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© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

SIUJ.ORG SIUJ  •  Volume 4, Number 3  •  May 2023

Key Words Competing Interests Article Information

prostatectomy, prostate cancer, urinary 
incontinence, pelvic floor, muscle contraction

None declared. Received on October 1, 2022 
Accepted on November 28, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2023;4(3):203–210

DOI: 10.48083/NSOV8979

203

ORIGINAL RESEARCH

Pelvic Floor Muscle Function and Its Relationship 
with Post-Prostatectomy Incontinence

Cecile T. Pham,1 Manish I. Patel,1,2 Sean F. Mungovan3,4

1 Specialty of Surgery, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia 2 Department of Urology,  
Westmead Private Hospital, Westmead, New South Wales, Australia 3 Westmead Private Physiotherapy Services, Westmead, New South Wales, Australia  
4 The Clinical Research Institute, Westmead, New South Wales, Australia

Abstract

Objectives Post-prostatectomy incontinence (PPI) is a common condition, but the underlying mechanisms are 
not completely understood. Transperineal ultrasound (TPUS) assessment of voluntary pelvic floor muscle (PFM) 
function may be associated with PPI. This study investigates the relationship between PPI and pre- and postoperative 
displacement of anatomical landmarks related to PFM function.

Methods This was a prospective longitudinal cohort study of 40 patients undergoing robotic-assisted radical 
prostatectomy (RARP) by a high-volume single surgeon. All patients underwent PFM training pre- and 
postoperatively. TPUS was used to obtain sagittal images of pelvic structures during maximal voluntary PFM 
contractions: (1) preoperatively, (2) 3 weeks postoperatively, and (3) 6 weeks postoperatively. TPUS images were 
analyzed to calculate displacement of anatomical landmarks associated with activation of striated urethral sphincter 
(SUS), bulbocavernosus muscle (BC), and puborectalis muscle (PR). Continence was assessed at 3 and 6 weeks 
postoperatively, defined as use of ≤ 1 pad/day. The relationship of continence to the displacement of SUS, BC, and PR 
was analyzed.

Results SUS, BC, and PR displacement decreased significantly 3 weeks postoperatively (P = 0.042, P = 0.002, 
P < 0.001, respectively). Continent men exhibited significantly greater SUS displacement (median, 5.13 mm) than 
incontinent men (median, 3.90 mm) 3 weeks postoperatively (P = 0.029). Between 3 and 6 weeks following RARP, 
there was significant increase in SUS, BC, and PR displacement (P = 0.003, P = 0.030, P < 0.001, respectively).

Conclusions A significant decrease in PFM function occurs following RARP, with a subsequent recovery of 
postoperative PFM function between 3 and 6 weeks post-procedure in men who undergo PFM training. SUS 
activation was significantly greater in continent patients compared to incontinent patients at 3 weeks following RARP.

Introduction

Post-prostatectomy incontinence (PPI) is a predictable consequence following radical prostatectomy. The incidence 
of PPI has been reported to occur in 59% to 63% of patients in the first 6 weeks following surgery[1–3]. The severity of 
PPI and the variation in the recovery of continence give rise to a significant clinical management issue. Despite the 
high incidence of PPI, the etiology of PPI and the variable time course for recovery are not well understood.

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mailto:manish.patel%40sydney.edu.au?subject=SIUJ
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PPI typically occurs when urethral closure pressure 
is exceeded by bladder pressure. Inadequate urethral 
sphincter function (insufficiency) can lead to a reduc-
tion in urethral pressure and incomplete sphinc-
ter closure[4–8]. Urethral pressure can increase with 
voluntary contraction of the muscles that comprise the 
pelvic floor, including, the striated urethral sphinc-
ter (SUS), the bulbocavernosus muscle (BC), and 
the puborectalis muscle (PR)[9]. Contraction of the 
SUS results in dorsal displacement of the membra-
nous urethra; BC contraction causes compression of 
the urethra at the bulb of the penis; and PR contrac-
tion results in ventrocaudal motion of the urethra 
to compress the urethra against the pubic symphy-
sis[10–13]. Activation of the SUS, BC, and PR results 
in the displacement of anatomical landmarks includ-
ing posterior displacement of the mid-urethra (in the 
case of SUS), anterior displacement of the bulb of the 
penis (BC), and anterior-superior displacement of 
the anorectal junction (PR)[11,12]. Using noninvasive 
transperineal ultrasound (TPUS) imaging, activation 
of the SUS, BC, and PR can be reliably measured and 
has been validated against electromyography (EMG) 
recordings[14,15].

