Conservative interventions for treating urinary incontinence in women: an Overview of Cochrane systematic reviews

Randomised controlled pilot trial to assess effect of electrical stimulation of weak pelvic floor muscles

INTRODUCTION AND HYPOTHESIS

Pelvic floor muscle training (PFMT) has level 1A scientific evidence for the treatment of urinary incontinence and pelvic organ prolapse. Past studies, however, have often excluded women with very weak pelvic floor muscles (PFM). The aim was to investigate the hypothesis that intravaginal electrical stimulation (iES) improves PFM strength more than PFMT in women with weak PFM, and to use these results to calculate sample size required for a future large randomised controlled trial (RCT).

METHODS

This assessor-blinded pilot RCT had a two arm, parallel design with computer-generated Randomisation. Both groups were offered 12 one-to-one physiotherapy sessions over a 6-month period. The iES group received individual tailored electrical pulse parameters. The PFMT group received PFM exercises, with the addition of facilitation techniques at therapy sessions. A power calculator was used to calculate sample size.

RESULTS

Fifteen women were recruited. Eight were randomised to iES and 7 to PFMT. Two subjects dropped out of the iES group. Median age was 49 years (range 36-77) and parity 2.1 (range 1-3). Both groups showed increases in PFM strength measured by manometery (iES 12.3, SD 12.0 vs PFMT 10.0, SD 8.1) cmH2O. There was no significant difference between groups. With a power of 0.80 we need a sample size of 95 women in each group to detect a difference between groups.

CONCLUSION

There was no significant difference between the groups in improvements in PFM strength. To detect a difference, we would have required 95 women in each group.

Symptomatology and knowledge regarding pelvic floor dysfunctions and influence of gender stereotypes in female athletes

Pelvic floor dysfunctions (PFD) are highly prevalent among females who do athletics, a sport requiring jumping, strength, and running. Although educational approaches are useful options, the educational need for this particular population remains unknown. The objective of the present study was to describe the level of knowledge regarding PFD and its relationship with symptomatology and gender stereotypes in female athletes in Spain. A total of 255 female athletes completed an anonymous online survey to explore their knowledge regarding urinary incontinence (UI), pelvic organ prolapse (POP), anal incontinence (AI), and sexual dysfunction (SexD), as well as their PFD symptoms and gender stereotyped beliefs related to sport. Educational level and sports characteristics (training volume, experience, and athletic modality) were also explored. Participants demonstrated a low level of knowledge in terms of POP (52.5%), AI (64.0%), and SexD (40%), but not for UI (70.8%). The proportion of PFD complaints was 63.5% for dyspareunia, 51.8% for urine leakage, 42.4% for pelvic pain, 17.3% for AI, and 9.0% for POP, with no associations with knowledge (p > 0.05). Lower knowledge about UI and SexD was related to greater gender stereotypes (p < 0.05) and rejection of professional healthcare (p = 0.010). As a conclusion, the level of knowledge about PFD was low in female athletes who train and compete in athletics in Spain, mainly with regard to sexual dysfunction. Although 63.5% of athletes had dyspareunia and 51.8% urinary leakages, symptomatology was not associated with level of knowledge. However, a lower level of knowledge was associated with more stereotyped beliefs and rejection of professional healthcare for PFD. These findings confirm the need to design appropriate educational interventions to disseminate information on all the types of PFD, particularly sexual contents. The potential influence of gender stereotypes makes it appropriate to include the gender perspective in these interventions.

Maintaining A Long-Term Practice of Daily Pelvic Floor Muscle Exercises: What Do Childbearing Women Think?

INTRODUCTION

To be effective, pelvic floor muscle therapy (PFMT) exercises should be intense, be practiced consistently, and include clinical support. Many women do not adhere to a consistent PFMT program, compromising the resolution or prevention of urinary incontinence (UI). This study aimed to answer 2 key questions: What prevents women from performing PFMT long term, and what can health care providers do to support women to perform them?

METHODS

Postpartum women from 4 sites in the United States completed a questionnaire about experiences with PFMT or Kegel exercises during and after pregnancy. This study focused on one of the 7 open-ended questions: What would prevent you from performing Kegels lifelong? Thematic analysis was implemented via an inductive approach using Braun and Clarke's 6-phase process.

RESULTS

Three salient themes emerged that help explain factors that prevent women from adhering to a daily PFMT routine: (1) life gets in the way, (2) inadequate PFMT education and instruction, and (3) disconnect exists about long-term consequences. The sample included 368 participants.

