This chapter introduces the epidemiology, risk factors, pelvic and prostatic anatomy, disease behaviour and metastatic patterns of prostate cancer, and links them to the assessment and physiotherapy management that students will use in practice.
Epidemiology and Burden
Prostate cancer is the most commonly diagnosed non-cutaneous cancer in men in the United States. The lifetime risk of diagnosis is about 1 in 8 (approximately 12–13%), while the lifetime risk of death from the disease is about 1 in 40. The median age at diagnosis is 66–67 years, and over 60% of cases are diagnosed in men aged 65 or older. Cases under 40 are rare.
Most cancers are detected at a localized stage, and 5-year relative survival for localized and regional disease approaches 100%. Survival falls to about 35% for distant metastatic disease. Because so many men survive for years or decades, physiotherapists mainly manage survivorship problems: continence, sexual function, bone health, fatigue and treatment-related deconditioning.
Risk Factors
Non-modifiable factors
- Age is the strongest risk factor.
- Race. African American men have roughly 1.7 times the incidence and about twice the mortality of White men, and their lifetime risk is about 1 in 6. They are also more often diagnosed younger and with more aggressive disease. The cause is multifactorial, including genetic, socioeconomic and healthcare-access factors.
- Family history. A first-degree relative with prostate cancer roughly doubles risk. Risk is higher if the relative was diagnosed before age 65 or if several relatives are affected. Germline variants include BRCA2, BRCA1, HOXB13 and Lynch syndrome genes.
For a 55-year-old asking about prevention: keep a healthy weight, stay active, avoid smoking and eat a balanced diet, while being honest that this does not guarantee protection.
Modifiable or possibly modifiable factors
- Obesity (BMI ≥30 kg/m²) is associated more with aggressive disease and prostate cancer-specific mortality than with overall incidence.
- Smoking is associated with higher cancer-specific mortality.
- Regular vigorous physical activity is associated with a lower risk of advanced disease.
- Diets high in red and processed meat and low in vegetables have inconsistent evidence. No dietary pattern is proven to prevent prostate cancer.
- 5-alpha-reductase inhibitors reduced overall cancer incidence in the Prostate Cancer Prevention Trial but are not recommended for chemoprevention. This is a medical decision outside physiotherapy scope.
For a 55-year-old man asking about prevention, appropriate advice is to maintain a healthy weight, stay physically active, avoid smoking and eat a balanced diet. The therapist should also be honest that these measures reduce overall disease risk and do not guarantee protection.
Screening and Risk Communication
Screening uses serum prostate-specific antigen (PSA) with or without digital rectal examination (DRE). Guidelines (ACS, AUA, NCCN, USPSTF) favour shared decision-making.
- Men at average risk are offered a discussion from about age 50 (USPSTF: 55–69).
- Men at higher risk, including African American men and those with an affected first-degree relative, are offered discussion from about age 40–45.
- A PSA of 4 ng/mL has been the traditional threshold. PSA is organ-specific, not cancer-specific, and is raised by BPH, prostatitis, instrumentation and ejaculation. Age-specific ranges and PSA density are used in practice.
Physiotherapists do not order or interpret screening tests. Their role is to give balanced evidence-based information about risk, encourage men to discuss screening with their physician, and refer promptly when findings are concerning.
Anatomy of the Prostate and Pelvic Floor
The prostate is a walnut-sized, roughly 20 g fibromuscular and glandular organ. It lies inferior to the bladder neck, posterior to the pubic symphysis, and anterior to the rectum, separated from it by Denonvilliers' fascia. It surrounds the prostatic urethra, with the ejaculatory ducts passing through its posterior aspect. Its apex rests on the urogenital diaphragm and the external urethral sphincter. Because of its rectal relationship, DRE can palpate the posterior and lateral surfaces.
McNeal zonal anatomy
- Peripheral zone (about 70% of glandular tissue) is the site of most cancers (about 70%) and is palpable on DRE.
- Central zone (about 25%) surrounds the ejaculatory ducts and is the origin of only 5–10% of cancers.
- Transition zone (about 5%) surrounds the proximal urethra and is the site of BPH. Enlargement here causes hesitancy, weak stream and nocturia.
- The anterior fibromuscular stroma contains no glandular tissue.
Vascular, lymphatic and neural supply
- Arterial supply: the inferior vesical artery (internal iliac branch), with contributions from the middle rectal and internal pudendal arteries.
- Venous drainage: the prostatic venous plexus (connected with the dorsal venous complex), draining to the internal iliac veins. Valveless connections with the vertebral venous plexus of Batson provide a route for vertebral and pelvic metastasis.
- Lymphatic drainage: primarily the obturator, internal iliac and external iliac nodes.
