Physiotherapy Before and After Pelvic Floor Surgery

The clearest preoperative finding in this site’s evidence base is a negative one: the European Association of Urology records that preoperative pelvic floor muscle training does not confer additional benefit to men undergoing radical prostatectomy, at level of evidence 1b. Physiotherapy around surgery is still worth having for reasons this article sets out, and those reasons are clinical rather than trial-derived, and the difference matters¹.

I have not had pelvic floor surgery and my own condition was treated conservatively, so nothing here is a personal account of an operation. What I can bring is the thing that surprised me most when I went looking: prehabilitation is widely offered and much less well evidenced than its ubiquity suggests, and saying so out loud is more useful than repeating the marketing. Read red flags and when to stop and get checked first.

What the evidence actually shows about training before an operation

One clear negative, and one very small evidence base.

Men, before radical prostatectomy. The European Association of Urology states in its summary of evidence that preoperative pelvic floor muscle training does not confer additional benefit to men undergoing radical prostatectomy, at level of evidence 1b¹. That is about as direct as guideline language gets, and it concerns the single most commonly offered form of pelvic floor prehabilitation in the world.

Women, before prolapse surgery. The 2011 Cochrane review of conservative prevention and management of pelvic organ prolapse included 6 trials in total, of which 2 compared pelvic floor muscle training plus surgery against surgery alone, in 118 women². This site publishes no effect size from those two trials, because none was verified against the source under its house rule. What the trial count tells you on its own is that this is a small evidence base by any standard.

So anyone quoting a percentage improvement from adding physiotherapy before an operation should be asked which trial it came from. That question is answerable, and the answer is usually not one of these.

Then why is prehabilitation offered

Because there are sensible clinical reasons that are not the same as a demonstrated effect on the operation’s result, and separating them is the honest way to present it.

• Learning the movement is easier before than after. Contraction technique is genuinely hard to acquire, and it is harder to acquire while sore, catheterised or frightened. Learning it in advance is a practical argument, not an outcome claim.
• The habits that load a repair can be changed in advance. Chronic straining on the toilet is a daily high-pressure load on the structures an operation has just repaired, and it takes weeks to change. Starting that conversation before the date is simply better timing: see bowel habit and defaecation technique and constipation and obstructed defaecation.
• A baseline exists to compare against. An assessment before an operation gives an afterwards something to be measured against, which is otherwise reconstructed from memory.
• The conservative option gets a fair trial. For many people the appointment that was meant to be prehabilitation turns into treatment, because a supervised programme had never actually been tried.

None of those four is a claim that the operation goes better. Two of them, the second and the fourth, are the ones I would defend hardest.

Where the guideline puts surgery, and why the ordering is emphatic

After conservative treatment has not improved symptoms, or after it has been declined.

NICE recommendation 1.8.1 says to offer surgery for pelvic organ prolapse to women whose symptoms have not improved with or who have declined non-surgical treatment³. Recommendation 1.5.2 sets out the stress incontinence options when non-surgical management has failed and the woman wishes to consider surgery: colposuspension, open or laparoscopic, or an autologous rectus fascial sling, including a retropubic mid-urethral mesh sling subject to further conditions.

Read the declined clause carefully, because it is frequently omitted. An informed refusal is a legitimate route into a surgical conversation, and nobody has to complete a programme they have decided against in order to earn one.

The reason the ordering is stated so firmly is recent and documented. The Independent Medicines and Medical Devices Safety Review stated that conservative measures must be offered to women before surgery, and recorded hearing from women who underwent mesh surgery for relatively minor stress urinary incontinence without having first had, or having been offered, conservative treatment⁴. The same paragraph adds a concern that specialist pelvic floor physiotherapy cannot match the demand. Mesh and what changed after the inquiries covers that history in full.

What a fair trial is, before you decide it has failed

Three components, and most people have not had all three.

A supervised programme, meaning delivered by a physiotherapist or other healthcare professional with the appropriate expertise, not a leaflet⁵. A programme run for at least the guideline duration: at least 3 months for stress or mixed urinary incontinence, at least 16 weeks or 4 months for symptomatic prolapse, with both durations deriving from the same evidence and reflecting the points at which trials measured results³⁵. And two reviews, one during the programme and one at the end, as NG210 recommendation 1.6.18 requires.