DISCUSSION

The themes were congruent with the limited body of qualitative literature on experience with PFMT exercises. This study was able to identify areas of need in the US maternal health care system to help childbearing people adopt daily PFMT, such as (1) inadequate parental leave and childcare support, (2) no formalized education related to UI and PFMT and a lack of pelvic health promotion, (3) lacking prioritization of long-term PFMT, and (4) the need to dispel the acceptance that UI postbirth is normal. Health care providers should prioritize interactive education, emphasizing how to correctly perform PFMT and the importance and effectiveness of integrating clinical support. To adequately encompass pelvic floor health care and education up to one year postbirth, changes are needed to the US perinatal health care system, providing sufficient insurance reimbursement and parental social support programs.

Pelvic floor therapy program for the treatment of female urinary incontinence in Belize: a pilot study

Introduction

Urinary incontinence (UI) is highly prevalent in low- and middle-income countries (LMIC). Concurrently, the availability of surgical or conservative UI treatments in LMIC is limited.

Methods

We conducted a prospective feasibility study of Belize women with UI treated with pelvic floor physical therapy (PFPT) and education (PFE). Patients received individual PFPT/PFE over 2 days, consisting of biofeedback-enhanced PFMT in addition to behavioral, dietary, and general pelvic education. Patient completed a daily 6-month home regimen including 7 PFMT exercises (total 70 repetitions) comprising both endurance and quick flick exercises. Patients also performed comprehensive dietary and behavioral modification activities. Outcomes were assessed at baseline and 6-months, including validated symptom (ICIQ-FLUTS) and QOL (IIQ-7) questionnaires, and strength testing (PERFECT score, perineometry).

Results

Twenty-eight patients underwent baseline assessment. Four patients were lost to in-person 6-month follow-up, with two of these patients completing subjective assessment only by telephone. The mean (±SD) patient age, BMI, and parity were 50.0 (±10.0) years, 33.2 (±5.8), and 2.8 (±1.5). Provider assessment demonstrated patient comprehension of basic, endurance, and quick flick pelvic floor contractions in 28 (100%), 24 (86%), and 24 (86%) patients, respectively. At 6-month follow-up, significant improvements were seen across multiple validated questionnaire and strength measurement assessments. Median patient-reported improvement level was 7.0 on a 10-point Likert scale.

Discussion

Study patients demonstrated good understanding of PFMT/PFE and program completion was associated with significant improvements across a variety of subjective incontinence and quality of life outcomes, as well as objective strength testing.

Management of mixed urinary incontinence: IUGA committee opinion

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) is defined by the International Urogynecology Association (IUGA) and International Continence Society as the complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing. It therefore implies the coexistence of both stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). MUI is a heterogeneous diagnosis that requires an assessment of its individual components of SUI and UUI. Management requires an individualised approach to the symptom components. The aim of this review is to identify the assessment/investigations and management options for MUI.

METHODS

A working subcommittee from the IUGA Research & Development (R&D) Committee was created and volunteers invited from the IUGA membership. A literature review was performed to provide guidance focused on the recommended assessment and management of MUI. The document was then evaluated by the entire IUGA R&D Committee and IUGA Board of Directors and revisions made. The final document represents the IUGA R&D Committee Opinion.

RESULTS

The R&D Committee MUI opinion paper provides guidance on the assessment and management of women with MUI and summarises the evidence-based recommendations.

CONCLUSIONS

Mixed urinary incontinence is a complex problem and successful management requires alleviation of both the stress and urge components. Care should be individualised based on patient preferences. Further research is needed to guide patients in setting goals and to determine which component of MUI to treat first. The evidence for many of the surgical/procedural treatment options for MUI are limited and needs to be explored in more detail.

Effect of Pelvic Floor Muscle Training With Smartphone Reminders on Women in the Postpartum Period: A Randomized Controlled Trial

IMPORTANCE

Standard postpartum pelvic floor muscle training (PFMT) can effectively reduce the incidence of pelvic floor dysfunction diseases.

OBJECTIVE

This study aimed to evaluate the adherence of PFMT with smartphone application reminders on women in the postpartum period.

STUDY DESIGN

We conducted a randomized controlled trial. This single-center randomized (1:1) controlled study included primiparous women admitted to Tongji Hospital between March 2022 and June 2022 (ChiCTR2200059157). Every puerpera was given pelvic floor muscle (PFM) assessment and PFMT guidance at 6 weeks after delivery. After randomization, women in the intervention group received daily training reminders from the smartphone application WeChat. Adherence to PFMT, a symptom of stress urinary incontinence, and PFM characteristics were measured 3 months later.