- Cavernous nerves run in the neurovascular bundles posterolaterally. They are vulnerable in surgery and radiotherapy and are the main determinant of erectile function outcomes.
Pelvic floor relations. The levator ani (puborectalis, pubococcygeus, iliococcygeus) forms a sling inferior to the prostate. Puboprostatic ligaments anchor the gland to the pubis. The external urethral sphincter (rhabdosphincter) is striated muscle at the membranous urethra, innervated by pudendal nerve branches (S2–S4). It is rich in slow-twitch fibres, which provide tonic continence. Superficial muscles (bulbospongiosus, ischiocavernosus) contribute to ejaculation, erection and post-micturition emptying. After prostatectomy, the bladder neck mechanism is lost, so continence depends heavily on the external sphincter and pelvic floor support.
Pathophysiology and Staging
Over 95% of cases are acinar adenocarcinoma. Androgen receptor signalling drives growth, which is why androgen deprivation therapy (ADT) is central to systemic treatment. Tumours are graded by Gleason score, reported as ISUP Grade Groups 1–5 (Grade Group 1 = Gleason 6; 2 = 3+4; 3 = 4+3; 4 = 8; 5 = 9–10). Staging uses TNM (T1 clinically inapparent, T2 confined to the prostate, T3 extraprostatic extension or seminal vesicle invasion, T4 invasion of adjacent structures, N1 regional nodes, M1 metastasis). Risk groups (NCCN/D'Amico) combine PSA, grade group and T stage into low, intermediate and high risk. Treatment ranges from active surveillance to radical prostatectomy, radiotherapy, ADT and systemic therapy. In the ProtecT trial, 15-year prostate cancer mortality was low (about 3%) regardless of treatment arm in screen-detected localized disease.
Clinical Presentation and Red Flags
Early peripheral zone cancer is usually asymptomatic. Hesitancy, weak stream, frequency and nocturia more often reflect BPH of the transition zone, although they can coexist with cancer. Locally advanced disease can cause haematuria, haematospermia, obstruction, and erectile dysfunction.
Prostate cancer metastasizes mainly to bone and to pelvic and retroperitoneal nodes. Bone metastases are typically osteoblastic and favour the axial skeleton: lumbar spine, pelvis, ribs and proximal femur. Complications include:
- Skeletal-related events: pathological fracture, pain requiring radiotherapy, hypercalcaemia and spinal cord compression.
- Metastatic spinal cord compression (MSCC): an oncological emergency.
- Lymphoedema of the legs or genitalia from nodal disease or treatment.
Red flags requiring same-day medical referral
- New or progressive thoracic or lumbar pain that is unremitting, worse at night or when supine.
- Band-like trunk pain, leg weakness, gait change, sensory level, or saddle anaesthesia.
- New bladder retention, overflow incontinence or bowel dysfunction.
- Unexplained weight loss, or haematuria in an untreated patient.
- Calf swelling or pain (deep vein thrombosis risk).
A 68-year-old man with 6 months of hesitancy and nocturia and a firm, nodular prostate on DRE has a suspicious finding regardless of urinary symptoms. This requires urgent urological referral, not a trial of exercise.
Physiotherapy Assessment
Assessment should be adapted to treatment phase (pre-treatment, post-surgery, during radiotherapy or ADT, or advanced disease).
- History: treatment type and date, catheter removal date, pad use, medications (ADT, bisphosphonates, denosumab), and comorbidities. Screen for bone metastases and review the latest imaging.
- Urinary symptoms: a 3-day bladder diary, the ICIQ-UI Short Form (0–21; ≥1 indicates incontinence) and the IPSS (0–7 mild, 8–19 moderate, 20–35 severe).
- 24-hour pad test: commonly <20 g mild, 20–50 g moderate, >50 g severe leakage.
- Quality of life: EPIC-26 (urinary, bowel, sexual and hormonal domains, scored 0–100 with higher being better).
- Pelvic floor function: the Modified Oxford Scale (0–5) by digital palpation, where available and within scope, or transperineal real-time ultrasound. Record strength, endurance (seconds held, up to 10) and repetitions (up to 10), fast contractions (up to 10) and relaxation. Ask about the "Knack" (pre-contraction before cough).
- Fitness and function: 6-minute walk test, 30-second sit-to-stand, timed up and go (>12 s indicates falls risk in older adults), handgrip dynamometry and ECOG performance status.
- Neurological screen: myotomes (graded 0–5 MRC), dermatomes, reflexes and gait if spinal pain is present.
Physiotherapy Management: Staged Approach
Stage 1: Pre-treatment education (ideally 2–4 weeks pre-surgery). Use anatomical diagrams to explain the prostate's relationship to the bladder, rectum, urethra, pelvic floor and sphincter. Teach correct pelvic floor contraction (lift and squeeze around the urethra and anus, without breath holding, gluteal or abdominal substitution). Begin PFMT at about 3 sets of 8–10 contractions held 5–10 s, daily. Introduce aerobic and resistance exercise to improve baseline fitness.
