Hypothesis / aims of study
Stress urinary incontinence (UI) is common in males after radical prostatectomy (RP) surgery. The prevalence of any type of UI one year after RP is 53 - 61% according to National register data. Pelvic floor muscle training (PFMT) is recommended to be started pre-operatively and to be continued after surgery [1]. Studies have shown that pre-operative or immediate post-operative PFMT may lead to a faster return to continence than in a control group [2], but results regarding long-term effects are inconsistent with each other.
Self-management of female stress UI with the support of a mobile app that includes an extensive PFMT programme has been shown to reduce symptoms and improve quality of life in comparison with controls [3]. Men undergoing RP requested a similar app adapted to men. The new app was developed based on the same structure as the app for women. It contained a programme for twelve levels of PFMT with visual and auditory instructions, and recommendations to do the exercises three times a day. The app allowed users to set reminders and to receive an exercise log. In addition, it included information about RP, UI, lifestyle and sexuality. During the development of the app, several versions of it were tested by men that had undergone RP, urotherapists and family practitioners. The final version was released in June 2018.
The aim of this study was to describe the characteristics of the users and to evaluate if an app might facilitate PFMT in men undergoing RP.
Study design, materials and methods
This was a cohort study conducted from June 2018 to March 2019. The data was collected via the app from a questionnaire that appeared on three different occasions; when the app was first opened, and at 30 and 90 days after download. The user was informed about the study and answering the questionnaires was voluntary. The questionnaires were submitted anonymously to a secure research database. A unique identification number for the questionnaires was generated within the app so that the questionnaires could be correctly paired in the secure database. The questionnaires could not be traced back to any telephone number, specific mobile phone or person. For this study, we included men that were planned to undergo RP and men that reported that they had undergone RP as well as the time since surgery (“completed RP”). We excluded men that had undergone transurethral resection of the prostate (TURP).
The baseline data collected was age, level of education, residing in rural/ urban areas, reason for downloading, type and severity of UI according to the International Consultation on Incontinence Modular Questionnaire–Urinary Incontinence Short Form (ICIQ-UI SF) (score ranging from 0 - 21), self-reported frequency of PFMT, and whether the users felt confident that they could correctly identify and contract their pelvic floor muscles. UI was defined as having an ICIQ-UI SF score of 1 or more. In addition, the severity of the UI was categorised based on the score (1 - 5 = slight, 6 - 12 = moderate, 13 - 18 = severe and 19 - 21 = very severe).
After one month the ICIQ-UI SF questionnaire was repeated, along with questions regarding frequency of PFMT and whether the user felt that they could perform a contraction correctly. Users were also asked to rate whether the app had facilitated PFMT using the alternatives: “yes, a lot”, “yes, somewhat”, “no, not particularly” and “no, not at all”.
Results
Of the 426 users that responded to the first questionnaire, 251 (58.9%) men met the target group criteria and 95 (37.8% of target group) of those answered the 30-day follow-up. The age of the 251 men in the target group ranged from 42 to 81 years with a mean age of 65.9 (SD 7.6). Of the men included, 43% had a university education and 51% lived in urban areas (city with >50,000 residents).
At inclusion, 215 men had completed RP and 36 were planned to have RP (Table 1). Of the 215 men that had undergone surgery, 3% were continent and the proportions of slight, moderate, severe and very severe UI were 12%, 38%, 35% and 12% respectively. The mean ICIQ-UI SF score was 11.4 (SD 5.5) for this group and 78% of the incontinent men had stress UI symptoms. Of the 36 men that were planned for surgery, 66% were continent and those who were incontinent had slight or moderate UI, except for one individual. The mean ICIQ-UI SF score for this group was 1.9 (SD 3.3) and one third of those who were incontinent had stress UI symptoms.
Of the 95 respondents at one-month follow-up, 76% performed PFMT daily compared to 47% at baseline, p<0.001. The percentage of users that reported that they could correctly identify and contract their pelvic floor muscles increased from 40% at baseline to 78% at follow-up, p<0.001. Upon answering the question “does the app facilitate PFMT”, 64% answered “yes, a lot”, 29% “yes, somewhat” and 7% “no, not particularly”.
Interpretation of results
In this pilot study, most men had already undergone RP and half of those had severe or very severe UI symptoms. Men who used the app at one-month follow-up had increased their frequency of PFMT and felt more confident in performing the contractions correctly. In further studies, we hope to reach more men that are planned to undergo RP. Larger controlled studies are needed to evaluate the effectiveness of PFMT in men undergoing RP.