RESULTS

A total of 148 participants were included in the final analysis (76 in the intervention group and 72 in the control group). The adherence rate of daily PFMT was higher in the intervention group than in the control group (53.9% vs 20.8%, P = 0.00) at 3-month follow-up. In addition, participants in the intervention group showed higher peak surface electromyography of PFMs (39.8 ± 6.2 vs 37.5 ± 5.9 μV, P = 0.03) and longer PFM endurance (8.1 ± 2.0 vs 7.3 ± 2.0 seconds, P = 0.01) than in the control group, whereas there was no difference between the 2 groups in International Consultation on Incontinence Questionnaire-Short Form ( P = 0.60) and the Patient Global Impression of Improvement scores ( P = 1.00).

CONCLUSIONS

Smartphone application-based PFMT could increase adherence and improves electromyography of PFMs in the short term but did not affect stress urinary incontinence symptoms in women in the postpartum period.

Novel online comprehensive pelvic floor therapy program following prostatectomy

Background

Although pelvic floor muscle training (PFMT) is widely shown to improve post-prostatectomy incontinence (PPI), numerous barriers impede access to formal PFMT and include the limited availability of specialized therapists and financial or scheduling barriers. To address these barriers, we developed a novel online program delivering comprehensive long-term PFMT, pelvic floor education (PFE), and dietary/behavioral modification education. This study is a prospective interim analysis of online PFMT/PFE (oPFMT/PFE), with focus on feasibility, satisfaction, and continence outcomes.

Methods

Patients anticipating robotic-assisted laparoscopic prostatectomy (RALP) were recruited (6/2021-9/2022) for oPFMT/PFE. oPFMT/PFE comprises a 12-month program of 3 phases, including multiple exercises with varied contraction types and duration, and comprehensive dietary and behavioral technique education. Incontinence and quality of life (QOL) outcomes are assessed at 3 weeks, 3, 6, and 12 months following RALP using validated International Consultation on Incontinence Questionnaire Male Lower Urinary Tract Symptoms (ICIQ-MLUTS) and Incontinence Impact Questionnaire (IIQ-7) questionnaires and additional items assessing satisfaction, improvement, and daily pad use. Primary study outcomes included ICIQ-MLUTS stress urinary incontinence (SUI) domain score (SDS) and SUI cure [ICIQ SUI domain score (SDS) =0]. Interim 6-month analysis was performed using mixed effects linear regression and mixed effects Poisson regression.

Results

Analysis included 21 men (64±6 years). At 6-month follow-up, men undergoing oPFMT/PFE showed significant improvement in SDS compared to the 3-week time point [mean ± standard error (SE) =1.05±0.24 vs. 0.45±0.17, P=0.011], but still experienced higher scores than at baseline (P=0.017). Six-month patient-reported improvement averaged 7.42±0.74 (10-point Likert scale). All (100%) of 19 respondents (2 missing data) found the program easy to use, educational, and would recommend it to others, with 89% expressing satisfaction with the program. During patient interview at 6-month follow-up, no men reported inability to access the program online or any adverse events. Finally, IIQ-7 score improved significantly from the 3-week timepoint (4.47±1.10) at both time points (3-month 1.14±0.44, P<0.001 and 6-month 1.10±0.37, P<0.001), and neither 3- nor 6-month scores differed from baseline (P=0.808 and P=0.444, respectively).

Conclusions

Our novel oPFMT/PFE yields significant improvements to validated urinary incontinence (UI) and QOL measures, providing a valuable and accessible treatment option for PPI.

Pelvic floor muscle training with biofeedback or feedback from a physiotherapist for urinary and anal incontinence after childbirth - a systematic review

BACKGROUND

Childbirth is one of the biggest risk factors for incontinence. Urinary and anal incontinence can cause pain and social limitations that affect social life, cohabitation, and work. There is currently no up-to-date literature study on the effect of pelvic floor muscle training with feedback from a physiotherapist, which involves verbal instructions based on vaginal and anal digital palpation, compared to treatment without feedback (e.g., recommendations for pelvic floor muscle training).

AIM

The objective of this systematic review was to examine the scientific evidence regarding the impact of pelvic floor muscle training (PFMT) with feedback from a physiotherapist and/or biofeedback on urinary and anal incontinence in women during the first six months following vaginal delivery, compared to treatment without feedback.

METHODS

The literature search was conducted in the databases PubMed, Cochrane, and CINAHL. In addition, a manual search was conducted. The search terms consisted of MeSH terms and synonyms in the respective search block including population, intervention, and study design, as well as the terms pelvic floor and postpartum. An evaluation of each included study was conducted for methodological quality, evidence value, and clinical relevance.

RESULTS

Eight studies were included, three of which showed a significant difference between groups, in favor of the intervention group that received pelvic floor muscle training with feedback from a physiotherapist and/or biofeedback. Due to the varying results and insufficient quality for the majority of the studies, the scientific basis was considered insufficient.

