Adherence and barriers to penile rehabilitation over 2 years following radical prostatectomy.

BACKGROUND: A variety of penile rehabilitation (PR) therapies are available to improve post-prostatectomy erectile dysfunction (ED) with mixed results. It is uncertain how adherent men are to PR therapies. The aim of this study is to determine adherence to and identify barriers to PR treatment. METHODS: A longitudinal cross-sectional approach was used in men who underwent radical prostatectomy over 2 years. Men were instructed to take a PDE5 inhibitor (PDE5i) three times per week, and if required, utilize a vacuum constriction device (VCD) daily. Outcomes were measured by multiple validated questionnaires. In addition, penile stretched length, side effects, compliance to PR regimen & barriers to participation were documented. RESULTS: Seventy-seven patients were enrolled, however only 49 completed evaluation at 3 or more timepoints and were included in analysis. This cohort was an average age of 58.1 years (±7.7), had robotic laparoscopic radical prostatectomy (91.7%), and had bilateral nerve sparing procedures (95.8%). Majority (62.5%) reported normal SHIM pre-operatively, however 79% used PDE5i. Erectile function as measured by IIEF and Erection Hardness Rating were negatively affected post-operatively, with gradual improvement in parameters throughout the 24 month follow up. Of the participants who had normal pre-op SHIM, only 23.1 and 28.6% regained baseline function at 1 and 2 years, respectively. Orgasm was significantly diminished immediately post-operatively, however, at the end of the study period only 37% of men reported diminished climax and no men reported absent orgasm. Adherence to penile rehabilitation therapies declined overtime. Men took oral PDE5i on average 2.3 times weekly at 12 and 24 months (p < 0.001). Men used the VCD 2.3-3.9 days a week, which declined overtime (p = 0.014). CONCLUSIONS: Improvement in erectile and orgasm parameters was observed over time, but most men did not return to baseline function. Despite comprehensive instructions and a frequent follow up schedule, PDE5i and VCD adherence was poor. High attrition rates were noted with only 55.8% of men remaining at 12 months and 45% of men completing 24 months. The most common barriers to PR adherence were cost, inconvenience and perceived ineffectiveness.

Anterior Cruciate Ligament Reconstruction Rehabilitation Clinical Practice Patterns: A Survey of the PRiSM Society.

BACKGROUND: Recovery after anterior cruciate ligament (ACL) reconstruction (ACLR) requires extensive postoperative rehabilitation. Although no ideal rehabilitation procedure exists, most experts recommend a fusion of time and strength and functional measures to guide decision making for activity progression during rehabilitation. This process is often directed by surgeon protocols; however, the adoption of contemporary rehabilitation recommendations among surgeons is unknown. PURPOSE: To understand the current landscape of surgeon practice as it relates to ACLR rehabilitation recommendations in adolescent athletes. STUDY DESIGN: Cross-sectional study. METHODS: An online survey was distributed among members of the Pediatric Research in Sports Medicine (PRiSM) Society in January 2017. The survey was designed to identify clinical practice patterns during 3 key transitional points of rehabilitation after ACLR: progression to jogging, modified sports activity, and unrestricted return to sports. RESULTS: Responses from 60 orthopaedic surgeons were analyzed. While 80% of surgeons agreed upon initiating jogging within a 1-month range (3-4 months postoperatively), similar levels of agreement were only captured when including a wider 4-month (4-8 months) and 6-month range (6-12 months) for modified sports activity and unrestricted return to sports, respectively. All respondents (100%) reported using knee strength as a determinant to progress to modified sports activity; however, the mode of testing varied, with most using manual muscle testing (60%), followed by isokinetic (28%) or isometric (12%) testing. Most surgeons (68%) reported using some form of functional testing to return to modified sports activity, but the mode of testing and required progression criteria varied considerably among all reported testing procedures. The use of patient-reported outcome measures was limited to 20% of the sample, and no respondents reported using fear or self-efficacy questionnaires. Upon completion of rehabilitation, 73% recommended injury prevention programs, and 50% recommended the use of a functional ACL brace. CONCLUSION: Rehabilitation progression practices in adolescent athletes are variable and become more inconsistent as the time from surgery increases. While the majority of the sample considered strength and functional testing important, the mode of testing and criteria thresholds for activity advancement varied considerably.

Rehabilitation Practice Patterns Following Anterior Cruciate Ligament Reconstruction: A Survey of Physical Therapists.

