Pelvic floor muscle training

This card describes pelvic floor muscle training (PFMT), a non-surgical approach to urinary leakage that is often discussed around bladder and prostate procedures. It covers what the exercises are, who they are offered to, how they are taught and where the evidence is mixed. It is general information, and a person's own clinician or continence physiotherapist decides what to recommend.

What it is

The pelvic floor is a hammock of muscle and other tissue that stretches between the pubic bone at the front and the tailbone at the back. The urethra and the rectum pass through it, and it supports the bladder and bowel. An NHS hospital leaflet from University Hospitals Sussex says these muscles can be weakened by some operations for an enlarged prostate, straining with constipation, chronic cough and being overweight. PFMT strengthens them through repeated, controlled contractions. Terms are defined in the glossary.

Why it is done

PFMT is offered to reduce urinary leakage. The NICE guideline on urinary incontinence in women recommends a trial of supervised PFMT lasting at least 3 months as first-line treatment for women with stress or mixed urinary incontinence. The NHS advice on helping a weak bladder says pelvic floor exercises can be effective at reducing leaks.

For men, a common context is leakage after prostate surgery. A Cochrane review notes that between 2 percent and 60 percent of men may have incontinence after prostate surgery, and that it can improve naturally, though some men continue to leak and their quality of life can be affected. The Sussex leaflet states that pelvic floor exercises have been shown to be effective following surgery on the prostate and for dribbling after passing water. See also the cards on transurethral resection of the prostate and holmium laser enucleation of the prostate.

How it is done, in outline

The first step is finding the right muscles. The Sussex leaflet suggests tightening the ring of muscle around the back passage as if trying to control wind, and imagining stopping the flow of urine midstream. It says to do the stream-stopping only briefly, to learn which muscles to use, and not as a habit, because it can interfere with normal bladder emptying. People who cannot feel a definite squeeze and lift are told to seek professional help, and the leaflet notes that even men with very weak muscles can be taught by a physiotherapist or continence adviser.

The leaflet's routine is to squeeze and lift while counting to five, then relax, holding for up to ten seconds as strength improves, repeating up to 8 to 10 times. It adds five to ten short, fast contractions, and says to do the whole routine at least 4 to 5 times a day, in lying, sitting, standing or walking positions. It advises not holding the breath, not pushing down, and not tightening the stomach, buttocks or thighs. The NHS page gives a simpler example: squeeze for 2 seconds, relax, repeat 10 times, gradually building the hold toward 10 seconds.

Recovery

PFMT is a gradual process. The Sussex leaflet says an improvement probably will not be noticed for several weeks and maximum strength may take a few months, and that once control returns people should continue twice a day for life. The NHS says it may take a few months of exercises to see benefits. NICE specifies at least 3 months for its recommendation for women, and the length of a person's own program is for their team to set.

Many people exercise alongside other recovery steps, such as catheter care (see urinary catheters after surgery) and the wider topics in recovery and rehabilitation.

Risks

The Cochrane review found it uncertain whether PFMT with biofeedback causes skin-related effects (such as reactions or bruising) or muscle-related effects (such as soreness), because the evidence is of very low certainty, and it notes that adverse events in this field are often poorly documented. The larger open question is how well the training works.

Evidence on benefit after prostate surgery is mixed. The 2023 Cochrane review of conservative treatments included 25 studies with 3,079 men, nearly all of whom had radical prostatectomy. It found that PFMT plus biofeedback may result in more men reporting cure from 6 to 12 months (low-certainty evidence), yet men doing it may be less likely to be cured by objective clinician measures. Combinations of conservative treatments may make little difference to cure or improvement, and probably little difference to quality of life. The authors conclude that the value of these interventions remains uncertain, because trials are small, often at risk of bias, and use varied techniques. The available trials are not strong enough to settle the question either way.

Questions to ask your clinician

• Should I start pelvic floor exercises before my operation, and for how long?
• Can a continence physiotherapist check that I am using the right muscles?
• How many times a day should I do the exercises, and how should I build up?
• When should I expect to notice a difference, and when should we review progress?
• If leakage continues, what other treatments could be considered?
• Should I keep doing the exercises long term once control returns?