Anxiety, depression, and urinary control outcomes in prostate cancer patients undergoing pelvic floor muscle training combined with electrical stimulation at different postoperative intervals after radical prostatectomy

Background and Objectives: Post-radical prostateectomy urinary incontinence (PRP-UI) impacts a large majority of prostate cancer survivors, and is strongly linked to high levels of psychological morbidity such as anxiety and depression. Pelvic floor muscle training (PFMT) with electrical stimulation (ES) proved to be effective in speeding up the rate of urinary recovery; nevertheless, the most effective period after surgery to start combined rehabilitation is not yet clear. The purpose of this study was to determine the effect of the initiation of Pelvic floor muscle training and ES at various post-operative periods on recovery of urinary control, anxiety, and depressive symptoms among prostate cancer patients undergoing radical prostatectomy (RP). Methods:This prospective, parallel-group, randomized controlled trial involved 113 men undergoing robot-assisted radical prostatectomy (RARP) in two tertiary urology centers. The participants were randomly allocated to three groups Group A (immediate PFMT+ES, initiated within 24 hours after surgery; n=38), Group B (early PFMT+ES, initiation at catheter removal, mean 7.2 days; n=38), and Group C (delayed PFMT+ES, initiation at 6 weeks after surgery; n=37). The main outcomes were the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), 24-hour pad weight test, and pad usage at 3 months and 6 months. The Generalized Anxiety Disorder-7 (GAD-7) scale, Patient Health Questionnaire-9 (PHQ-9), pelvic floor muscle strength (PFMS) assessed using perineal dynamometry, and SF-36 Mental Component Summary (MCS) scores were considered as secondary outcomes. Results:  At 3 months, continence rates (defined as 0–1 security pad/day) were 52.6%, 73.7%, and 34.2% for Groups A, B, and C, respectively (p<0.001). At 3 and 6 months, Group B showed much better results in all urinary parameters than the Groups A and C (p<0.001). GAD-7 scores at 6 months were 5.1±2.3, 3.8±1.9, and 6.4±2.7 for Groups A, B, and C, respectively (p=0.001). PHQ-9 scores at 6 months were 5.4±2.4, 3.9±2.0, and 7.1±2.9 for Groups A, B, and C, respectively (p<0.001). Strong positive correlations were found between ICIQ-SF scores and both GAD-7 (r=0.58, p<0.001) and PHQ-9 (r=0.61, p<0.001). The strength of the pelvic floor muscles was a considerable negative predictor of anxiety and depression (β= -0.54, p<0.001 and β= -0.59, p<0.001, respectively). Conclusion: PFMT with electrical stimulation on catheter removal (mean 7.2 days after surgery) results in better urinary continence recovery and more anxiety and depression reduction than immediate or delayed intervention. The restoration of urinary function was strongly correlated with psychological outcomes and thus rehabilitation protocols should be conducted timely in the context of an integrated biopsychosocial approach to the management of prostate cancer survivors.