The assessment of PFM function using TPUS prior 
to and following radical prostatectomy provides the 
opportunity to better understand the role of PFM func-
tion in continence recovery[16–19]. To date, the time 
course of pre- and postoperative activation of the SUS, 
BC, and PR and the association with return to conti-
nence have not been well described. Therefore, the aim 
of this study was to investigate the relationship between 
PPI and displacement of anatomical landmarks related 
to PFM activation before and at 3 and 6 weeks follow-
ing robot-assisted radical prostatectomy (RARP).

Abbreviations 
BC bulbocavernosus muscle
BMI body mass index
ICC intraclass correlation coefficient
ICIQ-UI SF  International Consultation on Incontinence 

Questionnaire–Urinary Incontinence Short Form
IQR interquartile range
PFM pelvic floor muscle
PPI post-prostatectomy incontinence
PR puborectalis muscle
PSA prostate-specific antigen
RARP robotic-assisted radical prostatectomy
SUS striated urethral sphincter
TPUS transperineal ultrasound

Materials and Methods
Participant selection
This prospective longitudinal cohort study included 
patients who underwent RARP performed by a high-
volume surgeon at a metropolitan center. Consecutive 
patients were prospectively recruited during an initial 
consultation prior to RARP between February and 
November 2019. Patients with a history of pad usage, 
pelvic surgery, or pelvic radiotherapy and patients who 
were unable to attend all physiotherapy consultations 
were excluded. This study was approved by the Western 
Sydney Local Health District Human Research Ethics 
Committee (ETH02769) and all patients gave written 
informed consent.

Experimental protocol
At the time of recruitment, each patient’s demographic 
information, including age, body mass index (BMI), 
a nd prost ate c a ncer cha rac ter ist ic s (prost ate-
specif ic antigen [PSA] and histopatholog y) were 
collected. The patients were referred to a men’s health 
continence physiotherapist 1 month before R ARP 
for the prescription of a preoperative PFM training 
program[20]. The International Consultation on 
Incontinence Questionnaire–Urinary Incontinence 
Short Form (ICIQ-UI SF) was completed preoperatively. 
Postoper at ively, pat ient s were re v iewed by a 
physiotherapist at 3 and 6 weeks following RARP. 
During these postoperative continence reviews, daily 
pad usage was recorded, and an individualized PFM 
training program was prescribed[20].

Pelvic floor muscle training
Patients underwent a progressive individualized 6-week 
pre- and postoperative PFM training program that 
focussed on the activation and training of the SUS[13]. 
TPUS was used to teach voluntary PFM activation and 
to provide visual biofeedback feedback to the patient and 
physiotherapist to maximize SUS activation[11,17].

TPUS assessment
All patients underwent TPUS imaging upon completion 
of the preoperative PFM training program and within 
1 week of surgery and at 3 and 6 weeks postoperatively. 
TPUS was performed by 2 experienced physiotherapists 
using a Philips iU22 ultrasound machine (Philips 
Healthcare; Australia) in greyscale cine-loop format. 
At each review (preoperatively, and 3 and 6 weeks 
postoperatively), with each patient in a standing position, 
a curved array ultrasound transducer (7.0 MHz) was 
aligned on the perineum in the midsagittal plane so that 
the pubic symphysis, urethra, penile bulb, and anorectal 
angle were visible[11–13]. Following a standardized 
verbal instruction: “Contract your pelvic floor muscles as 
strongly as you can and hold,” TPUS data were recorded 

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while the patients performed 2 sustained maximal 
voluntary PFM contractions with a 10-second rest interval 
between the 2 contractions.

