What are the recommended rehabilitation protocols after prostatectomy for improving sexual function and continence?
Executive summary
A multi-modal, personalized rehabilitation program beginning before or immediately after radical prostatectomy—centered on pelvic floor muscle training (PFMT) with physiotherapist guidance, supplemented where appropriate by biofeedback, electrical or magnetic stimulation, and penile rehabilitation techniques—offers the best evidence for earlier recovery of continence and for preserving sexual function; surgical approach and nerve-sparing status remain dominant predictors of outcomes and must shape expectations [1] [2] [3]. High‑quality trials vary in methods and endpoints, so protocols should be individualized and escalated to mechanical or surgical solutions when conservative measures fail [4] [5].
1. Pelvic floor muscle training: the backbone of continence rehab
Structured PFMT—ideally taught by a physiotherapist and started preoperatively or in the immediate postoperative period—consistently accelerates return to pad‑free continence versus no or unguided exercise, and is recommended by guideline bodies as standard first‑line therapy after radical prostatectomy [1] [6] [7]. Trials differ in intensity and delivery (supervised daily sessions versus home programs), but meta‑analyses and randomized trials show that guided PFMT, reinforced with repeated practice, improves early continence recovery and quality of life [2] [8].
2. Biofeedback, electrical stimulation and magnetic innervation: adjuncts to PFMT
When PFMT alone is insufficient or when patients have difficulty isolating pelvic floor contractions, biofeedback‑guided programs or pelvic floor electrical stimulation can hasten early continence recovery by improving muscle recruitment and strength [8] [7]. Extracorporeal magnetic innervation has shown benefit in select studies for functional bladder capacity and quality‑of‑life metrics after robotic prostatectomy, but evidence is heterogeneous and best viewed as an adjunct rather than a routine replacement for PFMT [8] [4].
3. Penile rehabilitation: vacuum devices, pharmacotherapy and novel stimulation
Penile rehabilitation programs aim to prevent hypoxia‑induced corporal fibrosis after nerve injury and to maintain sexual activity; early use of a vacuum erection device (VED) promotes sexual activity and may speed erectile function recovery after nerve‑sparing surgery [3] [9]. Phosphodiesterase‑5 inhibitors are commonly used in rehabilitation regimens (supported by systematic reviews though with variable trial designs), while penile vibratory stimulation has shown promise in randomized trials for aiding both continence and erectile recovery after nerve‑sparing prostatectomy [3] [5]. Evidence supports initiating rehabilitation early, balanced against individual nerve‑sparing status and patient tolerability [3] [5].
4. Timeline, realistic expectations and monitoring
Clinicians must counsel that short‑term incontinence is typical and that most men improve substantially by 12 months, often achieving pad‑free status within that period, but a minority will have persistent symptoms necessitating further intervention [1]. Erectile function recovery is less predictable and often slower; surgical technique (robotic, nerve‑sparing) and patient factors govern recovery rates, so rehabilitation should be framed as supportive care that may improve speed and degree of recovery but cannot fully overcome major nerve injury [2] [10].
5. When to escalate: devices and surgical interventions
For persistent stress urinary incontinence unresponsive to conservative rehabilitation, minimally invasive options such as male slings for mild‑moderate incontinence and artificial urinary sphincters (AUS) for more severe or refractory cases are standard escalation steps, with evidence of durable benefit from high‑volume centers [5] [4]. Similarly, when penile rehabilitation fails to restore sufficient erectile function, referral for second‑line therapies (intracavernosal injections, penile prosthesis) should be discussed as part of shared decision‑making [5].
6. Controversies, evidence gaps and a pragmatic protocol
Trials differ in definitions of continence and erectile recovery, timing of interventions, and intensity of PFMT, producing heterogeneity in outcomes and preventing a single universal protocol [1] [4]. Pragmatically, recommended rehabilitation combines preoperative PFMT education, early postoperative supervised PFMT with home practice, consideration of biofeedback/electrical or magnetic adjuncts for non‑responders, and early penile rehabilitation (VED ± PDE5i ± vibratory stimulation) for nerve‑sparing cases, with timely escalation to slings/AUS or prosthesis if conservative measures fail—while setting expectations that surgical technique and nerve integrity largely determine ultimate outcomes [6] [8] [3] [5].