, smooth muscle sphincters, and the prostate itself, as well as the striated urethral sphincter muscles and the levator ani or pelvic floor muscles. The PFM provides primary dynamic support for the bladder and urethra. The puborectal sling elevates the bladder neck and combines with the striated muscles to increase urethral closure pressure whenever intra-abdominal pressure increases. While recent research helps with the understanding about the contribution of the PFM to urinary continence (Neumann, Fuller, & Sutherland, 2015; Stafford et al., 2016), the exact mechanism for maintaining continence following removal of the prostate remains unclear (Stafford et al., 2012). A study by Cameron and colleagues (2014) used urodynamics and 3T MRI to find out if there was a difference in the pelvic floor and sphincter of men who are continent and men who are not, all at least 12 months post-RP. Fourteen cases of incontinent men were compared to 12 controls who were not wearing pads. This study found differences in the anatomy of the sphincters of continent versus incontinent men, and continent men could contract the striated muscles of the sphincter and pelvic floor to constrict the urethra (Cameron et al., 2014).

Participants who perform PFM exercises have a better rate of returning to urinary continence post-RP than those who do not (Centemero et al., 2010; Fernandez et al., 2015; Overgard et al., 2008; Patel, Yao, Hirschhorn, & Mungovan, 2013). One study concluded that participants with better developed PFM can achieve earlier recovery of continence (Song et al., 2007). While there are conflicting results about the benefit of PFM exercises in the prevention and treatment of UI (Anderson et al., 2015; Hunter, Moore, & Glazener, 2007), a systematic review of 11 studies indicated that exercising the PFM hastens the return to continence in men after RP, compared to those men who did not perform these exercises (MacDonald et al., 2007). A further systematic review and meta-analysis of 11 studies concluded that preoperative PFM exercises improves short-term but not long-term continence rates (Chang et al., 2016).

Centemero and colleagues (2010) conducted a study to determine whether the introduction of PFM exercise preoperatively and continued postoperatively resulted in improved return to continence when compared with postoperative instruction in PFM exercise only. One hundred eighteen men were randomized either to start the exercises preoperatively continuing postoperatively (n = 59), or to start PFM exercises postoperatively (n = 59). After one month, 44.1% of participants in the pre- and postoperative exercise group were continent as assessed on a 24-hour pad test, compared with 20.3% in the postoperative-only exercise group. This difference was statistically significant (p = 0.018). Similarly, at 3 months, significantly more participants were continent in the pre- and postoperative PFM exercise group (59.3%) compared to the postoperative-only group (37.3%) (p = 0.028).

Methods of PFM Assessment

There are a few options to objectively and individually assess PFM and determine if a correct contraction is being performed. However, at the time the study was initially designed, little research described these methods, and the validity and reliability of each.

External observation of the penis and scrotum identifies scrotal and testicular lift and penile retraction, as well as visualisation of abdominal activity, breathing, and posture. The experienced clinician can correctly identify movement using the PFM, and incorrect movement using upper abdominal and other accessory muscles (gluteal and adductor muscles).

Digital rectal examination (DRE) is a reproducible test of levator ani function (Dorey, 2007). DRE measures the strength of the striated external sphincter and the lift of the posterior aspectof the levator ani (puborectalis). The validity of assessing the pelvic floor via DRE has been questioned, including a letter to the editor in The Lancet, because it focuses more on anal rather than urethral closure (Lazzeri, Guazzoni, & Montorsi, 2012).

Real-time trans-abdominal ultrasound has been used by physiotherapists for some time. Disadvantages are there are no bony landmarks, requiring urine in the bladder, and it has poor correlation with DRE in men (Nahon, Waddington, Adams, & Dorey, 2011).

Real-time transperineal ultrasound (TPUS) is an emerging assessment tool. It is a non-invasive means to assess PFM contraction and the more important activity of the striated urethral sphincter (SUS). In addition to measuring bladder neck elevation, TPUS visually demonstrates the posterior kinking of the SUS that contributes to urethral closure. There are visible bony landmarks making measurement more reliable, and only a minimal amount of urine in the bladder is required.

