RADIATION THERAPY & PELVIC HEALTH: WHAT YOU SHOULD KNOW

What Causes Urinary Incontinence Post-Radiation?

The Gift That Keeps Giving
Radiation-related changes can progress and accumulate over time, even long after treatment ends. This delayed and ongoing tissue response is a hallmark of radiation injury.

Key Mechanisms Leading to Incontinence and Erectile Dysfunction:
Radiation Fibrosis is the primary driver of both urinary incontinence and erectile dysfunction post-radiation. Radiation causes all affected tissues to stiffen—leading to increased rigidity and decreased elasticity.
• Pelvic Floor Muscles (PFMs): Reduced contractility and motor control
• Urethra: Fibrosis, stiffness, and strictures
• Bladder: Fibrosis leads to decreased capacity and early urgency—often noticeable around 18 months post-treatment
• Blood Vessels: Mucosal vascular damage compromises healing and tissue health
• Surrounding Tissues: Scar tissue replaces smooth muscle, disrupting mechanics and compliance of pelvic structures; this delayed healing is dose-dependent

Radiation Therapy Types:
• External Beam Radiation Therapy (EBRT)
• Brachytherapy (Seed Implantation): Notably reduces urethral length, increasing risk of complications
Acute & Long-Term Effects on the Lower Urinary Tract (LUT):
• Acute: Edema
• Long-term: Strictures

Strictures and Surgical Challenges
• Anastomotic Strictures have declined since the introduction of robotic surgical techniques.
• Brachytherapy carries the highest prevalence of strictures.
• Urethroplasty success rates are lower in radiated patients, and even successful repairs often result in higher rates of post-operative incontinence.

But There Is Hope—Exercise!
Therapeutic exercise may help:
• Prevent fibrotic changes in pelvic floor muscles
• Improve circulation and tissue health
• Manage inflammation and preserve function

Early intervention and consistent pelvic health rehabilitation can make a measurable difference in outcomes.

• CPPS or Non Bacterial Prostatitis is the most common urologic diagnosis in men older than age 50 years and is the third most common diagnosis in men younger than age 50 years.

• The Pudendal nerve is the main nerve supplying the genitalia, bladder and rectum can become irritated due to prolonged cycling and/or sitting

• Nocturia Got You Up at Night?
  Frequent nighttime urination—known as nocturia—is more than just a nuisance. It can interfere with sleep quality and worsen incontinence. Learn what causes it, how it’s connected to pelvic floor health, and how physiotherapy can help.
  Here are 5 evidence-informed approaches I often recommend, tailored to the unique changes that occur after prostate surgery:1. Fluid Timing and Management
  • Why it matters: Many men unknowingly consume most of their fluids later in the day, increasing nighttime bladder filling.
  • Action steps:
  • Front-load fluid intake earlier in the day.
  • Stop drinking 2–3 hours before bed, except for medications.
  • Track intake and output for patterns.2. Bladder Training and Urge Suppression Techniques
  • Why it matters: The bladder can become overactive or hypersensitive post-surgery. Training can help increase bladder capacity and control.
  • Action steps:
  • Delay voiding gradually during the day to build capacity.
  • Use urge suppression strategies (e.g., pelvic floor contractions, deep breathing, distraction techniques) when you feel the urge but it’s not yet time to void.
  • Avoid “just-in-case” peeing before bed if not needed.

  3. Pelvic Floor Muscle Training (PFMT)
  • Why it matters: The pelvic floor muscles (PFMs) support the bladder and urethra. After surgery, these muscles can weaken or lose coordination.
  • Action steps:
  • Learn coordinated, functional pelvic floor contractions (not just Kegels—think HEgels: strength + coordination + relaxation).
  • Emphasize timing and control, especially with urgency or when transitioning positions (e.g., standing up from bed).
  • Work with a pelvic floor physiotherapist for guided rehab.

  4. Address Underlying Contributors
  • Why it matters: Nocturia can be multifactorial, including non-urological causes.
  • Common culprits:
  • Sleep apnea (frequently underdiagnosed in men with nocturia)
  • Medications (especially diuretics taken late in the day)
  • Swollen legs or fluid retention
  • Action steps:
  • Elevate legs during the day or use compression stockings to reduce nighttime fluid shift.
  • Discuss meds and potential sleep disorders with your physician.

