Pelvic floor physical therapy helps men after prostatectomy

In Male Pelvic Pain by Melinda Fontaine2 Comments

By Melinda Fontaine, DPT, PHRC Walnut Creek


What would men’s health month be without a blog about prostate cancer? One in seven men will be diagnosed with prostate cancer in his lifetime. Will this number be affected by the recent change in the U.S. Preventive Services Task Force’s change in recommendations on screening for prostate cancer? What happens when a man has his prostate removed? Is it possible to predict, prevent, or repair urinary incontinence and erectile dysfunction?


U.S. Preventive Services Task Force’s (USPSTF) Recommendations on Screening for Prostate Cancer


Since prostate specific antigen (PSA) screening for prostate cancer became widely used, men are being diagnosed younger and with more limited spread of disease. Last month, the USPSTF upgraded its recommendation for screening men ages 55-69. The task force previously recommended that men not be screened for prostate cancer using (PSA) tests.  Now the recommendation is that men ages 55-69 discuss their risk factors with their doctor and decide if PSA testing would be beneficial on an individual basis. African American men and men with a family history of prostate cancer are at higher risk for prostate cancer and may need closer monitoring. The USPSTF still does not recommend PSA screening for men over the age of 70 because they feel the possible harm outweighs the benefits.




Now switching gears, let’s talk about when prostate cancer screenings are positive. Your doctor may say, “It has got to go!” Depending on the cancer, an oncologist may recommend radical prostatectomy, a surgery to remove the whole prostate. Luckily, prostatectomy is very effective at getting rid of many prostate cancers, but let’s look at life without a prostate.


Urinary Control


One year after surgery, 89-100% of men who had robot assisted laparoscopic prostatectomy are using 0-1 pads for incontinence.   Of men who had open radical retropubic prostatectomy, 80-97% are using 0-1 pads for incontinence. Risk for incontinence increases when the man is over 70 years old or has detrusor overactivity (overactive bladder) before surgery and if the surgeon uses certain surgical techniques or does not have a lot of experience. The prostate surrounds the urethra and supports it to help control urination. After prostatectomy, the pelvic floor muscles have to work overtime to make up for the loss of support. If they are not up for the challenge, urine can leak. Coughing, laughing, sneezing, jumping, or getting up from a chair can be especially challenging for the muscles to control. If leaks only occur during these activities, it is called stress urinary incontinence. Pelvic PT before and after surgery can help train the pelvic floor muscles to reduce incontinence.³ The body is asking the muscles to do something they have never had to do before, so average muscles need conditioning to bulk them up (think bodybuilder’s bulky muscles) and support the urethra.  Strength, endurance, and coordination training for the pelvic floor help prevent leaks. MRI images comparing pelvic muscles before and after recovering from incontinence showed that pelvic muscles were thicker and the bladder neck was moved higher and forward after they regained continence.³


Sometimes the weakness is also in the middle of the abdominal wall, called diastasis recti. This is common after robotic/laparoscopic surgeries and also during pregnancy; in fact Malinda wrote a blog all about it here. Basically, it is a weakness in the abdominal wall which has been associated with difficulty getting good closure of the urethra. Think of it like stepping on a garden hose to stop the flow.  If the abdominal wall is weak, then it is like stepping on a garden hose on a trampoline; you can’t get good closure. Pelvic PTs also strengthen the abs.




The prostate, along with the testicles and seminal vesicles, create secretions for ejaculation. After prostatectomy, the prostate and seminal vesicles are not there to create fluid, so these men have dry orgasms.  


