Abstract
Objective
To review the effectiveness of pelvic floor muscle strengthening before radical prostatectomy.
Methodology
A search of publications was conducted in the following databases: PubMed, Scopus, Cochrane and Enfispo for articles published from 2019 to September 2024. A total of 199 articles were reviewed, of which 6 were selected and peer-reviewed using the CASPe questionnaire to assess methodological quality, resulting in the inclusion of 5 studies with a total of 642 participants.
Results
Pelvic floor prehabilitation in patients undergoing radical prostatectomy aims to improve urinary continence, sexual function and quality of life. The studies analyzed show significant methodological variability, adding difficulty in comparing the results. Treatments that combine pelvic floor exercises with aerobic and resistance training show better functional recovery and continence outcomes. Less intensive programs do not show significant differences between groups. Studies with longer durations demonstrate clearer benefits, while shorter follow-up periods limit the evaluation of long-term efficacy. Additionally, few studies address erectile dysfunction, despite its impact on quality of life.
Conclusion
Pelvic floor prehabilitation may help improve urinary continence following radical prostatectomy; however, there is a paucity of studies evaluating its application prior to surgery, and considerable variability exists in treatment protocols. No standardized clinical protocol exists, which hinders result comparisons. Although prehabilitation shows promising potential, current studies present heterogeneous results. Clinical trials are needed to standardize interventions, expand sample sizes, and conduct long-term follow-ups to consolidate evidence and improve patient care.
Prospero Register
Prospero Register: CRD42024619694
Keywords: Pelvic floor, Prehabilitation, Radical prostatectomy, Pelvic floor exercises, Urinary incontinence
Introduction
The prostate is a gland of the reproductive system that produces part of the semen [1]. When there is cancer, the symptoms can be characterized by urinary issues such as decreased stream caliber or interrupted urine flow; increased frequency of urination and others [1].
In Spain, prostate cancer is expected to be the most frequently diagnosed cancer in men in 2025, as it was in 2024, with an estimated 32,188 new cases for 2025 [2]. It is estimated that 1 in 8 men in Spain will be diagnosed with this disease. The majority of cases affect older men, with 90% of patients being over 65 years old, and the average diagnosis age is 75 years [1].
Furthermore, various treatment options are available for prostate cancer patients. Some treatments are standard (currently in use) and others are being tested in clinical trials (experimental treatments). Standard treatments include surgery, radiation therapy, drug therapy, hormone therapy, chemotherapy, and targeted therapy [3, 4].
This review focuses on patients undergoing radical prostatectomy. Radical prostatectomy is a surgical procedure to remove the prostate, surrounding tissue, and seminal vesicles. Nearby lymph nodes may also be removed [4].
The most common sequelae of this surgery are urinary incontinence (UI) and erectile dysfunction (ED), which typically appear immediately after surgery but may improve over time [1].
Bladder health is essential for maintaining independence and functional performance; UI is the most common condition that can affect bladder health and quality of life (physical, emotional, and social impact) [5]. UI is the involuntary loss of urine, affecting up to 36 million people in Europe [6, 7]; the annual average per capita treatment cost is €300–600 per country [7]. The total direct cost in Germany, Italy, Spain, Sweden, and the United Kingdom has been estimated at €5 billion per year, with this burden projected to increase with a 25% rise in the prevalence of UI by 2030 [7].
Physical activity plays an important role as a modifiable protective factor that can reduce or even prevent UI [8]. Physiotherapy is one of the main methods for strengthening the pelvic floor, but barriers to its acceptance exist, including waiting lists that limit access to treatment and poor adherence to exercises [6, 9].
The purpose of this review is to analyze the existing literature on pelvic floor muscle prehabilitation in patients undergoing prostate cancer surgery. This is an important rehabilitative approach, yet the available evidence is still limited and developing.
Given that physical therapy is proven to be effective in treating symptoms after radical prostatectomy, we propose a review to analyze the current literature about this subject.
Materials and methods
The bibliographic search was conducted during the month of September 2024 (last day was September 25) in various databases, seeking clinical trials published in the past five years to update the existing literature. The search was performed in the following databases: PubMed, Scopus, Cochrane and Enfispo. The search strategy included filters where applicable, such as language (English), publication type (article: randomized controlled trial, clinical trial) and publication date. The following search strategies were used across the databases:“(pelvic floor exercise) OR (kegel) AND (before prostatectomy) NOT (after)”, “(pelvic floor exercise) OR (kegel) AND ((before prostatectomy) OR (preoperation) AND (urinary incontinence))”. In Cochrane, additional terms were added: “(pelvic floor) OR (pelvic floor) AND (exercise) OR (kegel) OR (exercise therapy) AND (prostatectomy)”, “(pelvic floor) OR (pelvic floor) AND (exercise) OR (kegel) OR (exercise therapy) AND (prostate surgery)”, “(pelvic floor exercise) OR (kegel) AND (before prostatectomy) AND (urinary incontinence)”, “(pelvic floor muscle exercise) AND (radical prostatectomy) AND (prehabilitation)” due to a lack of results.