TPUS provides visual biofeedback that can assist in teaching correct PFM contractions (Sherburn, Murphy, Carroll, Allen, & Galea, 2005). More recently, the use of real-time TPUS has been applied to assess PFM contractions in men (Nahon et al., 2011; Stafford, Ashton-Miller, Constantinou, & Hodges, 2013). Stafford, Coughlin, Lutton, and Hodges (2015) found TPUS has good to high reliability when used in young men. It must be noted, however, that TPUS is unable to detect if a PFM has increased resting tension (Stafford et al., 2015). With increased PFM tension, a PFM contraction viewed on TPUS will appear as though it is weak with little movement and minimal bladder neck elevation. The individual PFM exercise program is designed to accommodate increased PFM tension. Increased PFM tension (either resting or contractile activity) may also contribute to other symptoms, such as pelvic pain, so it is important that this is recognised and managed appropriately.

PFM Contraction and Exercise Instruction

Learning how to do a PFM contraction and PFM exercises correctly is essential for full benefit. Participants must learn how to identify and correctly contract the levator ani muscle without recruiting the adjacent upper abdominal, gluteal, and leg muscles (Robinson, 2000). In clinical practice, providing verbal and written instruction, plus or minus a physiotherapy consultation, is a common method of instructing participants about PFM exercise (Lekan-Rutledge, 1994). One study found that providing verbal and written information was as effective as intensive PFM training in return to continence post-RP (Moore, Valiquette, Chetner, Byrniak, & Herbison, 2008).

In Australia, patient instruction pamphlets, such as Pelvic Floor Muscle Training for Men, are provided by the Continence Foundation of Australia. This text provides men with written instructions and diagrams on how to do a correct PFM contraction and outlines a general PFM exercise program. These are widely used and available in several different languages. Despite provision of these or other written and verbal instructions by clinicians, many participants still report difficulty in understanding the role of the PFM, how the PFM works, and how to perform a PFM contraction correctly (Lekan-Rutledge, 1994; Neumann et al., 2015). In addition, despite pelvic floor physiotherapy instruction being best practice, face-to-face instruction is not always accessible (e.g., in rural or remote areas).

A clear understanding of the structure and function of the PFM may assist participants in mastering the correct technique of PFM contractions (Lekan-Rutledge, 1994). Scott and colleagues (2013) found that verbal instructions alone were not enough to teach young men how to correctly contract their PFMs. We were unable to find any studies looking at older men's ability to learn PFM exercises. One older study by Lekan-Rutledge (1994) reported on the success of using a three-dimensional model of the pelvis in female participants that permitted visual and tactile demonstration of pelvic floor structure and function.

Computer-based education is an effective means of knowledge transfer and skill development for both male and female participants across all age groups (Lewis, 1999), and other healthcare fields have begun to successfully employ multimedia education (Batuyong, Birks, & Beischer, 2012). The use of animation is beneficial in illustrating functional anatomy, and it can easily be adapted for patient education (Guttmann, 2000; Peltier et al., 2015).

Research Questions

The use of animation-based modelling may offer an option for educating participants about how to correctly perform a PFM contraction and how to do PFM exercises, especially because accessing anatomical location of the PFM is difficult. Further, real-world visual demonstration of a correct muscle contraction is not always possible, particularly for clinicians without access to real-time transperineal ultrasound. Therefore, the first goal of this randomized, control trial was to evaluate the effect viewing an animated pelvic floor model had on participants' ability to correctly perform a PFM contraction prior to RP. The second goal was to determine the effect of viewing this model on participants' confidence in performing PFM exercise correctly. The third goal was to determine satisfaction with viewing the model, and the fourth goal was to ascertain if viewing the animated pelvic floor model had any impact on participants' return to urinary continence following RP. Finally, the fifth goal was to determine who would provide PFM exercise information to participants their urologist, nurse, or other source.


Setting and Participants

Ethics approval was obtained from two hospital ethics review boards. The sample size was a convenience sample based upon what was feasible in terms of time and cost. Between December 2014 and August 2016, 105 consecutive participants were recruited from 6 private urology practices and 1 public urology outpatient clinic all located in Melbourne, Australia. All men diagnosed with localized prostate cancer and scheduled for RP were invited to participate in the study. Participants were excluded if they were of non-English-speaking background, unable to provide informed consent, were unable to view a DVD, were deemed unsuitable by their clinician, or had previously seen a physiotherapist for PFM assessment and instruction. Participants with known existing neurologic or neuropathic conditions that may impact their ability to successfully perform PFM contractions were not excluded from the study.

