Original Papers - Incontinence & Urodynamics Open access

Aquatic pelvic floor rehabilitation for persistent stress urinary incontinence after robot-assisted radical prostatectomy: a prospective single-arm study

Authors

Published
9 November 2026
Issue
Early Access
Section
Original Papers - Incontinence & Urodynamics
DOI
10.4081/aiua.2026.16053

Abstract

Background: Persistent stress urinary incontinence (SUI) remains one of the most troublesome functional complications after robot-assisted radical prostatectomy (RARP). Although pelvic floor muscle training (PFMT) represents the standard conservative treatment, a proportion of patients continue to experience bothersome symptoms. Aquatic rehabilitation may facilitate pelvic floor activation through reduced gravitational loading, enhanced proprioceptive input, and trunk stabilization; however, its role in post-prostatectomy incontinence has not been investigated. This prospective pilot study evaluated the feasibility, safety, and clinical outcomes associated with hydrokinesitherapy in men with persistent SUI following RARP. 

Methods: Men with persistent pure SUI after rArP despite three months of standardized conservative management, including PFMT and biofeedback, were prospectively enrolled between January and May 2023. Participants underwent a five-week hydrokinesitherapy program consisting of ten supervised 40-minute sessions performed twice weekly. outcomes included the 24-hour pad test, International Consultation on Incontinence Questionnaire-short Form (ICIQ-sF), Incontinence Quality of Life questionnaire (I-QoL), International Prostate symptom score (IPSS), IPSS quality-of-life item, and Patient Global Impression of Improvement (PGI-I), assessed at baseline, end of treatment (5 weeks), and 12-week follow-up.

Results: Twenty patients completed the rehabilitation program without treatment-related adverse events or dropouts. significant improvements were observed at the end of treatment in pad weight, IPSS, IPSS-QoL, ICIQ-SF, and I-QoL scores (all p ≤ 0.01). These improvements were maintained or further improved at 12 weeks, particularly for pad weight, QoL, and incontinence-related symptom scores. overall patient satisfaction was high according to PGI-I. Two patients (10%) subsequently underwent male sling surgery because of persistent bothersome sUI. 

Conclusions: Hydrokinesitherapy was feasible, safe, and associated with clinically meaningful improvements in urinary continence and health-related QoL in men with persistent SUI after RARP who had not achieved satisfactory recovery following initial conservative rehabilitation. These findings should be considered hypothesis-generating and warrant confirmation in adequately powered randomized controlled trials.

Keywords

Ethics Approval

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Institutional review board approval was obtained from the local ethics committee: Comitato Etico Lazio 1 Azienda Ospedaliera San Camillo Forlanini, Rome, Italy (STS CE Lazio 1; approval no. N-960, April 18th, 2023).

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, [VI], upon reasonable request.

