Pelvic floor muscle training (PFMT) may represent a valid treatment for urinary incontinence (UI), erectile dysfunction (ED) and pelvic pain after radical prostatectomy (RP).(1) Related outcomes are controversial, limiting the ability to draw definitive conclusions about the efficacy of this approach.(2) This issue is mostly due to the heterogeneity of methods applied for PFMT and to the 
lack of standardized protocols.(1-2) The aim of this study is to investigate real life practice of PFMT after RP in Italy to highlight the adopted approaches and employed techniques.

An original questionnaire was designed by PFMT experts aimed to evaluate the real-life practice of PFMT after RP. The online anonymous questionnaire was administered to members of the Italian Association of Physiotherapy and Italian Society of Urodynamics.

Ninety-seven experienced professionals with a median specific experience of 8 years completed the questionnaire (Figure 1). Most of them were physiotherapists (93.8%), working in private setting (60.8%). PFMT often starts 1-3 months after RP (69.8%) or 3-6 months after surgery (31.3%). The 30.2% rehabilitators begin treatment in the preoperative phase. The most used approaches for UI are behavioral treatment (95.8%), patient education (95.8%), and manipulation (88.5%). The most used approaches for ED are behavioral treatment (69.9%), vacuum erection device [VED] (63.4%), and patient education (61.3%). Only 22.6% responders use electrostimulation (ES) for ED compared to 55.2% cases in UI. In UI, ES is performed with trans-rectal probes and with surface electrodes placed in the anterior perineum in 70.5% and in 20% cases, respectively. In ED, ES is performed with surface electrodes placed in the anterior perineum and with trans-rectal probes in 48.8% and in 30.4% cases, respectively. Only one responder uses St. Mark’s electrode for the ES in ED, none for UI. The 69.2% rehabilitators evaluate the histological examination before performing the ES. Biofeedback is used for UI in 64.6% cases compared to 31.2% for ED. Percutaneous or transcutaneous tibial nerve stimulation (PTNS/TTNS) is used for UI and for ED in 12.7% and in 6.9% cases, respectively. The majority of patients (77.8%) take phosphodiesterase type 5 inhibitors (PDE5i) during PFMT. Most rehabilitators (57%) perform sessions once a week. The majority of the participants (80%) follow the patient for 5-6 months for the rehabilitation program. Up to 96.8% responders use validated tools to assess treatment outcomes. The 84% people set up a remote control at the end of the rehabilitation program, after 1 to 6 months.

PFMT after RP is performed in different ways according to professionals’ choices. PFMT is the first-line treatment for post-RP UI. However, the type of ES (intracavitary or transcutaneous) and the placement of electrodes (perineal body or anteriorly on the bulbo-ischiocavernosus) highly varies by experts and may be influenced by the often coexistence of different types of dysfunctions (UI, ED, or pelvic pain). PTNS/TTNS is used in small percentage despite the emergent evidence of the technique and its feasibility. Despite the poor evidence a high percentage of rehabilitators advises VED in association with PDE5i.

The survey highlighted a high variability in ES and an agreement in using VED with PDE5i. The rehabilitative approaches and the protocols depend on the subjective choices of the professionals. To increase its consistency and role, the authors advocate the development of an international consensus to deliver PFMT after RP.

"A systematic review of supervised comprehensive functional physiotherapy after radical prostatectomy." B. Steenstrup et al. Prog Urology 2022 Jul;32(7):525-539.
"Effect of pelvic floor muscle training on urinary incontinence after radical prostatectomy: An umbrella review of meta-analysis and systematic review." Jia-Ming Yao et al Clinical Rehabilitation 2023 Apr;37(4):494-515.