Initial presentation
Mr X is a 62yr old man arriving for his first physiotherapy consultation which has been scheduled 4 weeks before his operation. Mr X has his wife with him, and they are sitting in the waiting room. Mr X and Mrs X are invited in to begin the consultation.

Mr X has only recently been diagnosed with prostate cancer. He is generally quite healthy and active; he was only going to see the GP for routine blood tests a few months ago. The blood tests showed a slightly elevated PSA which climbed a little more over a few months. The GP decided to send him to a Urologist who performed a digital rectal examination and discovered things did not feel quite right with the prostate. Mr X then had to undergo further tests.

It has been a whirlwind of shock, worry, investigations and appointments that has ruled his life over the past few weeks. Mr X is booked in for a prostatectomy in 4 weeks time. He understands a little bit about this surgery – the main thing he knows is that he might leak urine for a little while after it. This is why he is at physio – to learn how to use the pelvic floor muscles to help stop the leaking as soon as possible.

Mr X thought, vaguely, that he might have a pelvic floor muscle; he did know for sure that women definitely had a pelvic floor muscle, because – Mrs X needed to do pelvic floor muscle exercises after she had the children. In fact, Mrs X has been trying to tell her husband how to do the exercises, but he just doesn’t seem to understand very well. Mrs X is at the consultation today to help Mr X remember what was discussed during the consultation. He is finding it hard to remember everything due to the ‘whirlwind’ and coming to terms with his diagnosis.

Initially, the physio asks questions about how the diagnosis came about, what type of activity Mr X likes to do on a daily basis and what does Mr X understand about his operation and what to do post-operatively. The physio finds out that Mr X has a bit of an understanding about these things, but not much idea of where his pelvic floor muscles are and actually how to activate them.

After some anatomy education and instruction on how to activate the pelvic floor muscle, Mr X thinks he’s got it, however he is not confident. He is relieved when the physio says that we can look and check the pelvic floor muscles on a real time ultrasound machine – and even more relived when he finds out this does not require anything going in the rectum! Mr X is pleased to find out that yes indeed, he is activating his PFMs properly, although at times he tends to try a bit too hard and uses other muscles he doesn’t need to. Even though he can activate the muscles properly, they don’t seem to have much endurance and they are a bit sleepy which means his muscle coordination is less than optimal. Mrs X is intrigued to see his muscles working on the ultrasound machine, she is also interested to hear the different cues the physio gives to her husband to improve his understanding of how to do a pelvic floor muscle contraction.

Mr X is sent home with a structured and progressive pelvic floor muscle training regime. The exercise regime is specifically tailored to him after the initial assessment with the physio.

2 week follow up consultation
Mr X returns for his last pre-op consultation. The physio is impressed – he has been following the exercise program perfectly. This is demonstrated on the real time ultrasound machine where he can now hold his PFM contractions for longer and quickly recruit the muscles when asked, and on time. The physio upgrades his home program and they discuss the rest of the pre-operative information.

2 week post-operative consultation
Mr X returns for his scheduled review – the surgery went well and he has had his catheter removed a week ago. Despite this he is leaking quite a lot and needing pads for this. He is very worried about leaking and going to the toilet every 30 minutes or so to prevent the leakage. He has been doing his pelvic floor exercises, but not sure if this is making any difference. He is not doing any of his usual activities because he is unsure if he is allowed.

Mr X feels better after the physio asks some questions, checks his pelvic floor exercises, makes some modifications and then reassures him that he is on track. The physio gets him to practice activating his pelvic floor muscle when he needs it – especially when he goes from sit to stand, this is where he leaks the most. Within the 30 minute session with the physio he is already better able to control the leakage with standing. Mr X is sent home with his upgraded exercise program, guidelines for fluid intake/normal toilet visits and progressive general activity.

Over the next 3 months
Mr X visits the physio fortnightly then monthly. These sessions involve upgrading his pelvic floor muscle training program in relation to his symptoms and activity, weaning off pads and returning to all his normal house/leisure and exercise activities. By about 3-4 months Mr X is so pleased – he has returned to his normal activity and is now not needing a pad at night and mostly not during the day because he does not leak much urine anymore. Occasionally he leaks a few drops if he is tired, or had a bit more alcohol than usual, so he continues diligently with his pelvic floor muscle exercises and understands that this will improve. Mr X is confident to continue on his own now and very happy with his outcome all round. He knows he can contact the physio in future if he has any worries.

To protect confidentiality this case study is fictitious, being comprised of a number of different patients who make up a typical presentation of a man who is attending physiotherapy pre and post prostatectomy.