What is the recommended Kegel exercise protocol for an adult male without acute pelvic infection or severe pelvic pain, including technique, sets, repetitions, hold duration, contraindications, and indications for referral to pelvic‑floor physical therapy?

Kegel Exercise Protocol for Men

Men should perform Kegel exercises by contracting the pelvic floor muscles for 6-8 seconds, followed by 6 seconds of rest, doing 15 contractions per session, twice daily for at least 3 months. 1

Proper Technique

Muscle Isolation

• Contract only the pelvic floor muscles without engaging the abdomen, glutes, or thighs. 1
• The sensation should mimic stopping urination mid-stream or preventing gas passage. 1
• Maintain normal breathing throughout the entire exercise—never hold your breath or perform a Valsalva maneuver (bearing down). 1

Critical Importance of Professional Instruction

• Instruction from trained healthcare personnel is fundamental to ensure correct technique and avoid incorrect muscle activation. 1
• Without proper guidance, 25% of individuals perform Kegel exercises incorrectly, which can reduce effectiveness or potentially worsen symptoms. 2
• Consider biofeedback therapy using surface EMG perineal electrode feedback to teach proper muscle isolation and verify correct technique. 1, 2

Exercise Protocol Specifications

Duration and Frequency

• Hold each contraction for 6-8 seconds 1
• Rest for 6 seconds between each contraction 1
• Perform 15 contractions per session 1
• Complete two daily sessions (15 minutes each) 1
• Continue for a minimum of 3 months to obtain optimal benefits 1

Long-Term Adherence

• Long-term adherence to pelvic floor muscle training maintains the benefits over time. 1
• Benefits are sustained over months, not weeks, so patient counseling about realistic timelines is essential. 2

Clinical Indications

Post-Prostatectomy Incontinence

• The AUA/SUFU guidelines recommend offering pelvic floor muscle exercises or training in the immediate post-operative period after radical prostatectomy. 3
• PFME/PFMT after catheter removal improves time-to-achieving continence compared to control groups, with recovery occurring as early as 3-6 months. 3
• However, overall continence rates at one year remain similar between men who underwent PFME/PFMT and those who did not, suggesting the primary benefit is earlier recovery rather than improved long-term outcomes. 3

Erectile Dysfunction

• Kegel exercises are specifically recommended for patients post-prostatectomy with both incontinence and erectile dysfunction, addressing both conditions simultaneously. 1
• The AUA supports a shared decision-making model where Kegel exercises should be discussed with patients as a treatment option for erectile dysfunction. 1

General Stress Urinary Incontinence

• Kegel exercises are appropriate for men with stress urinary incontinence from various causes, not limited to post-surgical patients. 1

Contraindications

Absolute Contraindications

• Acute pelvic infection (defer until infection resolves)
• Severe pelvic pain (requires evaluation before initiating exercises)

Relative Contraindications

• Urinary retention with post-void residual >150-200 mL—pelvic floor exercises may worsen retention by increasing outlet resistance. 4
• Active urinary tract infection (treat infection first)

Indications for Referral to Pelvic Floor Physical Therapy

Immediate Referral Situations

• The American Cancer Society recommends referring survivors with post-prostatectomy incontinence to a physical therapist for pelvic floor rehabilitation at a minimum. 1
• Inability to identify or isolate pelvic floor muscles despite verbal instruction
• Severe incontinence (>3 pads daily) at 16 weeks post-prostatectomy, as PFME has limited benefit in this population. 5

Referral After Trial of Conservative Management

• Men with persistent leakage or other urinary symptoms despite 6 months of conservative therapy should be referred to a urologist for further evaluation and discussion of treatment options, including surgical placement of a male urethral sling or artificial urinary sphincter. 1, 4
• Patients showing no significant improvement after 6 months may be candidates for early surgical intervention. 3
• Men with persistent sexual dysfunction should be referred to a urologist, sexual health specialist, or psychotherapist. 1

Common Pitfalls and How to Avoid Them

Incorrect Muscle Activation

• Avoid contracting accessory muscles (abdomen, buttocks, thighs) which indicates improper technique. 1
• If the patient cannot isolate the correct muscles, refer for biofeedback-assisted training rather than continuing ineffective exercises. 1

Unrealistic Expectations

• Counsel patients that incontinence is expected in the short-term after prostatectomy and generally improves to near baseline by 12 months, but may persist and require treatment. 3
• Most men are not continent at catheter removal—continence is not immediate. 3
• The primary benefit of PFME is earlier return to continence (3-6 months vs. later), not necessarily higher overall continence rates at one year. 3

Delayed Intervention

• Do not delay urologic referral in patients with significant retention (>200cc), as the risk of acute urinary retention and renal complications increases. 4
• Surgery may be considered as early as 6 months if incontinence is not improving despite conservative therapy. 3

Mixed Incontinence Patterns

• Evaluate patients with history, physical exam, and appropriate diagnostic modalities to categorize type and severity of incontinence. 3
• Patients with urgency urinary incontinence or urgency-predominant mixed incontinence should be offered treatment per the AUA Overactive Bladder guideline, not just PFME alone. 3
• Overactive bladder occurs in up to 48% of men after prostate treatment and requires specific assessment and management. 3