  5. Optimize Sleep Hygiene
  • Why it matters: Sometimes, people wake due to poor sleep and then decide to void “while they’re up,” reinforcing a habit loop.
  • Action steps:
  • Establish a regular bedtime routine.
  • Reduce screen time before bed and create a cool, dark sleeping environment.
  • Avoid caffeine and alcohol, especially in the afternoon and evening, as they irritate the bladder.

  Click here to read more about the causes, symptoms, and management of Nocturia.

VACUUM ERECTION DEVICES (VED’S) – PATIENT INFORMATION

Intended Audience : Post Prostatectomy Patients

 

1. This treatment has been shown to be highly effective, regardless of what’s causing the erectile dysfunction (ED).
2. Reported satisfaction rates vary between 35% to 84%.
3. Can be a useful addition to PDE5i (Viagra, Cialis), and/or injection therapy following removal of the prostate, also known as a Radical Prostatectomy (RP).
4. Work best if the man has had one or both nerves sparred during the surgery
5. Improved results can occur when both parties have a positive attitude towards its use and receive sufficient instructions. 
6. Should be started 1-2months following RP.
7. Penile Traction Therapy using VEDs can maintain the length of the penis by possibly improving erection mechanisms and preventing structural changes.
8. Starting to use a VED one month after a RP can improve sexual function in the early stages and maintain the length of the penis through a process known as traction therapy.

Toussi, A., Ziegelmann, M., Yang, D., Manka, M., Frank, I., Boorjian, S. A., Tollefson, M., Köhler, T., & Trost, L. (2021). Efficacy of a Novel Penile Traction Device in Improving Penile Length and Erectile Function Post Prostatectomy: Results from a Single-Center Randomized, Controlled Trial. The Journal of Urology, 206(2), 416–426. https://doi.org/10.1097/JU.0000000000001792

Köhler, T. S., Pedro, R., Hendlin, K., Utz, W., Ugarte, R., Reddy, P., Makhlouf, A., Ryndin, I., Canales, B. K., Weiland, D., Nakib, N., Ramani, A., Anderson, J. K., & Monga, M. (2007). A pilot study on the early use of the vacuum erection device after radical retropubic prostatectomy. BJU International, 100(4), 858–862. https://doi.org/10.1111/j.1464-410X.2007.07161.x

 

Contraindications include:

1. Bleeding disorders such as excessive bleeding, blood clotting/clumping, and sickle cell anemia.
2. Concurrent anticoagulant therapy – taking more than one medication that helps prevent blood from clotting.
3. Anastomotic Dehiscence – medical term that refers to the separation or opening up of a surgical connection between urethra (the tube that carries urine from the bladder out of the body) and the bladder neck after the prostate gland has been removed.

 

Possible adverse effects include:

1. Bruising
2. over-stretching/micro-tearing of the penile tissue
3. Local pain
4. Failure to ejaculate – for men who still have their prostates.
5. Coldness of the penis
6. Urinary leakage can occur during use of the VED if urinary control has not been achieved following RP
7. Numbness
8. Altered sensation
9. Discoloration
10. Dysorgasmia (pain or discomfort during or after orgasm)
11. Petechia (Small flat purple circular marks that appear on the shaft of the penis)

 

Recommendations:

The VED constriction ring should not be worn for more than 30 minutes to prevent possible irreversible damage, and a break of at least 60 minutes should be taken between uses to allow full restoration of the penile blood supply. If a condom is to be worn, is should not be used during the vacuum process, but put on as a last step. It is also recommended that you consult your health care provider to rule out any underlying serious pathology. Please also note that if you have Peyronie’s disease (a curve or bend in the penis that results from the formation of plaque or scar tissue inside the penis) this device may not be suitable for you.

The repeated passage of feces in inapproprate locations. Incontinence must occur at least once a month for a minimum of 3 months. The child must be at least 4 years of age.

53% of constipated children have non-relaxation or pradoxical contraction of the anal sphincter during attempts at defecation, associated with poor abdomino-pelvic muscle recruitment patterns. This is known as rectosphincteric dyssynergia. 17% of these cases are victims of sexual abuse.

A rare congenital disorder that affects a small part of the lower colon due to a lack of appropriate neurological input. The area behind the constriction becomes swollen and predisposed to the over accumulation of feces or inappropriate evacuation efforts. This occurs more often in boys.