A total of 199 studies were identified following this search strategy. The inclusion criteria were: clinical trials published between 2019 and 2024, involving adult male individuals with prostate cancer (PC) undergoing radical prostatectomy (RP), with a preoperative pelvic floor muscle intervention and written in English. Exclusion criteria were: only postoperative interventions and studies where researchers had financial interests or others.
All articles were initially screened by reading the title or abstract, resulting in 25 results. Duplicates were removed, leaving 6 of them. The CASPe questionnaire for clinical trials was applied to assess methodological quality. This questionnaire consists of 11 questions divided into 3 blocks: Are the results of the trial valid? What are the results? Can these results help us? This tool helps determine whether a trial has sufficient quality or should be excluded. Both the article review and the CASPe questionnaire evaluation were peer-reviewed. In the event of a disagreement between authors over the inclusion of an article, a third reviewer conducted an independent assessment. One paper was excluded due to low methodological quality and for being incomplete. Finally, five publications in the past five years, meeting the inclusion criteria, were included. (Fig. 1)
Fig. 1.
Research strategy and articles qualitative analysis (Flowchart)
All the selected studies have been included in the descriptive table below, from which we extracted data on the study variables to compare the effectiveness of each treatment applied.
Risk of bias
Each study was peer-reviewed, both its selection and the CASPe questionnaire, to reduce the risk of bias.
Results and discussion
Pelvic floor prehabilitation in patients undergoing radical prostatectomy has been proposed as a strategy to improve both urinary incontinence and sexual dysfunction resulting from surgery, with the ultimate goal of preserving quality of life. However, the outcomes reported in the reviewed studies vary widely, partly due to significant methodological heterogeneity: differences in types of intervention, sample sizes, surgical modalities, inclusion/exclusion criteria and follow-up duration.
One of the most marked differences among the analyzed studies is the sample size, which ranges from 31 patients in the study by Hislano Heverton Soares de Lira et al. [12] to 97 in that of Joanne E. Milios et al. [9]. This difference is important, as a larger sample allows for more statistically robust results. Nevertheless, all studies share an equal distribution between control and intervention groups, which strengthens their internal comparability.
Regarding the content of the interventions, there are clear differences. While the studies by Joanne Milios et al. [9] and Au D et al. [13] implement multimodal programs that combine aerobic, resistance, and pelvic floor-specific exercises, other studies such as those by Cristina García-Sánchez et al. [10], Elif Gezginci et al. [11] and Hislano Heverton Soares de Lira et al. [12] focus exclusively on pelvic floor strengthening exercises. Studies that incorporate more comprehensive and intensive protocols, such as that by Joanne E. Milios et al. [9], tend to report more significant improvements in overall recovery and urinary continence compared to those that implement shorter or more limited interventions.
There is also considerable variation regarding pre-surgical interventions. For example, in the study by Cristina García-Sánchez et al. [10], three face-to-face sessions were conducted under the guidance of a physiotherapist specialized in the pelvic floor. While the studies by Joanne E. Milios et al. [9] and Au D et al. [13] applied multimodal programs combining aerobic, resistance and pelvic floor-specific exercises, other studies such as those by Cristina García-Sánchez et al. [10], Elif Gezginci et al. [11], and Hislano Heverton Soares de Lira et al. [12] focused solely on pelvic floor strengthening. Studies with more intensive and prolonged protocols, like Joanne E. Milios et al. [9], tend to report better results in overall recovery and urinary continence compared to those with more limited or brief interventions.
The frequency and modality of pre-surgical interventions also vary. For instance, Cristina García-Sánchez et al. [10] conducted only three face-to-face sessions, while Joanne E. Milios et al. [9] began intervention five weeks before surgery and included more demanding home-based guidelines. In contrast, the study by Elif Gezginci et al. [11] was limited to a single educational session prior to surgery, conducted at the hospital and in the study by Hislano Heverton Soares de Lira et al. [12], the duration of the intervention is not clearly specified. This diversity makes it difficult to draw firm conclusions, although studies with more intensive and prolonged programs tend to yield better outcomes.
