Randomised controlled trials consistently show that men who perform pelvic floor muscle training (PFMT) after radical prostatectomy regain continence faster than those who do not. The technique, not the repetitions, is what matters. Most men practise the wrong muscles.
Why continence is lost — and how Kegels help
The prostate sits immediately below the bladder, wrapped around the urethra. The urinary sphincter — the valve that keeps you dry — is closely associated with the apex of the prostate. During radical prostatectomy, the surgeon removes the prostate and re-joins the bladder neck directly to the urethra (the anastomosis). This disrupts the sphincter mechanism temporarily.
The external urethral sphincter, a ring of voluntary muscle, is what you control consciously when you "hold on." This sphincter is part of the pelvic floor — a sling of muscles stretching from the pubic bone at the front to the tailbone at the back. After surgery, the sphincter muscle is bruised, stretched, and partially denervated. Kegel exercises rebuild its strength and coordination.
A 2019 Cochrane systematic review of 65 trials (4,841 men) confirmed that men who performed supervised pelvic floor muscle training were more likely to be continent at 3 months post-surgery. The EAU and AUA both recommend PFMT as the first-line intervention for post-prostatectomy incontinence.
How to find the right muscles
This is where most men go wrong. Squeezing the buttocks, tensing the abdomen, or gripping the thighs does nothing for the urethral sphincter. You need to isolate the pelvic floor specifically.
The simplest way to identify the correct muscles:
Imagine you are stopping the flow of urine mid-stream
The squeeze you feel around the urethra — not the abdomen, not the buttocks — is the pelvic floor. Do NOT actually practise stopping urine mid-stream repeatedly; this is just for identification.
Imagine you are trying not to pass wind
The tightening around the anus and perineum (the area between your legs) also activates pelvic floor muscle. Both sensations together — front and back — confirm you have the right area.
Check your abdomen
Place one hand flat on your lower belly. It should remain soft and still during the squeeze. If you feel it bracing, you are using your abdominal muscles instead of your pelvic floor.
Check your breathing
You should be able to breathe normally while holding the squeeze. If you are holding your breath, you are bearing down (the opposite of what you want). Exhale gently during the squeeze.
Pushing down (bearing down, as if trying to pass stool) is the exact opposite of a Kegel. It increases intra-abdominal pressure and can worsen leakage. If you feel pressure downward, stop and restart more gently.
The correct technique — step by step
There are two types of pelvic floor contractions you need to train: slow holds (for sphincter endurance) and quick flicks (for urgent situations).
Slow holds (endurance contractions)
Position
Lying down is easiest when you are starting out — gravity works in your favour. As you improve, progress to sitting, then standing.
Squeeze and lift
Gently squeeze and draw up the pelvic floor muscles as if lifting them inside your body. Start with 50% of your maximum effort — a full-force clench tires the muscles quickly and trains the wrong fibres.
Hold for 5–10 seconds
Breathe normally throughout. If you can only hold for 2–3 seconds initially, that is fine — hold for as long as you can without losing form.
Release fully
Let the muscles relax completely for the same number of seconds you held. This rest phase is as important as the contraction — muscles need to recover between reps.
Repeat 8–12 times
This counts as one set. Do 3 sets per session, 3 sessions per day. That is a total of 72–108 contractions daily — in line with EAU guidelines.
Quick flicks (fast contractions)
After completing your slow holds, add 8–12 rapid contractions: squeeze hard for 1 second, release fully, repeat. These train the fast-twitch fibres that respond instantly when you cough, sneeze, or stand up — the moments most likely to cause a leak.
When to start — before or after surgery?
The evidence supports starting pelvic floor training before surgery. Pre-operative PFMT helps you identify the correct muscles while you still have normal bladder control — making post-operative training far more effective.
Ideally, begin 4–6 weeks before your surgery date. Even a single session with a pelvic floor physiotherapist pre-operatively significantly improves post-operative continence at 1 and 3 months (Ribeiro et al., Urology, 2010).
After surgery, restart Kegels the moment the catheter comes out — typically day 7–14 post-op. Do not wait for leakage to settle on its own. Early intervention matters.
The evidence-based programme
Learn the technique
See a pelvic floor physiotherapist if possible. Start 3 sets × 10 slow holds + 10 quick flicks, 3× daily. Build hold time toward 10 seconds.
