ORIGINAL RESEARCH & REVIEWS

A Systematic Review of Pelvic Floor Muscle Training for Erectile

Dysfunction After Prostatectomy and Recommendations to Guide
Further Research
Calvin Wong, MPT,1 Dennis R. Louie, MScPT,2 and Cheryl Beach, PhD1

ABSTRACT

Background: Erectile dysfunction is one potential complication after radical prostatectomy; often pelvic floor
muscle training is offered as an intervention to improve quality of life and erectile function post-operatively.
Aim: To provide a summary of current evidence regarding the effectiveness of pelvic floor muscle training in the
management of erectile dysfunction after radical prostatectomy and provide recommendations for future research.
Methods: An electronic search was conducted for relevant research studies using PubMed, EMBASE, CINAHL,
Medline, and PEDro. Quality of selected trials was assessed by 2 independent reviewers using the Modified
Downs and Black Checklist; disagreements were resolved by consensus.
Main Outcome Measure: The main outcome measure is the International Index of Erectile function (IIEF-5).
Results: 9 studies of various study design were included in this review. Most studies demonstrated improve-
ments in erectile dysfunction with pelvic floor muscle training; however, lack of methodological rigor for several
studies and variability among training protocols limited interpretation of results.
Clinical Implications: Further well powered and rigorously designed randomized controlled trials are needed to
investigate the effect of pelvic floor muscle training on erectile dysfunction after radical prostatectomy.
Strengths & Limitations: This review employed a systematic method of appraising the available evidence for
pelvic floor muscle training for erectile dysfunction after radical prostatectomy. Limited high-quality articles were
identified and few conclusions could be drawn from the existing evidence.
Conclusion: Future high-quality randomized controlled trials should include strategies to improve adherence to
exercise, clearly describe exercise protocols, and integrate new evidence for verbal cues and biofeedback for
muscles involved in erection. Wong C, Louie DR, Beach C. A Systematic Review of Pelvic Floor Muscle
Training for Erectile Dysfunction After Prostatectomy and Recommendations to Guide Further Research.
J Sex Med 2020;XX:XXXeXXX.
Copyright
2020, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Prostatectomy; Pelvic Floor; Erectile Dysfunction; Physiotherapy; Sexual Dysfunction; Rehabilitation

INTRODUCTION AND BACKGROUND
Radical prostatectomy (RP) is often performed in men who
are diagnosed with prostate cancer to remove cancerous prostate
tissue. One potential complication of this procedure is erectile
dysfunction (ED), which is defined as the inability to achieve and
maintain an erection for satisfactory sexual performance.1,2
Received September 15, 2019. Accepted January 4, 2020.
1
Rehabilitation Science Online Programs, University of British Columbia
(UBC), Vancouver, BC, Canada;
2
Graduate Program in Rehabilitation Studies, University of British Columbia
(UBC), Vancouver, BC, Canada
Copyright ª 2020, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jsxm.2020.01.008
Reported prevalence rates of ED in men after RP are approxi-
mately 85%.3,4 There are many well-documented psychological,
social, and emotional consequences for men who experience ED.
Depression and anxiety are commonly reported after prostatec-
tomy and are associated with uncertainty regarding recovery of
sexual function and notions of diminished masculinity.5
Furthermore, men report challenges with intimacy in partnered
and sexual relationships.5 Such findings highlight the importance
of addressing ED in this population as it can have profound long-
term impacts on quality of life.
Physiology of Erection and Function of the Pelvic
Floor in Erection
According to Dean and Lue,6 normal penile erection requires
optimal neural and vascular function, and it can be described in