The RP was performed robotically in the majority of cases (n = 47, 92%) and open in 4 cases (8%) by 4 urologists in both public and private hospitals. Standard pre-operative preparation for participants undergoing RP in these private practices and outpatient clinic included providing men with verbal and written information about performing PFM exercises using the Pelvic Floor Muscle Training for Men brochure. These men are then routinely referred to a specialized continence physiotherapist for instruction in PFM exercises and assessment of their technique.


Participants were randomised to either receive standard preoperative preparation as described (control group) or standard preoperative preparation with the addition of viewing the animated pelvic floor model (intervention group). Recruiting sites were provided with sealed, opaque, randomization envelopes prepared according to a randomization schedule generated by the study biostatistician, employing a blocked randomization technique, with random block length (Der & Everitt, 2012) in SAS 9.4 (SAS Institute Incorporated, Cary, North Carolina, 2012).

Intervention: The Animated Pelvic Floor Model

An animated pelvic floor instructional video was created and developed by the investigators (HC, SM, IN, and AC) with the assistance of medical animators at BioDigital Systems, New York. The video is 9.5 minutes long, provides information about basic anatomy and physiology of the male urogenitary system focusing on the pelvic floor, information about why RP may affect urinary continence, internal views of the pelvic floor during a PFM contraction, and external visual cues for participants, showing a correct PFM contraction. The animation is divided into visual chapters for ease of viewing and has an Australian male voiceover accompanying the visual content. The animation was available as a DVD for this study. The control group received a DVD about prostate cancer only, with no information about PFM exercise.


Incontinence Assessment

To assess levels of UI, the Expanded Prostate Cancer Index Composite (EPIC)-26 (Wei, Dunn, Litwin, Sandler, & Sanda, 2000) was given to all participants to complete at baseline (prior to their physiotherapy assessment). The EPIC-26 is a validated, widely accepted, user-friendly instrument that measures health-related QoL concerns related to urinary and sexual function due to prostate cancer treatment. The instrument is a 26-item subset of a larger questionnaire focussing on health-related QoL of men diagnosed with prostate cancer (Wei et al., 2000). This questionnaire was then mailed with a stamped self-addressed envelope for completion and return at 1 and 3 months following RP.

Study Diary

All participants were given a study diary to complete. They were instructed to record all occasions of watching their study DVD and the frequency of performing the PFM exercises. They were also asked to record details of PFM exercise instruction they received, both written and verbal, and who had provided the information to them. Study diaries were returned to the study physiotherapists at the time of their PFM assessment.

Satisfaction with PFM Exercise Information Received Questionnaire

Prior to their assessment by the study continence physiotherapist, participants were asked to complete a 6-item non-validated questionnaire designed by the research team to measure participants' levels of satisfaction regarding the information they received about PFM exercising. This included satisfaction with any verbal and written information received. The intervention group was asked about how they found the information on the animated pelvic floor model. Responses were rated on a 5-point Likert scale ranging from extremely satisfied to not at all satisfied.

Pelvic Floor Assessment

After completing the PFM Exercise Information Satisfaction Questionnaire, and returning the Study Diary and questionnaires, participants underwent a PFM assessment pre-operatively (from/ between 1 day to 4 weeks prior to surgery) conducted by 1 of 3 blinded continence physiotherapists to determine their ability to correctly perform a pelvic floor contraction. Participants' availability to attend the physiotherapy appointment, and the availability of appointments for these assessments determined the timing of this appointment. Participants were instructed they would not receive any feedback regarding their PFM action during the objective examination until the physiotherapist assessment of their PFM contractions were complete.

The precise PFM contraction assessment was devised by the investigators using a combination of the established methods described in the Introduction section of this article: observation of any accessory muscle use, TPUS, and DRE using the following criteria. Participants were instructed to 'contract their pelvic floor muscles' in two positions --standing and lying down, and the physiotherapist noted any accessory muscle activation. TPUS assessment was performed in crook lying using a Sonoscope S2 ultrasound using either a Curved Array C344 transducer 26MHz or a Mindray DR-50. The real-time TPUS was used to determine movement of the anorectal angle, antero-cranial lift of the bladder neck, posterior movement of the external urethral sphincter, and length of hold. Participants were then placed in a standard left side lying position for a DRE. The method of assessing a correct contraction was pre-determined based on the combined clinical experience of continence physiotherapists, discussions with researchers and clinical experts in the field, and recent studies (Neumann et al., 2015; Stafford et al., 2015). This examination assessed for anterior movement of the puborectalis, lift of the PFM, complete relaxation of the PFM, and length of hold.

