Optimising Physio Care for Post-Prostatectomy Incontinence

Post-prostatectomy incontinence (PPI) is one of the most common conditions seen in men’s pelvic health.

For many physios, it’s an area that feels both clinically important and clinically under supported: we know Pelvic Floor Muscle Training (PFMT) should help, but because approaches are largely borrowed from female pelvic health, they don’t always deliver consistent results in men.

This blog gives you a taste of a few key concepts of assessment and exercise prescription for PPI.

If you want a deep dive, check out David Cowley’s full Pelvic Health in Men Masterclass here.

Why does PPI occur?

To understand incontinence after prostatectomy, we first need to understand what continence requires: continence occurs when urethral pressure exceeds bladder pressure.

Two systems generate that urethral pressure:

1. The internal urethral sphincter (smooth muscle): autonomic, tonic, and responsible for most of the baseline closing force.
2. The striated pelvic floor muscles: the puborectalis, bulbocavernosus, and especially the Striated Urethral Sphincter (SUS), which kick in during rises in bladder pressure (e.g., coughing, sneezing, standing up).

During prostatectomy, this balance can be disrupted in several ways:

1. Removal of periurethral prostatic smooth muscle
These smooth muscle fibres form part of the internal urethral sphincter. Their removal means men lose a significant proportion of their passive urethral closure pressure.

2. SUS scarring, disruption or denervation
The SUS is the most important striated muscle for increasing urethral pressure during effort, such as coughing. Damage to it can significantly reduce dynamic urethral closure. Studies report that up to 88% of men experience sphincter insufficiency post-prostatectomy.

3. Bladder neck disruption and “funnelling”
When the bladder neck is dissected and reattached to the membranous urethra, the new shape is often wider, less elastic, and more “open”. This funnel can allow urine to enter the proximal urethra, triggering reflex bladder contractions and leakage.

4. Disruption of supportive ligaments and connective tissue
Reduced suspension and support around the bladder neck and urethra further decreases mechanical stability and increases susceptibility to leakage.

5. Changes to detrusor contractility
Bladder trauma during surgery can lead to either excessive or insufficient bladder pressure, both of which undermine continence.

Assessment and exercise prescription for PPI

There are some disruptions we as physios can address, and some we must compensate for. Something we can address is the strength and control of the voluntary pelvic floor muscles.

David covers pelvic floor muscle assessment and exercise prescription in his Masterclass, outlining how to use transperineal ultrasound as a valuable tool, supported by an international consensus on assessment, which recommends assessing:

1. Urethral, bladder and anorectal anatomy, including:
i) bladder neck configuration
ii) urethral mobility and integrity
iii) anorectal angle and puborectalis behaviour

2. Pelvic floor muscle activation during:
i) voluntary contraction (raw effort without cues, and with cues)
ii) coughing (raw and with pre-activation)
iii) repeated rapid contractions and relaxation (x10)
iv) sustained contraction (up to 30 seconds)

This approach recognises that the pelvic floor must perform in a range of different contexts, and after prostatectomy, each of those capacities needs to be individually assessed and trained.

In the clip from his Masterclass below, David highlights two common issues seen during rapid pelvic floor contractions on transperineal ultrasound:

What should PFMT programs for PPI include?

While the evidence supporting PFMT is not as strong for men as it is for women, some features of PFMT programs associated with greater success include (2):

• Training commenced pre-operatively
• Focus on urethral cueing
• Use of biofeedback

So keep these elements in mind when you’re building a program!

Additionally, see David outline a few key components of the 11 principles of PFMT programs in the below clip from his Masterclass:

What cues to use?

While all three voluntary muscles contribute to continence, training should usually prioritise the SUS, and the most effective cue to target this for men is to “shorten the penis”, followed by “stop the flow of urine” (1).

Key takeaways for PFMT in PPI

• Start pre-operatively whenever possible
• Begin early post-op once the catheter is removed and healing permits
• Avoid abdominal strategies that raise bladder pressure
• Train what’s deficient: strength, speed, timing, endurance or coordination
• Use motor learning principles, not just maximal contractions
• Use biofeedback (transperineal ultrasound) where available
• Practise functional tasks such as pre-contraction before coughing
• Progress gradually with clearly defined home programs

Wrapping up

Incontinence post-prostatectomy is distressing for patients, but with the right assessment tools and targeted PFMT, physiotherapists can directly influence the structures and behaviours most important for recovery.

Using transperineal ultrasound and impairment-specific exercise prescription allows us to move toward personalised rehabilitation. By understanding the mechanisms behind PPI and applying evidence-informed strategies, we can help men regain continence more effectively and confidently.

To explore these concepts in depth and understand how to apply them, watch David Cowley’s full Masterclass here.