J Sex Med 2020;-:1e12 1

2 Wong et al
2 phases—arterial dilation and venous occlusion. During sexual
stimulation, the parasympathetic cavernous nerves (supplied by
the sympathetic chain ganglia T11-L2) cause smooth muscle
relaxation of the corpora carvernosa and the corpus spongio-
sum.6 This relaxation allows increased blood flow via the
accessory branches of the pudendal artery that run through the
penile smooth muscle. This blood flow causes enlargement of
sinusoids within the corpora cavernosa and, to a lesser extent,
the corpus spongiosum which surrounds the urethra. As pres-
sure continues to increase, venous occlusion occurs which helps
maintain erection. During erection, the bulbospongiosus and
ischiocavernosus muscles contract and increase penile pressure.
Strong contraction of these muscles during intercourse can
drive more blood flow into the penis and further increase penile
pressure during erection.7 It has been suggested by Dorey7 that
training the pelvic floor muscles may be valuable in rehabili-
tation because it may directly augment these mechanisms of
penile erection. Contraction of the ischiocavernosus muscle has
been reported to increase intracavernosal pressure and reduce
venous return during erection. Bulbospongiosus contraction
drives blood to the distal (glans) penis and compresses the
dorsal penile vein to further prevent venous backflow resulting
in augmented erection.
Pathophysiology of ED After Prostatectomy
In nerve-sparing RP, there may be trauma to the periprostatic
neurovascular bundle resulting in neuropraxia.8 There may also
be vascular injury to the accessory pudendal arteries with a
subsequent loss of oxygenated blood flow to the penile soft tis-
sue. This may result in apoptosis of penile smooth muscle,
impaired venous occlusion, and penile tissue fibrosis.1,8,9
Conventional penile rehabilitation programs commonly
include medications, such as phosphodiesterase 5 inhibitors and
prostaglandin E1, as well as vacuum erection devices. These in-
terventions are widely considered to be safe and effective for ED
after RP.10 However, a recent Cochrane review concluded that
current evidence does not support the use of these forms of penile
rehabilitation to restore erectile function.1 Owing to the persistent
nature of ED after prostatectomy, it is pertinent to identify alter-
nate conservative interventions to improve outcomes. Although
general exercise is recommended, current clinical practice guide-
lines for the management of ED do not make any recommenda-
tions relating to pelvic floor muscle training (PFMT),11e14 which
has been used in the rehabilitation of urinary incontinence post-
prostatectomy. It has been reported that PMFT has a role in the
management of ED.7,15 Systematic reviews of conventional penile
rehabilitation have suggested that PFMT with and without
biofeedback or electrical stimulation (ES) can enhance outcomes
when ED is caused by venous leakage.16,17 As such, it is important
to investigate the state of the literature regarding this exercise-
based intervention. To date, only one review has investigated the
efficacy of physiotherapy interventions, including PMFT, after
either prostatectomy or transurethral resection of the prostate for
both ED and climacturia.18 The authors pooled results from 2
studies in a meta-analysis and found limited evidence for enhanced
outcomes for ED using PFMT with biofeedback. The authors
excluded studies comparing active interventions using ES, as well
as quasi-experimental studies.
The present review will include randomized, controlled trials,
including those comparing active interventions, and quasi-
experimental studies to provide a comprehensive overview of
the existing evidence surrounding ED after RP. A thorough
investigation of methodological quality will be presented to
ensure that differences in the quality of study design are
accounted for during the synthesis of data. The aim of this review
was to answer the following question: Among men who have
undergone RP, does PFMT alone or in combination with other
treatment techniques improve erectile function? A second aim of
the review was to describe the current state of evidence regarding
PFMT for post-RP ED and describe considerations for future
research.
METHODS
Search Strategy
The review was conducted following the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines and the protocol was registered with the
International Register of Systematic Reviews (PROSPER-
OeCRD42019128146). The flow of studies through the review
process as well as the 5 electronic databases (PubMed, EMBASE,
CINAHL, Medline, and PEDro) that were searched for English
language articles from inception to November 2019 can be found
in Figure 1. The following keywords were combined for the search:
(prostatectomy OR post prostatectomy OR radical prostatectomy)
AND (erectile dysfunction OR sexual dysfunction OR impotence)
AND (pelvic floor muscle training OR pelvic floor exercise OR
pelvic floor rehabilitation OR physiotherapy OR physical therapy
OR pelvi-perineal exercise). A search for relevant ongoing trials
was performed through clinicaltrials.gov using the search terms
“erectile dysfunction” and “pelvic floor muscle training” with the
limitation to trials with male subjects. In addition, reference lists
from selected articles were hand searched for trials relevant to the
review.
The inclusion criteria are as follows:

Clinical trials including randominzed controlled trials (RCT’s)
and quasi-experimental designs

Interventions include PFMT preoperatively or postoperatively

Target men who underwent RP

Studies with a primary aim of measuring ED postoperatively
using any validated outcome measure

Study language in English

Published in a peer-reviewed journal
J Sex Med 2020;-:1e12
PFMT for ED After RP
Figure 1. PRISMA flow diagram. PRISMA ¼ Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Figure 1 is available in
color online at www.jsm.jsexmed.org.
The exclusion criteria are as follows:

