Mediation analysis of adherence to pelvic floor muscle training and weekly self-monitoring on urinary symptoms in men with localized prostate cancer

A secondary analysis of the Prostate Cancer-Patient Empowerment Program (PC-PEP) randomized controlled trial

Authors

  • Emily Chedrawe Department of Urology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia
  • Nathan K. Smith Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University https://orcid.org/0000-0002-8577-3023
  • Gabriela Ilie Departments of Urology, Radiation Oncology and Community Health and Epidemiology, Faculty of Medicine, Dalhousie University https://orcid.org/0000-0002-1602-6374
  • Ricardo A. Rendon Department of Urology, Faculty of Medicine, Dalhousie University
  • Ross Mason Department of Urology, Faculty of Medicine, Dalhousie University
  • Andrea Kokorovic Department of Urology, Faculty of Medicine, Dalhousie University
  • Cody MacDonald Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University
  • Nikhilesh Patil Department Radiation Oncology, Faculty of Medicine, Dalhousie University
  • David Bowes Department of Radiation Oncology , Faculty of Medicine, Dalhousie University
  • Greg Bailly Department Urology, Faculty of Medicine, Dalhousie University
  • Eva Abou-Samra Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University
  • Alice Bourne Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University
  • Liam-Patrick Hagerman Department of Radiation Oncology, Faculty of Medicine, Dalhousie University
  • Robert Rutledge Department of Radiation Oncology, Faculty of Medicine, Dalhousie University

DOI:

https://doi.org/10.5489/cuaj.9525

Keywords:

prostate cancer, survivorship, curative disease, urinary function, incontinence, PFMT, pelvic floor muscle training, patient education, patient empowerment, patient activation, eHealth, digital health

Abstract

Introduction: Men treated curatively for localized prostate cancer often experience urinary compli-cations that impairs quality of life. The Prostate Cancer-Patient Empowerment Program (PC-PEP) is a six-month digital intervention integrating pelvic floor muscle training (PFMT), fitness, nutrition, and intimacy support. While early initiation of PC-PEP improves urinary outcomes, the influence of adherence remains unclear. This mediation analysis examined whether reported PFMT duration and engagement with self-monitoring mediate the association between timing of PC-PEP delivery (early vs. late) and urinary outcomes.

Methods: In a randomized crossover trial, 128 men with localized prostate cancer were assigned to receive PC-PEP immediately (early group, n=66) or after six months of standard care (late group, n=62). Urinary outcomes were assessed using the Expanded Prostate Cancer Index Composite (EPIC) and International Prostate Symptom Score (IPSS). Weekly compliance surveys tracked en-gagement. Mediation and moderated mediation analyses adjusted for age, comorbidity, treatment modality, and baseline urinary function.

Results: Mean reported weekly PFMT duration did not differ between groups. The early group had higher compliance survey completion (98.8% vs. 64.1%, p<0.001) and higher post-intervention EPIC urinary incontinence scores (81.5±21.9 vs. 68.2±17.0, p<0.001), indicating better continence. Com-pliance survey completion mediated 41% of the association between early intervention and post-intervention EPIC urinary incontinence scores. No significant mediation was observed for IPSS or EPIC irritative/obstructive scores. Treatment modality did not moderate effects.

Conclusions: Early initiation of PC-PEP was associated with greater engagement in structured self-monitoring, which mediated improvements in urinary continence independent of reported PFMT duration. Integrating early patient activation and digital self-monitoring into post-treatment care may improve urinary continence outcomes and support scalable rehabilitation.

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Author Biographies

Emily Chedrawe, Department of Urology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia

PGY4 Urology Resident at Dalhousie University, Department of Urology, Faculty of Medicine

Gabriela Ilie, Departments of Urology, Radiation Oncology and Community Health and Epidemiology, Faculty of Medicine, Dalhousie University

Dr. Ilie’s substantive interests are in the areas of prostate cancer health related quality of life, survivorship, patient education and patient empowerment programs, patient-reported outcomes, population health, mental health, substance use, and health policy. She is particularly interested in the intersection of chronic illness and various patient-reported disease-specific and health related quality of life outcomes, with a special emphasis on adults and aging.

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Published

2026-03-30

How to Cite

Chedrawe, E., Smith, N. K., Ilie, G., Rendon, R. A., Mason, R., Kokorovic, A., … Rutledge, R. (2026). Mediation analysis of adherence to pelvic floor muscle training and weekly self-monitoring on urinary symptoms in men with localized prostate cancer: A secondary analysis of the Prostate Cancer-Patient Empowerment Program (PC-PEP) randomized controlled trial. Canadian Urological Association Journal, 20(8). https://doi.org/10.5489/cuaj.9525

Issue

Vol. 20 No. 8 (2026): CUAJ August

Section

Original Research

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