CThe quality of ancer treatment has increased significantly in the last few decades. This means that patients are living longer and more often after receiving medical and surgical interventions. This has led to the emergence of an area of cancer care called survivorship, which takes a holistic view of the patient’s well-being and sometimes involves therapies that haven’t always been part of the oncology playbook.
Sometimes physical therapy is required to improve the functioning of the pelvic floor in order to help bladder cancer survivorship.
The pelvic floor refers to “the muscles involved in bowel and bladder health and function,” says Dr. Matthew Mossanen, a surgical oncologist with the Dana-Farber Cancer Institute in Boston and assistant professor of surgery at Harvard Medical School.
Ting-Ting Kuo, a board-certified women’s health clinical specialist and director of rehabilitation at Memorial Sloan Kettering Cancer Center in New York City, describes the region as a “group of muscles, ligaments, and connective tissue that form the bowl-like structure at the base of the pelvis.”
A healthy muscle tone and control is important for core stability, bladder function and bladder control. It also supports other internal organs.
However, treatment of bladder cancer may be very invasive and cause damage to the structures and function. Data show that patients who receive chemotherapy in combination with surgery have the highest chance of long-term survival. However, surgery may cause problems that affect the function of this particular area.
Some bladder cancer patients undergo a cystectomy, a major surgical procedure that “involves removal of the bladder, and in men it involves removal of the prostate,” Mossanen says. “For women it involves removal of the uterus, the ovaries, and fallopian tubes, and part of the vagina. It’s a huge operation, and it’s done when bladder cancer has become life-threatening.”
Fortunately, “the majority of patients who have bladder cancer do not have to go through a cystectomy,” says Dr. Emily Slopnick, a urologist at the Cleveland Clinic in Ohio. The procedure is only for patients with advanced stage bladder cancer, who are still young enough and well-informed to undergo such complex surgery.
After it’s removed, the urinary system needs to be rebuilt, since the urine that the kidneys will still produce needs to go somewhere. Mossanen states that it can be either one or both.
First, a urostomy allows the surgeon to create an opening in your abdomen so that urine can flow into an external bag. Once it is full, the bag can be empty. Another option, a Neobladder (which creates an entirely new bladder in the body), is the second. “A neobladder is literally a substitute bladder that’s formed from a section of intestine,” Mossanen says.
Creation of a neobladder “can give patients a very good quality of life by helping some of the younger patients avoid the bag,” Mossanen says.
Slopnick states that any disruption in the urinary tract can cause issues. “Any time there’s any sort of trauma per se in the pelvis, the pelvic floor can react to that. People tend to get tension or spasms, almost like a cramping of the pelvic floor muscles,” as the body tries to protect itself from the trauma. It can also affect sexual function and continence.
What’s more, especially after a neobladder reconstruction, some patients may develop a variety of unwelcome symptoms, including urinary incontinence, an inability to fully drain the bladder, and leakage of urine, particularly when laughing, coughing, or sneezing. Mossanen suggests that patients suffering from these symptoms should be referred to a physical therapist for the pelvic floor, as rehabbing these important structures can improve bladder cancer survivors’ quality of life.
When it’s used
While physical therapy is typically thought of as a post-surgical intervention aimed at restoring function that’s been disrupted by illness and surgery, in the case of bladder cancer, prehabilitation of the pelvic floor may also be advisable, Mossanen says.
“I really do believe strongly in prehab,” he says. Mossanen at the Dana-Farber Cancer Institute has designed programs in this vein to assist patients with surgery. This includes classes in nutrition and overall health, as well as exercises that patients can perform to build their bodies before they go into surgery.
The concept of prehab makes sense: if you’re stronger heading into surgery, you’ll likely be able to recover faster. Though the idea hasn’t fully caught on in all places yet, Mossanen believes that prehab will likely become a more common feature of bladder cancer treatment in the future.
Prehab can be especially useful as patients prepare for a cystectomy and the long—about three months or so—post-surgical recovery period. “Many patients will have fatigue after surgery and have slow recovery or complications,” Mossanen says, in some cases due to the chemotherapy that often precedes a cystectomy. “Because of these factors, some patients cannot participate in rehabilitation, so there’s a wonderful justification to do prehab so that patients can recover with more resilience.”