TPUS analysis
InteleViewer digital imaging and communications in 
medicine (DICOM) viewer software (Intelerad Medical 
Systems Inc.; Montreal, Canada) was used to analyze 
single-image frames from the cine-loop TPUS data. 
The displacement of anatomical landmarks from the 
resting to the contracted position included posterior 
displacement of the mid-urethra (SUS), anterior 
displacement of the bulb of the penis (BC), and anterior-
superior displacement of the anorectal junction (PR)
[11,12]. The mean displacement of the 2 SUS, BC, 
and PR voluntary PFM contractions was used for the 
analysis of PFM function. A random subset of the data 
(10 participants) was reanalyzed after 3 weeks by the 
same assessor to determine the test-retest reliability 
of the TPUS image analyses of the SUS, BC, and PR 
displacement measurements at each time point.

Statistical analysis
The median and interquartile range (IQR) were used to 
describe continuous variables. Pre- and postoperative 
SUS, BC, and PR displacement were compared using 
a one-way repeated measures analysis of variance 
(A NOVA). Pat ients were categor i z ed based on 
their continence status at 3 and 6 weeks following 
RARP, defined as use of ≤ 1 pad daily. SUS, BC, and 
PR displacement measurements were compared as 
continuous variables using a Mann-Whitney U test 
between continent and incontinent patients. Test-
retest reliability was determined using the intraclass 
correlation coefficient (ICC) with a 2-way mixed model 
for absolute agreement. ICC values were interpreted 
as poor (< 0.5), moderate (0.5 to 0.75), good (0.75 to 
0.9), and excellent (> 0.9)[21]. P-values < 0.05 were 
considered statistically significant. IBM SPSS Statistics 
Version 28 (IBM, Armonk, United States) was used for 
the statistical analysis.

Results
In this study, 52 consecutive patients were recruited, 
with 12 patients lost to follow-up. A total of 40 patients 
completed all experimental protocol procedures and 
were included in the analysis. The patients’ demographic, 
clinical, and operative characteristics are summarized 
in Table 1. While 5 patients had a preoperative ICIQ-UI 
SF score > 0 (range, 3–8), they reported no symptoms of 
stress urinary incontinence or pad usage. These patients 
all reported episodes of urge urinary incontinence 
occurring less than once per week, with the ICIQ-UI 
SF score predominately determined by question 5 on 
the ICIQ-UI: “Overall, how much does leaking urine 
interfere with your everyday life?”. Excluding these 

TABLE 1. 

Demographic, clinical, and operative 
characteristics 

Characteristic

Age (median, IQR) 66 (60–72)

BMI (kg/m2) (median, IQR) 28.2 (26.4–32)

PSA (ng/mL) (median, IQR) 7 (4.3–9.2)

Prostate weight (g) (median, IQR) 35 (30–50)

ISUP grade, n (%)

2 21 (52.5)

3 12 (30)

4 2 (5)

5 5 (12.5)

Clinical stage, n (%)

T2 16 (40)

T3 24 (60)

D’Amico risk group, n (%)

Intermediate 16 (40)

High 24 (60)

Nerve-sparing procedure, n (%)

Not performed 2 (5)

Unilateral 13 (32.5)

Bilateral 25 (62.5)

BMI: body mass index; IQR: interquartile range; ISUP: International 
Society of Urological Pathology; PSA: prostate-specific antigen.

5 patients from the analysis did not change the results of 
our investigation.

The return to continence rate following RARP was 
70% (n  =  28) at 3 weeks and 95% (n  =  38) at 6 weeks 
postoperatively. At 3 weeks following RARP, there was 
a significant decrease in SUS, BC, and PR displacement 
(Table 2). Between 3 and 6 weeks following RARP, there 
was a significant increase in SUS, BC, and PR displace-
ment (Table 2). At 6 weeks following RARP, there was 
no significant difference between preoperative and 
postoperative SUS and BC displacement but there was 
significantly less PR displacement (P < 0.001) (Table 2).

Continent patients (n = 28) had significantly greater 
SUS displacement (median, 5.1 mm) compared to 
patients who were incontinent (n  =  12) (median,  

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TABLE 2.

