Lynda McClatchie, Author at Elevation Physiotherapy & Wellness

Kegel Exercises for Men Post-Prostatectomy May Not Always Be Good

Kegel Exercises for Men Post-Prostatectomy May Not Always Be Good

Pelvic floor physiotherapy does not equal Kegels. It also involves teaching each patient how to manage the increased pressure in the system when they cough, sneeze or move, and also learning how to appropriately engage their pelvic floor muscles as they are moving in certain ways. Each patient is different: many men don’t properly engage their pelvic floor muscles, and other men might keep their pelvic floor muscles engaged too much of the time and need to learn to relax them.

A new study in International Urology and Nephrology, suggests there may be a subset of post-prostatectomy patients who need to learn to relax their pelvic floor in order to improve incontinence. Many men have significant incontinence initially following radical prostatectomy—not just stress urinary incontinence, but a consistent drip requiring the use of many pads through the day and night. Of course they improve as time goes on, and continence improves first when the man is not moving (sitting or lying down). Commonly, men continue to leak with movement for several months. Many men get in the habit of engaging their pelvic floor consistently in an effort to prevent any leaking, and over months can lead to them having difficulty getting those muscles to relax. Keeping the pelvic floor muscles tight too much of the time can lead to urinary urgency and frequency. As well, men often urinate more frequently because they don’t want to leak, so over time their brain teaches the bladder to become less of a reservoir.

The above retrospective study had136 patients with post-RP SUI who were treated with pelvic physiotherapy. Of these, 25 had underactive pelvic floor muscles, 13 had overactive pelvic floor muscles, and 98 had evidence of both. All men received therapy to either relax or strengthen their pelvic muscles. The total number of pelvic physical therapy sessions depended on a patient’s progress. Incontinence improved in 87% of them, with 58% achieving what is considered the optimal improvement of needing 2 or fewer protective pads per day. Further, pain was a problem for 27% of the men, but that proportion dropped to 14% by the end of therapy.

The authors concluded that this study was the first to demonstrate that pelvic health physiotherapy can be a beneficial treatment modality for men who have pelvic pain after prostatectomy, because the pain for some men may be due to pelvic floor muscle overactivity.

It appears that men who have surgery often develop pelvic floor overactivity or muscle tightness postoperatively, and any type of pelvic floor dysfunction can lead to stress incontinence. Kegel exercises can worsen pelvic floor overactivity, and are not the best treatment for every patient.

Nearly all men have urinary incontinence immediately after a prostatectomy, but that percentage drops to about 5% to 20% within 24 months following RP. Men who have not seen improvement within 2 to 6 months should seek physiotherapy.

It was also concluded that pelvic floor training engages the patient in their rehabilitation process, and is a good resource to utilize postoperatively. It also underscores that personalized treatment of post-RP incontinence may be warranted, as some patients will benefit from strengthening work, while others need to learn to relax their pelvic floor muscles.

Reference Scott, KM, Gosai E, Bradley MH. et al. Individualized pelvic physical therapy for the treatment of post-prostatectomy stress urinary incontinence and pelvic pain

[published online December 5, 2019]

Pelvic floor physiotherapy does not equal Kegels. It also involves teaching each patient how to manage the increased pressure in the system when they cough, sneeze or move, and also learning how to appropriately engage their pelvic floor muscles as they are moving in certain ways. Each patient is different: many men don’t properly engage their pelvic floor muscles, and other men might keep their pelvic floor muscles engaged too much of the time and need to learn to relax them.

A new study in International Urology and Nephrology, suggests there may be a subset of post-prostatectomy patients who need to learn to relax their pelvic floor in order to improve incontinence. Many men have significant incontinence initially following radical prostatectomy—not just stress urinary incontinence, but a consistent drip requiring the use of many pads through the day and night. Of course they improve as time goes on, and continence improves first when the man is not moving (sitting or lying down). Commonly, men continue to leak with movement for several months. Many men get in the habit of engaging their pelvic floor consistently in an effort to prevent any leaking, and over months can lead to them having difficulty getting those muscles to relax. Keeping the pelvic floor muscles tight too much of the time can lead to urinary urgency and frequency. As well, men often urinate more frequently because they don’t want to leak, so over time their brain teaches the bladder to become less of a reservoir.