ED occurring in populations other than in those that under-
went RP

Not a full-text article (eg, conference abstract)
Procedure
The lead author performed the search using the established
search strategy. Article titles and abstracts were screened sepa-
rately by 2 authors (C.W., D.R.L.) to ensure objectivity, and
full-text articles were then screened separately to identify those
that met the inclusion criteria. Discrepancies were resolved
through discussion between authors (C.W. and D.R.L.). The
third author (C.B.) was available for arbitration in the case of
unresolved disagreements. The data that were extracted included
the following: study design, study date, study population, au-
thors names, number of participants, details of intervention,
results of the intervention, and outcome measures taken.
J Sex Med 2020;-:1e12
3
Data Synthesis
Data from the selected studies were extracted by one reviewer
(C.W.) and recorded in table format. There was significant
heterogeneity in study design and treatment protocols amongst
studies which did not allow for meta-analysis of data from the
studies.
Methodological Quality
2 reviewers (C.W. and D.R.L.) independently appraised the
methodological quality of the 8 selected studies using the Modi-
fied Downs and Black checklist, which has been developed to
appraise studies involving public health interventions. It has been
reported to have acceptable validity and inter-rater reliability.19
Studies selected were rated on 5 subscales within the checklist:
reporting, external validity, internal For validity—bias, internal
validity—confounding, and power. Any disagreements between
reviewers were resolved through discussion and consensus.
 Table 1. Summary of study characteristics

4
Outcome measures†
Study authors Sample population Sample Study Duration Pelvic floor [outcome at trial
and date (surgical approach) size design of study Intervention assessment end point]

Fode et al Postradical 83 RCT 12 months PFMT with penile vibratory No reported assessment IIEF-5 [not effective]
201524 prostatectomy stimulation device daily at procedure
(surgical approach not home program.
specified)
Geraerts et al Radical prostatectomy 33 RCT 6 months Therapist supervised PFMT with Did not report an IIEF-EF, VAS
201525 (open and ES 1 time per week for assessment procedure. [effective]
laparoscopic) 6 weeks; 1 time every
2 weeks for next 6 weeks.
Home program 60
contractions split between 2
sessions per day.
Glazener et al Radical prostatectomy 411* RCT 12 months Therapist instruction on Digital rectal examination ICSmale, ICSsex
201122 (laparoscopic, perineal, performing 3 MVC held up to assessing ability to questionnaire [not
and retropubic) 10 s, performed in various attain “strong anal effective]
positions, 2 times per day. squeeze” rated on a
Given written instructions to 0 to 6 scale.
review at home.
Encouraged to contract pelvic
floor muscles during sexual
activity.
Karlsen et al Radical prostatectomy 7 couples Single-arm trial 12 months Group or individual PFMT with Digital rectal IIEF-15 [effective]
201726 (retropubic, robot physiotherapist and sexual examination of one
assisted laparoscopic) health counseling with nurse voluntary contraction
practitioner.
Laurienzo et al Radical prostatectomy 123 RCT 6 months a. Home exercise group: bridge, Digital perinometer with IIEF-5, perinometer
201827 (surgical approach not adductor squeeze, pelvic floor rectal balloon, average recordings [not
specified) contractions 2-3 times per of 3 maximal muscle effective]
day for 6 months. contractions recorded.
b. ES group: same home
program and anal electro-
stim with physiotherapist 2
time per week for 7 weeks.
Lin et al 201221 Radical prostatectomy 72 RCT 12 months PFMT: 3  10sec MVC, 2 times Digital rectal IIEF-5 [effective]
(open and per day in various positions examination
J Sex Med 2020;-:1e12

laparoscopic) and given PFMT DVD for

home practice.
Sighinolfi et al Radical Prostatectomy 3 Case Series 3 months PFMT with ES, 90 contractions Digital rectal examination, IIEF-EF [effective]
200928 (Surgical approach not per day with EMG using an with instructions to

Wong et al
specified) anal probe. tighten and lift pelvic
floor muscles as if to
stop the flow of urine.
(continued)
PFMT for ED After RP 5

RESULTS

DVD ¼ digital video disc; EMG ¼ electromyography; ES ¼ electrical stimulation; IIEF ¼ International Index Erectile of Function; MVC ¼ maximal voluntary contraction; PFMT ¼ pelvic floor muscle training;
Outcome measures†
[outcome at trial Descriptive Summary of Studies Selected for Data

IIEF-5 [effective]

IIEF-5 [effective]
Extraction
A search of the selected databases returned 223 articles for
end point]

screening. 55 articles were removed as duplicates, and 146 arti-

cles were excluded based on inclusion and exclusion criteria. 22
articles were reviewed for eligibility, and 13 were excluded with
reasons listed in Figure 1.

assessment procedure.
Methodological quality of the studies was generally fair with 2
studies rated “good,” 4 studies rated as “fair,” and 3 studies rated
measuring MVC