In terms of clinical results, the studies by Joanne E. Milios et al. [9] and Elif Gezginci et al. [11] report significant improvements in urinary continence at three months postoperatively, reinforcing the idea that supervised and sustained training is more effective. In contrast, Cristina García-Sánchez et al. [10] and Hislano Heverton Soares de Lira et al. [12] did not find significant differences between groups, possibly due to the lower intensity or shorter duration of their programs and limited follow-up periods.
Regarding quality of life, which is assessed with various instruments, differences are also observed between studies. Elif Gezginci et al. [11] and Joanne E. Milios et al. [9] document improvements in several aspects related to quality of life, reflecting a connection between continence recovery and overall well-being. On the other hand, in the work by Cristina García-Sánchez et al. [10], lower scores were found in emotional aspects in the experimental group compared to the control group. Due to this result, the study highlights the importance of considering psychological factors and mentions the need for better expectation management in future research.
Regarding erectile function, Gislano Heverton Soares de Lira et al. [12] is the only author who evaluated this variable, without finding significant differences between the two groups analyzed. Despite the result, there are few scientific studies that consider erectile dysfunction as a variable, even though it significantly impacts patients’ quality of life after surgery.
A novel aspect addressed only by Au D et al. [13] is the analysis of postoperative physical activity. Their results indicate that prehabilitated patients showed higher levels of physical activity during hospitalization and in the first week after discharge, suggesting a positive impact on early functional recovery.
It is important to highlight the need to understand postoperative outcomes and whether these benefits are maintained or vary over time. Studies like those by Joanne E. Milios et al. [9] and Elif Gezginci et al. [11] feature intensive protocols and extended follow-up periods, allowing for the observation of medium-term benefits. In contrast, studies like those by Cristina García-Sánchez et al. [10] and Hislano Heverton Soares de Lira et al. [12] are limited by their short application periods.
The studies analyzed present widely varying follow-up durations, which influence how their results are interpreted and the strength of their conclusions. Cristina García-Sánchez et al. [10] conducted follow-up only one month after the intervention, whereas the study by Au D et al. [13] limited its assessment to the first week after hospital discharge. In contrast, the studies by Elif Gezginci et al. [11], Heverton et al. and Joanne E. Milios et al. [9] carried out three-month post-surgery follow-up, allowing for better analysis of urinary continence and quality of life evolution. Shorter follow-up periods may underestimate the benefits of prehabilitation, as functional recovery often extends beyond the first month. Therefore, a longer observation period provides a more complete evaluation.
Finally, the reviewed studies present several limitations that make it difficult to draw firm conclusions. While studies such as those by Joanne E. Milios et al. [9] and Elif Gezginci et al. [11] offer three-month follow-up, enabling a better assessment of functional progress, others such as Cristina García-Sánchez et al. [10] and Au D et al. [13] are limited to the first month or even the first postoperative week, preventing long-term benefit evaluation. Additionally, there is limited assessment of key variables such as erectile function and scant information about adherence to exercises. A lack of control over psychological factors is also observed, which may influence outcome. (Table 1)
Table 1.
Methodological characteristics, interventions and main outcomes of five clinical studies on pelvic floor prehabilitation in patients undergoing radical prostatectomy
| Author | Journal & Year | Patients (control group/intervention) | Comparison | Results |
|---|---|---|---|---|
| Joanne E Milios [9] | BMC Urol. 2019 | Total n = 97 (47/50) | PFM training focusing on activating fast- and slow-twitch muscle fibres. | An intensive PFM training intervention applied before surgery improved postoperative pelvic floor muscle function, reduced UI and improved quality of life outcomes compared to the control group. |
| Cristina García-Sánchez [10] | Archivos Españoles de Urología, August 2022 | Total n = 62 (31/31) | Comparing physiotherapist-guided pelvic floor exercises before radical prostatectomy vs. written instructions. | Preoperative physiotherapist-guided PFM training did not improve incontinence rates, incontinence severity or quality of life one month post-intervention compared to written instructions. |
| Elif Gezginci et al. [11] | October 2022, Sarge Journals | Total n = 60 (30/30) | Comparing prehabilitation and postoperative PFM exercises vs. no PFM exercises. | The perioperative pelvic floor muscle training programme was effective in reducing urinary incontinence symptoms and improving quality of life three months after radical prostatectomy. |
| Gislano Heverton Soares de Lira, et al. [12] | December 2019, IBJU Int. Braz J Urol | Total n = 31 (15/16) | Comparing preoperative and postoperative PFMT vs. no rehabilitation treatment. | Preoperative physiotherapist-assisted PFMT with additional instructions did not significantly improve urinary continence or erectile function three months after radical prostatectomy. |
| Au D, et al. [13] | Springer Open, 2019 | Total n = 42 (21/21) | Analysing one-week post- discharge physical activity levels in relation to prehabilitation participation before radical prostatectomy. | There were no correlations between in- or outpatient physical activity and preoperative changes in 6MWT or length of stay. |
Practical implications for clinical professionals
Despite the methodological variability among the studies reviewed, the findings suggest that pelvic floor prehabilitation may offer clinically relevant benefits for patients undergoing radical prostatectomy, particularly in relation to urinary continence recovery and postoperative quality of life.
