Male Urinary Incontinence: From Pelvic Floor Physiotherapy to Surgical Options
Urinary leakage in men is more common than you might think, yet it's something we rarely talk about openly.
For some men, it starts after prostate surgery or cancer treatment. For others, it develops gradually, without an obvious cause.
Regardless of why it happens, many men simply learn to live with it.
They wear pads, avoid certain activities, plan their day around bathroom access or stop doing things they enjoy.
But here's what I want more men to know: There are treatment options, and wearing a pad for the rest of your life isn't necessarily your only choice.
In Episode 133 of The Pelvic Floor Project, I sat down with Kelowna-based urologist Dr. Jennifer Locke, who specializes in functional and reconstructive urology, to discuss why men experience urinary incontinence and the many ways we can help.
We covered everything from pelvic floor physiotherapy and bladder retraining to penile clamps, male slings and artificial urinary sphincters.
And there was plenty to learn!
Why do men experience urinary incontinence?
One of the first things Dr. Locke explained is that urinary incontinence in men can be complicated because several different structures are involved.
Think of the urinary system as a plumbing system.
You have the bladder, which stores urine.
The urethra, which is the tube that carries urine out of the body.
The prostate, which surrounds part of the urethra.
And the sphincter muscles, which act like valves to help prevent urine from leaking.
When any part of this system isn't working as it should, urinary leakage can occur.
Dr. Locke described three common reasons men experience incontinence.
1. Overactive bladder (urge incontinence)
This happens when the bladder muscle contracts at times when you aren't intending to urinate.
You might experience a sudden, overwhelming urge to pee and struggle to make it to the bathroom.
Perhaps you notice it when you arrive home and put your key in the door.
Or when you hear running water.
These are common examples of urinary urgency, and sometimes that urgency results in leakage.
2. An enlarged prostate and incomplete bladder emptying
As men age, the prostate can enlarge and make it more difficult for urine to pass through the urethra.
If the bladder doesn't empty properly, urine can build up.
In some cases, the bladder becomes so full that leakage occurs. This is sometimes called overflow incontinence.
It's important to recognize that this is a different problem from having a weak pelvic floor, and treatment needs to address the reason the bladder isn't emptying.
3. A weakened urinary sphincter (stress incontinence)
The sphincter is one of the structures responsible for keeping urine in the bladder.
Prostate surgery, including surgery for prostate cancer or an enlarged prostate, can sometimes affect this mechanism. Radiation treatment can also contribute.
When the sphincter isn't functioning effectively, men may leak urine when they:
Cough or sneeze
Lift something heavy
Stand up from a chair
Exercise or play sports
Bend over
This is called stress urinary incontinence.
And although prostate treatment is a common reason for this type of leakage, it's not the only possible cause of male incontinence.
How does a urologist investigate urinary leakage?
Before deciding on treatment, it's important to understand why the leakage is happening.
Dr. Locke explained that a urologist may recommend several investigations depending on the symptoms.
Urine testing: Helps identify whether an infection may be contributing to urinary symptoms.
Cystoscopy: A small camera is passed through the urethra to examine the urethra and bladder. This allows the urologist to look for structural problems, including narrowing or scar tissue.
Urodynamic testing: Small catheters are used to measure bladder pressure and function as the bladder fills and empties. This can help determine whether the bladder is contracting unexpectedly, how effectively it stores urine and whether there are problems with the sphincter mechanism.
Ultrasound: May be used to assess the prostate or measure how much urine remains in the bladder after urinating.
Not everyone needs every test. The investigations depend on the person's symptoms, medical history and examination findings.
Where does pelvic floor physiotherapy fit in?
One of my favourite parts of this conversation was hearing Dr. Locke's perspective on physiotherapy.
She feels that men with urinary incontinence can often benefit from pelvic floor physiotherapy, although the treatment approach depends on what's causing the leakage.
And this is where I think there's a big misconception.
Pelvic floor physiotherapy isn't just about doing Kegels.
In fact, for some men, strengthening exercises aren't even the first thing we need to address.
Sometimes we need to strengthen
For men experiencing stress incontinence, particularly after prostate surgery, learning how to correctly contract and coordinate the pelvic floor muscles can help improve bladder control.
But there's a difference between doing exercises at home and knowing that you're actually activating the intended muscles.
I regularly see people who think they're lifting their pelvic floor when they're actually bearing down.
Others are tightening muscles that aren't particularly helpful for the task.
A pelvic floor physiotherapist can assess muscle function and help develop a program specific to the person's needs.
An internal examination isn't always necessary. There are different ways to assess and teach pelvic floor muscle function, depending on the person's comfort and circumstances.
Sometimes we need to relax
Here's something that surprises a lot of my patients.
A pelvic floor that is constantly tight can also contribute to urinary problems.
Imagine someone who has had an enlarged prostate for years.
