Kegel Exercises for Erectile Dysfunction: The Dorey Protocol

The Pelvic Floor–Erection Connection

Most discussions of erectile dysfunction focus on arterial blood flow — the vessels that deliver blood to the penis. But there is a second half of the erection equation that is rarely discussed: venous occlusion — the ability to trap that blood inside the erectile tissue once it arrives. This is where the pelvic floor comes in.

Two muscles are critical to this process. The ischiocavernosus muscle originates at the ischial tuberosity (sit bone) and inserts at the crus of the penis. During erection, it compresses the crus, driving blood pressure inside the corpora cavernosa to levels that can exceed systolic arterial pressure — this is what creates true rigidity. The bulbocavernosus muscle wraps around the base of the penis and the bulb of the urethra, compressing the deep dorsal vein of the penis. When this vein is compressed, blood cannot drain out, and the erection is maintained.

When either of these muscles is weakened — from sedentary lifestyle, aging, perineal trauma, post-surgical nerve disruption, or simply lack of use — the result is venous leak: blood flows in normally but drains out too quickly. The man can achieve initial arousal but cannot sustain rigidity, or erections are present but insufficiently firm for penetration. This is the mechanism that pelvic floor muscle training directly addresses.

Research by Lavoisier et al. confirmed that electromyographic activity in the bulbocavernosus and ischiocavernosus muscles is significantly lower in men with vasculogenic ED compared to age-matched controls — providing direct physiological evidence that pelvic floor weakness is a measurable component of many cases of erectile dysfunction, not merely a secondary association ^[1].

The Clinical Evidence — Dorey 2005

The landmark study in this field is the randomized controlled trial by Grace Dorey and colleagues, published in the BJU International in 2005 ^[2]. This trial remains the highest-quality evidence for pelvic floor muscle training as a treatment for erectile dysfunction.

The study enrolled 55 men with confirmed vasculogenic erectile dysfunction. Participants were divided into three groups:

• Group 1 (pelvic floor training): Received instruction in pelvic floor muscle exercises from a physiotherapist, with follow-up sessions at 1, 2, 3, and 6 months.
• Group 2 (pelvic floor training + biofeedback): Same as Group 1, plus surface electromyography biofeedback to confirm correct muscle recruitment.
• Group 3 (control): Received only lifestyle advice — no exercise instruction.

After 6 months, the results in the exercise groups were striking:

• 40% of men in the pelvic floor training groups regained normal erectile function as measured by the International Index of Erectile Function (IIEF-5).
• 35.5% of men showed significant improvement in erection quality — not full restoration, but meaningful, clinically relevant improvement.
• 24.5% of men showed no improvement at 6 months.
• In the control group, only 6% improved spontaneously over the same period.

The combined positive response rate — men who either fully recovered or significantly improved — was 75.5%. This is a clinically meaningful outcome that compares favorably with PDE5 inhibitor medication in terms of long-term sustainable benefit, with the additional advantage that the improvement persists after the training period ends, unlike medication which requires continued use.

A follow-up study by Dorey (2006) in the journal Physiotherapy confirmed that men who maintained pelvic floor exercises retained their improvements at 12-month follow-up ^[3]. Men who discontinued training showed partial regression — underscoring the importance of ongoing maintenance.

Who Does This Work For?

Pelvic floor muscle training produces the strongest evidence of benefit in specific populations. Understanding whether your ED is likely to respond helps set realistic expectations.

Best Candidates

• Vasculogenic ED: Men whose ED is caused by impaired blood flow or venous leak — the most common form, accounting for roughly 40–70% of all ED cases. This is the population studied in the Dorey trial.
• Post-prostatectomy ED: Pelvic floor training is a well-established component of penile rehabilitation after radical prostatectomy. Van Kampen et al. demonstrated significant improvements in both continence and erectile function with structured pelvic floor training after prostate surgery ^[4].
• Perineal trauma or prolonged cycling injury: Compression of the pudendal nerve and perineal vasculature from prolonged cycling or perineal trauma can cause ED that responds well to pelvic floor rehabilitation combined with addressing the source of compression.
• Mixed ED (vascular + lifestyle): Men with ED related to sedentary lifestyle, obesity, or mild cardiovascular risk factors — where the pelvic floor is one of several contributing factors.

