L18: Men's Health Flashcards
(100 cards)
1
Q
Pelvic floor dysfunction is _____ and _____ in men
A
common; diverse
2
Q
What are 5 pelvic floor dysfunction in men?
A
- Urinary incontinence
- Erectile dysfunction
- Pelvic pain disorders
- Faecal incontinence
- Obstructive disorders
3
Q
How does anatomy of pelvic floor muscles differ between males and females?
A
Position of the icshiocavernous muscle and bulbocavernous muscle are different Able to be palpated in females
4
Q
What are the peri-urethral muscles?
A
5
Q
Everytime healthy females contract their pubic rectilus, the ______ also contracted
A
sphincter
6
Q
What are 4 pelvic floor muscles in males?
A
- Smooth muscle sphincter
- Lissosphincter, internal urethral sphincter
- Striated urethral sphincter
- Rhabdosphincter, external urethral sphincter, peri-urethral striated muscle
- pushes on the urethra
- Levator ani
- Puborectalis, pubovisceralis, pubococcygeus
- loops around the rectus for rectal control
- Bulbocavernosus
- compress distal part of urethra
7
Q
What are 2 smooth muscle sphincter muscles?
A
- Lissosphincter
- internal urethral sphincter
8
Q
What are 3 striated urethral sphincter muscles?
A
- Rhabdosphincter
- external urethral sphincter
- peri-urethral striated muscle
9
Q
What is the function of striated urethral sphincter muscle?
A
pushes on the urethra
10
Q
What are 3 levator ani muscles?
A
- Puborectalis
- pubovisceralis
- pubococcygeus
11
Q
What is the function of levator ani?
A
loops around the rectus for rectal control
12
Q
What is the function of the bulbocavernous?
A
compress distal part of urethra
13
Q
What are the 5 actions of the pelvic floor muscles and what does that contribute to?
A
postural control
- Pelvic organ support
- Urethral anal/rectal pressure
- Intra-abdominal pressure generation
- Sacroiliac forces
- Sexual function –> Impact of pressures from above
14
Q
______ (similar/different) muscle anatomy in males and females
A
Similar
15
Q
Why are prostatectomy so disabling?
A
Removes some of the smooth muscle (affects continence)
16
Q
What is the bias to consideration of SUS in males?
A
risk of damage with radical prostatectomy
17
Q
What is the bias to consideration of levator ani in women?
A
Childbirth trauma and possibility to assess via vagina
18
Q
What are the 2 ways to use electromyography recordings for urethral muscles?
A
- Fine-wire EMG
- Puborectalis
- Bulbocavernosus
- Transurethral electrode
- Striated urethral sphincter
19
Q
What are the 3 characteristics of using electromyography recordings in anal electrodes??
A
- Primarily record from external anal sphincter
- Often suboptimal design
- Wrong orientation of electrodes
- Low quality of activation
- Does not provide information of urethral control
20
Q
What is the function of using anal electrodes?
A
used for biofeedback and assessment
21
Q
What is the problem with using anal electrodes?
A
- Only looks at external anal sphincter
- Anal EMG is clinical viable, but potentially of limited value
- Methods to assess activation of urethral muscles limited to laboratory
22
Q
What is the purpose of doing ultrasound on the transabdominal muscles?
A
Urethral support mechanism- what we want to measure done with transabdominal ultrasound
23
Q
What is the levator ani/puborectalis?
A
when contracts –> lifts the bladder
Commonly used in women
24
Q
What are the 3 problems with transabdominal ultrasound imaging
A
- Difficult to quantify - no bony landmark
- Affected by abdominal displacement
- Limited information of multiple mechanisms
25
What are the 2 actions of the puborectalis in Transperineal ultrasound imaging?
1. Ano-rectal angle elevation & anterior disp.
2. Urethrovesical junction elevation & anterior disp.
If contract puborectalis --\> will pull it forwards (wraps around rectus) --\> lift the bladder --\> pull backwards of the mid part of urethra --\> compression of bulb
26
What is the action of he striated urethra; sphincter?
Posterior motion mid urethra
27
What is the action of the bulbocavernosus?
Compression bulb penis
28
What is the 3 purposes of data analysis to find out which muscles are being activated/affected?
1. have they had a prostatectomy
2. have they injured sphincter? is it still able to contract
3. are they over-using or under-using the muscles
29
Are the ultrasound measures related to the amplitude of muscle activity?
Non-linear relationship between US & EMG Best relationship between EMG and the muscle is when it reflects a certain point
30
Why is transperineal US a valid measure?