Pelvic floor muscle displacement prior to and 3 and 6 weeks following RARP 

Displacement (median, IQR) (mm) P-value

Preoperative
3 weeks 

Preoperative
6 weeks 

Preoperative
Preoperative vs.  

3 weeks
Preoperative vs.  

6 weeks
3 weeks vs. 6 weeks

SUS 5.7 (4.0–7.3) 4.6 (3.4–6.6) 5.7 (4.3–7.9) 0.042 1.00 0.003

BC 5.3 (3.8–7.0) 3.8 (2.4–5.4) 4.4 (3.7–5.7) 0.002 0.24 0.030

PR 6.2 (3.8–7.9) 2.9 (2.0–5.0) 4.2 (3.3–6.4) < 0.001 < 0.001 <. 0001

BC: bulbocavernosus muscle; IQR: interquartile range; PR: puborectalis muscle; RARP: robotic-assisted radical prostatectomy; 
SUS: striated urethral sphincter.

TABLE 3.

Postoperative pelvic floor muscle displacement in continent and incontinent men  
at 3 and 6 weeks following RARP 

Displacement (median, IQR) (mm)
P-value

All participants Continent (Pad number ≤ 1) Incontinent (Pad number > 1)

SUS
3 weeks 4.6 (3.4–6.6) 5.1 (3.9–6.8) 3.9 (2.5–4.6) 0.029

6 weeks 5.7 (4.3–7.9) 5.7 (4.2–7.9) 6.4 (5.4–7.4) 0.34

BC
3 weeks 3.8 (2.4–5.4) 4.0 (2.7–5.6) 2.8 (2.1–4.3) 0.13

6 weeks 4.4 (3.7–5.7) 4.4 (3.6–5.6) 5.5 (4.3–6.7) 0.26

PR
3 weeks 2.9 (2.0–5.0) 3.1 (1.9–5.1) 2.9 (2.0–4.2) 0.59

6 weeks 4.2 (3.3–6.4) 4.2 (3.2–6.4) 4.3 (3.3–5.2) 0.78

BC: bulbocavernosus muscle; IQR: interquartile range; PR: puborectalis muscle; RARP: robotic-assisted radical prostatectomy; 
SUS: striated urethral sphincter.

FIGURE 1. 

Pelvic floor muscle displacement in continent and incontinent men 3 weeks following RARP. 
(A) SUS, (B) BC, and (C) PR

B
C 

di
sp

la
ce

m
en

t (
m

m
)

Continence status
Continent Incontinent

10

8

6

4

2

0

p = .13

A

SU
S 

di
sp

la
ce

m
en

t (
m

m
)

Continence status
Continent Incontinent

10

8

6

4

2

0

p = .029

B

PR
 d

is
pl

ac
em

en
t (

m
m

)

Continence status
Continent Incontinent

10

8

6

4

2

0

p = .59

C

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3.9 mm) (P = 0.029) at 3 weeks following RARP (Table 3, 
Figure 1). Continent patients had greater median BC 
and PR displacement than incontinent patients 3 weeks 
postoperatively; however, this did not reach statistical 
significance (P = 0.13 and 0.59, respectively) (Table 3, 
Figure 1). At 3 weeks following RARP, there were no 
significant differences in age (P = 0.99), BMI (P = 0.83), 
prostate weight (P = 0.94), tumor volume (P = 0.072), or 
nerve-sparing status (P = 0.50) between continent and 
incontinent men. At 6 weeks following surgery, there 
was no significant difference between SUS, BC, and PR 
displacement between continent (n = 38) and inconti-
nent men (n = 2).

There was good test-retest reliability of PFM displace-
ment measures, with ICC ranging from 0.86 to 0.99 
(P < 0.001) (Table 4).