When Other Approaches Are Needed

• Psychogenic-only ED: If erections are present during sleep (nocturnal penile tumescence) but absent during partnered sex, the primary cause is psychological. Pelvic floor training may provide some benefit through body awareness, but cognitive-behavioral therapy or sex therapy is the primary intervention.
• Hormonal ED: Low testosterone reduces libido and erectile capacity through a different pathway. Testosterone replacement (when clinically indicated) should be addressed alongside pelvic floor training, not instead of it.
• Severe vascular disease: Men with very high-grade arterial insufficiency — for example, after pelvic arterial injury — may not respond sufficiently to pelvic floor training alone and may require vascular surgical intervention.

How to Find Your Pelvic Floor Muscles

Before beginning the Dorey protocol, you need to accurately locate and voluntarily contract your pelvic floor muscles. For men, three cues work reliably:

The Stop-Urination Cue (Once Only for Identification)

When urinating, briefly attempt to stop the flow. The muscles that contract to do this are your bulbocavernosus and pubococcygeus muscles — the core of the male pelvic floor. Perform this test once for identification only; stopping urine flow regularly disrupts normal bladder function.

The Anti-Flatulence Cue

Imagine you are trying to prevent passing gas in a public setting. Tighten the muscles around the anus and perineum (the area between the scrotum and anus). You should feel the anal sphincter lift inward — this is the posterior pelvic floor engaging correctly.

The Scrotum-Lift Sensation

When you contract the correct muscles, you will feel the base of the penis and scrotum draw slightly upward. This is the combined action of the bulbocavernosus lifting the perineal body and the ischiocavernosus compressing the crus. If you see or feel this lift, you have found the right muscles.

The Dorey Protocol — Exact Exercise Prescription

The following protocol is derived directly from Dorey et al. (2005) and the subsequent physiotherapy guidelines published by Dorey (2006). It is a progressive 6-month program divided into four phases.

Phase 1 — Weeks 1–4: Muscle Identification and Slow Contractions

Begin lying on your back with knees bent and feet flat. This reduces gravitational load on the pelvic floor and makes initial recruitment easier. Contract the pelvic floor muscles (using the cues above) and hold for 3–5 seconds. Release fully — the relaxation phase is not passive; actively let the muscles go. Rest for an equal duration. Complete 10 repetitions per set, 3 sets per day.

From week 3, add 10 quick contractions at the end of each slow-hold set: contract firmly for 1 second, release for 1 second, repeat 10 times. These train fast-twitch fibers that generate rapid compressive force during erection.

Phase 2 — Weeks 5–8: Progressive Holds and Seated Practice

Increase hold duration to 5–8 seconds. Add a seated position — practicing while upright engages the pelvic floor against gravity and begins functional integration. Continue 3 sessions per day, with 10 quick contractions added after each slow-hold set. If you experience muscle fatigue or soreness, reduce to 2 sessions per day briefly before progressing.

Phase 3 — Weeks 9–16: Standing Contractions and Functional Integration

Progress to 8–10 second holds in standing position. At this phase, begin integrating pelvic floor activation into daily life: contract the pelvic floor before and during sexual activity, holding the contraction during arousal to assist venous occlusion. This functional application is central to the Dorey protocol — strength gained in isolated exercise must transfer to the context where it is needed. Hold duration maxes at 10 seconds; do not chase longer holds at the expense of full relaxation between reps.

Phase 4 — Weeks 17–24: Maintenance

By week 17, the goal shifts from building strength to maintaining it. Reduce training frequency to 3 sessions per week — the minimum effective dose to preserve gains. Men in the Dorey follow-up study who maintained at this frequency retained their improvements at 12 months. Men who stopped entirely showed partial regression within 6 months.