* Valid measure of activation of individual pelvic floor muscles in men during voluntary contractions
* Muscles can be individually assessed during gentle contractions
31
What is the caution of transperineal US?
muscle will lengthen during eccentric contractions – high IAP may cause descent of the pelvic floor
32
What are the 4 characteristics of digital rectal examination?
Evaluation of:
1. Contraction of external anal sphincter and puborectalis
2. Strength
3. Endurance
4. Coordination
* Muscle tone
* Identification of areas of tenderness
33
When do you do a digital rectal examination?
If information will influence management- as it is very sensitive/private for patients (eg. shy)
34
What are 2 issues with digital rectal examinations?
1. Requires training
2. Requires consent
35
What are 10 incontinence in men?
1. Post-prostatectomy incontinence
2. Stress urinary incontinence
3. Urge incontinence
4. Mixed incontinence
5. Detrusor/bladder overactivity
6. Increased frequency
7. Nocturia- wetting the bed
8. Hesitancy
9. Incomplete emptying
10. Detrusor-Sphincter dyssynergia
36
What is the prevalence of urinary incontinence in men?
1. Up to 39% and increases with age- still quite common --\> happens later and for different reasons
* often think its more common in women due to post partum
2. Post-prostatectomy incontinence
* up to 60%
* Symptoms beyond 12 months for many (depends on definition)
* Major impact on quality of life
37
What does the neural control of continence look like?
38
What is the pre-activation of Evoked cough: Pelvic floor muscle EMG?
* Bulbocavernosis
* Puborectalis
* Striated urethral sphincter
* Initial pre-activation by SUS shortening
* SUS/BC shortening & PR lengthening during preparatory and expulsion phases sphincter is contracting but the puborectalis also undergoes some stretching
39
What are 2 characteristics of striated muscles?
1. Each muscle has unique mechanical action on urethra
* New
* clear role for PR and BC
* not considered previously
* SUS
* tonic and phasic functions
2. Complex interaction in function
* Independent and coordinated activation
* Tonic activation: PR \> SUS
* Phasic burst with increased demand: distal before proximal
* Differential fatiguability
40
What are 5 clinical implications for training to target normal function?
1. Tonic activation – PR \> SUS
2. Sustained activation
3. Phasic burst with increased demand – Distal (SUS/BC) before proximal (PR)
4. Pre-active before predictable
* eg. before step or cough
5. Activate quickly after unpredictable
41
What is the prevalence of prostate cancer?
1. Most common cancer in men (1 in 6)
2. Second most common cause of cancer death in men
42
What is the good news with prostate cancer/?
one of the highest 5-year survival rates (92%)
43
What is the bad news with prostate cancer/?
morbidity from treatments is high- 66% of men experience urinary incontinence- and problems with sexual function --\> due to cancer treatment
44
What are 3 diagnosis of prostate cancer?
1. PSA – prostate specific antigen
2. DRE – digital rectal examination- hardness of prostate --\> possible tumour
3. Biopsy- only way to confirm a diagnosis (for tumour) look under a microscrop
45
What is the grading system for prostate cancer?
* Gleason system
* Histological appearance of cells- how aggressive they are
46
What is the metastasis for prostate cancer?
* Lymph node biopsy
* PET/MRI, bone scan some prostate cancers can metastasis --\> cause bone cancers some prostate cancers are slow growth --\> no surgery for it/die with it, not from it
47
What are the 5 treatment for prostate cancer?
1. Watchful waiting
* Monitor progress and avoid treatment unless necessary- for many men, prostate cancer is very slow growing --\> usually die with it rather than from it
2. Radical prostatectomy
* Removal of prostate in localised disease to prevent metastasis- if growing fast but localised
3. Radiation therapy
* Treatment of localized disease
* Alternative to surgery, more aggressive cancer, not all cancer removed with surgery
4. Chemotherapy
* Treatment of systemic disease- eg. metastasis
5. Hormone therapy
* Androgen deprivation therapy (ADT) to slow progression
* Prostate cancer needs testosterone to grow- can also remove testes (as last resort option) to prevent testosterone - permanent but life extending procedure
48
What is watchful waiting as prostate cancer treatment?
Monitor progress and avoid treatment unless necessary- for many men, prostate cancer is very slow growing --\> usually die with it rather than from it
49
What is radical prostatectomy as prostate cancer treatment?
Removal of prostate in localised disease to prevent metastasis- if growing fast but localised
50
What is radiation therapy as prostate cancer treatment?
Treatment of localized disease – alternative to surgery, more aggressive cancer, not all cancer removed with surgery
51
What is chemotherapy as prostate cancer treatment?
Treatment of systemic disease- eg. metastasis
52
What is hormone therapy as prostate cancer treatment?
