Dr Daniela Moise, DPT
Recovering from prostate surgery can be stressful. Many men are told simply to “do Kegels” or to practice stopping their urine stream whenever they urinate. While those instructions are easy to remember, they oversimplify how continence works. Continence relies on two different sphincters working in harmony with your diaphragm, core and posture. After prostate surgery the internal sphincter is partly or completely removed and the pelvic floor must adapt. Habitually clenching the pelvic muscles or repeatedly stopping urine flow can disrupt this adaptation and even worsen bladder problems. Understanding the anatomy and biomechanics of continence helps explain why a more comprehensive, personalized approach is needed.
Understanding the Two Sphincters
Urinary control depends on two “valves” rather than one. The internal urethral sphincter sits at the bladder neck. It is part of the detrusor muscle and closes automatically; you cannot consciously control it. Below this is the external urethral sphincter, a ring of skeletal muscle within the pelvic floor that you can contract voluntarily. Both sphincters stay closed while the bladder fills and then relax as the bladder empties. In males, the prostate gland surrounds the urethra just below the bladder. When the prostate is removed the internal sphincter within the prostate is also removed, so more pressure is placed on the external sphincter. The pelvic floor and external sphincter must adapt to compensate.
When this adaptation is successful most men regain continence within a year or so. However, variation in pelvic floor strength, scar tissue and nerve signalling means some men leak more than others. Therefore recovery is highly individual.
Why Repeatedly Stopping the Urine Stream Is Not a Functional Exercise
The idea of “practising” continence by stopping the flow of urine comes from the fact that you recruit the outer layer of pelvic floor muscles to interrupt urination. Stopping your stream once can help you identify these muscles, but doing it repeatedly creates problems. The Mayo Clinic warns that using Kegels to start and stop urine should not become a habit because it can prevent the bladder from emptying fully and increase the risk of urinary‑tract infections. In guidelines for men, the Mayo Clinic Health System notes that you should identify the correct muscles by stopping urination no more than once a month; doing it more often can create a habit of contracting while urinating. Habitual clenching may also cause the pelvic floor muscles to become overactive and fatigued.
Continence is not achieved by standing still and squeezing your pelvic floor all day. It happens during breathing, walking, lifting, coughing and other daily activities. Repeatedly interrupting urine flow does not train the pelvic floor to coordinate with breathing and movement. Instead it can increase tension, impair bladder emptying and lead to unhealthy pressure patterns.
The Pelvic Floor as Part of a Pressure System
The pelvic floor does not act in isolation—it is part of a dynamic pressure system that includes the diaphragm, deep abdominal and back muscles. When you inhale, your diaphragm contracts and flattens, pushing your abdominal organs down and increasing pressure on the pelvic floor; the pelvic floor responds by lengthening and relaxing. When you exhale, the diaphragm lifts, abdominal pressure drops and the pelvic floor gently rebounds upward to support the spine and pelvis. This “dance” must occur every breath to maintain optimal core pressure. If you hold your breath, brace your abdomen or habitually “suck in” your stomach, you disrupt this balance and force the pelvic floor to overwork. Over time, poor breathing and posture can produce a tight, weakened pelvic floor and symptoms such as leakage, pelvic or low‑back pain and constipation.
Leakage After Prostate Surgery: More Than Weakness
Following a prostatectomy, men often worry that they are leaking because their pelvic floor is “weak.” Weakness can contribute, but it is only one factor. Surgery may affect the surrounding tissues, nerves and bladder neck, leading to difficulty coordinating and strengthening the pelvic floor. Scar tissue and post‑operative swelling can restrict movement. Pelvic pain or muscle tightness can inhibit normal relaxation. Core and postural weakness may alter pressure patterns and make leaks more likely. These factors explain why some men leak when coughing, exercising or getting out of bed even if they can stop their urine stream.
A Comprehensive Approach to Pelvic Floor Therapy
Because continence depends on a complex interplay of muscles, nerves and pressure, rehabilitation after prostate surgery requires more than “do Kegels.” Pelvic floor therapy offers a comprehensive approach:
- Correct muscle activation: Therapists teach you how to contract and relax the pelvic floor at the right times, using biofeedback if needed. Incorrectly performing Kegels can be ineffective or even counterproductive.
- Relaxation and breathing training: Therapy focuses on breathing mechanics, coordinating the pelvic floor with the diaphragm and learning to let the muscles lengthen during inhalation. Reducing breath‑holding and abdominal gripping relieves excess pressure and tension.
- Pressure management and posture: Core strengthening and postural retraining improve stability so that pressure is distributed evenly and the pelvic floor does not have to compensate. Therapists often address how you move and lift to prevent leaks.
- Scar mobility and soft‑tissue work: Manual techniques such as scar tissue mobilization and myofascial release can reduce pain and improve flexibility.
- Bladder retraining and habit education: Learning healthy voiding habits, fluid management and timed toileting can reduce urgency and frequency.
- Individualized progression: Programs are tailored to your symptoms, healing stage and goals. Treatment may include safe return‑to‑exercise progressions, core strengthening, sexual function support and guidance on everyday activities.
When therapy integrates these components, men often experience better bladder control, less pain and improved core strength. Importantly, the goal is not simply stronger muscles; it is more efficient function. Reducing muscle tightness, improving timing and integrating the pelvic floor into breathing and movement are just as important as building strength.
Recommendations
- Find and feel the right muscles. Stopping your urine stream once can help identify the pelvic floor muscles, but do not make a habit of it. Practice contracting these muscles when you are not urinating, and ask a pelvic floor therapist to confirm you are using the correct muscles.
- Avoid constant clenching. Continence relies on muscles that contract and relax quickly. Habitual holding can cause fatigue, tightness and poor coordination. Rest and relaxation are part of recovery.
- Coordinate with breath and posture. Practice diaphragmatic breathing. On inhalation, feel your lower belly and ribs expand and your pelvic floor gently lengthen; on exhalation, feel the pelvic floor lift back toward your abdomen. Maintain neutral spinal alignment to allow this synergy.
- Keep moving and manage pressure. Avoid holding your breath when lifting or exercising. Use proper body mechanics and exhale through exertion. Drink adequate water; restricting fluids can irritate the bladder and worsen leakage.
- Seek personalized pelvic floor therapy. Pelvic floor therapists can evaluate your breathing, posture, movement patterns, scar mobility and pelvic floor function to design a plan that addresses your unique needs. Evidence shows that starting therapy before or soon after surgery leads to faster recovery and improved continence.
Final Thoughts
Continence is not achieved by constant tightening but by restoring natural coordination among the pelvic floor, diaphragm and core. After prostate surgery, the internal sphincter’s contribution to continence is lost and the external sphincter must adapt. Factors such as scar tissue, tension patterns, posture, breathing mechanics and core strength influence how well this adaptation occurs. A holistic rehabilitation program that balances strength, relaxation, breathing, posture and movement retraining provides the best path to regaining control and confidence.
