After Prostatectomy: Why Pelvic PT Should Start Before Surgery
If you have been diagnosed with prostate cancer and are preparing for a radical prostatectomy, there is probably a long list of things on your mind: the surgery itself, recovery time, cancer treatment, urinary changes, sexual function, and what life will look like afterward.
One thing that is often overlooked is pelvic floor physical therapy.
Many men are referred to pelvic floor physical therapy after surgery once urinary leakage becomes a problem. But there is a strong argument for starting before surgery instead.
Preoperative pelvic floor physical therapy, sometimes called pelvic floor prehabilitation, gives you an opportunity to understand and train the muscles that will play an important role in your recovery before you actually need them.
What Happens to the Pelvic Floor After Prostatectomy?
The prostate sits just below the bladder and surrounds part of the urethra. During a radical prostatectomy, the prostate and seminal vesicles are removed, and the bladder and urethra are surgically reconnected.
Even with modern surgical techniques, this can temporarily affect the structures responsible for urinary control.
It is common for men to experience some degree of urinary leakage after the catheter is removed. The American Urological Association notes that incontinence is expected in the short term after radical prostatectomy, with most men experiencing significant improvement over the following months.
The pelvic floor muscles are one part of the system that helps maintain urinary continence. Learning how to properly contract, relax, and coordinate these muscles can be an important part of preparing for recovery.
Why Start Pelvic PT Before Surgery?
Think of it as training before the big event.
Starting pelvic PT before surgery allows you to learn what your pelvic floor muscles are supposed to do while you are still feeling relatively normal.
A pelvic floor physical therapist can assess your individual muscle strength, endurance, coordination, and ability to fully relax. You can also learn how to use your pelvic floor muscles appropriately during activities that increase abdominal pressure, such as coughing, sneezing, lifting, and changing positions.
This is different from simply being told to "do Kegels."
In fact, more pelvic floor contraction is not always better. Some men have difficulty relaxing their pelvic floor muscles or unintentionally use other muscles instead. A physical therapist can help determine what you actually need rather than giving you a one-size-fits-all exercise program.
You Can Learn the Muscles Before You Need Them
Immediately after surgery, your body is recovering. You may have a catheter, surgical restrictions, fatigue, and changes in urinary control.
Trying to learn how to properly activate your pelvic floor for the first time during this period can be challenging.
Working with a pelvic floor physical therapist beforehand gives you time to develop body awareness and proper technique.
Your therapist may teach you:
• How to identify your pelvic floor muscles
• How to contract the muscles correctly
• How to completely relax the pelvic floor
• How to build pelvic floor endurance
• How to coordinate the pelvic floor with your breathing
• How to use the pelvic floor during coughing, sneezing, lifting, and other activities
• What to expect during the early stages of recovery
• How and when to progress your exercises after surgery
The goal is not to "strengthen as much as possible." The goal is to have a pelvic floor that can contract, relax, and respond appropriately to what your body is asking it to do.
Does Preoperative Pelvic PT Actually Reduce Incontinence?
This is where it is important to look at the research realistically.
Studies have found mixed results regarding whether pelvic floor muscle training before prostatectomy ultimately changes long-term continence rates. However, several studies and systematic reviews suggest that preoperative training may help with earlier recovery of urinary continence.
A systematic review and meta-analysis found that men who performed pelvic floor muscle exercises before radical prostatectomy had better continence outcomes at three months, although the difference was not maintained at six months.
A more recent meta-analysis of 12 studies involving 1,365 participants similarly found a benefit at three months, but not at six or 12 months.
Other research has not found a significant reduction in postoperative incontinence from preoperative pelvic floor exercise.
So pelvic PT should not be presented as a guarantee that you will not experience urinary leakage after surgery.
Instead, the potential benefit is helping you be better prepared for the recovery process and potentially helping you regain continence sooner.
The American Urological Association currently states that men undergoing radical prostatectomy may be offered pelvic floor muscle exercises or training before surgery. Their guideline notes that beginning approximately three to four weeks before surgery allows time for neuromuscular adaptation.
What About Urinary Leakage After Surgery?
Some degree of leakage immediately after catheter removal is common.
That does not necessarily mean something went wrong with your surgery or that you will have permanent incontinence.
Recovery varies from person to person and can depend on factors such as age, baseline urinary function, surgical technique, cancer characteristics, and other individual factors.
Pelvic floor physical therapy can continue after surgery to help address urinary leakage and improve pelvic floor coordination.
The AUA recommends offering pelvic floor muscle exercises or training in the immediate postoperative period, after catheter removal. Research suggests that postoperative pelvic floor training can help men achieve continence sooner, although long-term continence rates may eventually become similar.
Pelvic PT Is About More Than Kegels
For men preparing for prostatectomy, pelvic floor physical therapy is not simply a prescription to squeeze a muscle repeatedly throughout the day.
Your pelvic floor is part of a larger system involving your abdomen, diaphragm, hips, and lower back.
A pelvic floor physical therapist can look at how these areas work together and identify factors that may affect your recovery.
Your treatment may include education, breathing and coordination exercises, pelvic floor strengthening or endurance training, relaxation strategies, movement assessment, and individualized preparation for the postoperative period.
Your therapist can also help you understand what to expect once you return home after surgery and how your program should change throughout recovery.
When Should You Start?
If you know that you are having a radical prostatectomy, it is worth asking your urologist about pelvic floor physical therapy before your surgical date.
The AUA guideline notes that preoperative pelvic floor muscle training is commonly started approximately three to four weeks before surgery, although there is not currently a single standardized program or ideal timeframe for every patient.
Even if your surgery is coming up sooner, it can still be worthwhile to meet with a pelvic floor physical therapist. Your therapist can help you understand the muscles, establish appropriate exercises, and prepare you for what to expect during recovery.
Give Yourself a Head Start
You cannot completely control how your body responds to prostatectomy. But you can control how prepared you are going into surgery.
Starting pelvic floor physical therapy before prostatectomy gives you an opportunity to learn the right muscles, understand how they function, and establish a foundation for your postoperative recovery before surgery ever takes place.
You should not have to wait until you're leaking urine to learn how to manage your pelvic floor.
If you're preparing for prostatectomy, talk with your urologist about starting pelvic floor physical therapy before surgery. A few weeks of preparation may give you a valuable head start on the recovery process.
References
American Urological Association. Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline. Amended 2024.
https://www.auanet.org/documents/Guidelines/PDF/2024%20Guidelines/IPT%20Unabridged%20Final%206-18-24.pdfChang JI, Lam V, Patel MI. Preoperative pelvic floor muscle exercise and postprostatectomy incontinence: a systematic review and meta-analysis. European Urology. 2016;69(3):460-467.
https://pubmed.ncbi.nlm.nih.gov/26610857/Rangganata E, Rahardjo HE. The effect of preoperative pelvic floor muscle training on incontinence problems after radical prostatectomy: a meta-analysis. Urology Journal. 2021;18(4):380-388.
https://pubmed.ncbi.nlm.nih.gov/33931846/Preoperative pelvic floor muscle exercise for continence after radical prostatectomy: a systematic review and meta-analysis. 2023.
https://pubmed.ncbi.nlm.nih.gov/37588123/Terzoni S, et al. Preoperative pelvic muscle training for continence recovery after prostatectomy: yet another meta-analysis? Neurourology and Urodynamics. 2026;45(1):127-136.
https://pubmed.ncbi.nlm.nih.gov/41104623/Burgio KL, et al. Preoperative biofeedback assisted behavioral training to decrease post-prostatectomy incontinence: a randomized, controlled trial.
https://pubmed.ncbi.nlm.nih.gov/20227168/