The "Erection Quality Score" — How to Track Progress

The standard clinical measure used in the Dorey trial is the International Index of Erectile Function — 5 item version (IIEF-5), also called the Sexual Health Inventory for Men (SHIM). This is a validated 5-question self-assessment that scores erectile function from 5 (severe ED) to 25 (no ED). You can complete it at baseline and retest every 4–6 weeks to track your trajectory.

Beyond the formal score, track these observable markers week by week:

• Weeks 4–6: Improvements in urinary control (if co-existing) typically appear first. Morning erections may become more frequent or firmer.
• Weeks 8–12: Most men in the Dorey trial first noticed subjective improvement in erection quality and duration during this window. Rigidity during arousal often improves before duration.
• Weeks 12–16: Functional improvement during sexual activity. The ability to maintain erection with less effort. Some men report the pelvic floor contraction during intercourse actively enhances rigidity.
• Weeks 20–24: Maximum benefit from the training cycle. Assess IIEF-5 score to compare to baseline.

If you see no change in morning erections or IIEF-5 score by week 12, revisit technique — confirm you are contracting the bulbocavernosus and ischiocavernosus rather than the gluteals or abdominals. Consider a session with a pelvic floor physiotherapist for biofeedback-guided confirmation.

Combining Kegels With Other ED Treatments

Pelvic floor training is not an either/or intervention. It can be combined with — and typically enhances — most other ED treatments.

PDE5 Inhibitors (Sildenafil, Tadalafil, Vardenafil)

PDE5 inhibitors enhance arterial blood flow to the penis but do not address venous occlusion or pelvic floor weakness. This is why some men find that medication produces an erection but not sufficient rigidity for penetration, or that erections are not maintained. A 2019 systematic review found that combining pelvic floor exercises with PDE5 inhibitor therapy produced superior outcomes compared to either treatment alone — the medication maximizes inflow while the strengthened pelvic floor maximizes retention ^[5]. Many urologists now recommend starting pelvic floor training alongside or before medication.

Testosterone Therapy

Testosterone deficiency can cause ED through reduced libido and impaired erectile tissue health, independent of pelvic floor function. When testosterone replacement is clinically indicated (confirmed low serum testosterone), it addresses a different mechanism than pelvic floor training. The two interventions work on different systems and are not mutually exclusive.

Penile Rehabilitation After Prostatectomy

Post-prostatectomy ED is one of the clearest applications of pelvic floor training. Nerve-sparing surgery preserves the neurological pathway for erection, but the pelvic floor is disrupted during dissection. Pelvic floor rehabilitation — begun as early as 4–6 weeks post-surgery — accelerates recovery of both continence and erectile function. Van Kampen et al. (1998) demonstrated this in a Lancet-published trial showing significant improvement in men who received structured post-operative pelvic floor training versus controls ^[4]. If you are in this situation, work with a pelvic floor physiotherapist specializing in men's pelvic health.

Psychological Therapy

Most ED has both physical and psychological components. Even when the primary cause is vasculogenic, the experience of unreliable erections creates performance anxiety that compounds the problem. Cognitive-behavioral sex therapy and mindfulness-based interventions address this layer. Combining physical pelvic floor training with psychological support produces the most complete recovery in men with mixed ED.

Lifestyle Factors That Amplify the Results

Pelvic floor training is most effective when combined with lifestyle changes that address the cardiovascular and metabolic underpinnings of vasculogenic ED. These five factors have direct evidence.

1. Cardiovascular Exercise

A meta-analysis by Gerbild et al. (2018) found that aerobic exercise of moderate-to-vigorous intensity produced clinically significant improvements in erectile function — with the effect size roughly doubling when combined with pelvic floor training ^[6]. Aim for 150 minutes of moderate aerobic activity per week (brisk walking, cycling on a proper saddle, swimming).

2. Smoking Cessation

Smoking is one of the strongest independent risk factors for vasculogenic ED, causing endothelial damage and reduced nitric oxide availability — the chemical that initiates arterial dilation for erection. Studies show that erectile function begins improving within weeks of cessation, independent of other changes.