On TPUS, a PFM contraction was deemed correct if there was antero-cranial movement of mid-uretrovesical junction ([greater than or equal to]3 mm or more), minimal accessory muscle use, and the patient could maintain the contraction for at least 2 seconds. On DRE puborectalis, PFM contraction was assessed as correct if antero-cranial movement of the puborectalis muscle was demonstrated (weak, moderate, or strong), minimal accessory muscle use, and the patient could maintain the contraction for at least 2 seconds. Study participants had to perform a correct PFM contraction both via TPUS and DRE with minimal or no accessory use for the PFM to be assessed as a 'correct technique.'

After these assessments were completed, the physiotherapist provided participants with pelvic floor education, and further assessment and treatment as per best clinical pre-operative prostatectomy continence physiotherapy practice.

Data Analysis

All statistical analyses were carried out using IBM SPSS 23 (IBM Corporation, New York, 2015). Descriptive statistics were calculated for the sample. Independent samples t tests and a Mann-Whitney U test were performed to assess if there were differences between control and intervention groups on age and UI. To address the primary research question, Chi-squared tests were conducted to determine associations between groups (control or intervention) and ability to correctly perform the PFM exercise, assessed by DRE and TPUS. Logistic regression analysis was also used to determine if each group predicted successful performance of PFM exercise after controlling for days of exposure to PFM exercise information and age. Analysis of covariance (ANCOVA) was conducted to determine the effect of the group on urinary continence at 3 months post-RP, adjusting for baseline continence as a secondary outcome (Van Breukelen, 2006).


Of the 105 participants approached to participate in the study, 20 (18%) were unable because of the distance required to be assessed by the study continence physiotherapist, 14 (12%) did not wish to participate, 3 (2.8%) were ineligible due to limited English skills, 2 (1.9%) had surgery scheduled within a week, 2 (1.9%) had a previous continence physiotherapy assessment, 2 (1.9%) were too busy, and 2 (1.9%) did not want a DRE assessment by the continence physiotherapist. The remaining 60 participants were enrolled in the study.

Nine of the 60 participants enrolled withdrew from the study, leaving 51 evaluable participants - 28 in the control group and 23 in the intervention group. Reasons for withdrawal were varied and included anxiety around forthcoming surgery (3 participants), feeling stressed by involvement in the study (1), deciding against proceeding with RP (1), failing to make physiotherapy assessment appointment (1), declining any study follow up (1), and no stated reason (2). Remaining participants appeared well-matched for age; mean age (SD) for the control group was 61.5 (7.18) years and for the intervention group was, 62.0 (7.63) years (p=0.78).

Ability to Perform a PFM Contraction Correctly

Table 1 displays the proportion of participants in both the control and intervention groups who were able to correctly perform PFM contraction when assessed by the continence physiotherapist at baseline using both DRE and TPUS. No statistically significant differences between each group's ability to correctly perform PFM contraction were found, as assessed by both DRE and TPUS ([c.sup.2] [1]=0.53, p=0.58). Viewing the PFM contraction animated model did not predict successful performance of PFM contraction, even after controlling for the number of days participants had access to PFM information and age (p=0.63).

Confidence in Ability to Perform a PFM Contraction Correctly

Sixty-five percent of the intervention group and 52% of the control group indicated they felt either "extremely confident" or "quite confident" they could correctly perform a PFM contraction prior to their physiotherapist assessment. Of these participants reporting high levels of confidence, 8 of 16 participants (50%), incorrectly performed PFM exercise when assessed by both DRE and TPUS.

Satisfaction with Information

Participants were asked to rate the ease of understanding the information about PFM exercises they had received, the clarity of the description of pelvic floor anatomy, the explanation received of how to correctly perform a PFM contraction, the explanation of how PFM affects urinary continence, and their confidence in performing a PFM contraction. Each question had five ratings: Extremely Satisfied, Quite Satisfied, Moderately Satisfied, A Little Bit Satisfied, and Not at All Satisfied. Satisfaction questionnaires were completed and evaluated for 25 members of the control group and 18 members of the intervention group. Results are displayed in Table 2.

