Throughout the lifespan, there are multiple variables that can place one at risk for experiencing urinary incontinence (UI), which is defined as the involuntary loss of urine. One of the key variables is gender, with women experiencing a higher rate of UI versus males [6]. Women may experience pregnancy, delivery, and postmenopausal changes that can influence the strength and muscle performance of the PFM, with epidemiological studies reporting up to 64% prevalence of UI during their life [3]. The excessive muscle lengthening, weakness, and ligamentous laxity postdelivery can also place women at further risk for pelvic organ prolapse (POP) later in life.

Additional factors that can influence risk for UI in both females and males include advanced age, obesity, race, and other neurological influences. Studies report 59% of people over 65 years old who are institutionalized experience some form of UI [7]. Additionally, the impact of UI in one’s life can negatively impact one’s health-related quality of life (HRQOL) from a psychological, social, work participation, sexual, and physical health position. The impact of these changes is also apparent in urogynecological cancer survivors.

White et al. explain how there are very few studies investigating the impact of UI on HRQOL among cancer survivors. In fact, UI and cancer are heavily associated with a decreased quality of life [8]. As postoperative UI symptoms have been associated with several forms of cancer, including prostate, breast, bladder, colorectal, uterine, and lung cancer, a multidisciplinary approach to care is most logical to improve the continuum of care for the patient. Stress urinary incontinence (SUI) is the most prevalent type of UI seen in those post-orthotopic neobladder surgeries, noting up to 23% prevalence in women post-surgery. Studies also demonstrate better return to daytime continence in the first 6–12 months versus nighttime continence. However, 20–50% of patients will experience persistent nocturnal enuresis.

Physical therapists specialized in treating pelvic floor dysfunction have an important role in helping cancer survivors regain their continence, as many of the principles of strengthening and neuromuscular reeducation can benefit this population. The initial process is through prehabilitation, or in other words, preoperative training of the pelvic floor along with patient education regarding pelvic health and the postoperative expectations.

The model of prehabilitation has shown to have merit in the areas of sports and orthopedic physical therapy. Although more studies are needed in the orthotopic neobladder population, there has been literature supporting the value of preoperative education and PFM training for men undergoing radical prostatectomy [9]. Centemero et al. compared two groups of men, one who received both pre- and postoperative PFM training and the other who received only postoperative training. His results showed improved early return to continence and quality of life in the preoperative training group, noting significant findings of 44.1% of patients reporting continence 1 month post-op versus 20.3% who only received postoperative PFM training. This trend continued at 3 months with 59.3% of men reporting continence versus 37.3% in the postoperative training group [10]. Further data and research continue to be needed in those post-orthotopic neobladder, but we can make an educated hypothesis that there will be a similar correlation between those results in the radical prostatectomy groups and neobladder population, given the similarities in the surgeries.

The roles of the surgeon and medical team play can be quite different, although complimentary. The overall goal of the surgeon is to prolong the patient’s life after a diagnosis of cancer, and the goal of the physical therapist is to help rehabilitate the patient post-medical treatment (surgery, chemotherapy), in order to help restore his or her function and quality of life. A collaborative approach is always the most beneficial to the patient’s continuum of care, and fortunately many surgeons see the value that pelvic floor physical therapy, both pre- and post-op, can hold for their patients.

It is imperative that the postoperative PFM training program be initiated immediately after the catheter is removed because the external urethral sphincter, part of the pelvic floor, has been dormant for about 3 weeks while the indwelling catheter was in place. This time frame is to allow the postoperative anastomosis tissue healing. Therefore, the PFM are in desperate need of assistance to “wake up” again. Following the principles of exercise physiology, the physical therapist can devise a patient-specific program to help achieve the patient’s goals of returning to continence and his or her activities of daily living. The timeline for recovery can vary, depending on many variables, including the patient’s commitment with their rehabilitation program, level of fitness, general health, and any postoperative complications or existing comorbidities. Interestingly, in the post-prostatectomy group, patients who receive pelvic floor physical therapy (PFPT) demonstrated better retention of urinary continence, defined as no pads/day at 6 and 12 months versus those who do not receive one-on-one-guided PFPT [11].

Table 10.1 provides the recommended guideline for a PFPT protocol pre- and post-neobladder surgery based on the principles of exercise physiology and postoperative tissue healing