The above retrospective study had136 patients with post-RP SUI who were treated with pelvic physiotherapy. Of these, 25 had underactive pelvic floor muscles, 13 had overactive pelvic floor muscles, and 98 had evidence of both. All men received therapy to either relax or strengthen their pelvic muscles. The total number of pelvic physical therapy sessions depended on a patient’s progress. Incontinence improved in 87% of them, with 58% achieving what is considered the optimal improvement of needing 2 or fewer protective pads per day. Further, pain was a problem for 27% of the men, but that proportion dropped to 14% by the end of therapy.

The authors concluded that this study was the first to demonstrate that pelvic health physiotherapy can be a beneficial treatment modality for men who have pelvic pain after prostatectomy, because the pain for some men may be due to pelvic floor muscle overactivity.

It appears that men who have surgery often develop pelvic floor overactivity or muscle tightness postoperatively, and any type of pelvic floor dysfunction can lead to stress incontinence. Kegel exercises can worsen pelvic floor overactivity, and are not the best treatment for every patient.

Nearly all men have urinary incontinence immediately after a prostatectomy, but that percentage drops to about 5% to 20% within 24 months following RP. Men who have not seen improvement within 2 to 6 months should seek physiotherapy.

It was also concluded that pelvic floor training engages the patient in their rehabilitation process, and is a good resource to utilize postoperatively. It also underscores that personalized treatment of post-RP incontinence may be warranted, as some patients will benefit from strengthening work, while others need to learn to relax their pelvic floor muscles. Reference Scott, KM, Gosai E, Bradley MH. et al. Individualized pelvic physical therapy for the treatment of post-prostatectomy stress urinary incontinence and pelvic pain [published online December 5, 2019]. Int Urol Nephrol

9 HELPFUL BACK PAIN FACTS

1. Most back pain is not a serious, life-threatening condition.

2. A weak core does not cause back pain, ever. Really.

3. Feeling like you won’t get better and avoiding moving around can make the pain last longer.

4. Imaging of the back (Xray, MRI) do not determine outcomes or how long pain lasts. Often they are not helpful at all.

5. Graduated exercise and movement in all directions is safe and healthy for the spine.

6. Spine posture during sitting, standing and lifting does not predict back pain or its persistence.

7. Pain flare-ups are more related to changes in activity, stress and mood rather than structural damage.

8. Spine movement and loading is safe and builds structural resilience when it is done regularly and properly. Effective care for LBP is relatively cheap and safe. This includes: education that is patient-centred and fosters a positive mindset, and coaching people to optimise their physical and mental health (such as engaging in physical activity and exercise, social activities, healthy sleep habits and body weight and remaining in employment).

At Elevation Physiotherapy & Wellness, we are very good at helping people through their back pain to get to the source of the problem and getting them back to full life!

Get better, faster.

Back to basics: 10 facts every person should know about back pain. Peter B O’Sullivan et al. British Journal of Sorts Medicine. Editorial. Dec 2019

Returning to Running After Baby

Let’s face it—giving birth is trauma to the body, and it takes time to heal before returning to anything even remotely athletic. Several authors established the guidelines below based on the classifications from the Royal College of Obstetricians and Gynecologists (Goom, Tom & Donnely, Grainne & Brockwell, Emma. (2019). Returning to running postnatal – Guidelines for medical, health and fitness professionals managing this population.)

I can summarize it all by saying 3-6 months, depending on several factors, and it is best to start with low impact exercise and progress to running.

0-2 Weeks:

• Pelvic Floor muscle exercises (Kegels)

• Basic core exercises (e.g. pelvic tilt, bent knee drop off, side lying abduction)

• Walking

2-4 Weeks:

• Progress walking/pelvic floor muscle/core rehab

• Consider introduction of squats, lunges, bridges

4 -6 Weeks:

•can introduce biking, cross trainer or other low impact exercise, if new mother is comfortable

6-8 Weeks:

• Scar mobilization (for either C-Section or perineal scar)

• Power Walking

• Increased duration/intensity of low impact exercises

• Deadlift techniques beginning with light weights, no more than the weight of the baby in a car seat (15kg) with gradual load progression (e.g. barbell with no weight). This aims to strengthen and restore strategies for carrying out the normal everyday tasks required when caring for a newborn and/or older sibling

8-12 Weeks:

• Introduce swimming (if lochia has stopped and there are no issues with wound healing)