The majority of the intervention group (n=22, 95%) found the information provided in the pelvic floor animation "extremely easy" or "quite easy" to understand. Comments from these participants included "Clear diagram showing moving muscle," "Showing functional elements of the pelvic floor," "Very simple," "Animation makes explanation much easier to understand and replicate," and "I found far more information on the DVD than the brochure." The control group reported they wanted more information: "I would have understood the information more if I had viewed it visually," and "I need to understand what I am doing need more help to do all this."

Urinary Incontinence

Baseline, 1-, and 3-month post-RP EPIC urinary incontinence scores for both groups are displayed in Table 3. There were no statistically significant differences between the groups on EPIC-26 UI at baseline. The overall urinary function in the control group compared to the intervention group was lower, but this difference narrowly failed to approach statistical significance (p=0.092). Overall urinary function was assessed via a Mann-Whitney U test performed on an EPIC-26 item asking participants to report their 'overall urinary function' at baseline.

ANCOVA with baseline urinary incontinence scores entered as a covariate into the model indicated the intervention group did not display a statistically significant difference in mean urinary incontinence at 3 months compared to the control group (F [1,35]=0.18, p=0.68). The estimated means of urinary incontinence scores and the 95% confidence intervals are displayed in Table 4.

PFM Exercise Information Received

Nearly half (49%) of the total evaluable study participants (n=51) reported they did not receive any verbal information about PFM exercise from their specialist, and 20% (n=10) reported they did not receive any written information. Participants who reported receiving PFM exercise information were more likely to have been given this information by nurses (74%) rather than doctors (23%). Table 5 displays the type of PFM exercise information received by participants, verbal or written, and sources of this information.


At the time of diagnosis and scheduling for RP, participants receive a great deal of information about their proposed surgery, hospital admission information, post-discharge details, and information about PFM exercises and erectile dysfunction management. Provision of information about pelvic floor exercises is considered routine pre-operative preparation prior to RP in private urology practices and the clinic used for this study. However, many study participants reported they did not receive verbal and/or written information about PFMs prior to receiving their physiotherapy assessment. It cannot be determined whether this information was omitted or whether the patient had no recollection of receiving the information provided because of a potential information overload at a stressful time.

Limitations of verbal instructions alone have been documented in an early study (Bump, Hurt, Fantl, & Wyman, 1991) that found only 49% of women were able to correctly perform a PFM contraction after standardized verbal instructions. A further 25% of participants in this study actually bore down on their pelvic floor rather than elevate it, potentially worsening their symptoms (Bump et al., 1991). In a more recent study, approximately 30% of healthy young males also had difficulty performing PFM contractions correctly after receiving verbal instruction (Scott et al., 2013). There is a lack of published evidence regarding education of males about correctly performing PFM exercises, and much clinical practice is derived from studies of females.

Following conventional verbal instruction and written information, 13 (46%) in the control group were still unable to correctly perform a PFM contraction using the combined method of TPUS and DRE, and thus, PFM exercises when assessed by a continence physiotherapist. In addition, participants' confidence in their ability to correctly perform a PFM contraction was not matched by correct technique. This mismatch in confidence and correct technique was also reported in a study examining visual methods of providing education, which found more males than females reported feeling confident in their performance of exercise whether they were exercising correctly or not (Weeks et al., 2002). This highlights the importance of individual assessment to determine whether participants are correctly performing PFM exercises prior to RP. Weeks and colleagues (2002) did not demonstrate any significant differences between control and intervention groups in terms of ability to correctly perform PFM contraction. However, some participants reported that viewing the animated model improved their understanding of the pelvic floor anatomy. Viewing the pelvic floor animation did not impact urinary continence levels when assessed 3 months following RP. This is not surprising because participants in both control and intervention groups received individual continence physiotherapist preoperative assessment, instruction in correct PFM contraction, and an individualised PFM exercise pre-operative program.

Differences reported in individual men's ability to correctly perform PFM exercise according to the mode of assessment--DRE and TPUS--may possibly be explained by the finding that DRE, the most commonly utilised clinical method for PFM exercise assessment, assesses the external anal sphincter puborectalis and the more posterior components of the levator ani muscle. TPUS, only recently included in male pelvic floor assessment, provides more information about external urethral sphincter activity, which may be more closely correlated with post-RP continence (Stafford et al., 2012). The most accurate means of assessing the pelvic floor requires further investigation, and a combination of assessment methods may be preferred.

Intuitively, researchers believed visualising the internal pelvic anatomy as demonstrated in the animated pelvic floor model would improve participants' understanding, and in turn, men's ability to correctly perform PFM exercises. This was not demonstrated in this study.