BACKGROUND: Recovery from anterior cruciate ligament reconstruction (ACLR) requires an intensive course of postoperative rehabilitation. Although guidelines outlining evidence-based rehabilitation recommendations have been published, actual practice patterns of physical therapists are unknown. OBJECTIVES: To analyze the current landscape of clinical practice as it pertains to rehabilitation progression and the use of time and objective criteria in rehabilitation following ACLR. METHODS: In this cross-sectional study, an online survey was distributed to members of the Academy of Orthopaedic Physical Therapy, the American Academy of Sports Physical Therapy, and the Private Practice Section of the American Physical Therapy Association between January and March 2017. RESULTS: The study analyzed a sample of 1074 responses. Supervised physical therapy was reported to last 5 months or less by 56% of survey respondents. The most frequent time frames for activity progression were 3 to 4 months (58%) for jogging, 4 to 5 months (50%) for modified sports activity, and 9 to 12 months (40%) for unrestricted sports participation. More than 80% of respondents reported using strength and functional measures during rehabilitation. Of those physical therapists who assessed strength, 56% used manual muscle testing as their only means of strength testing. Single-limb hop testing (89%) was the most frequently reported measure used to allow patients to begin modified sports activity following ACLR. Performance criteria for strength and functional tests varied significantly across all phases of rehabilitation. The 45% of respondents who reported using patient-reported outcome measures indicated that just under 10% of those measures involved fear or athletic confidence scales. CONCLUSION: Considerable variation in practice exists among American Physical Therapy Association members regarding rehabilitation following ACLR. This variability in practice may contribute to suboptimal outcomes and confusion among practitioners and patients. J Orthop Sports Phys Ther 2018;48(10):801-811. Epub 22 May 2018. doi:10.2519/jospt.2018.8264.

Sexual Dysfunction and Intimacy for Ostomates.

Sex and intimacy presents special challenges for the ostomate. Since some colorectal surgery patients will require either temporary or permanent stomas, intimacy and sexuality is a common issue for ostomates. In addition to the stoma, nerve damage, radiotherapy, and chemotherapy are often used in conjunction with stoma creation for cancer patients, thereby adding physiological dysfunction to the personal psychological impact of the stoma, leading to sexual dysfunction. The purpose of this paper is to describe the prevalence, etiology, and the most common types of sexual dysfunction in men and women after colorectal surgery and particularly those patients with stomas. In addition, treatment strategies for sexual dysfunction will also be described.

Life after prostate cancer treatment: a mixed methods study of the experiences of men with sexual dysfunction and their partners.

BACKGROUND: Prostate cancer is the most common non-skin cancer in men and sexual dysfunction is the most frequently reported long-term side effect of prostate cancer surgery or radiation. The aim of this study was to examine the experiences of men with sexual dysfunction and their partners following prostate cancer treatment. METHODS: Men with sexual dysfunction from either surgical removal or radiation therapy 1-5 years after treatment were interviewed, as well as their partners. A mixed method design was used to determine the lived experience of men with sexual dysfunction. Open-ended questions guided the interviews. RESULTS: Twenty seven men completed the study with a mean age of 61 years (SD = 8.0; range = 44-77 years). Nine partners also participated. The majority of men (92.6%) had surgery. The average time from treatment to the interview was 23.5 months (SD = 11.7). Themes were frustration with sexual dysfunction, importance of support and understanding from others, depression and anxiety related to sexual dysfunction, importance of intimacy with partner, factors that impact treatment satisfaction, and education and comprehensive information about sex. CONCLUSIONS: Prostate cancer survivors and partners need accurate information about sexual side effects before during and after treatment. Men and partners required individualized help and guidance to manage sexual dysfunction. Support and understanding from partners, family, and others was also identified as an important aspect of healing and adjustment after prostate cancer treatment. Prostate cancer education/support groups played a key role in helping men and partners gain advocacy, education, and support. Psychological problems such as depression and anxiety need to be identified and addressed in men after prostate cancer treatment. Men and partners need assistance in understanding and navigating their way through intimacy to move forward with connectedness in their relationship. Satisfaction with treatment and with providers is dependent on patient education and understanding of all aspects of prostate cancer treatment including sexual side effects and incontinence.

A Longitudinal Study of Predictors of Sexual Dysfunction in Men on Active Surveillance for Prostate Cancer.