A course that was none of those things is not evidence that conservative treatment does not work for you, and that distinction is worth making before an operating date is set. When physiotherapy is not enough works through it, and how long does pelvic floor physiotherapy take covers the durations.

For context on what a fair trial can achieve, the POPPY trial randomised 447 women with symptomatic stage I, II or III prolapse and found an adjusted difference of 1.52 points on a 0 to 28 symptom score at 12 months in favour of individualised training, with a 95% confidence interval of 0.46 to 2.59, and only 295 women, 66%, still in the trial at that point⁶. Good evidence of direction, modest evidence of magnitude, and not a reason to expect surgery to become unnecessary.

Afterwards: what physiotherapy is for once the operation is done

Not undoing the surgery, and not proving it worked.

The muscle still has jobs to do, the habits that loaded the structures beforehand are still there unless something changed them, and returning to lifting, impact and ordinary work still needs staging. That is the honest case for post-operative physiotherapy: the surgical repair addresses support, and it does not train a muscle, change how you empty your bowels, or decide how you get back to running. Returning to running and lifting covers the load side, and pelvic floor exercise programmes explained covers how any programme is built and progressed.

There is one caution that belongs here more than anywhere. If contraction work makes symptoms worse after an operation, that is a reason to be reassessed rather than to persist, and an operated pelvis with pain and guarding may need release work rather than strengthening: see hypertonic pelvic floor and downtraining.

The prostate surgery case, in full and unsoftened

This is where the site’s willingness to publish a null result matters most, because it is where the marketing is loudest.

A Cochrane review of 50 trials and 4,717 men found no evidence from eight trials that pelvic floor muscle training, with or without biofeedback, was better than control for men with urinary incontinence up to 12 months after radical prostatectomy: 57% still incontinent in the intervention group against 62% in control, a risk ratio of 0.85 with a 95% confidence interval of 0.60 to 1.22, moderate quality evidence. A prevention-oriented pooling across all men after radical prostatectomy gave 10% incontinent after one year against 32% in controls, a risk ratio of 0.32 with a 95% confidence interval of 0.20 to 0.51, and the review notes that this was not supported by pad test data. The authors concluded the value of conservative management here remains uncertain and the evidence is conflicting⁷.

The European Association of Urology nonetheless recommends offering training, alone or with biofeedback or electrostimulation, to men undergoing radical prostatectomy to speed recovery from incontinence, and rates that recommendation Weak. On duration it recommends none: its only timing guidance is that training is commonly started as soon as possible after surgery, between seven and ten days after withdrawal of the urethral catheter, described as common practice rather than a recommendation¹. Any claim that the EAU recommends a course length is false.

On what to expect from the operation itself, the definition does more work than anything else. A panel review records that reported prevalence of post-prostatectomy incontinence varies from 1% to 87% depending on definition, timing, surgical approach and who carries out the assessment, that most men experience transitory incontinence reaching complete continence within 2 to 3 months, and that continence rates at 12 months range from 68% to 97%⁸. In a UK randomised study of 1,643 men with PSA-detected localised prostate cancer, pad use in the prostatectomy group rose from 1% at baseline to 46% at 6 months, and 17% were still using pads at year 6, against 8% in active monitoring and 4% after radiotherapy, using the most inclusive definition available, any use of absorbent pads⁹.

Men’s pelvic health after prostate surgery sets all of that out from the patient’s side, including what remains worth doing given a null treatment analysis.

Questions worth asking before the date

Four, and the third is the one people forget.

What is this operation expected to change, and what is it not expected to change. How will continence or prolapse symptoms be measured before and afterwards, and by whom. How will success be defined, and defined now rather than later, because a definition chosen after the fact tends to be the one that fits the result. And is physiotherapy part of the plan, before or after or both, and who arranges it.

Questions to ask at your first appointment covers the physiotherapy version of the same discipline, and pelvic floor physiotherapy sets out the treatment that sits either side of the theatre door.