Androgen deprivation therapy (ADT) to slow progression – prostate cancer needs testosterone to grow- can also remove testes (as last resort option) to prevent testosterone - permanent but life extending procedure
53
What are 2 roles of physiotherapy?
1. Exercise
* Positive effects on many aspects of disease
* General health
* Disease progression?
* Mental health
2. Management of side effects of prostatectomy
Research shows that men do better with and after prostate cancer if they are active (using exercise)
* some studies suggest that it can slow progression of the disease
* helps with mental health (since they are concerned/depression --\> positive)
54
What are the 3 positive effects on many aspects of disease on exercise?
1. General health
2. Disease progression?
3. Mental health
55
What is radical prostatectomy?
* Surgical removal of all or part of the prostate gland and seminal vesicles
* Remove cancer before it metastasises
* Considered a cure for localised prostate cancer
* Debate regarding decision for when and when not to undertake surgery
56
What are the 4 operative approaches of radical prostatectomy?
1. Radical retropubic prostatectomy
* Single incision in the abdomen
* umbilicus to the pubic bone
2. Laparoscopic radical prostatectomy
* Laparoscope/instruments inserted through incision in the umbilicus
3. Robotic radical prostatectomy
* da Vinci robot
* more precision and less pain
4. Radical perineal prostatectomy
* Incision in perineum rare
57
What are the 4 benefits of radical perineal prostatectomy?
1. surgeon has greater precision
2. less complications
3. less time in surgery
4. no correlation with better outcomes (with erectile function)
58
What are the 4 side effects of radical prostatectomy?
1. Impotence- due to removal of nerves that innervate the blood vessels of the penis ( controlling blood flow - basis for an erection)
* 7-8/10 affected
* Injury to nerves innervating penis
2. Urinary incontinence- most men do improve but some men do continue to have incontinence in the future
* 1/3 to 2/3 affected
* depends on definition
* Small proportion ongoing major problems
3. Urinary obstruction
* Rare
* Scar tissue at join between urethra and bladder neck
* Can't actually urinate as there is a blockage due to the scar
4. Pelvic pain
59
What are the 5 impacts of radical prostatectomy?
1. Removal of prostatic urethra including smooth muscle
2. Interference with bladder neck
3. +/- Striated urethral sphincter injury
4. Exposure/irritation of bladder
5. Lower bladder position different mechanical forces --\> puborectalis pulling forward might squeeze the bladder = can make continence worst
60
What are 2 multifactorial of post-prostatectomy incontinence?
1. Sphincter
2. Detrusor
61
What are 3 characteristics of sphincter of post-prostatectomy incontinence?
1. Sphincter incompetence (40-80%)
* Sphincter injury
* Nerve injury
* Lower maximal urethral closure pressure
2. Urethral length \> 12 mm --\> less incontinence
3. Post-operative stricture (anastamosis) --\> reduced elasticity of striated urethral sphincter (up to 67%)
62
What are 3 characteristics of detrusor of post-prostatectomy incontinence?
1. Detrusor overactivity (4-40%)
* Pre-/post-operative
* Vascular/nerve injury or inflammation- due to irritation
* Rare as sole cause of incontinence
* Common with sphincter insufficiency
* activation of vesicourethral reflex
2. Impaired detrusor compliance/capacity(12-82%)
* surgical or reduced perfusion from obstruction
* might be incontinent --\> dont store urine in bladder --\> bladder shrinks --\> bladder storage oroblems
3. Impaired detrusor contractility (1%)
* surgical nerve trauma or obstruction
63
What are 3 clinical implications of Recovery of continence after PR?
using striated muscles that can be activated voluntarily--\> need to take over some functions of smooth muscles
1. Compensate for reduced smooth muscle contribution to continence --\> Striated muscles change function --\> Enhanced tonic activation --\> Neural adaptation? --\> Muscle fibre adaptation? --\> Enhanced capacity
2. Compensate for compromised striated urethral sphincter --\> greater reliance on puborectalis & bulbocavernosus
3. Restore bladder function --\> Train bladder storage
If sphincter is problematic --\> puborectalis and bulbocavanosus
64
Why are men usually incontinent after prostatectomy?
* when they contract pelvic floor muscles, they don't elevate their bladder (normal), they push it down
* rather than contracting pelvic floor to lift up bladder, they contract their abdominals to push down = this is counter-productive = over-activity of abdominals
* under-activation of sphincter = less displacement (unable to compress)
65
What is the probability of continence in relation to pelvic floor muscle function?