A limitation of this study is the small sample size. Further, after being advised about a prostate cancer diagnosis and discussing potential treatments is a difficult time to enrol participants into clinical trials. This factor may have contributed to the high (15%) withdrawal rate from the study. Further limitations include having four surgeons who performed the procedures in the study population; thus, we were unable to control for difference in surgical technique among the four surgeons. This may account for variations in participants outcomes and that not all men underwent the same surgical technique (either open or robotic RP).


There remains much to discover about the male continence mechanism and the contribution of the pelvic floor to urinary continence, especially in men following RP surgery. There is increasing evidence that some form of PFM exercise commenced preoperatively hastens the return to continence; however, specific aspects of how to teach the correct pelvic floor contraction, exercise prescription, and program remain unclear. This study supplemented usual verbal and written information with a visual animated DVD. We did not find a significant improved ability of men pre-RP to correctly perform a PFM contraction as assessed by a combination of TPUS and DRE. The mismatch between participants' confidence in their ability to correctly perform a PMF contraction and their actual ability to do so highlights the importance of individualised assessment and exercise prescription.

Despite negative study findings, the model has the potential to assist urology nurses and other health professionals by supplementing existing methods for instructing participants in correct technique for performing PFM contraction. The model may be of particular benefit for clinicians providing education and support for participants scheduled for RP who live in rural and remote areas, who have limited or no access to information about PFM exercise, or to continence physiotherapists. Further research is required.

Research Summary


Urinary incontinence following radical prostatectomy (RP) for prostate cancer is a common occurrence. Some evidence supports the role of pelvic floor muscle (PFM) exercises in improving post-prostatectomy incontinence (pPi).


To determine the effect on viewing an animated pelvic floor model on participants' ability to correctly perform PFM exercises prior to RP.


Fifty-one participants were randomized into either the control group (usual pre-RP preparation) or the intervention group (usual pre-RP preparation with the addition of viewing the animated pelvic floor model).

Primary Outcome Measures

Outcome measures were the ability to correctly perform a PFM contraction assessed by both digital rectal examination and trans-perineal ultrasound by a blinded continence physiotherapist, questionnaires to evaluate urinary continence completed at baseline and 1--and 3-month post-RP, and a satisfaction with PFM information received was completed prior to the physiotherapist assessment.


No statistically significant differences were found between the groups' ability to correctly perform PFM contraction. There were no statistically significant differences between the groups in mean urinary continence scores at 3 months.


The study did not demonstrate an advantage viewing the animated pelvic floor model in the ability to correctly perform PFM contraction. However, despite this, the model may be a useful supplement to existing methods of instructing participants in PFM exercise technique.

Level of Evidence--III-A

Johns Hopkins Hospital/Johns Hopkins University, 2016.

Helen Crowe, MNurs Sci, GDip Epi Biostats, B App Sc (Ad Nurs), RN, is a Urology Nurse Practitioner, Private Practice, and a Research Nurse, Epworth HealthCare, Melbourne, Australia.

Anne Harbison, RN, RM, Grad Cert Cancer Nursing, is a Research Assistant, Epworth HealthCare, Melbourne, Australia.

Addie Wootten, DPsych (Clinical Psychology), is a Clinical Psychologist, Private Practice and Epworth HealthCare, Melbourne, Australia.

Brindha Pillay, DPsych (Clinical Psychology), is a Clinical Psychologist and Research Fellow, Epworth HealthCare, Melbourne, Australia.

Shan Morrison, FACP, Post Grad Cert (Continence & Pelvic Floor Rehabilitation), is Director, Women's and Men's Health Physiotherapy, Melbourne, Australia.

Melissa Martin, B App Sc (Physio), Post Grad Cert Physio (Continence and Pelvic Floor Rehabilitation), is a Senior Physiotherapist, Women's and Men's Health Physiotherapy, Melbourne, Australia.

Irmina Nahon, PhD, M Physio, B App Sci (Physiotherapy), Post Grad Cert (Continence and Pelvic Floor), is a Pelvic Floor Physiotherapist and Assistant Professor, the University of Canberra, ACT, Australia.

Dean McKenzie, PhD, BA (Hons), is a Biostatistician, Epworth HealthCare, Melbourne, Australia.

