Before Your Prostatectomy

I have worked at large urology practices. This means that I have had the opportunity to work with a lot of doctors doing prostatectomies. Most men are getting a prostatectomy because they have prostate cancer. Some men get a prostatectomy for other reasons. But, I can assure you that no man gets a prostatectomy to lose a few pounds.

The idea of doing “prehab” - “pre” surgical “rehabilitation” - is really catching on. This means that before prostate removal, men see a pelvic floor physical therapist. In my practice, I see men once before surgery. There are several goals in this appointment. After the prostatectomy, I see men a handful of times. At that point, I’m acting as an athletic trainer and a fortune teller. Imagine me spotting a man’s pelvic floor. Just imagine.

Are you done imagining? So what are these goals I mentioned above? The pre-operative physical therapy appointment is intended to tell you what to expect after your prostate is removed and how to best prepare yourself for optimal outcomes.

I tell men what the spectrum of “normal” leakage looks like after the catheter is removed. I warn them that they might not truly comprehend the volume of leakage until it happens, but hopefully they will look back and think “Ah, Sara told me about this. I choose not to worry. She said this would happen. She knew. That girl…she knew.” I give it to men straight. You might leak like a faucet, even when you are not moving. It could be that bad. Or, you might just leak with coughing and sneezing. Either way, both extremes are “normal”.

I teach men about what makes the bladder spasm. Bladder spasms create urinary leakage after prostate removal. They might make some men feel like they have an urge to constantly urinate or the bladder spasm might cause straight leakage without any message to the brain. Again, both are “normal”. I get guys who say they never get urges to urinate because their bladder doesn’t get the chance to fill. It all just falls out.

I talk about protection. It’s important to protect the skin from constant dampness. It’s important to feel confident when you are out and about. Knowing what kind of incontinence padding to use is important.

I talk about the fact that they won’t be wearing protection. Meaning…there will be no need to use a condom* because there will be very little likelihood for unadulterated erections for quite some time. Can we just stop and appreciate what I just did words right there? I used the word “unadulterated” to describe erections. Unadulterated means that something is basically pure. I’m saying that for quite some time you won’t be able to get a meaningful erection without assistance from a device or medication. Can we stop one more time and appreciate that in the midst of being in awe of my own writing, I did something again that left me in awe. I double-awed myself. “Meaningful erection”. So many things in those two words added together. If you double-awe yourself, does that mean you are no longer in awe of yourself? Does it negate everything?

And what exactly do I mean by “quite some time”, right? I was being pretty vague there, but I know most men want me to be very specific about when erections will return. The reality is, some men get awesome erections back in 1-2 or even 3 years. Some men get awesome erections earlier. Some men get awesome erections only with medications or use of an assistive device. Not like a walker, not that kind of assistive device, but something like a penis vacuum that forces blood into the shaft. Or - less conservatively - a penile pump or prosthesis.

In this appointment, I let guys know that their penis will appear shorter after surgery. I’ve heard this described as an “outie” belly button. I sometimes use the phrase “turtle head”. This length can be regained. We help with that in physical therapy, but even those who don’t go to a physical therapist can see length come back over time.

Finally and arguably most importantly, this pre-operative appointment is supposed to teach you how to properly active your pelvic floor muscles so you can go home with a pelvic floor work out. The point of working out the pelvic floor before surgery is to beef up the muscles, make them more supple, make them better at restricting urine from completely falling out. When the pelvic floor muscles are in their best shape you are hypothetically likely to return to continence and erections faster. How do I teach proper pelvic floor muscle activation? I personally opt to put my finger in the rectum. I do use gloves. I do use lubrication. I do use care. I do use a lot of time. I give several different verbal cues to see which one gives the best contraction. I make sure the patient isn’t cheating with non-pelvic floor muscles and I make sure the patient is still breathing…during the contraction. No one has stopped breathing all together in my appointments. I mean…except when my knowledge and professionalism has taken their breath away. But, I mean, that just can’t be helped and it happens. No one’s fault. I digress. I then have patients contract non-pelvic floor muscles to see which of them enhance the pelvic floor muscle contraction by default. This is a form of cheating, but I mix it up. I teach how to isolate the pelvic floor muscles, but I also bump it up a notch by involving other muscle groups that are wired with the pelvic floor muscles.

While tons of men are getting “prehab”, there are multitudes more who never got the opportunity. All is not lost for these men. I will discuss what post-operative appointments are like in the next post.

*I do have to say that I am not advocating unprotected sex unless you are in a consensual relationship where all parties want to have unprotected sex and have been fully informed of each other’s health history. I was merely telling a joke. Some men can actually still penetrate soon after a prostatectomy either because they are extremely lucky or because they are using medication or a vacuum device.