Did not report an

as “poor” quality. Quality categories for the Black and Downs
Pressure probe
assessment

checklist have been previously described in the literature and can

Pelvic floor

be found in Appendix 3.20 Studies generally scored lower on the

external validity, internal validity—bias, internal val-
idity—confounding, and power subscales. A scoring legend for
the Black and Downs checklist can be found in Appendix 2.
Physiotherapist led PFMT using

contractions and 3 sustained

PFMT using anal pressure

strength and endurance

consecutive sessions of

EMG biofeedback (anal

contractions and home

Reporting Subscale
probe biofeedback for
10 therapists supervised

probe), 3  10 rapid
training days before

The results of the studies rated on the 10-item reporting

subscale of the Modified Downs and Black checklist are sum-
prostatectomy.

marized in Appendix 1. All 9 studies fulfilled 4 items of the

Intervention

subscale (described the hypothesis, outcomes, patient character-

program

istics, and patients were lost to follow-up). Only one study

adequately reported on adverse events. 8 of 9 studies received an
overall reporting score of 6 or higher, and 2 of those received a
score of 10. The mean total score for the subscale was 7.67
Not defined

12 months

(SD ¼ 1.83) with a range of 5-10.

Duration
of study

External Validity
Overall scores on the external validity subscale were poor. A
summary of scores is shown in Appendix 1. 3 of the studies failed
to provide enough information to make a determination
regarding any items in the subscale. Only one study reported that
design
Study

*Only subjects recruited to the Radical Prostatectomy trial were included.

RCT

RCT

they ensured their recruited sample was representative of the

population. 5 studies had intervention conditions that were
RCT ¼ randominzed controlled trials; VAS ¼ visual analogue scale.

similar in context (ie, staff, facilities) to the representative pop-

Sample

ulation. There was a mean score of 1.11 (SD ¼ 0.99) with a

size

Only measures related to erectile function are reported.

52

52

range between 0 and 3.

Internal Validity—Bias
Radical prostatectomy

Radical prostatectomy

Most studies (89%) did not explicitly describe an attempt

(surgical approach)
Sample population

to blind participants to the intervention. Blinding of exam-

(retropubic)

iners taking outcome measures was also generally not

described with only 3 studies fulfilling the criteria; studies not
(open)

fulfilling this criterion either did not provide adequate infor-

mation to make a judgment or did not attempt to blind ex-
aminers. Compliance with the intervention was high at 89%;
Table 1. Continued

however, misclassifications in trials that biased results toward

Study authors

the null hypothesis were considered to have fulfilled this cri-

Perez et al

Prota et al
201829

201223
and date

terion. Generally, there was poor reporting of adherence

measures of compliance with at-home PFMT programs which
may represent a limitation in many of the studies reviewed.
†

J Sex Med 2020;-:1e12

 6
Table 2. Summary of scores on the Black and Downs checklist and study quality assessment
Total quality
score
Internal (<14 ¼ poor,
External Internal validity— 15-19 ¼ fair, Suitability of study to assess effectiveness
Author, year Reporting validity validity—bias confounding Power >20 ¼ good) of intervention* (greatest/Moderate/Least)

Fode et al 9/11 1/3 5/7 4/6 0/1 19/28 Greatest: concurrent comparison group with pre- and post-measure of
201524 exposure by phone interviews and outcome measures.
Geraerts et al 9/11 0/3 5/7 3/6 1/1 18/28 Moderate: concurrent comparison groups and pre- and post-IIEF-EF
201525 measures, but no reported measures of adherence to exposure (ie,
at-home PFMT program) reported
Glazener et al 10/11 3/3 6/7 5/6 1/1 25/28 Greatest: concurrent comparison group with pre- and post-measure of
201122 at-home PFMT by self-report and outcome measures.
Karlsen et al 6/11 1/3 1/7 2/6 0/1 10/28 Least: no concurrent comparison group
201726
Laurienzo et al 5/11 2/3 4/7 4/6 0/1 15/28 Moderate: concurrent comparison group with preoutcome
201827 postoutcome measures but no measure of adherence to at-home
PFMT reported
Lin et al 201221 10/11 1/3 5/7 5/6 1/1 22/28 Greatest: concurrent comparison group with pre- and post-measures
of at-home PFMT by scheduled phone calls and outcome measures.
Sighinolfi et al 6/11 0/3 2/7 1/6 0/1 9/28 Least: no comparison group, single pre- post-measurements.
200928
Perez et al 8/11 0/3 3/7 1/6 0/1 12/28 Greatest: concurrent comparison group and prospective measurement
201829 of exposure and outcome.
Prota et al 6/11 2/3 5/7 5/6 0/1 18/28 Moderate: concurrent comparison group with preoutcome and
201223 postoutcome measures, written instructions provided but no
measure of adherence to at-home PFMT reported.
*Criteria for defining suitability can be found in Appendix 3.
J Sex Med 2020;-:1e12