• Spinning (if comfortable sitting on spinning saddle)

Assessment of Pelvic Health

• Return to running is NOT advised if the following is present:

• Urinary and/or fecal incontinence

• Pressure/bulge/dragging in the vagina before or during the start of running

• Ongoing or onset of vaginal bleeding, not related to menstrual cycle, during or after attempted low impact or high impact exercise

• Reduced pelvic floor muscle endurance. Recommended baseline in standing: 10 x fast reps, 10x 6-8 second holds, and 60 seconds submaximal (30-50% contraction) hold

• strength testing of the pelvic floor muscles by a Physiotherapist should be > Grade 3/5

Objective Assessment

Before returning to running, it is recommended that the new mother needs to be able to complete the following without pain, heaviness or incontinence:

• Walking 30 minutes

• Single leg balance 10 seconds

• Single leg squat 10 repetitions each side

• Jog on the spot 1 minute

• Forward bounds 10 repetitions

• Hop in place 10 repetitions per leg

Aim for 20 repetitions of each test:

• Single leg calf raise

• Single leg bridge

• Single leg sit to stand

• Side lying abduction

And Other Considerations:

Weight: increased weight puts greater load on the pelvic floor
Fitness: it is better to start with lower impact activities, and where you have to start will depend on your birth experience and symptoms
Breathing matters!
Diastasis Recti: expert consensus is that a mother can return to running if the DR is functional (there are strategies to control intro-abdominal pressure) and not before
Scar Mobilization: Both C-Section and perineal scars can result in pain and restriction. It is recommended to assess and implement advice and guidance regarding scar mobilization.
Sleep: Sleep deprivation (<7-9 hours/night) is associated with increased risk of injury, increased stress, and may reduce muscle protein synthesis. Education regarding optimizing sleep, day-time naps and good sleep hygiene may be warranted.

So… clearly it is more involved than just “3-6 months”. If you are not leaking, feel psychologically ready, and can perform the above pelvic floor and strength testing, it would still be smart to return to running using a walk:run program, such as 1 min run and 1 minute walk (with the run speed being able to hold a conversation, not faster), with gradual increase to 10:1

The Physiotherapists at Elevation Physiotherapy & Wellness excel at the proper and safe return to running after baby. Contact us anytime to make sure your pelvic floor health is adequate, and we can devise an individual program for you to improve strength to reach all of your fitness goals!

Peeing all the time? Physiotherapy can help!

Symptoms of urinary urgency or frequency are very common and can be incredibly disruptive to your life. It is not a good feeling to have to run your life by where your next bathroom is.

A physiotherapist with advanced training to treat pelvic floor dysfunction can help! There are several factors that you need to look at:

1. Consider your pelvic floor: the pelvic floor muscles work like every other muscle in the body, they’re just inside. It is important to make sure you can properly engage those muscles and also relax the muscles easily. These muscles can be involved with issues with urinary urgency and frequency or pelvic-area pain.

2. Measure things: sometimes certain tools can be used to get a big-picture sense of what is going on, and can help your Physio design the plan that will help you fastest. These can include tests like:

Bladder diary- provides a picture of your bladder and bowel habits, how much and what you drink to figure out any patterns. Constipation is important to address as it can impact bladder function as well as pelvic pain.
DASS (Depression, Anxiety and Stress Scale)
PCS (Pain Catastrophization Scale)

4. Look at everything: a thorough physiotherapy assessment includes looking at how you breathe, your posture, how you move, your lower back, and overall strength—not just the pelvic floor itself. The pelvic floor muscles are very important with urinating, having a bowel movement, and sexual function. There are many reasons for the onset of overactive pelvic floor muscles, and it is important to get to the driver or source of this in order to move symptoms forward.

5. Diet modification– caffeine, alcohol, carbonated beverages, tomato products, citrus fruits and juices and cranberry juice are several irritants that can contribute to intense discomfort. Sometimes they need to be stopped for a period of time to help symptoms.

6. Breathing– HOW you are breathing matters! Purposeful deep breathing can calm your nervous system, and can be one of the easiest, yet most effective, interventions to learn.

7. Help improve sleep– three out of four people who have ongoing pelvic pain have difficulty staying asleep, and that is worse if you have to get up in the night to pee. Going to sleep at the same time every day, staying warm, and no screens right before bed can all be helpful.