Because urine has difficulty passing through, they begin pushing or straining every time they urinate.
Eventually, that becomes a habit.
Even after their prostate has been treated, they may continue to push.
But here's the problem: straining can cause the pelvic floor muscles to tighten rather than relax.
And when we're trying to urinate, we need those muscles to let go.
This pattern is sometimes referred to as dysfunctional voiding.
I often spend time helping men recognize the difference between contracting their pelvic floor and relaxing it.
Sometimes that simple awareness is a significant part of improving how they empty their bladder.
Of course, difficulty emptying should also be medically assessed. We don't want to assume that muscle tension is the cause when there could be an obstruction or another bladder problem.
Sometimes we need to retrain the bladder
For men experiencing urinary urgency or overactive bladder, treatment may focus on understanding the communication between the bladder and brain.
We can work on strategies to manage urgency, change certain bladder habits and gradually improve confidence in bladder control.
Fluid habits and possible bladder irritants, such as caffeine or alcohol, may also be worth reviewing.
The important point is that treatment should be individualized.
It's not just about the pelvic floor—it's also about pressure
Here's another area I spend a lot of time discussing with patients.
Imagine your bladder is a balloon.
At the bottom of that balloon is a valve that helps keep urine inside.
Now imagine squeezing the balloon.
The pressure inside increases.
If the valve can't withstand that pressure, urine may leak.
That's essentially what can happen when someone coughs, sneezes, lifts something heavy or stands up from a chair.
So while we certainly want to improve the function of the pelvic floor, we also need to consider how someone manages pressure through their abdomen.
Sometimes something as simple as changing their breathing strategy during a movement can make a difference.
I often encourage people to experiment with exhaling as they stand up or lift something, rather than holding their breath and bearing down.
It's not a one-size-fits-all technique, but it's a great example of why physiotherapy involves much more than strengthening one muscle group.
Should men see a pelvic floor physiotherapist before prostate surgery?
Yes, there's a valuable role for physiotherapy before prostate surgery, not just afterward.
Dr. Locke explained that she refers her patients for pelvic floor physiotherapy before prostatectomy.
This is often called prehabilitation.
The idea is to help men understand their pelvic floor muscles and learn how to contract and relax them before surgery.
After surgery, it can be more challenging to recognize those muscles, particularly when someone is dealing with pain, swelling and urinary leakage.
Research suggests that preoperative pelvic floor muscle training may help some men regain continence sooner after prostatectomy.
And physiotherapy can continue to be beneficial after surgery, including for men who are still experiencing leakage months or even years later.
I would love to see this become a more routine part of prostate cancer care.
When someone receives a cancer diagnosis, understandably, their focus is on treating the cancer.
Thinking about bladder control months down the road may not be at the top of their priority list.
But providing education and rehabilitation early can help people feel better prepared for recovery.
What if physiotherapy isn't enough?
This was a particularly interesting part of my conversation with Dr. Locke.
As a physiotherapist, I often see people who have tried conservative management but continue to experience leakage.
And while we can do a lot through rehabilitation, sometimes additional treatment is needed.
Dr. Locke walked us through several options for men experiencing leakage related to a weakened urinary sphincter.
Penile clamps
A penile clamp is an external device that applies gentle compression to the penis to reduce urine leakage.
For some men, this can be useful during certain activities or social situations.
However, clamps must be fitted and used correctly.
They aren't designed to be worn continuously, and excessive pressure or prolonged use can damage the skin and underlying tissues.
A continence nurse or knowledgeable healthcare professional can help someone determine whether this is an appropriate option and explain how to use it safely.
Urethral plugs
A urethral plug is a small device inserted into the urethra to help prevent leakage.
These devices require appropriate medical assessment and fitting.
Dr. Locke explained that while some men find them helpful, they aren't suitable for everyone.
Condom catheters
A condom catheter is an external urine collection device that fits over the penis and connects to a drainage bag.
Unlike an indwelling urinary catheter, it doesn't extend into the bladder.
For some men, this can be a useful way to manage leakage, particularly overnight or in situations where other strategies aren't practical.
These devices manage leakage rather than correcting its underlying cause, but they can still make a meaningful difference to quality of life.
What surgical treatments are available for male incontinence?
For men with persistent stress urinary incontinence, surgery may be an option.
Dr. Locke discussed three procedures.
1. Male urethral sling
A male sling is a surgically implanted piece of mesh that supports and repositions the urethra to help reduce leakage.
It's generally considered for selected men with milder stress incontinence.
One advantage is that it doesn't require the person to operate a device every time they urinate.
However, not everyone is a suitable candidate, and outcomes depend on factors such as the severity of leakage and previous prostate treatments.
2. Artificial urinary sphincter
This is one of the most interesting procedures we discussed.
An artificial urinary sphincter is a surgically implanted device that helps control the flow of urine.