Wong et al
PFMT for ED After RP
The mean score on the internal validity subscale was 4.00
(SD ¼ 1.56) with a range of 1e6, results can be found in
Appendix 1.
Internal Validity—Confounding
More than half of the studies failed to meet internal validity
criteria for 3 items on the subscale (recruitment of patients from
the same population, concealment of group randomization from
experimenters, and adequate adjustment for confounding in data
analysis). Most studies (67%) reported that they recruited sub-
jects into intervention groups over the same time period, and
88% reported that they accounted for losses to follow-up in their
data analysis. The mean score on the internal val-
idity—confounding subscale was 3.33 (SD ¼ 1.56) with a range
of 1e5.
Power
3 studies reported they were adequately powered based on
their calculations.21e23 One study23 reported a power calculation
requiring 30 subjects per group; however, they were only able to
recruit 26 subjects each to the intervention and control group.
Most studies did not include power calculation.
Pelvic Floor Muscle Assessment
There was significant variation in the method of pelvic floor
muscle assessment used in each study (Table 1). Methods of
assessment included digital rectal examination21,22,26,28 and
digital anal perinometer,27 and 3 did not report a specific method
of assessment.23,24,25 2 studies included ES in combination with
PFMT and neither found that ES was effective for improving ED
in the post-RP population.25,27
PFMT Protocols
There was significant heterogeneity in the content and
reporting of PFMT protocols in the selected studies (Table 1).
Training protocols differed on instructions calling for maximal
voluntary contraction or submaximal contractions and varied
between 3 and 90 repetitions, with contractions held up to 10 s,
practiced 1e2 times per week or once every 2 weeks. Various
levels of supervision by experimenters or therapists (typically
physiotherapists or nurses) were used, and in one instance, an
instructional PFMT digital video disc was provided to facilitate
at-home practice.
PFMT and ES
3 studies used ES in combination with PFMT with in-
terventions beginning at 12 months after RP to study men with
persistent ED symptoms.25,27,28 However, one was of low
methodological quality and least suitable for assessing effec-
tiveness of PFMT with ES.28 The other was an RCT with fair
methodology and moderate suitability for assessing interven-
tion effectiveness. The authors of this study found using
J Sex Med 2020;-:1e12
7
therapist-supervised PFMT supported by ES for 3 months in
combination with a PFMT home program yielded an
improvement in postoperative IIEF-EF mean scores of 4.1 for
the treatment group and e0.2 for the control group
(P ¼ 0.025).25 In a third study,27 a home PFMT program was
compared with PFMT with ES applied via anal electrode. At
6-month follow-up, there was an improvement in the IIEF-5
score across all groups, and no significant difference in
improvement between groups was reported.27
PFMT and Penile Vibratory Stimulation
Penile vibratory stimulation (PVS) has been reported to in-
crease pressure to the external urethral sphincter and has been
used to induce ejaculation in a group of men with injured spinal
cord, and when applied to the perineum, it has been used to treat
female urinary incontinence.24 In the group of men who un-
derwent RP, authors self-selected a cutoff point of 18 on the
IIEF-5 as inclusion criteria to their study.24 PVS applied to the
frenulum 10 times in 10-second increments in conjunction with
PFMT was used 1 week preoperatively and for 6 weeks after
surgery. Authors reported a trend toward improvement in out-
comes with their intervention but did not reach statistical sig-
nificance (P ¼ 0.07).24 The authors suggested that a longer
intervention period may have resulted in greater changes in IIEF-
5 scores. Minor self-limiting side effects of PVS including pain,
redness, and bleeding were reported with PVS use.
PFMT with Biofeedback
For the purposes of PFMT, biofeedback has been used to
improve a subject's awareness of pelvic floor muscle contraction
to promote accurate performance of prescribed exercises. One
study examined the effect of PFMT with biofeedback using an
anal electromyography (EMG) electrode once per week for
12 weeks.23 The authors reported a significantly shorter time to
recovery of potency (defined here as an IIEF-5 score of 20)
among the intervention group in their study (P ¼ 0.032). At 12
months postoperatively, 47.1% of men in the intervention group
were considered potent compared with 12.5% in the control
group.23 2 studies using the same Men After Prostate Surgery
exercise protocol used biofeedback by verbal confirmation from
study examiners through digital rectal exam.21,22 Both studies
used biofeedback for skill acquisition during the first 2 in-person
sessions. One of these studies continued to provide biofeedback
by digital rectal examination to inform subjects of exercise per-
formance, and some subjects in the intervention group also
received biofeedback by anal probe EMG based on availability
and therapist discretion.22 This study compared mean scores on