Gentle activation
Very gentle squeezes only — do not strain. Focus on awareness and light activation. The catheter prevents any meaningful contraction, but gentle activity promotes healing circulation.
Full programme begins
3 sets × 10–12 slow holds (hold 5–10s, rest equal time) + 10 quick flicks, 3× daily. Do lying, then progress to sitting, then standing as confidence grows.
Functional integration
Add "the knack" — squeeze before and during any activity that causes leakage (coughing, sneezing, rising from a chair). Walk, then progress to light exercise while maintaining control.
Maintenance
Most men who will regain continence do so by 3 months. Continue daily exercises regardless. Those still with significant leakage at 3 months should see a pelvic floor physiotherapist for assessment.
Realistic timeline: what to expect week by week
Recovery varies significantly depending on age, nerve preservation, pre-operative continence, and surgical technique. These are population-level averages from published series.
- Week 1–2 (catheter in): No continence assessment is possible. Focus on wound healing and gentle activation.
- Week 2–4 (catheter removed): Leakage is often significant at this stage. Most men use 2–4 pads per day. This is expected and does not indicate a bad outcome.
- Week 4–8: The majority of men notice gradual but clear improvement — fewer pads, drier at rest, better control when standing.
- Month 3: Approximately 50–60% of men are pad-free or using one light security pad. Those with nerve-sparing surgery tend to recover faster.
- Month 6: Around 80% of men achieve social continence (≤1 pad/day for security, not necessity).
- Month 12: 85–90% achieve full continence. A small percentage take up to 18–24 months.
Age is the strongest predictor of continence recovery speed, not surgical technique alone. Men under 60 typically recover faster than men over 70. However, age does not determine final outcome — older men can and do achieve full continence with consistent effort.
7 mistakes that delay recovery
Squeezing the wrong muscles
Clenching buttocks, thighs, or abdomen instead of isolating the pelvic floor. See a physiotherapist for hands-on confirmation if unsure.
Not resting between contractions
Muscles strengthen during recovery, not during effort. Skipping the rest phase leads to muscle fatigue and no improvement.
Doing too many at once
500 Kegels in one session is counterproductive. Three daily sessions of 10–12 reps is more effective than one marathon session.
Stopping when leakage seems worse
Leakage often fluctuates — it may seem worse after a longer walk or a stressful day. This does not mean the exercises are failing. Consistency over weeks matters, not day-to-day variation.
Bearing down instead of lifting up
Straining increases intra-abdominal pressure and forces urine out rather than holding it in. The direction of a correct Kegel is upward and inward — like a gentle lift.
Only doing Kegels lying down
The pelvic floor needs to work against gravity. Progress to sitting, then standing, then during activity. Continence in real life happens upright — train upright.
Quitting at 6 weeks because progress feels slow
Neural recovery after prostatectomy takes months. Men who continue the programme consistently beyond 3 months continue to see improvement. Do not stop.
Myths vs facts
"Kegels are for women — they won't work for men."
Men and women have identical pelvic floor anatomy in terms of the external urethral sphincter. Multiple large RCTs confirm PFMT significantly improves post-prostatectomy continence in men.
"If I leak, it means the surgery went wrong."
Temporary incontinence after prostatectomy is universal — 100% of men experience some degree of leakage immediately after catheter removal. It is a consequence of the procedure, not a complication.
"I should wait until the leakage is bad before starting exercises."
Earlier is always better. Starting Kegels as soon as the catheter is removed — even if leakage is moderate — produces faster recovery than waiting.
"If I'm still leaking at 3 months, I'll never be dry."
Continence recovery continues for up to 12–24 months. At 3 months, 40–50% of men are still using pads — that does not predict their final outcome.
When to seek help
See your surgeon or a specialist pelvic floor physiotherapist if:
- You are still using more than 2 pads per day at 3 months
- You have not noticed any improvement by 6–8 weeks after catheter removal
- You are unsure whether you are doing the exercises correctly
- Leakage is getting worse rather than better
- You experience pain during exercises
Specialist physiotherapy, biofeedback, and in some cases electrical stimulation can accelerate recovery significantly when self-directed exercises alone are not producing results.
This article provides general educational information and is not a substitute for personalised medical advice. Your individual recovery will depend on your specific surgery, anatomy, and health. Always follow the guidance of your urologist and physiotherapy team.