It has three main components:
A cuff placed around the urethra
A small pump placed in the scrotum
A fluid-filled reservoir placed in the lower abdomen
The cuff gently compresses the urethra to help prevent leakage.
When the person wants to urinate, they squeeze the pump in the scrotum.
This temporarily transfers fluid away from the cuff, allowing the urethra to open and urine to pass.
Afterward, fluid gradually returns to the cuff, helping close the urethra again.
Pretty fascinating, isn't it?
Dr. Locke explained that patient satisfaction with artificial urinary sphincters is high, including among men who previously experienced severe leakage.
She discussed satisfaction rates around 90%, while also emphasizing that these devices can require additional surgery over time.
Because it's a mechanical device, there is a possibility of wear, malfunction or other complications.
The person also needs enough hand function and dexterity to operate the pump.
But for the right candidate, it can significantly improve quality of life.
3. Adjustable balloon devices (ATOMS)
Dr. Locke also described a newer option known as the ATOMS device.
This involves an adjustable cushion placed beneath the urethra to provide support and compression.
One interesting feature is that the amount of fluid in the device can be adjusted through a port in the scrotum.
That means the level of support can potentially be modified after surgery.
Dr. Locke explained that this option is newer in Canada, with less long-term evidence available compared with artificial urinary sphincters.
The best surgical option depends on the individual's anatomy, previous treatments, severity of leakage, goals and medical history.
What about men who have had radiation treatment?
Dr. Locke emphasized an important point about men who have received radiation to the pelvis or prostate.
Radiation can affect multiple parts of the urinary system.
It may contribute to bladder irritation, reduced bladder capacity, sphincter dysfunction or scar tissue that narrows the urethra.
That means urinary symptoms following radiation aren't always straightforward.
If you've had pelvic radiation and are experiencing urinary leakage or difficulty emptying your bladder, involving a urologist in your assessment is particularly important.
Some devices or treatments may not be appropriate if there is underlying scar tissue or obstruction.
Understanding the cause of the symptoms helps ensure treatment is both safe and effective.
Why aren't more men accessing pelvic floor physiotherapy?
This is something Dr. Locke and I discussed toward the end of our conversation.
In my practice, many men arrive after being referred by a urologist.
It's much less common for them to seek pelvic floor physiotherapy on their own.
Part of that may be a lack of awareness that physiotherapy can help men with bladder problems.
Part may be embarrassment.
And for men going through prostate cancer treatment, there is already so much to process.
But access is also an issue.
In our community, pelvic floor physiotherapy isn't routinely available as a publicly funded service.
That creates an additional barrier for patients who might benefit from education and rehabilitation before and after treatment.
Dr. Locke and I both see opportunities for better collaboration between urologists, physiotherapists and other healthcare professionals.
Ideally, men would receive information about all their options early, rather than discovering them years later.
The takeaway: You have options
If there's one message I hope men take away from this conversation, it's this:
Urinary incontinence is a symptom, not a diagnosis—and understanding why it's happening is the first step toward finding the right treatment.
For some men, the solution may involve bladder retraining and changing habits.
For others, it may be pelvic floor strengthening, relaxation or learning how to manage pressure during movement.
Some may benefit from medications or continence devices.
And for those with persistent, bothersome leakage, surgical options may be worth exploring.
You don't necessarily have to accept urinary leakage as an unavoidable part of aging or prostate treatment.
And you certainly don't need to navigate it alone.
This blog is intended for educational purposes only and does not replace individualized medical advice.
About Dr. Jennifer Locke
Dr. Jennifer Locke is a Royal College of Physicians and Surgeons of Canada certified Urologist with subspecialty training in reconstructive urology (female urology, male urology, neurogenic bladder, overactive bladder, urinary incontinence, urethral stricture disease).
Dr. Locke grew up in Tsawwassen, British Columbia and attended the University of British Columbia for her undergraduate degree in chemistry. She then completed a PhD in experimental medicine at the University of British Columbia followed by her MD training at the University of Toronto. She completed her residency training in urology at the University of British Columbia followed by her fellowship training in reconstructive urology at the University of Toronto.
Her current clinical practice is based out of Kelowna and consists of a mixture of general urology and reconstructive urology. Operating out of the Kelowna General Hospital she serves the greater Okanagan region and beyond.
Episode Partners
This episode of The Pelvic Floor Project is supported by Embodia and SRC Health, organizations that help make it possible for me to continue creating evidence-based pelvic health education.
Embodia provides online continuing education and mentorship for pelvic health and rehabilitation professionals, including access to courses and expert-led learning from clinicians around the world.
SRC Health creates medical compression garments designed to provide support during pregnancy, postpartum recovery and for women experiencing pelvic health concerns.
Sponsorship does not influence the topics, guests or educational content of The Pelvic Floor Project.