the ICSmale questionnaire between the intervention and control
groups and found no statistically significant change between
groups at follow-up time points.22 The other study found a
statistically significant difference in IIEF-5 scores at 12-month
follow-up for the intervention group as compared with the
controls (P < 0.05).21
8 Wong et al
Preoperative PFMT
Although preoperative PFMT has been assessed in the urinary
incontinence literature, only one study was identified for PFMT
for ED after RP.29 This study used an anal pressure probe to
provide the patient with visual biofeedback about the timing and
strength of muscle contractions administered during 10 consecu-
tive preoperative PFMT sessions with a physiotherapist in the days
preceding open prostatectomy. A biofeedback program used to
assess maximal voluntary contraction and training for maximal
and submaximal endurance contractions was implemented in the
10 training sessions. Preoperative and postoperative IIEF-5 scores
were compared, and statistically significant differences were noted
in the intervention compared with control groups (P < 0.001).
Methodological Quality and Suitability to Assess
Intervention Effectiveness
Of the 7 RCTs included in this review, only 4 possessed the
attributes for the greatest suitability to assess the effectiveness of
PFMT on post-ED outcomes (Table 2).21,22,24,29 Of these 4
studies, 2 had the strongest methodological quality among
reviewed studies. One of these studies reported PFMT was
effective, and the other reported no difference compared with
usual care.21,22 The remaining 2 had fair24 and poor29 meth-
odological quality and reported that PFMT was effective and
improving ED outcomes. The other RCTs were of fair meth-
odological quality and had moderate suitability to assess PFMT
effectiveness on ED outcomes.23,25,27 All of these studies re-
ported effective outcomes at trial end points. The 2 least suitable
studies also represent the poorest methodological quality and
reported effective outcomes on ED which underscores the need
to reduce risk of bias in future studies reporting on this topic.
Follow-up Period
Most studies had follow-up periods within the first 12 months
after prostatectomy,21e24,26,27 and 2 had recruitment after
1 year.25,28 Most studies had 3e4 outcome evaluations during
the follow-up period. One study had a follow-up evaluation at 3
months after recruitment to the study.25
Sample Population
Most studies included sample populations with both open and
laparoscopic RP procedures, with the exception of one trial that
included laparoscopic, open, and perineal surgical approaches.22
4 studies did not report the type of RP included in their trial
populations.24,27e29 Most studies included both nerve-sparing
and nonenerve-sparing procedures and noted that there were
no differences in randomization into control and intervention
groups. 3 studies recruited only participants who had nerve-
sparing procedures.24,28,29
Outcome Measures
The present review included trials using validated outcome
measures related to erectile function. The 15-item IIEF (IIEF-
15),30 the abridged 5-item (IIEF-5)31 version, or the erectile
function domain (IIEF-EF)32 was used in all but one study to
measure change in ED. Minimal clinically important differences
(MCIDs) assist in meaningful interpretation of change in
outcome measures.33 The anchor-based MCID for the IIEF-EF
has been previously defined as a change of 4 (sensitivity: 0.74,
specificity: 0.73).32 Furthermore, previous studies have reported
a cutoff score of 21 to classify ED in the IIEF-5 and a score of 25
for the IIEF-15.30,31 A grading scale for the IIEF-5 has been
defined by authors and separates ED into the following cate-
gories: severe, moderate, mild to moderate, mild, and no ED.31
Other outcome measures used included a visual analogue scale of
erectile quality rated on hardness, length, tumescence, elevation,
and persistence25 and the ICSmale and ICSsex questionnaires.22
The ICSmale questionnaire has been shown to have good psy-
chometric validity and reliability and has been shown to be able
to detect change in male urology patients who have received
interventions including prostatectomy.34 Most studies reported
outcomes as mean changes between baseline and selected time
points and commented on whether changes were statistically
significant. It is important to recognize that meaningful change
based on MCID or defined cutoff points are not always equiv-
alent to statistically significant change. Only 4 studies clearly
defined meaningful categories based on predetermined cutoffs or
MCIDs for the selected outcome measures.16,17,22,29 Future
studies should clearly report the psychometric validity and reli-
ability of their chosen outcome measures and clearly define
MCIDs where available.
DISCUSSION
While ED is widely known to occur in men who underwent
RP, there have been few high-quality clinical trials investigating
the efficacy of PFMT as a conservative treatment in this popu-
lation. Most studies selected for review had methodological
limitations in study design, treatment protocol, and information