Can be continent with poor sphincter function but only of BC and PR are working to compensate
66
What should the focus of training?
striated urethral sphincter
67
Some capacity for compensation by _______ and \_\_\_\_\_\_\_
puborectalis; bulbocavernosus
68
What is the impact of treatment is limited by poor understanding of mechanisms?
1. Pelvic floor muscle training for incontinence
* Early RCTs - optimistic outcomes
* Recent large RCT & SR - no benefit
2. Direct extrapolation of treatment from women to men, but is this ideal?
69
What is the new approach needed for treatment for incontinence after prostatectomy, what can limited efficacy from existing trials could be explained by?
1. Wrong muscles (anal [access to assessment via anus] vs. urethral)
2. Wrong treatment goal (short maximal contractions vs. coordination)
3. Wrong time (after incontinence developed)
70
What are 8 clinical implications for treatment for incontinence after prostatectomy?
1. Wrong muscles (anal [access to assessment via anus] vs. urethral)
2. Wrong treatment goal (short maximal contractions vs. coordination)
3. Wrong time (after incontinence developed)
4. 5. Focus on muscle complexes that control urethral pressure
6. Innovative assessment and feedback of muscle contraction using transperineal ultrasound imaging
7. Start pre-operatve
8. Training using principles of motor skill training
71
What are the instructions of voluntary activation?
1. “Retract/Shorten the penis” - greatest dorsal displacement of the mid-urethra and SUS muscle activity
2. “Elevate the bladder” - greatest increase in abdominal EMG and IAP
3. “Tighten around the anus” - greatest anal sphincter muscle activity
72
What are the 7 characteristics proposed optimal program?
1. Optimise pattern of pelvic floor muscle control for urethral pressure control
* Enhance SUS – instructions include “contract as if stopping the flow of urine”; “retract penis”
* Reduce over-activity (abdominal muscle/PR)
* No focus on anal contraction
2. Integrate pelvic floor control into function - Train for likely triggers – cough, lift, laugh, golf swing, sit-to-stand
3. Bladder training to increase volume and time between emptying
4. Condition muscle to hold gentle contractions for longer periods to compensate for reduced smooth muscle
5. Progress to higher level endurance training for sustained tasks
6. Progress to strength training for high intensity control
7. High performance training for high demand functions and unexpected challenges
73
What are the 5 adjunct treatment considerations for post-prostatectomy rehabilitation?
1. Penile rehabilitation
2. Maintain positive attitude
3. Management of persistent pelvic pain
4. Weight control
5. Physical activity
74
What is Benign prostatic hyperplasia?
prostatic enlargement due to histologic benign prostatic hyperplasia
75
What are 3 symptoms of Benign prostatic hyperplasia?
1. Voiding symptoms
* Hesitancy, delay in initiating micturition, intermittency, weak stream, dysuria
2. Storage symptoms
* Urinary frequency, nocturia, urgency with/without UI
3. Post micturition symptoms
* Feeling of incomplete voiding, post micturition dribble
76
What are 3 treatments of Benign prostatic hyperplasia?
1. Reduce bother, prevent/delay progression of symptoms
2. Pharmaceutical management
3. Surgery
* Transurethral resection of prostate (TURP) - “rebore”
* Post-surgical incontinence can occur
77
What are the 2 roles of physiotherapy in Benign prostatic hyperplasia?
1. Post-surgical management
2. May be a role of PFM training for incontinence
78
What are 3 characteristics of Sexual dysfunction?
1. Erectile dysfunction
2. Retrograde ejaculation
3. Pain – during and after ejaculation
79
What are 3 causes of Erectile dysfunction?
1. Cardiovascular disease
* E.g. atherosclerosis
2. Psychological
* E.g. up to 70% of patients with depression have sexual dysfunction
3. Medication
* Many drugs impact blood flow and libido
80
What are the 4 treatments of Erectile dysfunction?
1. Pharmaceutical
* E.g. Viagra (Sildenafil)/Cialis (Tadalafil)
2. Surgical
* Penile prosthesis
3. Vacuum pumps
4. Pelvic floor muscle training
* E.g. RCT evidence
81
What are the role of the pelvic floor in sexual function in superficial layer?
Bulbocavernosus, ischiocavernosus, external anal sphincter
82
What are 3 contributions of the role pelvic floor in sexual function
1. Ejaculation
2. Penile rigidity and hardness – compression of vascular structures
3. Orgasm – contraction of PFM
83
What are the 4 roles of physiotherapy?
1. Pelvic floor muscle training – RCT evidence for improved erectile function
2. General exercise – health
3. Counseling/education
4. Part of multifaceted intervention
84
What are 3 Pelvic pain disorders?
