Pelvic floor muscle training

Urinary incontinence (UI) is a common problem among adults living in the community. It is more frequent in women, increases with age and is particularly common among those in residential care (Hunskaar 2003). Estimates of prevalence vary between 25 per cent to 45 per cent in most studies (Milsom 2017), influenced by the definition of incontinence, the sample population and the format of questions on frequency of symptoms. Additionally, figures are unlikely to reflect the true scope of the problem because stigma, embarrassment and other factors may lead to under-reporting.

UI is a serious medical condition in that it can lead to perineal rash, pressure ulcers and urinary tract infections (McNichol 2018) and it is also an undeniable social problem, creating embarrassment and negative self-perception (Papanicolaou 2005). UI reduces both social interactions and physical activities (DuBeau 2006) and is also associated with poor self-rated health (Johnson 1998), impaired emotional and psychological wellbeing (Coyne 2012) and impaired sexual function (Sen 2006). 

Moreover, UI in older women doubles the risk of admission to a nursing home, independent of age or the presence of comorbid conditions (Thom 1997).  

UI is often split into three main categories based on what is reported by the woman (symptoms), what is observed by the clinician (signs), and based on urodynamic studies (Haylen 2010). If urine leakage occurs when performing physical activities, including coughing, sneezing, playing sports or suddenly changing position this is called stress UI. If urine leakage is associated with or immediately preceded by a sudden, strong need to urinate that cannot be deferred, this is called urgency UI. Many women have symptoms or signs of both stress and urgency UI, which is called mixed UI.

Clinical practice guidelines recommend pelvic floor muscle training (PFMT) as a first-line treatment for all types of UI in women of all ages (Level A evidence) (Dumoulin 2017). However, as there is still uncertainty about the long-term effectiveness and cost-effectiveness of PFMT, a new Cochrane systematic review (Dumoulin 2018) gathered the available clinical trials to update the current evidence on PFMT versus no treatment or placebo for women with UI.

How PFMT works for treating UI

PFMT is a programme of exercises meant to improve pelvic floor muscle strength, endurance, power, relaxation or a combination of these (Bø 2017). The biological rationale for PFMT in women with stress UI is twofold. First, an intentional, effective pelvic floor muscle contraction (lifting the pelvic floor muscles in a cranial and forward direction) prior to and during effort or exertion clamps the urethra and increases urethral pressure, preventing urine leakage (Delancey 1998). 

Second, the bladder neck receives support from strong, toned pelvic floor muscles resistant to stretching. This limits downward movement during effort and exertion, preventing urine leakage (Bø 2004). 

PFMT is also used in the management of urgency UI. The biological rationale is based on the observation that a detrusor muscle contraction can be inhibited by a pelvic floor muscle contraction induced by electrical stimulation (Godec 1975). After preventing the urgency to void, the woman can reach the toilet in time and avoid urine leakage.

Findings of the review

Ten new trials were added in this review update. In total, 31 trials involving 1,817 women were included. The authors sub grouped these trials by type of UI and analysed a variety of outcomes, including whether the condition was ‘cured’, or ‘cured or improved’, participant-reported measures, clinician-reported measures and adverse effects. 

Even though four clinical subgroups for baseline type of UI (stress, urgency, mixed and UI of all types) were pre-specified, most of the trials found reported data on two of them (stress UI, UI of all types). Two small trials included in this update investigated the effect of PFMT versus control in the two remaining subgroups. 

Overall, there was considerable variation in interventions used, study populations, and outcome measures. However, the more recent trials reported PFMT exercise regimens more in line with the literature on skeletal muscle training theory and pelvic floor muscle dysfunction, with supervised progressive training protocols. Additionally, patient-reported symptoms and quality of life outcomes were more often used in line with recent recommendations (Diaz 2017).

The addition of 10 new trials did not change the essential findings of the previous review. From the pooled results, after a PFMT programme, women with stress UI alone were eight times more likely to report cure and PFMT women with UI of all types were five times more likely to report cure. Women with stress UI undertaking PFMT were six times more likely to report cure or improvement, and PFMT women with UI all types were twice as likely to report cure or improvement.

For women with urgency UI treated with PFMT there is now one report of reduction of urinary leakage episodes and, for women with mixed UI treated with PFMT, there is now one report of better quality of life. 

Based on the data available, we can be confident that PFMT can cure or improve symptoms of stress UI and all other types of UI. It may reduce the number of leakage episodes, the quantity of leakage on short pad tests in the clinic and symptoms on UI-specific symptom questionnaires. Women undertaking PFMT were also generally more satisfied with their treatment and sexual outcomes. Side-effects were rare and, in the two trials that did report them, they were minor.

Implications for practice

The wider range of populations, countries and secondary outcomes within these new trials emphasised the strength of recommendations for PFMT in treating women with UI. New trials now support the cost-effectiveness of PFMT, although the limited nature of follow-up beyond the end of treatment in the majority of the trials means that the long-term outcomes and cost-effectives of use of PFMT remain uncertain. 

• Licia Pazzoto Cacciari is a PhD student at the University of São Paulo
• Chantal Dumoulin is an assistant professor at the École de réadaptation, Université de Montréal

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