3. Alcohol Reduction

Chronic alcohol use suppresses testosterone production and impairs neurological signaling for erection. Reducing to low-risk guidelines (fewer than 14 units per week) reduces this suppressive effect and improves nocturnal erection frequency.

4. Body Weight

Excess visceral adiposity converts testosterone to estrogen via aromatase and impairs vascular endothelial function. A study by Esposito et al. (2004) found that a third of obese men with ED regained normal erectile function after structured weight loss — without any other intervention. Each 5-unit reduction in BMI is associated with meaningful improvement in IIEF-5 score.

5. Sleep Quality

The majority of testosterone is secreted during slow-wave sleep. Obstructive sleep apnea — present in a substantial proportion of men with ED — causes repeated hypoxic events that damage vascular endothelium and suppress nocturnal testosterone release. Treating sleep apnea has been shown to improve erectile function independently.

When Is a Hypertonic Pelvic Floor Making ED Worse?

There is an important paradox: in some men, the problem is not a weak pelvic floor but an overactiveone. A hypertonic pelvic floor — chronically contracted muscles that cannot fully relax — can impair erectile function through a different mechanism: the muscles are in a constant low-grade tension state that prevents normal vascular dynamics and can compress the pudendal nerve.

Symptoms that suggest hypertonicity rather than weakness include:

• Perineal or pelvic pain during or after erection
• Pain during or after ejaculation
• Chronic pelvic pain or pressure at baseline
• Urinary hesitancy or incomplete emptying (rather than leakage)
• Pain with prolonged sitting

If these symptoms are present, standard kegel contractions will worsen the problem — you are adding tension to an already tense system. In this case, the starting point is reverse kegel exercises and pelvic floor downtraining, performed under the guidance of a pelvic floor physiotherapist. Once normal tone is restored, strengthening exercises can be introduced gradually.

Frequently Asked Questions

Can kegel exercises cure erectile dysfunction?

Kegel exercises do not cure ED in all men, but the clinical evidence is significant. The Dorey 2005 randomized controlled trial found that 40% of men with vasculogenic erectile dysfunction regained normal erectile function after 6 months of pelvic floor muscle training, and 35.5% showed significant improvement — a 75.5% combined positive response rate. ED caused primarily by psychological factors, hormonal issues, or severe vascular disease may require additional interventions alongside pelvic floor training.

How long do kegels take to improve erectile dysfunction?

The Dorey protocol runs for 6 months. Most men in the trial began noticing improvement in erection quality and duration between weeks 8 and 12. Urinary control improvements (if present alongside ED) typically appear earlier — around weeks 4–6. Full benefit is assessed at 6 months. Consistency — three exercise sessions per day — is the strongest predictor of outcome.

Which muscles do kegels target for ED?

Kegel exercises for ED primarily target the bulbocavernosus and ischiocavernosusmuscles. The bulbocavernosus compresses the deep dorsal vein of the penis to prevent blood from draining during erection. The ischiocavernosus compresses the crus to elevate intracavernous pressure beyond systolic arterial pressure — creating rigidity rather than mere engorgement. Weakness in either muscle causes the venous leak pattern that underlies most vasculogenic ED.

Are kegel exercises safe for men with ED?

Yes. Pelvic floor muscle training is non-invasive, has no systemic side effects, and is safe for the vast majority of men. The principal exception is men with a hypertonic (overly tight) pelvic floor — in this case, kegel contractions can worsen symptoms. If standard kegels cause pelvic or perineal pain, stop and consult a pelvic floor physiotherapist for assessment before continuing.

Should I do kegels before or after other ED treatments?

Pelvic floor training can be started alongside other ED treatments — it is not a "last resort." The 2019 systematic review by De Rose et al. found that combining pelvic floor exercises with PDE5 inhibitor therapy produced better outcomes than either treatment alone. Many urologists now recommend pelvic floor training as first-line conservative treatment, particularly for vasculogenic ED and post-prostatectomy rehabilitation. Starting it early — before or alongside medication — produces the best long-term outcomes.