8. Manual therapy– different treatment techniques will be helpful for different people—one thing does not work for everyone, of course! Your Physio will likely want to work with stretching or strengthening different muscles (pelvic floor and others), and techniques for your nerves and connective tissue With the pelvic floor, it is possible to be both too tight and too weak, and lengthening must be addressed first.

9. Exercise: exercises that are fun, non-irritating and novel will help to change the brain to look at pain differently.

All of these things can help change pain, frequency or urgency issues to help get better, faster!

Is Pelvic Organ Prolapse Reversible?

Pelvic organ prolapse (POP) is when the bladder or the uterus starts to descend in the vagina due to the muscles and connective tissue in the area not providing enough support. It is not typically painful per se, but can create a feeling of heaviness and pressure in the vagina that gets worse the longer a person is on her feet.

Pelvic support changes throughout the day! The degree of descent can depend on pregnancy, the contents of the bowel and bladder, hormones, recent physical activity, stage in the menstrual cycle—the list goes on.

So… there are several factors that could influence the support of the pelvic floor:

Change in the strength of the levator ani muscles of the pelvic floor: strengthening means they can better resist the downward movement of the pelvic organs with pressure changes due to breathing and movement. If the levator ani muscles are worked regularly, they show improvement in strength, endurance, coordination and function— and the nervous system is better able to recruit the muscles.
Connective tissue changes: pelvic ligaments in those with prolapse are longer than those without prolapse. The bladder, urethra, vagina and uterus are attached to the pelvic walls through connective tissue called the endopelvic fascia, and that can be vulnerable due to childbirth and repetitive straining. It is not likely that the connective tissue will adapt much to pelvic floor muscle strengthening, but the prevention of further stretching of the ligaments is positive.
Hormonal influences are huge: estrogen receptors in the bladder, uterus, vagina and pelvic floor can make collagen to increase the thickness of the vaginal wall. With decreased estrogen with menopause, the vaginal walls can become thinner, more acidic and have decreased blood flow. An estrogen supplement can lead to reproduction of collagen to support the tissues to withstand downward forces.
Pressure changes: the pelvic floor responds to what is happening above it, and adjusts the pressure; be sure to contract the pelvic floor before coughing, sneezing, laughing etc to better manage the pressure system.
Time of day- people report that POP seems to worsen as the day goes on, likely due to the amount of time spent upright, which will increase the demand of the pelvic floor due to gravity

Research shows that 19% of participants in pelvic floor strengthening program experienced a decrease in grade of POP, but 74% reported a reduction of bothersome symptoms. Instead of thinking about “reversal” of prolapse, it is maybe better to think about regaining function and restoring strength through the pelvis. There can be improvement due to remodeling of tissue and increasing estrogen levels, and it is very important to control what you can! There is hope to improve a prolapse through strengthening the area, managing the pressure system, controlling weight and looking at supplemental estrogen. Symptoms can be significantly improved—work with the pelvic floor physiotherapists at Elevation Physiotherapy & Wellness to help you get better, faster!

Safe Return to Exercise After Baby

Exercise is good, right? But how soon is too soon after giving birth?

If you had an uncomplicated vaginal birth, you can start gentle exercise (walking, stairs, breathing exercises, some abdominal exercises) almost immediately after giving birth, but clear it with a medical professional first.

Research on women who begin exercise after giving birth shows that there can be a disconnect between the pelvis and the rest of the body when trying to get back to exercise after baby. The muscles and connective tissue through the abdomen is put on stretch for several months, and are longer and softer for a period of time after giving birth, and this can lead to pain in the joints of the pelvis and pubic bone.

It would not be at all typical to experience severe pain, dizziness, weakness, vision changes, chest tightness, bleeding or leg pain—be sure to check in with your physician if experiencing any of these. Otherwise, start back at up to 30 minutes of walking each day—if you can’t do 30 minutes all in one shot, then try two 15 minute walks, or even six 5 minute walks spaced through the day. Just keep moving.

Also, get your pelvic floor moving—it would be best to be checked by a pelvic floor physiotherapist who can make sure that you are engaging properly and give you a specific exercise program to start, and teach you how to breathe on exertion. The National Academy of Sports Medicine in the U.S. recommends breath work and easy abdominal exercises with moving your legs to start.