Discussion
Our study investigated pre- and postoperative voluntary 
PFM function and PPI at 3 and 6 weeks following RARP. 
TPUS was used to measure displacement of anatomical 
landmarks that are associated with PFM activation. Our 
primary findings were (1) a significant decrease in PFM 
function at 3 weeks following RARP, (2) a significant 
increase in postoperative PFM function between weeks 
3 and 6, and (3) SUS activation was significantly greater 
in continent patients compared to incontinent patients 
at 3 weeks following RARP. The pre- and postoperative 
TPUS assessment of PFM function and its relationship 
with return to continence adds new knowledge to our 
understanding of the etiology and clinical management 
of PPI.

TABLE 4. 

Test-retest reliability coefficients for pelvic floor muscle displacement measures

ICC 95% CI P-value

Preoperative 0.88 0.52–0.97 < 0.001

SUS

3 weeks 0.99 0.95–0.98 < 0.001

6 weeks 0.93 0.77–0.98 < 0.001

Preoperative 0.97 0.79–0.99 < 0.001

BC

3 weeks 0.95 0.80–0.99 < 0.001

6 weeks 0.86 0.52–0.96 < 0.001

Preoperative 0.96 0.66–0.99 < 0.001

PR
3 weeks 0.93 0.74–0.98 < 0.001

6 weeks 0.89 0.51–0.98 < 0.001

BC: bulbocavernosus muscle; CI: confidence interval; ICC: intraclass correlation coefficient; PR: puborectalis muscle; SUS: striated urethral sphincter.

TPUS is a noninvasive and accessible imaging modal-
ity that can provide clinicians with the ability to reliably 
assess PFM function prior to and following RARP, and 
thereby assess the effects of RARP and PFM training 
on continence recovery. Milios et al. (2019) demon-
strated that PFM training results in an improvement in 
the speed and endurance of PFM contractions postop-
eratively. Men who did not undergo PFM training had 
greater 24-hour pad weights; however, the authors did 
not correlate PFM function with continence status[16]. 
There is a paucity of knowledge in the literature regard-
ing pre- and postoperative PFM function, with only 
a handful of studies comparing PFM between time 
points. Colarieti et al. (2022) demonstrated the feasi-
bility and technique of TPUS assessment of men prior 
to and following RARP but similarly did not correlate 
PFM function with continence status[17]. Stafford et al. 
(2022) investigated SUS, BC, and PR function at 2 weeks 
pre- and postoperatively in men who had undergone 
PFM training. SUS activation was significantly greater in 
continent men[18]. We also observed a significant differ-
ence in SUS activation between continent and inconti-
nent patients at 3 weeks following RARP. We used pad 
number as an objective measure of continence. The daily 
number of pads is widely used in clinical practice and 
has been correlated with 24-hour pad weight[22,23]. 
Our pre- and postoperative TPUS assessment of PFM 
function provides further evidence that SUS activation 
may contribute to early continence recovery. PPI occurs 
when urethral pressure is less than bladder pressure, 
which can occur due to urethral sphincter insufficiency 
following radical prostatectomy[24]. Urodynamic inves-

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tigations before and after radical prostatectomy report 
on the importance of urethral sphincter closure and the 
capacity of the SUS to increase urethral pressure[4–8]. 
The SUS forms a muscular coat in an omega-shaped loop 
that surrounds the entire length of the membranous 
urethra[25]. Activation of the SUS following radical 
prostatectomy is important for increasing urethral pres-
sure due to removal of the prostatic urethra containing 
smooth muscle[26].

