Urinary incontinence (UI) and erectile dysfunction (ED) are common complications after radical prostatectomy (RP) for localized prostate cancer and significantly impair quality of life (QoL) [1]. Despite nerve-sparing techniques, ED prevalence ranges from 30% to 50% [2], and early postoperative UI may reach 87% [3]. Beyond physical morbidity, prostate cancer survivors experience considerable psychosocial distress related to diagnosis, treatment, and fear of recurrence [2]. Pelvic floor muscle training (PFMT) is recommended as the first-line conservative treatment for post-prostatectomy UI [3]. Aerobic exercise improves erectile function by enhancing endothelial function, increasing penile perfusion, and promoting psychosocial well-being. Relaxation training is an established and effective therapeutic approach for the management of anxiety and depression [2]. Therefore, the aim of this study was to investigate the effects of PFMT combined with aerobic exercise and relaxation training in individuals with UI and ED following RP.

This study was designed as a two-arm parallel randomized controlled trial (Group 1: EMG biofeedback-assisted PFMT+aerobic exercise+guided imagery relaxation training; Group 2, control group: EMG biofeedback-assisted PFMT only). The inclusion criteria were age between 40 and 65 years, having undergone nerve-sparing robotic RP within the previous 12 months, reporting UI and ED, and being able to voluntarily contract the pelvic floor muscles. Assuming a between-group effect size of d = 0.85, the sample size was calculated as 36 participants in total (18 participants per group) in a one-way hypothesis test design, with 80% power and a 5% type I error rate. Considering a total 10% dropout rate, the final planned sample size was determined as 40 participants. Participants were allocated using block randomization. Both groups received supervised EMG biofeedback-assisted PFMT once weekly, including fast, slow, and submaximal contractions. The intervention group additionally received moderate-intensity aerobic exercise three times weekly and guided imagery relaxation once weekly for 12 weeks. Home-based PFMT and aerobic exercise programs were also given to both groups. Assessments were conducted at baseline and after 12 weeks. Primary outcomes were urinary, sexual, and emotional symptom levels. Secondary outcomes included objective and subjective incontinence severity, prostate cancer-specific QoL, cognitive function, and aerobic capacity. Within-group analyses were performed using the Wilcoxon test, and between-group comparisons were conducted using the Mann-Whitney U test.

A total of 37 individuals were included in the study (mean age: 61.49 ± 4.71 years; BMI: 27.45 ± 3.18 kg/m²). At the end of the 12th week, between-group comparisons showed a greater increase in aerobic capacity in Group I. Group I also demonstrated significantly greater improvements in the sexual domain of prostate cancer-specific QoL, erectile function, and levels of anxiety and depression compared with the control group (p<0.05). No significant between-group differences were observed in the other outcome measures (p>0.05) (Table 1).

To our knowledge, this study is the first to investigate the effects of aerobic exercise and relaxation training combined with PFMT in individuals with UI and ED following RP. Both groups showed significant improvements in urinary, sexual, and emotional symptoms. The greater improvements observed in sexual and emotional health in the combined intervention group may be explained by cardiovascular adaptations associated with aerobic exercise training and by reductions in anxiety and depressive symptoms achieved through relaxation training. On the other hand, aerobic exercise and relaxation training did not demonstrate additional short-term effects on the severity of UI or cognitive function.

PFMT improves urinary, sexual, and emotional health after RP. The addition of aerobic exercise and relaxation training further enhances sexual and emotional outcomes by increasing aerobic capacity. Rehabilitation programs for the management of urinary, sexual, and emotional symptoms after RP should extend beyond pelvic floor function and include interventions targeting cardiovascular and emotional health.

Eastham JA, Auffenberg GB, Barocas DA, Chou R, Crispino T, Davis JW, et al. Clinically localized prostate cancer: AUA/ASTRO guideline, part I: introduction, risk assessment, staging, and risk-based management. The Journal of urology. 2022;208(1):10-8.
Burnett AL, Nehra A, Breau RH, Culkin DJ, Faraday MM, Hakim LS, et al. Erectile dysfunction: AUA guideline. The Journal of urology. 2018;200(3):633-41.
Cornford P, van den Bergh RC, Briers E, Van den Broeck T, Brunckhorst O, Darraugh J, et al. EAU-EANM-ESTRO-ESUR-ISUP-SIOG guidelines on prostate cancer—2024 update. Part I: screening, diagnosis, and local treatment with curative intent. European urology. 2024;86(2):148-63.