If you’ve had a Cesarean- section, you may have to wait a bit longer to get back to the exercise game. Walking is good, and do get back to pelvic floor strengthening, but hold off at least 8 weeks for more vigorous exercises.

If you are wanting to get back to running post-partum, try the jump test first: have a full bladder, and jump up and down 20 times in a row, followed by coughing four times in a row—if you didn’t leak urine or feel any heaviness in your pelvis or vagina, you’re likely ready for that run!

Prepare for Fall Hiking: 5 Minute Dynamic Stretching

Fall is such a great time to get outside for a hike and explore our paths and trails—the cooler temperatures and the bright fall colours make getting outside a wonderful and healthy activity. Whether you are new to hiking or have experience, it is important to know how to prepare for a hike. Of course it is important to bring water and wear appropriate footwear, but it is also essential to prepare your body for a hike.

Dynamic stretching can warm up your muscles and get them ready for the hike. They involve moving through the stretches instead of holding one position. Typical static muscle stretching require you to hold a position for 10 seconds or more, and dynamic stretching can better prepare your body for the different movements you will do during a hike.

A good dynamic warm up can improve your range of motion and flexibility around the joints in your hips and legs, and bring blood flow to those muscles to get them ready to move. For hiking, the hip flexors, hamstrings and quads of the thighs, and calves are working all the time, especially if your trails are up and down hills. A pre-hike stretch should only take about 5-10 minutes, and should never be painful.

Then you’re all set to hit the trail!

Dynamic Stretches for Hiking:

Straight-Leg Lateral Swing: holding on to something for stability, keep your right leg straight and swing it in front of your body like a pendulum, lifting it as high as you can out to the side. Do not move your trunk. Swing 10 times, then switch legs.

Side Lunge: start with both feet wide apart and facing forward. Bend your right knee as you shift your weight over your right foot, then shift your weight all the way over to your left foot as you bend the left knee. Lunge back and forth 10 times in each direction.

Bent- Knee Forward Swing: with your hands on a wall, bend up your right knee to a 90° angle, then drive it away to straighten behind you. Repeat by swinging the leg up and back 10 times, then switch sides.

Heel Raises over a Step: While holding on for balance, keep the balls of your feet on the edge of a step or ledge. Come up onto your toes of both feet, then lower down slowly until your heels are below the step, moving through the whole range of motion at the ankles. Repeat 10 times, keeping equal weight through both legs

Do We Really Need to Sit Up Straight?

Posture– or avoiding slouching—is often discussed by people who have lower back or neck pain. People are often told to sit up straight, as poor posture has been thought to be one of the causes of back or neck pain. Research shows that people with low back pain may find certain postures painful, but it can’t be proven that the postures are the cause of pain.

Movement and changing positions can be helpful, as sedentary lifestyles are a risk factor for low back pain, among many other health conditions.

1. There is no single “correct” posture. Despite common posture beliefs, there is no strong evidence that one optimal posture exists or that avoiding “incorrect” postures will prevent back pain.

2. Differences in postures are a fact of life. There are natural variations in spinal curvatures, and there is no single spinal curvature strongly associated with pain. Pain should not be attributed to relatively “normal” variations.

3. Posture reflects beliefs and mood. Posture can offer insights into a person’s emotions, thoughts, and body image. Some postures are adopted as a protective strategy and may reflect concerns regarding body vulnerability. Understanding reasons behind preferred postures can be useful.

4. It is safe to adopt more comfortable postures. Comfortable postures vary between individuals. Exploring different postures, including those frequently avoided, and changing habitual postures may provide symptom relief.

5. The spine is robust and can be trusted. The spine is a robust, adaptable structure capable of safely moving and loading in a variety of postures. Common warnings to protect the spine are not necessary and can lead to fear.

6. Sitting is not dangerous. Sitting down for more than 30 minutes in one position is not dangerous, nor should it always be avoided. However, moving and changing position can be helpful, and being physically active is important for your health.

7. One size does not fit all. Postural and movement screening does not prevent pain in the workplace. Preferred lifting styles are influenced by the naturally varying spinal curvatures, and advice to adopt a specific posture or to brace the core is not evidence based.

D. Slater et al. (2019) “Sit Up Straight”: Time to Re-evaluate. JOSPT. 49(8):562-564

How Normal is it to Pee in the Night?