References

  1. 1. Alivizatos G and Skolarikos A. Incontinence and erectile dysfunction following radical prostatectomy: a review. ScientificWorldJournal 2005; 5:747-758. DOI: https://doi.org/10.1100/tsw.2005.94
  2. 2. D'Ancona C, Haylen B, Oelke M, et al. Standardisation Steering Committee ICS and the ICS Working Group on Terminology for Male Lower Urinary Tract & Pelvic Floor Symptoms and Dysfunction. The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction. Neurourol Urodyn. 2019;3 8:433-477. DOI: https://doi.org/10.1002/nau.23897
  3. 3. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function. Report from the standardisation subcommittee of the International Continence Society. Neurourol Urodyn. 2002; 21:167-178. DOI: https://doi.org/10.1002/nau.10052
  4. 4. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010; 29:4-20; International Urogynecology J. 2010; 21:5-26. DOI: https://doi.org/10.1007/s00192-009-0976-9
  5. 5. Holm HV, Fosså SD, Hedlund H, et al. How should continence and incontinence after radical prostatectomy be evaluated? A prospective study of patient ratings and changes with time. J Urol 2014; 192:1155-1161. DOI: https://doi.org/10.1016/j.juro.2014.03.113
  6. 6. Stanford JL, Feng Z, Hamilton AS, et al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the prostate cancer outcomes study. JAMA 2000; 283:354-360. DOI: https://doi.org/10.1001/jama.283.3.354
  7. 7. Patel MI, Yao J, Hirschhorn AD and Mungovan SF. Preoperative pelvic floor physiotherapy improves continence after radical retropubic prostatectomy. Int J Urol 2013; 20:986-992. DOI: https://doi.org/10.1111/iju.12099
  8. 8. Anderson CA, Omar MI, Campbell SE, et al. Conservative managemen for postprostatectomy urinary incontinence. Cochrane Database Syst Rev 2015; 1:CD001843. DOI: https://doi.org/10.1002/14651858.CD001843.pub5
  9. 9. Huang YC and Chang KV. Kegel Exercises. In: StatPearls. Treasure Island (FL): StatPearls Publishing Copyright© 2022, StatPearls Publishing LLC.; 2022.
  10. 10. Becker BE. Aquatic therapy: scientific foundations and clinical rehabilitation applications. PM R. 2009; 1:859-72. DOI: https://doi.org/10.1016/j.pmrj.2009.05.017
  11. 11. Penson DF, McLerran D, Feng Z, et al. 5-year urinary and sexual outcomes after radical prostatectomy: results from the prostate cancer outcomes study. J Urol 2005; 173:1701-5. DOI: https://doi.org/10.1097/01.ju.0000154637.38262.3a
  12. 12. Imamoglu MA, Tuygun C, Bakirtas H, et al. The comparison of artificial urinary sphincter implantation and endourethral macroplastique injection for the treatment of postprostatectomy incontinence. Eur Urol 2005; 47:209-13. DOI: https://doi.org/10.1016/j.eururo.2004.08.019
  13. 13. Ficarra V, Novara G, Rosen RC, et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol. 2012; 62:405-17. DOI: https://doi.org/10.1016/j.eururo.2012.05.045
  14. 14. Theissen L, Preisser F, Wenzel M, et al. Very early continence after radical prostatectomy and its influencing factors. Front Surg. 2019; 6:60. DOI: https://doi.org/10.3389/fsurg.2019.00060
  15. 15. Iacovelli V, Carilli M, Sandri M, et al. The role of preoperative prostatic shape in the recovery of urinary continence after roboticradical prostatectomy: a single cohort analysis. Prostate Cancer Prostatic Dis. 2023; 26:374-378. DOI: https://doi.org/10.1038/s41391-022-00563-0
  16. 16. Carilli M, Iacovelli V, Sandri M, et al. Early Continence Recovery after Robot-Assisted Radical Prostatectomy: A Multicenter Analysis on the Role of Prostatic Shape. J Endourol. 2025;39:381-388. DOI: https://doi.org/10.1089/end.2024.0605
  17. 17. Johnson EE, Mamoulakis C, Stoniute A, et al. Conservative interventions for managing urinary incontinence after prostate surgery. Cochrane Database Syst Rev. 2023; 4:CD014799. DOI: https://doi.org/10.1002/14651858.CD014799.pub2
  18. 18. Bo K, Frawley HC, Haylen BT, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction. Neurourol Urodyn. 2017; 36:221-244. DOI: https://doi.org/10.1002/nau.23107
  19. 19. Imamura M, Williams K, Wells M, McGrother C. Lifestyle interventions for the treatment of urinary incontinence in adults. Cochrane Database of Systematic Reviews 2015. DOI: https://doi.org/10.1002/14651858.CD003505.pub5
  20. 20. Sheng Y, Carpenter JS, Ashton-Miller JA, Miller JM. Mechanisms of pelvic floor muscle training for managing urinary incontinence in women: a scoping review. BMC Women's Health 2022; 22:161. DOI: https://doi.org/10.1186/s12905-022-01742-w
  21. 21. Straczynska A, Weber-Rajek M, Strojek K, et al. The Impact Of Pelvic Floor Muscle Training On Urinary Incontinence In Men After Radical Prostatectomy (RP) - A Systematic Review. Clin Interv Aging. 2019; 14:1997-2005. DOI: https://doi.org/10.2147/CIA.S228222
  22. 22. Wang T, Wang J, Chen Y, et al. Efficacy of aquatic exercise in chronic musculoskeletal disorders: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res. 2023; 18:942. DOI: https://doi.org/10.1186/s13018-023-04417-w
  23. 23. Barker AL, Talevski J, Morello RT, et al. Effectiveness of aquatic exercise for musculoskeletal conditions: a meta-analysis. Arch Phys Med Rehabil. 2014; 95:1776-86. DOI: https://doi.org/10.1016/j.apmr.2014.04.005
  24. 24. Melo RS, Cardeira CSF, Rezende DSA, et al. Effectiveness of the aquatic physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in healthy community-dwelling older adults: A systematic review and meta-analysis. PLoS One. 2023; 18:e0291193. DOI: https://doi.org/10.1371/journal.pone.0291193
  25. 25. Palladino L, Ruotolo I, Berardi A, et al. Efficacy of aquatic therapy in people with spinal cord injury: a systematic review and metaanalysis. Spinal Cord. 2023; 61:317-322. DOI: https://doi.org/10.1038/s41393-023-00892-4
  26. 26. Dai S, Yuan H, Wang J, et al. Effects of aquatic exercise on the improvement of lower-extremity motor function and quality of life in patients with Parkinson's disease: A meta-analysis. Front Physiol. 2023; 14:1066718. DOI: https://doi.org/10.3389/fphys.2023.1066718
  27. 27. Naeimi N, Rastkar M, Shahraki A, et al. The Effects of Aquatic Therapy on Depression, Fatigue, and Balance in Patients with Multiple Sclerosis (MS): a Systematic Review and Meta-Analysis. Maedica (Bucur). 2024; 19:86-93. DOI: https://doi.org/10.26574/maedica.2024.19.1.86
  28. 28. Faíl LB, Marinho DA, Marques EA, et al. Benefits of aquatic exercise in adults with and without chronic disease-A systematic review with meta-analysis. Scand J Med Sci Sports. 2022;32:465-486. DOI: https://doi.org/10.1111/sms.14112
  29. 29. Alikhajeh Y, Afroundeh R, Mohammad Rahimi GR, Bayani B. The Effects of Aquatic Exercise Training on Functional and Hemodynamic Responses in Patients With Heart Failure: A Systematic Review and Meta-Analysis. Biol Res Nurs. 2025; 27:127-141. DOI: https://doi.org/10.1177/10998004241263943

Metrics

Citations and online attention from Dimensions, Altmetric and PlumX.

PlumX Metrics

License

Copyright (c) 2026 the Author(s)

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.