On 12 May 1926, Piłsudski staged the May Coup, a military overthrow of the civilian government mounted against President Stanisław Wojciechowski and the troops loyal to the legitimate government. Hundreds died in fratricidal fighting. Piłsudski was supported by several leftist factions who ensured the success of his coup by blocking the railway transportation of government forces. He also had the support of the conservative great landowners, a move that left the right-wing National Democrats as the only major social force opposed to the takeover.

Following the coup, the new regime initially respected many parliamentary formalities, but gradually tightened its control and abandoned pretenses. The Centrolew, a coalition of center-left parties, was formed in 1929, and in 1930 called for the "abolition of dictatorship". In 1930, the Sejm was dissolved and a number of opposition deputies were imprisoned at the Brest Fortress. Five thousand political opponents were arrested ahead of the Polish legislative election of 1930, which was rigged to award a majority of seats to the pro-regime Nonpartisan Bloc for Cooperation with the Government (BBWR).

The authoritarian Sanation regime ("sanation" meant to denote "healing") that Piłsudski led until his death in 1935 (and would remain in place until 1939) reflected the dictator's evolution from his center-left past to conservative alliances. Political institutions and parties were allowed to function, but the electoral process was manipulated and those not willing to cooperate submissively were subjected to repression. From 1930, persistent opponents of the regime, many of the leftist persuasion, were imprisoned and subjected to staged legal processes with harsh sentences, such as the Brest trials, or else detained in the Bereza Kartuska prison and similar camps for political prisoners. About three thousand were detained without trial at different times at the Bereza internment camp between 1934 and 1939. In 1936 for example, 369 activists were taken there, including 342 Polish communists. Rebellious peasants staged riots in 1932, 1933 and the 1937 peasant strike in Poland. Other civil disturbances were caused by striking industrial workers (e.g. events of the "Bloody Spring" of 1936), nationalist Ukrainiansand the activists of the incipient Belarusian movement. All became targets of ruthless police-military pacification.Besides sponsoring political repression, the regime fostered Józef Piłsudski's cult of personality that had already existed long before he assumed dictatorial powers.

Piłsudski signed the Soviet–Polish Non-Aggression Pact in 1932 and the German–Polish declaration of non-aggression in 1934, but in 1933 he insisted that there was no threat from the East or West and said that Poland's politics were focused on becoming fully independent without serving foreign interests. He initiated the policy of maintaining an equal distance and an adjustable middle course regarding the two great neighbors, later continued by Józef Beck. Piłsudski kept personal control of the army, but it was poorly equipped, poorly trained and had poor preparations in place for possible future conflicts. His only war plan was a defensive war against a Soviet invasion.The slow modernization after Piłsudski's death fell far behind the progress made by Poland's neighbors and measures to protect the western border, discontinued by Piłsudski from 1926, were not undertaken until March 1939.

When Marshal Piłsudski died in 1935, he retained the support of dominant sections of Polish society even though he never risked testing his popularity in an honest election. His regime was dictatorial, but at that time only Czechoslovakia remained democratic in all of the regions neighboring Poland. Historians have taken widely divergent views of the meaning and consequences of the coup Piłsudski perpetrated and his personal rule that followed.