Absence of sphincteric relaxation at micturition. When advanced, can cause bladder diverticulum, reflux, trabeculation. May lead to: Dysuria (painful or uncomfortable micturition), Overflow incontinence or Cystitis (inflammation of bladder).

AKA. Atresia, prevalence: 1/5000 births. More boys than girls. Lesion may be high or low. Congenital defect e.g. Currarino syndrome.

• Infra-levator. Puborectalis, striated and smooth anal sphincter are present.
• Supra-levator. Rectum, internal sphincter and vasculo-nervous bundles are absent. Puborectalis and striated sphincter are hypoplasic. Prognosis for continence less favorable.

SIGNS THAT CHILD IS READY TO POTTY TRAIN

• Having a BM around same time each day
• No BMs at night
• Dry diaper after a nap
• Dry diaper for at least 2 hrs at a time
• Gross MOTOR Signs
• Ability to low squat
• Climbing
• FINE motor Signs
• Able to do fasteners (buttons)
• Able to pull down pants/underwear
• Emotional Readiness
• Child must have an emotional stake in toilet training. If they don’t, try and increase their desire to do so. If child has an accident, have the child take the diaper and empty it in the toilet to reinforce positive behaviours

If you have a sensation of heaviness, pressure or bulging in the vagina, or urinary symptoms such as a slowed stream, a sense of incomplete emptying, frequency and urgency with urination or bowel symptoms whereby you have difficulty evacuating stools and you sometimes add pressure on the vagina to help fully empty the rectum, then you may be experiencing a POP.

After vaginal delivery or once a woman reaches her post-menopausal years, the muscles, ligaments and fascia that hold the pelvic organs in their optimal positions become weakened. This can result in the descent of the pelvic organs and produce the various symptoms mentioned above.

POP affects approximately 1 in 3 women who have had more than one child. However, surgery is only ever necessary for 1 in 9 women and Pelvic Floor Physiotherapy can help the others. Reducing the amount of pressure acting on the pelvic floor muscles is a strategy that can certainly help reduce the intensity of your symptoms. Some examples include, weight loss, smoking cessation as this can result in chronic coughing, increase fiber/water/exercise to manage chronic constipation, learn appropriate heavy lifting techniques and avoid straining to evacuate stools or empty your bladder.

A urinary tract infection (UTI) can occur in the kidneys, bladder or urethra. It is often caused by the bacteria E.Coli as this bacteria is often present in the rectum. Due to the closeness of the vagina to the anus, these bacteria can easily entre the urinary system and cause symptoms of burning, frequency and urgency with urination.  UTI’s are more common in sexually active women, during pregnancy, after surgery and post-menopause. The hormonal changes that occur during these times can increase a woman’s susceptibility to experiencing a UTI.

On the other hand, a large number of women will have ruled out the presence of an infection and will continue to experience frequency and urgency. This may likely be a result of the state of the pelvic floor muscles, in which case pelvic floor physiotherapy is an excellent option for determining the cause of your urgency and frequency

There are several different bodily systems that can contribute to the experience of pain during intercourse. These include; the muscular, hormonal, immune and nervous systems. Therefore, a detailed history taking will be necessary to reveal the systems contributing to your pain experience. A physical examination can further help reveal the source or cause of your pain. Some of the conditions to consider include the following:

• Genitourinary syndrome of menopause (GSM)
• Vulvodynia/Vestibulodynia
• Pelvic Inflammatory Disease
• Obstetric trauma (during delivery)
• Bladder or urethral pain syndromes
• Muscular Spasms
• Endometriosis/Adenomyosis
• UroGynecological Surgeries (hysterectomy/C-section)

The miraculous beauty of becoming pregnant and delivering a child is a unique experience for women. However, the beauty of this experience can sometimes be complicated by several factors and result in less than favorable outcomes. Delivering a child naturally is no easy feat and deserves the appropriate coaching and preparation. Learning the various ways that one can minimize their risk for obstetric trauma can enhance the experience. Proper prior planning prevents poor performance!

If you are currently pregnant book an appointment today to better prepare yourself for your big day! Thereafter, be sure to have your pelvic floor muscles reassessed by a pelvic floor physiotherapist to prevent the onset of pelvic floor dysfunction.