Pelvic Floor Rehabilitation After Cancer

Cancer treatment aimed at the pelvis leaves a specific set of problems behind: urine leaking, stool leaking, urgency, pain with sex, a vagina that has narrowed, erections that no longer work. People often carry these for years without telling anyone. They are treatable, and there is a body of practical, tested work behind that treatment.

Pelvic floor rehabilitation is that work. It starts with a group of muscles that sit under the bladder, the uterus, and the bowel.

Radiation to the pelvis irritates the bladder and urinary tract, usually starting a few weeks after treatment begins. NCI calls the result radiation cystitis. It brings pain or burning when passing urine, blood in the urine, urgency, going often, and bladder spasms.

In women, pelvic radiation also causes vaginal stenosis, which means the vagina becomes less elastic, narrower, and shorter. NCI lists it alongside vaginal atrophy, which is weak vaginal muscles and a thin vaginal wall, and vaginal itching, burning, and inflammation. All of these can make sex painful.

Surgery is the other driver. Prostate removal, bladder cancer surgery, and radical hysterectomy all raise the risk of urinary problems and infection. Surgery for penile, rectal, prostate, testicular, and other pelvic cancers may damage nerves, which makes it hard to get and keep an erection.

Radiation to the pelvis and brachytherapy, meaning radiation delivered from a source placed inside the body, can also damage blood vessels or nerves and cause erectile dysfunction.

Chemotherapy and hormone therapy lower estrogen levels in women. That brings hot flashes, irregular or absent periods, and vaginal dryness that can make sex difficult or painful.

These exercises tighten the muscles that control the flow of urine. MedlinePlus lists two clear uses: urinary stress incontinence, in women and in men after prostate surgery, and fecal incontinence, which is leaking stool.

NIDDK gives the technique in plain steps.

Find the muscles. Imagine you are trying to stop passing gas, and squeeze the muscles you would use. A woman can insert a finger into the vagina and squeeze as if holding in urine. A man can insert a finger into the anus and squeeze the same way. You can also stop the flow midstream once to identify the muscles, but do not make a habit of it.

Do the exercise. Hold the squeeze for 3 seconds. Build up to 10 to 15 repetitions each time. Do it at least three times a day, in three positions: lying down, sitting, and standing.

Expect it to be slow. NIDDK says bladder control may not improve until after 3 to 6 weeks. MedlinePlus reports most people notice some improvement at 4 to 6 weeks, and that major change can take 3 months.

Common mistakes. Do not tighten your stomach, thighs, or buttocks at the same time. That pushes more pressure onto the bladder and can make leaking worse. Do not practice while urinating on a regular basis, because it raises the risk of a bladder infection. Do not overdo it. Too much can cause straining when you urinate or move your bowels, and can tire the muscle so leaking increases.

If the exercise hurts, you are doing it wrong. Stop and ask for coaching.

NIDDK is explicit: check with your health care professional before you begin. A professional can confirm you are using the right muscles and can add tools.

Biofeedback uses electrodes and a monitor to display your muscle contractions on a screen, so you can see whether you have found the right muscles. Electrical stimulation is another aid. MedlinePlus lists Kegel exercises with biofeedback and pelvic floor physical therapy among the things to raise with your provider.

The professional most likely to run this is a physical therapist with training in pelvic health. Ask the oncology team for the referral by name. A urologist, a gynecologic oncologist, a colorectal surgeon, or a nurse continence specialist may also be involved.

Two things are worth settling in advance.

Consent for an internal examination. Some pelvic floor assessment involves an internal vaginal or rectal exam. You can ask what the therapist plans to do, ask for a chaperone, ask to start with an external assessment only, and stop at any point. Ask these questions when you book, not while you are on the table.

Clearance from the oncology team. Ask directly whether recent surgery, active radiation, an unhealed wound, an infection, or low blood counts change what is safe for you right now. Bring that answer to the therapist.

MedlinePlus sets out self-care that runs alongside the muscle training.

• Bladder training. Hold off going for 10 minutes at first. Slowly stretch to 20 minutes. The goal is holding urine up to 4 hours.
• Timed voiding. Urinate at set times whether or not you feel the urge, roughly every 2 to 4 hours.
• Fluids. Drink enough water. Cut fluids 2 to 4 hours before bed.
• Trigger foods. Caffeine, fizzy drinks, alcohol, citrus fruit, tomatoes, spicy food, chocolate, and artificial sweeteners can all make things worse.
• Constipation. Increase fiber. A loaded bowel makes bladder control worse.
• Skin. Clean gently after urinating. Barrier products with petroleum jelly, zinc oxide, or cocoa butter protect the skin. Absorbent pads help during exercise.

For scarring caused by radiation therapy or graft-versus-host disease, NCI names a dilator, a smooth device used to gently stretch the vagina, to help prevent or reverse that scarring. Ask who will teach you to use it, how often, and for how long. This is a routine part of care after pelvic radiation, not an optional extra.

For dryness and irritation, NCI mentions vaginal gels or creams to stop a dry, itchy, or burning feeling, and vaginal lubricants or moisturizers.

For men, NCI lists medicines that increase blood flow to the penis, and surgical options in which a firm rod or an inflatable device, called a penile implant, is placed in the penis. NCI's suggested question to your doctor is a good one to borrow: what specialists would you suggest that I talk with to learn more?

NCI says that in people being treated for cancer, a urinary tract infection can turn into a serious condition that needs immediate medical care. So the fever line here is not a phone call.

• Go to an emergency department, or call 911, if your temperature is 100.4°F (38°C) or higher, especially with shaking chills, or if you are confused, breathing fast, or too weak to stand. Tell them you are having cancer treatment. Also go straight in for heavy bleeding into the urine with clots you cannot pass, or if you suddenly cannot pass urine at all.
• Call your care team the same day if passing urine burns or hurts, your urine is cloudy or pink, or you are going far more often than usual without a fever.
• Call your care team within a day or two if leaking, urgency, pelvic pain or pain with sex is not improving, or the exercises hurt. Technique can be checked and the plan changed.

Do not wait to see whether it settles overnight.

• Which of my symptoms are from surgery, which from radiation, and which from hormone changes?
• Is pelvic floor physical therapy right for my particular problem?
• Am I cleared to start now, or do we wait for healing?
• Will you check that I am squeezing the correct muscles, and how?
• Would biofeedback help me?
• What will you do at the first visit, and can we skip the internal exam this time?
• How many sessions, how often, and what do I practice at home between them?
• When should I expect to notice a difference, and what do we do if I do not?
• Who handles the sexual side of this, and can I get that referral now?

• Urinary and Bladder Problems and Cancer Treatment — National Cancer Institute
• Sexual Health Issues in Women and Cancer Treatment — National Cancer Institute
• Sexual Health Issues in Men and Cancer Treatment — National Cancer Institute
• Kegel Exercises — National Institute of Diabetes and Digestive and Kidney Diseases
• Pelvic floor muscle training exercises — MedlinePlus Medical Encyclopedia
• When you have urinary incontinence — MedlinePlus Medical Encyclopedia