I always hesitate to use the word “normal”, as there are so many factors that go into how often you pee. If you typically get up once in the night, then that is probably normal for you. If your sleep is disrupted because you’re getting up more frequently, then possibly something needs to change during the day while you’re awake.

Are you drinking too much after dinner? Assuming you’ve been drinking fluids through the day and your kidneys are working properly, stopping all fluid intake 2-3 hours before bed will reduce waking up at night.
Are you drinking alcohol or caffeine? Both are diuretics, meaning they make the body produce more urine. Enough said.
Are you pregnant? There is a pregnancy hormone called human chorionic gonadotropin (hCG), which will increase blood flow to the kidneys and uterus—this will put pressure on the bladder.
Do you take medications for high plod pressure, muscle relaxants or sedatives? Some of these drugs can make you pee more.
Are you over 60? As you age, the bladder tends to not hold as much, so if you’re drinking the same amount as when you’re younger, then you may have to pee more often. As well, menopausal women can have changes in the urethral tissue—the tube from the bladder that urine flows out—that make the urge to pee more prominent in the brain, so women may want to keep less in the bladder and empty more often.
Do you have a UTI or prostate issue? If peeing in the night is also associated with burning or urgency, it could be due to a UTI or enlarged prostate. A larger prostate can lead to thickening of the bladder tissue, and the prostate can make the urethra smaller, so the bladder holds less and is less elastic, and then has to push against the obstruction of the prostate. This equals more peeing, day and night.

When should you get it checked?

If you are up a few times in the night, try to keep a bladder diary for two 24 hour periods and see if there is a pattern—track how much you take in, what you are drinking, how often you pee, and how long is the flow of pee in seconds. If you’re peeing more than 8 times in any 24 hour period, that is likely too much. If frequent peeing is also associated with increased thirst, weight loss or increased appetite, you should get checked by your family doctor. If you notice the frequency of peeing in the night getting worse, if you see blood in your urine, it is painful to pee, or if you’re going to pee often but only in small amounts, then get checked by your doctor.

Really, the pelvic floor?

If you’re peeing often, or have real urgency to pee through the day or night, then sometimes the brain and the pelvic floor can be the cause. If other things, like UTI or prostate issues, have been ruled out, sometimes having a pelvic floor that is too tight or too weak (or both) can be an issue. The pelvic floor is often ignored by most until they have a problem. At Elevation Physiotherapy & Wellness, we are your pelvic floor specialists who can help with bladder frequency and urgency due to pelvic floor issues—there is much that can be done, let’s start now!

Not Only Women Should Pay Attention to Their Pelvic Floor

It’s fair to say that most people never give their pelvic floor muscles any thought at all until they have a problem. The pelvic floor group of muscles work like every other muscle in the body, but because they are inside the body, they are easily ignored.

Of course both men and women have the same pelvic floor muscles—mostly. The superficial layer is a little different, but the deeper layers of muscles, bladder and rectum are all the same, and men can have the same issues with urinary incontinence or pelvic pain as women.

Recent studies show that many men undergoing a radical prostatectomy (having the prostate removed due to cancer)will be incontinent as a result of the surgery, and having a pre-operative program of Kegels (pelvic floor muscle exercises) can help after surgery for men to use fewer pads for a shorter period of time. These studies demonstrated that men who work to strengthen their pelvic floor muscles prior to surgery do better than the “controls”—the group who does Kegels leak less urine, and score better on the Incontinence Assessment Scale (ICIQ-SF).

At Elevation Physiotherapy & Wellness, we have physiotherapists who specialize in pelvic health, and can ensure that any man is performing Kegels properly, start a program of exercises to be done daily, and progress through more difficult variations of exercises as each man is able. Studies show that these treatments are inexpensive, and have zero side effects. Don’t buy pads forever—get to work strengthening the pelvic floor. It can help you get better, faster.

https://elevation-physio.com/services/pelvic-health-physiotherapy/

Aylin Aydın Sayılan and Ayfer Özbaş. The Effect of Pelvic Floor Muscle Training On Incontinence Problems After Radical Prostatectomy. 2018: American Journal of Men’s Health, Vol. 12(4): 1007-1015

Li-Hui Pan et al. Improvement of Urinary Incontinence, Life Impact, and Depression and Anxiety With Modified Pelvic Floor Muscle Training After Radical Prostatectomy. 2019: American Journal of Men’s Health, Vol. 13(2): 1-10