For clinical professionals, these results highlight the importance of incorporating structured preoperative interventions, preferably those combining specific pelvic floor exercises with aerobic and resistance training, and delivered under the guidance of specialised physiotherapists. Furthermore, initiating the intervention with sufficient lead time (ideally 4–5 weeks prior to surgery) and including supervised components may optimize patient outcomes.
Given the emotional and functional impact of postoperative sequelae, it is also advisable to include psychological support strategies and manage patient expectations as part of a multidisciplinary approach. Finally, although current evidence regarding variables such as erectile function and long-term adherence is still limited, the integration of prehabilitation programmes appears to be a promising strategy for enhancing functional recovery and overall patient well-being. (Table 1)
Limitations of the review processes
Several methodological limitations were identified during the development of this systematic review, which should be considered when interpreting the findings. Firstly, although inclusion and exclusion criteria were established in advance, the selection of studies may have been influenced by human error during the screening of titles and abstracts, potentially introducing selection bias.
Moreover, the search strategy employed may not have been sufficiently sensitive or comprehensive, given the diversity of relevant studies and the variability in key terms. An additional limitation was the language restriction, as only articles published in English and Spanish were considered, which may have led to the exclusion of relevant evidence published in other languages.
Another methodological constraint was the absence of automated tools or reference management software during the search and organisational process, which may have affected the thoroughness and efficiency of study identification.
Additionally, the review was conducted exclusively in Spain by three researchers, which could introduce a geographical or cultural bias in the interpretation of results. The duration of the review process may also have been limited, meaning that recent publications may not have been included.
Conclusion
After conducting the literature review, we conclude that pelvic floor prehabilitation is a potential intervention that may improve urinary continence, sexual function, and quality of life in patients undergoing radical prostatectomy. It is important to conduct further randomised controlled trials to investigate key aspects such as the optimal duration, progression, intensity, and type of pelvic floor exercises, as well as the appropriate timing and duration of implementation both pre- and postoperatively.
However, there is a significant lack of studies evaluating the effectiveness of prerehabilitation and considerable variability exists in the therapeutic approaches described by different authors. Currently, there is no standardized clinical protocol for these patients, which complicates the comparison of results and the uniform application of treatment.
In our opinion, the lack of literature may be due to an absence of assessment of this variable before and after the intervention. Additionally, there are important factors influencing erectile function—such as medication, nerve preservation, and adequate vascularisation—that must be taken into account. Finally, there is a shortage of studies on this topic, as well as a lack of consensus regarding treatment approaches, including the need for structured and reproducible treatment protocols.
This review highlights the need for randomized clinical trials to provide more evidence on the usefulness of pelvic floor prehabilitation and emphasizes the importance of developing a unified protocol. While prehabilitation shows promising potential to optimize recovery post-surgery, the existing studies present heterogeneous results, likely due to methodological differences. More comprehensive and intensive programs, combined with specialized follow-up, appear to offer greater benefits in urinary continence and quality of life, while less structured interventions show limited results.
Future research should focus on standardizing interventions, expanding sample sizes and conducting long-term follow-ups to consolidate evidence in this area and improve patient care.
Acknowledgements
We would like to express our gratitude for the support provided by all our colleagues in the rehabilitation service at Hospital Santa Maria de Lleida.
Author contributions
OA-G, AJ-V and CT substantially and equally contributed to the conception and design of the work as well as the drafting and revising of the manuscript. All authors finally approved the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding
The publication of this review is funded by the grant “Santa Maria fa recerca” obtained in 2023 from Hospital Santa Maria de Lleida (Spain).
Data availability
The data used and analyzed during the current study are available upon reasonable request to the corresponding author.Prospero Register : CRD42024619694.
Data search
All articles analyzed are available in the databases described. The CASPe questionnaire is available free online.
Declarations
Ethics approval and consent to participate
All OA-G, AJ-V, and CT review participants consented to participate
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Oscar Aguila-Gimeno, Email: oscarkinelleida@gmail.com.
Alba Jareño-Vicens, Email: alba.jareno@gmail.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data used and analyzed during the current study are available upon reasonable request to the corresponding author.Prospero Register : CRD42024619694.
All articles analyzed are available in the databases described. The CASPe questionnaire is available free online.