AIM: The aim of this study was to examine the relationship between sexual dysfunction, repeat biopsies and other demographic and clinical factors in men on active surveillance (AS). METHODS: Patient-reported outcomes (PROs) measures were administered at enrollment and every 6 months to assess quality of life (QOL), psychosocial and urological health outcomes. Using mixed-effects models, we examined the impact of repeat biopsies, total number of cores taken, anxiety, age, and comorbidity on sexual function over the first 24 months of enrolling in AS. MAIN OUTCOME MEASURES: PROs included the Expanded Prostate Cancer Index Composite-26 (EPIC-26) Sexual Function (SF) subscale, the American Urological Association-Symptom Index (AUA-SI), and the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). RESULTS: At enrollment (n = 195), mean age was 66.5 ± 6.8 with a mean EPIC-26 SF score of 61.4 ± 30.4. EPIC-26 SF scores steadily decreased to 53.9 ± 30.7 at 24 months (P < 0.01). MAX-PC scores also progressively decreased over time (P = 0.03). Factors associated with lower EPIC-26 scores over time included age, unemployed status, diabetes, coronary artery disease, and hypertension (all P < 0.05). Higher prostate-specific antigen (PSA) was associated with a more rapid decline in EPIC-26 SF over time (P = 0.03). In multivariable analysis, age, diabetes, and PSA × time interaction remained significant predictors of diminished sexual function. Anxiety, number of biopsies, and total cores taken did not predict sexual dysfunction or change over time in our cohort. CONCLUSIONS: Men on AS experienced a gradual decline in sexual function during the first 24 months of enrollment. Older age, PSA × time, and diabetes were all independent predictors of diminished sexual function over time. Anxiety, AUA-SI, the number of cores and the number of biopsies were not predictors of reduced sexual function in men in AS.

Urology nursing practice educational preparation, titles, training, and job responsibilities around the globe.

A descriptive study of urology nursing titles, educational preparation, and job functions revealed more than 80 titles, varied educational preparation, and some common and varied job functions. The results also indicated that urology advanced practice nurses continue to expand their independent roles.

Rehabilitation considerations for all epiphyseal acl reconstruction.

BACKGROUND: The management of the pediatric patient with an Anterior Cruciate Ligament (ACL) rupture is evolving towards earlier reconstruction. The rehabilitation progression and outcomes for skeletally immature individuals undergoing ACL reconstruction (ACL-R) are not well described in the literature. Differences in surgical procedure, age related physiology, and emotional maturity may have a significant impact on recovery and return to sports. The purpose of this case report is to present the rehabilitation and outcome of a skeletally immature patient that underwent an all-epiphyseal ACL-R, highlight important considerations in the rehabilitation process and present topics for future research. CASE DESCRIPTION: Single subject case report of an 8 year-old boy who underwent all epiphyseal ACL-R after complete ACL rupture. OUTCOMES: The patient was able to achieve at least 90% strength symmetry and pass all necessary functional criteria to return to sports by 9 months post surgery. Two year follow up data indicated that the patient was able to make a full return to previous level of athletic activity, as well as maintain lower extremity strength and power over time. DISCUSSION: Objective outcome measures, rehabilitation protocols and time frame for return to sports for skeletally immature patients following physeal sparing or all epiphyseal ACL-R are not well described in the literature. This case report outlines objective measures of strength and functional recovery in a patient from this unique population. As ACL-R in the skeletally immature patient is studied more, new information on rehabilitation progression and outcomes may alter the rehabilitation program and timeline for return to unrestricted activity. LEVEL OF EVIDENCE: 4, Case Report.

Addressing and managing erectile dysfunction after prostatectomy for prostate cancer.

Erectile dysfunction is the most common side effect after prostatectomy. There are currently five categories of available treatment options for erectile dysfunction for men following radical prostatectomy. The first and most common treatment is oral phosphodiesterase type 5 inhibitors (sildenafil, vardenafil, or tadalafil). Despite their popularity, these medications do not always produce an erection sufficient for intercourse after prostatectomy. The second treatment option is the noninvasive option of either a venous constriction band or the vacuum constriction device. Both treatments use a venous occlusive tension band or ring to maintain erection by retaining blood in the penis. The vacuum constriction device also utilizes external suction pressure to create an erection prior to application of the tension ring. The third treatment option is Muses, an intraurethral suppository containing alprostadil that dilates the penile blood vessels. The fourth treatment option involves penile injections. The fifth treatment is the penile prosthesis, in which artificial rods are surgically implanted into the corpora cavernosa to provide penile rigidity. Oral agents, the vacuum device, Muse, and injections have been used for penile rehabilitation to encourage spontaneous return of erectile function in men after radical prostatectomy with varied success. Untreated erectile dysfunction after radical prostatectomy has been associated with penile atrophy and further diminished erectile function. Therefore, it is critically important that clinicians provide comprehensive information about the positive and negative aspects of all treatment options and the penile rehabilitation potential of each. This will enable patients to make informed treatment choices about early intervention for erectile dysfunction.

Impact of penile injections on men with erectile dysfunction after prostatectomy.