Whether you’ll be engaging in pelvic-floor prehab or rehab related to bladder cancer, you’ll be working with a pelvic floor specialist—usually either a pelvic floor physical therapist or a rehabilitative medicine physician, also called a physiatrist. This group of specialists has the expertise and knowledge necessary to aid you with regaining function and decreasing complications.
When and how that provider gets involved “depends on the symptoms being experienced” as well as the type of care being provided, Kuo says. “The multidisciplinary team for the bladder cancer individual will identify the right time to refer for pelvic floor therapy.”
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How to get physical therapy for bladder cancer
If you’ll be undergoing physical therapy after bladder cancer, expect a very thorough physical exam, Slopnick says. “They’ll assess where you’re strong, where you’re weak.”
It may be necessary to insert a probe into the rectum or vagina to provide visual feedback. The screen maps the movement of the muscles. Also, the therapist may check for strength, coordination, and flexibility in the other core areas, such as the back and hips.
In the creation of an individualized care plan for you, your medical history will also be considered. “That includes a review of the past and current medical history, testing images, social history, lifestyle, and bowel and bladder habits,” Kuo says. For example, if your urgency to eliminate has increased after the surgery or you’re going to the bathroom more frequently, those changes may provide insight into what the pelvic floor specialist focuses on during therapy.
In this evaluation, the therapist will measure the pelvic floor function and then can review those measurements over time. This allows the therapist to assess how effective the therapy has been and to adjust the treatment plan.
As for the therapy itself, Slopnick says it’s always best to work with a trained provider. “I would not recommend just reading about it online and trying to figure it out on your own, because you’ve been through a complex disease process and had some complex treatments. It really is important to get evaluated by somebody to find out if it’s just the pelvic floor and make sure there’s nothing more going on.”
It’s difficult to estimate exactly how long pelvic floor therapy will last, as it’s so dependent on the individual’s needs and physical status. But typically, Kuo says, “it’s usually one to two times a week to start.” She notes that patients may need to complete exercises at home, outside of therapy sessions, too. “What’s really important is the consistency of the individualized care.”
Therapy options may include strengthening and relaxing exercises as well as manual massages to relax tight muscles. In other words, there’s a lot more to it than just doing some Kegels. “And it’s not just about the muscles around the pelvic girdle. It’s your legs, your trunk, your abdomen, your core, your back. We look at muscle balance, and we ensure that there’s really good mobility across the board,” Kuo says. This therapy also includes posture exercises and ergonomics for sitting or standing.
The benefits of pelvic floor rehab for bladder cancer
As the therapy progresses, “we’re going to be looking at some objective measures of pelvic floor muscle strength and coordination,” Kuo says. These can be used to assess soft-tissue flexibility and mobility as well as decreases in scar tissue and symptoms. “We take a look at whether [patients] decrease the number of incontinence pads they’re using, or have they increased the time between having to go to the bathroom.”
Mossanen also said that some patients might see these better metrics as secondary benefits to the psychological benefits they receive from working with a physical therapy to improve their pelvic floor. “I think there’s an emotional and cognitive benefit of having that support from another member of the team that can offer something that I can’t,” as a surgeon, he says.
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Rehabilitation for bladder cancer involves more than just physical therapy. It also includes nutritional counseling. Patients who are fitted with a neobladder made from part of their intestines have to be concerned about their bowel function. “That’s the big thing we’re watching for after surgery, is waiting for the bowel function to recover,” Slopnick says.
“The bowels slow down” as they recover from surgery, “and it takes a few days to a week for things to start moving through again,” she says. Patients during that time are usually advised to not eat too much fiber, and they are told to drink lots and plenty of fluids to support the healing process.
Kuo notes that drinking plenty of water is also particularly important for patients who’ve had a neobladder procedure; that new bladder pouch has been fashioned from a section of intestinal tissue that doesn’t have the same nerve endings or musculature that the urinary bladder did. With the Neobladder, there can be a different sense of urgency when it comes to having to go. “They’re not going to have the bladder muscle to let them know when they need to go, so they may need to set a time to go every few hours,” she says.
Walking and gentle exercise can be a great way to keep your digestive tract healthy and avoid complications like blood clots.
There’s a lot to know when undergoing surgery for bladder cancer, and some of these topics might make you feel a little uncomfortable. You’re not alone if you find it awkward talking about bowel and bladder function, and what goes on in the bathroom, with anyone, let alone a room of doctors. However, your healthcare team can help. “If you’re experiencing any symptoms, have a conversation with your health care provider,” Kuo urges.
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