reporting.
Effectiveness of PFMT for Post-RP ED
3 RCTs identified in this review had either fair or strong
methodological quality and the greatest suitability to assess the
effectiveness of PFMT on post-RP ED.21,22,24 Results of these
studies were mixed. Of note, 2 of these RCTs used the Men
After Prostate Surgery protocol to inform PFMT protocols,
yielding differing results.21,22 There was only a trend toward
significant improvement in ED outcomes identified in a study
using PVS; however, the intervention was only given for
2 months.24 3 RCTs had fair methodological quality and mod-
erate suitability to judge PFMT effectiveness. 2 of these studies
used ES in conjunction with PFMT25,27 but had notably
different exercise protocols and showed opposing impact on ED
outcomes. One study used EMG biofeedback and showed sig-
nificant change in outcomes.23 One study showed good effect of
preoperative PFMT on post-RP ED IIEF-5 scores (P < 0.001);
J Sex Med 2020;-:1e12
PFMT for ED After RP
however, there was poor reporting of blinding, randomization,
and recruitment and allocation of subjects to intervention and
control groups which impacts external and internal validity and
may put this study as risk of selection bias.29 Overall, the evi-
dence from RCTs does not allow adequate comparisons between
trials, and varying results limit conclusions that can be drawn
regarding the effectiveness of PFMT on post-RP ED. It is
important to note that in most RCTs, the control group received
usual care that typically included a form of written instruction or
alternative version of pelvic floor exercise because withholding
postoperative care was considered unethical.
Quasi-Experimental Study Design
One study used a case-series design to investigate the effect of
PFMT in combination with EMG biofeedback and ES of the
pelvic floor muscles.28 Although the authors were able to show
improvement in their subjects, without a control group inter-
pretation of their results is limited. Another study investigated a
combination of PFMT and couples' counseling relating to in-
timacy, communication, and sexual health concepts.26 Previous
literature has suggested that men with organic causes of ED may
also have psychosomatic overlay related to performance anxiety
and the accompanying stress that this produces.5,7 Although no
meaningful conclusions can be drawn from the single-arm trial
included in this review, it highlights the multidisciplinary nature
of ED after RP which may require the consideration of intimacy,
sexual communication, and sexual health education in combi-
nation with PFMT. There is a need for further study with trials
that identify the impact of the psychological overlay that are
present as part of ED. At present, there is no conclusive evidence
describing the impact of PFMT with counseling for ED after RP.
Information Reporting and Treatment Protocols
The studies included in this review generally had the lowest
scores on the external validity, and internal validity bias, and
confounding subscales. To improve external validity, future
studies should clearly report measures taken to ensure a repre-
sentative sample population. Internal validity scores were affected
by poor reporting of blinding measures for examiners taking
outcome measures, for concealment of randomization from ex-
perimenters, and adjusting for confounding in data analysis.
Improved reporting of these measures may help improve internal
validity in future studies. Studies were also generally under-
powered, and most studies failed to provide a power calculation.
Clear and comprehensive descriptions of exercise protocols and
use of valid and reliable outcome measures may improve
comparability between studies and improve ability for future
reviews to combine data for meta-analysis.
METHOD OF ASSESSMENT FOR PELVIC FLOOR
MUSCLES
It has been reported that both the ischiocavernosus and bul-
bospongiosus muscles are involved in producing and maintaining
J Sex Med 2020;-:1e12
9
penile erection.6,7,35,36 Although many of the selected studies
make note of this relationship, the method most commonly
selected to assess pelvic floor muscle recruitment was digital rectal
examination, which is regarded as a measure of puborectalis
function.21,22,28 Similarly, studies used EMG biofeedback with
anal probes, which most closely reflects puborectalis recruitment.
Future studies may need to match assessment and biofeedback
techniques to the muscles thought to be involved in erectile
function. Real-time ultrasound imaging can provide visual
feedback of recruitment of specific male periurethral structures
including bulbospongiosus.37,38 Interobserver and intraobserver
reliability have been demonstrated (P > 0.05) for real-time ul-
trasound as a measure of endurance and maximal pelvic floor
contractions in supine and standing postures after RP.39 Future
studies may consider ultrasound as biofeedback for pelvic floor
exercise prescription related to muscular endurance and strength
in supine and functional standing positions in post-RP ED.
In general, there was inconsistent reporting of the instructions
given to participants recruited to trials to elicit preferred pelvic