Penile injection has been shown to be an effective treatment for erectile dysfunction (ED) following prostatectomy, yet it is not commonly used by these men. The purpose of this study was to determine the impact on quality of life of injection treatment of ED in men after prostatectomy, as well as barriers to use. The study used a one-group, pretest/posttest design, with data collection before treatment, and one and three months after treatment. Use of penile injections resulted in improved erectile function, sexual self esteem and confidence, and satisfaction with the sexual relationship. Side effects reported were pain, priapism, bruising, and curvature or the penis.

Adolescent anterior cruciate ligament reconstruction: a retrospective analysis of quadriceps strength recovery and return to full activity after surgery.

BACKGROUND: This study was intended to provide quantitative assessment of quadriceps muscle recovery in adolescent athletes after anterior cruciate ligament (ACL) reconstruction. METHODS: Quadriceps peak torque values from 55 athletes who underwent ACL reconstruction were analyzed. The mean age of the patients was 15.93+/-1.65 years (40 girls, 15 boys). Isokinetic data were obtained using the Biodex System 3. Quadriceps muscle recovery was defined as achieving >or=85% peak torque for side-to-side comparison. RESULTS: Time-to-quadriceps muscle recovery was as follows: 15% by the end of 3 months, 11% by 4 months, 13% by 5 months, and 20% by 6 months. Overall, 32 patients (59%) achieved >or=85% quadriceps strength within 6 months of their surgery date. Of those patients, 16 (50%) patients returned to full activity within 6 months of the date of surgery. Sex was not found to be a significant difference in regard to strength outcomes. CONCLUSIONS: Quadriceps muscle recovery is one criterion considered when allowing return to unrestricted activities after ACL reconstruction. On the basis of results of this study, middle and high school age athletes have the ability to regain the necessary quadriceps muscle strength required to return to sport within 6 months. SIGNIFICANCE: Using objective measures of quadriceps muscle return after ACL reconstruction can pinpoint timing of recovery, aid in specific training of deficient muscle groups, and guide return-to-play recommendations for those treating athletes with ACL reconstruction.

Patient-reported pain with initial intracavernosal injection.

INTRODUCTION: Despite the efficacy of intracavernosal injections, one of the greatest impediments to injection therapy is the negative reaction of men to the thought of a needle inserted into the penis. AIM: To determine the severity of pain associated with the initial intracavernosal self-injections for erectile dysfunction (both pain associated with the needle insertion and the medications). METHODS: This is a descriptive study of self-reported pain associated with intracavernosal self-injections in 65 men with erectile dysfunction. Pain was assessed immediately after needle insertion and again approximately 10-20 minutes postinjection, utilizing a verbal 0-10 pain scale. MAIN OUTCOME MEASURES: A verbal 0-10 pain rating scale was used to assess pain both for injection pain and medication pain. RESULTS: For needle insertion, the mean pain rating was 0.80 (standard deviation [SD] = 0.81), with 40% reporting no pain at all. Of the 39 patients who reported pain, the mean pain rating was 1.33 (SD = 0.61). For the medication itself, the mean pain rating was 0.92 (SD = 1.5), with more than half (64.6%) reporting no pain. For those experiencing pain from the medication (N = 23), the mean pain rating was 2.6 (SD = 1.27, range 0.5-5.0). Significantly more patients with radical prostatectomy experienced pain from the medication than other men (51.9% vs. 23.7%, P = 0.02). CONCLUSION: The majority of patients experienced little or no pain from either the needle insertion or the medication. Even for men who experienced pain, the severity was relatively low. This study provides information to help diminish fears about injection pain for patients considering penile injections. In addition, this study suggests that medication pain is more common in men postradical prostatectomy, so that it may be advisable to start with lower dosages of prostaglandin alone or in combination with other vasoactive medications for these patients.

Measurement of quality of life in men with prostate cancer.

Prostate cancer continues to be one of the most common cancers diagnosed in men. In light of the excellent survival rates for prostate cancer, quality of life is a primary concern during and following prostate cancer treatment. Quality of life is defined and determined in multiple ways. This article explores quality of life in men with prostate cancer. Quality-of-life dimensions, measurement tools, and implications of quality of life with prostate cancer on clinical practice for oncology nurses will be presented.

Intracavernosal injection algorithm.

Intracavernosal injections provide an effective therapy for men with erectile dysfunction who can not take oral agents or for whom oral agents are not effective. Determining the best initial dosage can be a challenge for health care providers. A literature review and 13 years of experience working with patients receiving intracavernosal injections provide the basis for the algorithm designed to provide guidance with the dosage and titration of the injection medications.