Comparative effectiveness of pelvic floor muscle training strategies for urinary incontinence after radical prostatectomy: a systematic review and network meta-analysis

Post-prostatectomy urinary incontinence can substantially impair quality of life. Although pelvic floor muscle training (PFMT) is recommended as a first-line conservative intervention, the relative effectiveness of different PFMT-based strategies remains uncertain. This systematic review and network meta-analysis compared predefined PFMT-based rehabilitation strategies after radical prostatectomy. PubMed, Embase, Web of Science, and the Cochrane Library were searched from inception to April 2026. Randomised controlled trials enrolling men undergoing or having undergone radical prostatectomy were eligible. Five active strategies were evaluated: Basic PFMT, Intensified PFMT, Biofeedback-PFMT, PFMT plus electrical stimulation, and Biofeedback-PFMT plus electrical stimulation, with usual care/no structured PFMT as the reference. Separate random-effects network meta-analyses were conducted for urinary continence recovery at 3, 6, and 12 months and ICIQ-UI SF scores at 3 and 6 months. Confidence in the evidence was assessed using CINeMA. The review was registered in PROSPERO (CRD420261361267). Thirty randomised controlled trials involving 3,246 participants were included. In the separate 3- and 6-month networks, all active strategies were associated with higher continence recovery than usual care/no structured PFMT, although confidence in the estimates varied and several comparisons relied entirely on indirect evidence. PFMT plus electrical stimulation yielded an RR of 3.14 (95% CI 1.71–5.75) at 3 months and 2.87 (95% CI 1.79–4.60) at 6 months. At 12 months, Biofeedback-PFMT (RR 1.14, 95% CI 1.02–1.27), Intensified PFMT (RR 1.23, 95% CI 1.05–1.44), and Biofeedback-PFMT plus electrical stimulation (RR 1.61, 95% CI 1.29–2.01) were associated with higher continence recovery. The networks at different timepoints contained different studies and interventions; therefore, differences across timepoints should be interpreted descriptively. Restriction to studies using strict continence definitions reduced the available evidence and altered the statistical significance of some findings. For ICIQ-UI SF, only Biofeedback-PFMT was statistically significant at 3 months (MD − 3.22, 95% CI − 5.65 to − 0.79), and no strategy was statistically significant at 6 months. PFMT-based rehabilitation may improve urinary continence recovery after radical prostatectomy, but the evidence does not establish the clinical superiority of any specific strategy or support a definitive stage-specific treatment pathway. Findings and treatment rankings should be interpreted cautiously because of clinical heterogeneity, variable continence definitions, imprecision, sparse networks, and reliance on indirect evidence. Evidence regarding patient-reported urinary symptom severity remains inconclusive. The PROSPERO record was submitted on 6 April 2026, before formal screening and data extraction commenced, and was formally registered on 13 May 2026 (CRD420261361267).