1. Prostatitis-quite rare- inflammation of prostate gland
2. Chronic pelvic pain syndrome
3. Painful bladder syndrome/interstitial cystitis
85
What are 3 types of prostatitis?
1. Acute bacterial prostatitis
2. Chronic bacterial prostatitis
3. Chronic prostatitis/CPPS
* Inflammatory
* Non-inflammatory (formerly prostatodynia)
86
What is the diagnosis of Acute/chronic bacterial prostatitis?
Expressed prostatic excretions (EPS)
87
What are symptoms of acute/chronic bacterial prostatitis?
fever/chills, prostate pain, dysuria, perineal pain, difficulty urinating (hesitancy), urinary retention and low back pain
88
What is Chronic prostatitis/ Chronic pelvic pain syndrome?
Inflammatory and Non-inflammatory
89
What are 2 symptoms of Chronic prostatitis/ Chronic pelvic pain syndrome?
1. Perineal pain, burning, itchiness, muscle tension, pain radiating into testicles, scrotum, anus, rectal, suprapubic, penile, coccyx, groin, during and after ejaculation, low back pain
2. Urinary symptoms – Hesitancy, dysuria, nocturia, frequency and urgency, decreased stream, feeling of poor emptying
Probably unrelated to prostate
90
What are 3 characteristics of Chronic prostatitis/ Chronic pelvic pain syndrome?
1. Men are likely to be diagnosed with prostatitis if they complain of pelvic pain.
2. Most do not have bacterial infection
3. Despite the evidence, many prescribed antibiotics
---\> Chronic Pelvic Pain Syndrome
91
What are 5 characteristics of Chronic Pelvic Pain Syndrome?
1. Many different conditions
2. Lack of consensus of terminology
3. Multiple underlying mechanisms
4. Disagreement regarding pathophysiology
5. Differential diagnosis
* Exclude other causes – e.g. urinary tract infection, etc.
Urological Chronic Pelvic Pain Syndrome (UCPPS)
* Recurrent (\>once per week) pain in the genitals, perineum, suprapubic, or anal region
* Not explained by another medical diagnos
92
What are 2 characteristics of the Relevance of sensorimotor changes for chronic pelvic pain- Muscle/myofascial tissue as a primary source of nociceptive input?
1. Rich innervation by nociceptive neurons
2. Increased muscle tone/spasm/activation
* Muscle ischaemia - pain
* Hyperalgesia/Sensory changes
* Local inflammation
93
What are 3 characteristics of the Relevance of sensorimotor changes for chronic pelvic pain- Secondary changes in muscle/myofascial tissue?
1. Protective response
* Sexual trauma; threat of pain
2. Reactive response
* Bladder fullness, urgency
3. Excessive pressure from above - intra-abdominal pressure/breathing
94
What are 2 characteristics of the Relevance of sensorimotor changes for chronic pelvic pain- Sacroiliac joint/pubic symphisis?
1. Control depends on muscle
* Transversus abdominis, multifidus, pelvic floor muscles
2. Can be source of nociceptive input
95
What are the 3 active components of muscle "tone" activation?
1. Reflex – spinal cord/brain stem
2. Descending input from higher centres
3. ”trigger points” ??? – areas of --\> tension
96
What is a passive component of muscle "tone" activation?
* Viscoelastic properties of non-contractile elements
* Actin-myosin crossbridges
* Fascia
* Muscle connective tissue – e.g. endomysium
97
What are the 4 characteristics of Tonic activation: Electromyography?
1. Men - UCPPS N=21; control N=21
2. Intra-anal EMG
3. Higher resting muscle activity
4. Lower endurance
98
What are 2 characteristics of Tonic activation: Ultrasound imaging?
1. UCPPS N=24; controls N=26
2. Higher resting tone – More acute ano-rectal angle at rest and during contraction
3. More acute Rest ARA in UCPPS \> contracted in controls – Less levator plate elevation with contraction
4. ??greater IAP – Correlated with pain, sexual dysfunction, and anxiety
99
What are 5 characteristics of motor brain changes?
1. Men with chronic pelvic pain- have exaggerated pathways - with men with pelvic floor
2. Fractional anisotropy (FA) - degree of water diffusion along a principle axis
3. More parallel axons, more myelin in corticospinal projections to PFM
4. Correlated with pain
5. Strong/strengthening connection --\> Greater drive from motor cortex to PFM?
100
What are 4 physiotherapy management for Muscle “tone”/activation?
1. Motor control training
* Relaxation of pelvic floor muscles
* Diaphragmatic breathing
* Feedback
* Instructions
2. Manual therapy
3. Pain management
* Cognitive behavioural therapy
* Education
* Pain coping skills
4. Multidisciplinary team
