Comparative efficacy of multimodal physical therapies for urinary incontinence after radical prostatectomy: a systematic review and network meta-analysis

Abstract

Background: Post-prostatectomy urinary incontinence (PPUI) is a common complication of radical prostatectomy and significantly diminishes patients' quality of life. Although pelvic floor rehabilitation is widely recommended, the relative effectiveness of different modalities remains unclear.

Methods: A systematic search of PubMed and Web of Science was conducted up to May 2025 to identify randomized controlled trials evaluating physical therapy interventions for PPUI. The key interventions comprised pelvic floor muscle training (PFMT), biofeedback therapy (BFT), electrical stimulation (ES), and their combinations, each compared with routine care. The primary outcomes were Urinary Continence Recovery Rate (preferably data at 6 months postoperatively; if unavailable, the longest reported follow-up was used), 24-h Pad Test, and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score (ICIQ-UI-SF). A frequentist random-effects network meta-analysis was conducted. Effect sizes were expressed as odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs), and interventions were ranked according to the surface under the cumulative ranking curve (SUCRA).

Results: ES + BFT ranked highest for continence recovery (SUCRA = 89.9; OR = 35.58; 95% CI: 2.11 to 599.55); ES + BFT + PFMT was most effective for pad weight (SUCRA = 93.1; WMD = - 134.41; 95% CI: - 187.80 to -81.02) and ICIQ-UI-SF (SUCRA = 91.0; WMD = - 9.99; 95% CI: - 17.83 to -2.15). Pilates may be associated with worse outcomes. Limitations included heterogeneity (ICIQ-UI-SF: I2 = 95.61%) and limited data for ExMI and auricular acupuncture.

Conclusion: Multimodal regimens, especially the combination of ES, BFT, and PFMT, yield the most substantial improvements in both objective measures and patient-reported outcomes. In contrast, ES combined with BFT shows the greatest efficacy in promoting continence recovery. These findings provide the first comprehensive ranking of 13 rehabilitation strategies and highlight the value of individualized, combination-based protocols for men with PPUI.

Keywords: combination therapy; network meta-analysis; physical therapy modalities; post-prostatectomy urinary incontinence.