Erections and Penile Rehab


Erections are a common concern for men after prostate surgery because the nerves responsible for erectile function are often injured during surgery, even if it is a nerve-sparing surgery (meaning the nerve is not cut). Radiation therapy also can decrease quality of erections. Erectile dysfunction (ED) is less prevalent in men that are younger, fully potent before surgery, and healthy. Use of robot assisted, athermal dissection, and nerve-sparing surgical techniques also result in less ED.¹ Nerves are very slow to recover, so men can regain erectile function for up to two years after surgery. Nerves need a lot of oxygen, so the best thing to do for a recovering nerve is to supply it with a lot of oxygenated blood.¹ Can anyone think of a great way to get blood to a penis? You guessed it – have an erection! Does anyone else see a problem here? Men with erectile dysfunction aren’t having erections, so they aren’t getting good blood flow to the nerves, which is not optimal for nerve healing, which does not improve erection quality….To stop this never ending spiral, let’s talk about what is known as, penile rehabilitation. Men can still have arousal and orgasm without erection, and this brings some blood flow to the area, so it’s a good idea to continue sexual activity.  Use it or lose it! Check out my previous blog on sex after prostate cancer. Phosphodiesterase 5 inhibitors (PDE5-Is), such as Viagra, Cialis, and Levitra, relax the smooth muscles of the penis resulting in increased blood flow and possible erection. Studies show that using PDE5-Is on-demand improved erectile function, and daily use also preserved penis length.¹ Research has also found intraurethral alprostadil (IUA) and intracavernosal injection therapy (ICI) to be effective and even more useful when therapy is started soon after surgery.  Vibratory stimulation of the pudendal nerves in the penis can cause a reflexive erection. Vacuum erection devices do not require functioning nerves to create an erection, and can be used to increase oxygenated blood flow to the tissues and prevent fibrosis which leads to ED and shortened penile length.¹ Animal models have also shown success with using stem cell therapy to repair damaged tissue and improve erection quality.² Stay tuned to this blog for the next two weeks to learn more about erectile dysfunction.


Case report


Eli was a 69 yo male who came to PT three months after radical laparoscopic prostatectomy with urinary incontinence and erectile dysfunction. He presented with moderate pelvic floor strength and endurance, a small diastasis recti, and was not sexually active. Surgery led to lack of urethral support and control, weakness in the abdominal wall, and nerve injury resulting in urinary incontinence and erectile dysfunction. His goals were to decrease the amount of urine leaking and possibly regain an erection. I taught him various exercises for his pelvic floor and abs to make them perfectly strong and bulky enough to support the urethra, which helped decrease his incontinence. I also discussed his options for increasing blood flow to the nerves supplying the penis to help recover nerve function and erection. After many months, he spoke to his doctor and tried a vacuum device, a PDE5-I, and injections. He later joined a prostate support group.  


A year after beginning physical therapy, he was only using one Depends per day, which was not very wet, instead of three completely soaked Depends. His strength and endurance were perfect. He ranked his improvement as eight out of ten. He had a satisfying sex life even though his erection did not come back. He did have a delayed start to using the vacuum device, PDE5-I, and injections and remember, it can take up to two years for nerves to recover. He will continue to attempt erections regularly to improve blood flow for the next year and then as desired after that.


Pelvic PT


Prostate cancer affects the body and mind in different ways.  Physical therapy is useful after prostatectomy to improve urinary continence and erectile dysfunction. If you have been through treatment for prostate cancer and have urinary incontinence and/or erectile dysfunction, find a physical therapist here.





  1. Clavell-Hernandez J and Wang R. The controversy surrounding penile rehabilitation after radical prostatectomy. Transl Androl Urol 2017;6(1):2-11.doi: 10.21037/tau.2016.08.14.
  2. Mangir N and Turkeri L. Stem cell therapies in post-prostatectomy erectile dysfunction: a critical review.Can J Urol 2017;24(1):8609-8619.
  3. Pacik D and Fedorko M. Literature review of factors affecting continence after radical prostatectomy. Saudi Med J 2-17;38(1):9-17. Doi: 10.15537/smj.2017.1.15293.
  4. Santos NA et al. Assessment of physical therapy strategies for recovery of urinary continence after prostatectomy. Asain Pac J Cancer Prev 2017;18(1):81-86. doi:10.22034/APJCP.2017.18.1.81
  5. Glickman C and Emirzian A. The Ultimate Guide to Prostate Pleasure. Berkeley:Cleis Press, 2013.


What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.


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