floor muscle contractions. It has been suggested that recruitment
of the male pelvic floor is different, given specific verbal cues.40
Urethral closure has been suggested to be important for urinary
incontinence retraining in men.41,42 Furthermore, there has been
discussion regarding the necessary focus of pelvic floor cues
emphasizing urethral closure for urinary incontinence training
contrary to conventional training protocols often used in post-
prostatectomy rehabilitation trials.43 It is currently unknown
whether similar specific cueing may be necessary for ED recovery
after RP; however, future trials may consider reporting the spe-
cific exercise instructions used in their methodology to bring
clarity to this question.
Exercise Dosage
Of the studies reviewed, there was inconsistent reporting of
exercise dosage (repetitions, frequency, and intensity). Trials
tended to use a combination of maximal and submaximal con-
tractions. Repetitions ranged from 3 sustained holds to 90 rep-
etitions 2-3times per day. Future trials should ensure that
exercise protocols are clearly described to identify the purpose of
the exercises (proprioception, motor control, hypertrophy) and
an evidence base supporting the exercise prescription.
Adherence to Exercise
Difficulty with patient adherence to pelvic floor exercise
programs is a common occurrence and has been acknowledged in
the literature.44 Of the 9 studies included in the current review,
all but 3 studies failed to describe an explicit strategy to ensure
adherence to prescribed exercise.21,22,24 One of these studies
reported adherence to prescribed daily PFMT fell to 37% in the
intervention group and 27% in the control group at 12-month
follow-up.22 It has been suggested that factors contributing to
low adherence include forgetting to perform the exercises and
low motivation.45 As such, reminder aids including exercise
10
calendars, personal electronic device alarms, and scheduled
follow-up appointments have been recommended to improve
adherence to PFMT programs.45,46, One study described
teaching participants' family members about pelvic floor muscle
exercises.21 The authors suggested that family members perform
exercise with participants and remind them to complete their
exercises. Follow-up phone calls24 and information booklets with
written instructions22 were other methods used to remind par-
ticipants to complete PFMT exercises.
Limitations
The present study only included trials published in English.
There were several studies identified that were pertinent to the re-
view that were published in other languages but were not included.
Articles relating to the topic of PFMT and sexual health are some-
times published in nursing journal databases such as EBSCO and
SCOPUS, which were not included in the current review, and it is
possible that relevant studies were missed. The general paucity of
available evidence limits the strength of conclusions that can be
made from this review. The inclusion of quasi-experimental studies
in this review necessitates caution with conclusions derived from
these studies; however, these studies were purposefully excluded
from analysis of effectiveness of interventions.
CONCLUSION
There is limited high-quality evidence investigating the ef-
ficacy of PFMT on after RP with ED outcomes, and the
existing high-quality studies differ in conclusions drawn.
Although studies reviewed suggested that PFMT in combina-
tion with biofeedback may improve post-RP ED, there is a
need for well-powered, rigorously designed RCTs to draw
strong conclusions. Furthermore, studies should consider the
emerging evidence that provides insights into specific training
cues for pelvic floor muscle recruitment ensuring that precise
and individualized cueing and ability to maintain contraction
are both confirmed by biofeedback. Ideally, both supine and
standing postures should be included for exercise prescription.
Future studies should also clearly describe exercise dosage for
both preoperative and postoperative protocols, report strategies
used to improve patient adherence to exercise programs, and
strive to ensure adequate power to make meaningful
conclusions.
Corresponding Author: Calvin Wong, MPT, Rehabilitation
Science Online Programs, University of British Columbia
(UBC), Vancouver, BC, Canada. Tel: 604-423-9477; Fax: 604-
423-9474; E-mail: cal.wong@ymail.com
Conflicts of Interest: The authors Calvin Wong, Dennis R Louie,
and Cheryl Beach report no conflicts of interest.
Funding: This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-profit
sectors.
Wong et al
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Calvin Wong; Cheryl Beach
(b) Acquisition of Data
Calvin Wong
(c) Analysis and Interpretation of Data
Calvin Wong; Cheryl Beach; Dennis R Louie
Category 2
(a) Drafting the Article
Calvin Wong
(b) Revising It for Intellectual Content
Cheryl Beach; Dennis R Louie
Category 3
(a) Final Approval of the Completed Article
Cheryl Beach
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urinary incontinence. Neurourol Urodyn 2018;37:1120-1127. https://doi.org/10.1016/j.jsxm.2020.01.008.

J Sex Med 2020;-:1e12