Pelvic Floor Training for Venous Leak: What the Trials Show and How to Do It

Pelvic floor training is the least glamorous option for erectile dysfunction and one of the better evidenced. It costs nothing, has no side effects, and in men whose difficulty is holding an erection rather than achieving one, it addresses the actual mechanism.

It is not a quick fix and it does not work for everyone. What follows is what the trials show, why the muscles matter mechanically, and how the training is done.

What the pelvic floor muscles do during an erection

Two muscles matter here: the ischiocavernosus and the bulbospongiosus. Both sit at the base of the penis, below the surface, and both are under voluntary control.

When they contract, they compress the crura — the internal roots of the erectile tissue — and the deep dorsal vein. That compression raises pressure inside the erectile chambers and restricts the escape of blood. In other words, these muscles act on the outflow side of the equation. They do not bring blood in; they help keep it in.

This is why the training is relevant specifically to venous leak. A man who cannot achieve an erection at all has an inflow problem that pelvic floor work will not solve. A man who achieves an erection and then loses it has an outflow problem, and the pelvic floor is one of the few things he can strengthen himself.

What the trials found

Compared directly against surgery

A randomized study of 150 men with proven venous leakage compared pelvic floor training against venous surgery. Pelvic floor training was not inferior to surgery, either subjectively or objectively. Of the men in the exercise group, 42% were satisfied enough with the result that they declined the operation.

That comparison is worth sitting with. The guideline does not recommend penile venous surgery, a position we cover in this article. Against that benchmark, an exercise program performing comparably is a meaningful finding rather than a consolation.

Compared against lifestyle advice alone

A randomized controlled trial of 55 men with erectile dysfunction, published in the British Journal of General Practice, assigned 28 men to pelvic floor muscle exercises with biofeedback plus lifestyle advice, and 27 to lifestyle advice alone.

In the intervention group, 40% regained normal erectile function and a further 35% improved. That is three quarters of participants reporting benefit, against a control group receiving lifestyle advice only.

What the evidence does not show

These are modest-sized studies, and the larger one is now three decades old. Neither establishes that pelvic floor training works for erectile dysfunction generally, and neither was conducted in men whose problem was primarily arterial. The honest summary is that the evidence supports it for mild to moderate venous leakage, which is also where the mechanism predicts it should help.

How the exercise is done

Finding the right muscles

The muscles are the ones you would use to stop urine flow mid-stream, or to lift the penis slightly without moving anything else. Use the urine-stream test once to identify them, then stop — repeatedly interrupting urination is not recommended as an exercise.

A useful check: standing in front of a mirror with an erection, a correct contraction produces a small upward movement of the penis. If your abdomen, buttocks or thighs tighten, you are recruiting the wrong muscles.

A basic program

• Slow holds. Contract, hold for a slow count of five, then release completely for five. The release matters as much as the hold.
• Quick contractions. Contract and release rapidly, ten times in succession.
• Frequency. Two or three sets of each, three times daily.
• Position. Begin lying down, which is easiest, then progress to sitting and standing as the muscles strengthen.
• Breathing. Breathe normally throughout. Holding your breath recruits the wrong muscles.

How long before anything changes

This is skeletal muscle, and it responds on the same timescale as any other muscle training. Expect to give it three months of consistent daily practice before judging the result. Men who abandon the program at three weeks have not tested it.

If you are not sure you are contracting correctly, a pelvic floor physiotherapist can confirm it, and the trial above used biofeedback for exactly that reason. Technique matters more than effort.

Where it fits alongside other approaches

Pelvic floor training and external constriction devices act on the same side of the equation — both improve retention — and there is no conflict in using both. The training works slowly and permanently; a device works immediately and only while worn.

Where inflow is also impaired, medication that supports inflow can be combined with either. The 2018 AUA Guideline's shared decision-making framework explicitly permits combining approaches rather than working through them in sequence.

What to do next

• Identify the muscles correctly once, using the mirror check rather than repeated urine-stream interruption.
• Commit to three months before assessing whether it has helped.
• Ask for a referral to a pelvic floor physiotherapist if you are uncertain about technique, particularly after prostate surgery.
• Consider it alongside, not instead of, other approaches if your difficulty is significant.
• Raise it with your doctor if you have had prostate surgery, where pelvic floor rehabilitation is standard practice for continence and may assist erectile recovery.

References

• Claes H, Baert L. Pelvic floor exercise versus surgery in the treatment of impotence. British Journal of Urology. 1993;71(1):52–57.
• Dorey G, Speakman M, Feneley R, et al. Randomised controlled trial of pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction. British Journal of General Practice. 2004;54(508):819–825. https://bjgp.org/content/54/508/819
• Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. Journal of Urology. 2018;200(3):633–641. AUA Guidelines page