Stage 2: Early post-operative (0–6 weeks).
- Walk early and often, with deep breathing and calf pumps.
- Avoid heavy lifting (>4–5 kg), straining, and high-intensity abdominal or impact work for about 4–6 weeks, or per surgeon advice.
- Teach the Knack, bowel care to avoid straining, and log rolling for bed mobility.
- Start gentle PFMT once the catheter is removed, or earlier if the surgeon agrees.
Stage 3: Strengthening phase (6–12 weeks onward).
- PFMT: 3 sets of 10 slow contractions held up to 10 s, plus 10 fast contractions, 3 times daily; progress by position (supine → sitting → standing → functional tasks such as stairs and lifting).
- Supervised sessions weekly or biweekly with a home programme. Continue for at least 3–6 months.
- Reassess with a pad test, ICIQ-UI and Oxford grade every 4–6 weeks.
- Do not teach stop-start voiding as an exercise, because it may disrupt voiding reflexes.
Stage 4: Cancer-wide exercise prescription (ADT, radiotherapy, survivorship).
- Aerobic: 150 min/week moderate intensity (or 75 min vigorous).
- Resistance: 2–3 days/week, 2–4 sets of 8–12 repetitions at 60–80% 1RM across major muscle groups.
- Supervised exercise for men on ADT improves lean mass, strength, fatigue and physical function (Galvão et al.).
- Impact or weight-bearing work for bone health is appropriate only if no skeletal metastases exist.
Bone metastases. Obtain medical clearance and imaging details. Avoid high-impact activity, heavy axial loading and resisted or rotational loading near lesions. Use pain-guided, low-load and balance-based work, and use walking aids as needed. Stop and refer if pain escalates or neurological signs appear.
Precautions and contraindications
- Do not use transrectal probes or manual internal examination with active infection, severe radiation proctitis, recent rectal surgery or anastomotic concerns.
- Avoid vigorous exercise with fever, anaemia (Hb <8 g/dL), platelets <20–50 ×10⁹/L or untreated DVT.
- Use caution with cardiovascular risk during ADT.
Evidence and Clinical Pearls
- Cochrane evidence for PFMT after prostatectomy shows possible benefit for earlier recovery of continence, but the quality of evidence is low-to-moderate and the effect on long-term continence is uncertain. Supervised, individualized, adequately dosed programmes appear more effective than brief written advice.
- Evidence for preoperative PFMT is mixed, but it is low-risk and improves patient engagement and understanding.
- Most men recover substantial continence within 12 months, so setting expectations is important. Persistent moderate-to-severe leakage beyond 6–12 months warrants urology review.
- Peripheral zone tumours, such as the firm DRE nodule, are usually silent. Obstructive symptoms point first to the transition zone, which affects the interpretation of symptoms.
- Race and family history raise risk but do not alter physiotherapy management. Use culturally sensitive communication and explicitly address access to care.
- Never diagnose or reassure on the basis of symptoms alone. Document and refer.
Summary
Prostate cancer is common, strongly age-related, and more frequent and lethal in African American men and men with a family history. The prostate's zonal anatomy explains where cancers arise, why BPH produces urinary symptoms, and why DRE is useful. Its relationships with the bladder, rectum, sphincter and pelvic floor underpin post-treatment continence problems. Vertebral venous connections and osteoblastic bone spread explain the metastatic pattern and the importance of red-flag screening. Physiotherapists contribute through risk education, pelvic floor assessment and training, graded exercise, and safe management of patients with bone involvement, always within a multidisciplinary framework.
References
- Siegel RL, Giaquinto AN, Jemal A. Cancer statistics, 2024. CA Cancer J Clin. 2024;74(1):12–49.
- Mottet N, et al. EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer. European Association of Urology; current edition.
- National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer; current edition.
- Hamdy FC, et al. Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2023;388:1547–1558.
- Anderson CA, Omar MI, Campbell SE, et al. Conservative management for postprostatectomy urinary incontinence. Cochrane Database Syst Rev. 2015;(1):CD001843.
- Campbell KL, Winters-Stone KM, Wiskemann J, et al. Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable. Med Sci Sports Exerc. 2019;51(11):2375–2390.
- Galvão DA, Taaffe DR, Spry N, Joseph D, Newton RU. Combined resistance and aerobic exercise program reverses muscle loss in men undergoing androgen suppression therapy for prostate cancer without bone metastases: a randomized controlled trial. J Clin Oncol. 2010;28(2):340–347.
- McNeal JE. Normal histology of the prostate. Am J Surg Pathol. 1988;12(8):619–633.