Our longitudinal study design incorporated stan-
dardized pre- and postoperative (3 and 6 weeks) TPUS 
assessments of PFM function at uniform time points. 
While we identified a decrease in PFM function at  
3 weeks following RARP, SUS and BC activation had 
returned to preoperative levels at 6 weeks, with a 95% 
continence recovery rate. This provides novel insight 
into the pattern of perioperative PFM function. It is 
important to consider the surgical factors that may 
contribute to the reduction in PFM function in the early 
postoperative period, including trauma during prostate 
resection and temporary disruption to the sphincteric 
innervation (neuropraxia)[27]. The mechanisms under-
lying recovery of PFM function are likely to include 
minimal intraoperative trauma to SUS and BC fibers, 
full postoperative recovery of any neuropraxia, and the 
targeted PFM training program. By targeting and train-
ing the SUS rather than the PR and the anal sphincter, 
we reasoned that the PFM training program would have 
a direct effect on increasing urethral pressure and there-
fore an earlier return to continence. We hypothesize 
that the effects of the pre- and postoperative PFM train-
ing were able to be maximized due to optimal surgical 
and postoperative recovery factors. However, we did 
not include a control group of patients that underwent 
RARP and were not given comprehensive PFM train-
ing. Hence, we are unable to draw conclusions regarding 
whether the PFM training or intraoperative or post-
operative recovery factors were responsible for recov-
ery of PFM function at postoperative 6 weeks. Future 
randomized controlled trials will help to determine 
how these factors contribute to continence recovery[28]. 
Furthermore, there was less PR displacement at 6 weeks 
following surgery, which is consistent with recent stud-
ies[18,19]. This reduction in PR displacement may be due 
to either reduced PR activation or reduced capacity for 
PR displacement postoperatively. PR displacement may 
be affected by intraoperative disruption of pelvic fascial 
structures, including Denonvilliers’ fascia, peripros-
tatic fascia, endopelvic fascia, and puboprostatic liga-
ments[27].

There is emerging evidence that high-volume centers 
and greater surgeon experience with an annual surgical 
case load of greater than 50 cases results in improved PPI 
recovery time[29,30]. Furthermore, the increasing use of 
robotic surgery and improvements in surgical technique 

have accelerated continence recovery following radi-
cal prostatectomy[3]. Hence, variation among surgeons 
and techniques must be considered when conducting 
comparative analysis of factors influencing PPI rates, 
and efforts should be made to decrease the heterogeneity 
of the study cohort. We attempted to minimize possible 
confounding factors of surgical expertise and technique 
by limiting our series to participants who underwent 
RARP by a single high-volume robotic surgeon. Mean-
while, previous studies have reported differing surgical 
approaches and techniques[10,16,18] and unspecified 
number and expertise of surgeons[10,17–19].

Our study has several limitations. While a single 
surgeon series was chosen to reduce the confounding 
effect of surgeon experience and differing surgical tech-
nique, it may not be representative of a broader RARP 
population. A larger, multicenter study with high-vol-
ume surgeons should be considered to confirm our find-
ings. Furthermore, all patients in our study underwent 
a PFM training program, hence, our findings can be 
applied only to men who have had PFM training, partic-
ularly a program targeted for SUS activation. There was 
a 23% loss to follow-up, as these patients did not return 
to complete their postoperative PFM training program. 
The postoperative training program may have been 
bothersome for patients to attend. It is unclear whether 
return of continence status contributed to why these 
patients did not complete the postoperative PFM train-
ing program. Our study focuses on the early postoper-
ative period, as 95% of participants had ≤ 1 pad usage 
daily at postoperative 6 weeks. While we demonstrated 
that SUS activation is important in early postoperative 
continence control, we cannot comment on the impor-
tance of SUS activation in long-term follow-up. A longer 
study period would be useful in providing more longi-
tudinal data on long-term PPI rates and whether PFM 
function continues to increase in continent patients 
following RARP.

Conclusions
A significant decrease in PFM function occurs following 
R ARP, with a subsequent significant recovery of 
postoperative PFM function between 3 and 6 weeks 
in men who undergo a PFM training program. SUS 
activation was significantly greater in continent patients 
compared to incontinent patients at 3 weeks following 
RARP.

Acknowledgements
Funding statement: This was an investigator-
initiated study that was supported by funding from 
Westmead Private Physiotherapy Services and The 
Clinical Research Institute.

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Ethics approval statement: The study was approved 
by the Western Sydney Local Health District Human 
Research Ethics Committee (ETH02769).

Patient consent statement: Informed written 
consent was provided by each participant.

Author contributions: C.P. was involved in 

investigation, data curation, data analysis, and writing 
and reviewing of the manuscript. M.P. was involved 
in project conceptualization, supervision, and writing 
and reviewing of the manuscript. S.M. was involved in 
project conceptualization, supervision, investigation, 
data curation, and writing and reviewing of the 
manuscript.

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