Anthony Costello, MD, FRACS, MBBS, is a Urologist and Director of Urology, Royal Melbourne Hospital, and Epworth Prostate Centre, Epworth HealthCare, Melbourne, Australia.

Acknowledgements: Funding for the development of the pelvic floor animation was through an unconditional educational grant from Tolmar Australia Pty Ltd. The study was funded by the Epworth Research Institute Associate Professor Joe Tjandra Research Grant Award, and Perpetual's 2015 IMPACT Philanthropy Application Program Grant.

doi: 10.7257/1053-816X.2018.38.1.27


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Table 1.
Assessment of Pelvic Floor Muscle (PFM) Contraction Using Digital
Rectal Examination (DRE) and Transperineal Ultrasound (TPUS)

Assessment of PFM Contraction           Control (N=28)
(a,b) (N = 51)                              n (%)

Performed PFM contraction                 18 (64.3)
  correctly on DRE
Performed PFM contraction                 15 (53.6)
  correctly on TPUS
Performed PFM contraction correctly       13 (46.4)
  on both DRE and TPUS

Assessment of PFM Contraction           Intervention (N=23)     Total
(a,b) (N = 51)                                 n (%)            n (%)

Performed PFM contraction                    13 (56.5)        31 (60.8)
  correctly on DRE
Performed PFM contraction                    13 (56.5)        28 (54.9)
  correctly on TPUS
Performed PFM contraction correctly          10 (43.5)        23 (45.1)
  on both DRE and TPUS

(a) Assessed by the continence physiotherapist.

(b) Participants may belong to more than one group (i.e., DRE correct,
TPUS correct, and DRE/TPUS correct).

Table 2.
Satisfaction with Pelvic Floor Muscle (PFM) Exercise Information

"Extremely Satisfied " or "Moderately         Control    Intervention
Satisfied" with PFM Information                n (%)        n (%)

PFM information received.                     19 (76%)    18 (100%)
Clarity of description of PF anatomy.         22 (87%)    18 (100%)
Explanation of how to correctly perform       21 (83%)     16 (89%)
  PFM contraction.
How PFM affect urinary continence.            20 (80%)    18 (100%)
Confidence in ability to correctly perform    19 (76%)    18 (100%)
  a PFM contraction (prior to
  physiotherapist instruction).

Table 3.
Mean Expanded Prostate Cancer Index Composite (EPIC)-26
Scores at Baseline, and 1-Month and 3-Months
Post-Radical Prostatectomy

                          Baseline                1 Month
EPIC-26 Urinary
Incontinence           N         M (SD)      N       M (SD)

All participants     49 (a)   93.8 (12.2)    41   24.6 (18.2)
Control group          26     91.5 (14.5)    24   30.6 (20.7)
Intervention group     23      96.4 (8.5)    17    16.3 (8.9)

                         3 Months
EPIC-26 Urinary
Incontinence         N       M (SD)

All participants     39   50.3 (30.5)
Control group        19   47.5 (26.7)
Intervention group   20   52.9 (34.2)

(a) Two participants' responses on the EPIC /26 Urinary Incontinence
Scale could not be scored due to missing/invalid responses.

Table 4.
Estimated means of Expanded Prostate Cancer Index
Composite (EPIC)-26 Urinary Incontinence Scores at 3-Month
Post-Radical Prostatectomy

                              95% Confidence Interval

Group                 Mean    Lower Bound   Upper Bound

Control (n=19)        41.12      32.35         61.89
Intervention (n=20)   51.38      37.40         65.37

Note. Twelve participants' responses on the EPIC-26 Urinary
Incontinence Scale could not be scored due to missing/invalid

Table 5.
Pelvic Floor Muscle (PFM) Exercise Information
Received by Participants

PFM Exercise Information Received (a)
(N=51)                                               n (%)

Received verbal PFM exercise information.           25 (49)
Received written PFM exercise information.          41 (80)
Received both verbal and written PFM                20 (39)
  exercise information.
PFM exercise information provided by the doctor.    12 (23)
PFM exercise Information provided by the nurse.     31 (74)

(a) These groups are not mutually exclusive; participants may have
selected more than one response.
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Title Annotation:Research
Author:Crowe, Helen; Harbison, Anne; Wootten, Addie; Pillay, Brindha; Morrison, Shan; Martin, Melissa; Naho
Publication:Urologic Nursing
Article Type:Report
Geographic Code:8AUST
Date:Jan 1, 2018
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