CONCLUSION

The scientific evidence for pelvic floor muscle training with feedback from a physiotherapist or biofeedback on postpartum urinary and anal incontinence compared to treatment without feedback is considered insufficient. Further research on the subject is needed. The study is registered in PROSPERO CRD42022361296.

Development and evaluation of a rehabilitation training compliance scale for patients with urinary incontinence

BACKGROUND

Urinary incontinence treatment includes conservative treatment, physical devices, medication, and surgery. Pelvic floor muscle training combined with bladder training is among the most effective, non-invasive, and economical ways to treat urinary incontinence, and compliance with training is essential in urinary incontinence treatment. Several instruments assess pelvic floor muscle training and bladder training. However, no tool has been found that assesses compliance with pelvic floor muscle training when combined with bladder training for urinary incontinence. This study aimed to develop a rehabilitation training compliance scale for patients with urinary incontinence and to evaluate its validity and reliability.

METHODS

This study was performed in two tertiary hospitals in Hainan, China between December 2020 and July 2021, 123 patients were included. A literature review, group discussions, and two rounds of letter consultations were performed to acquire the item pool and finalise the 12 items for this scale. Exploratory and confirmatory factor analysis, Cronbach's α, split-half reliability, test-retest reliability, content validity, construct validity, convergent and discriminant validity, and criterion-related validity were used to examine the items in the scale.

RESULTS

A 12-item scale comprising three factors accounted for 85.99% of the variance in the data. The Cronbach's α, split-half reliability, test-retest reliability, and content validity index of the scale were 0.95, 0.89, 0.86, and 0.93, respectively. Comparison with the Chen pelvic floor muscle exercise self-efficacy scale showed high calibration correlation validity (coefficient = 0.89).

CONCLUSIONS

The training compliance scale developed in this study is a valid and reliable measurement tool to assess pelvic floor muscle training and bladder training compliance in patients with urinary incontinence.

Prevalence and severity of urinary incontinence and associated factors in Iranian postmenopausal women: a cross-sectional study

BACKGROUND

Urinary incontinence (UI) is one of the most common symptoms during menopause, leading to a decreased quality of life and limited social activities. This study aimed to determine the prevalence and severity of urinary incontinence and associated risk factors in postmenopausal women.

METHODS

It was a cross-sectional study using cluster sampling on 433 postmenopausal women in Tabriz-Iran, 2021-2022. Data were collected using questionnaires of socio-demographic characteristics, Questionnaire for Urinary Incontinence Diagnosis (QUID), and International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UISF). Multivariate logistic regression was used to determine factors related to urinary incontinence.

RESULTS

The overall prevalence of urinary incontinence was 39.5%; 20.6% stress urinary incontinence (SUI), 10.4% urgency urinary incontinence (UUI), and 8.5% mixed urinary incontinence (MUI). Multivariate logistic regression analysis showed that the prevalence of SUI (aOR 0.38; 95% CI 0.18-0.77) and UUI (aOR 0.38; 95% CI 0.15-0.94) was significantly lower in women with three childbirths than the ones with fewer childbirths. Also, the odds of UUI increased significantly in women at the 50-55 age range (aOR 3.88; 95% CI 1.16-12.93) than those less than 50 years.

CONCLUSION

Due to the high prevalence of urinary incontinence in postmenopausal women, caregivers should screen for early diagnosis and appropriate treatment of urinary incontinence to prevent its destructive impact on the quality of life.

Bio-Physics Approach to Urinary Incontinence Disabilities

BACKGROUND

The terminology of urinary incontinence (UI) and pelvic floor dysfunctions is complex. It affects quality of life and daily activities in personal, social, and professional fields. Managing UI without pharmacologic therapies is effective with a low risk of adverse effects and a large benefit for increasing continence rates. The aim of this preliminary retrospective observational study is to evaluate the effectiveness of the association between manual therapy and focused mechano-acoustic vibrations in women with nonspecific UI.

MATERIALS AND METHODS

A group of 15 incontinent women (mean age 59.5 ± 11.4), referred to the Physiotherapy Center, Rehabilitation and Re-education (Ce.Fi.R.R.), located at the University "Gabriele d'Annunzio" of Chieti-Pescara from January 2019 December 2021, were enrolled after medical examination. The women were evaluated at T0 (admission protocol), T1 (after 8 weeks), and T2 (after 12 weeks). All patients received the rehabilitation protocol twice a week for a total of 8 weeks (T1) and were reevaluated after 12 weeks (T2). Outcome measures were: the Pelvic Floor Disability Index, the Pelvic Floor Impact Questionnaire-7, and the MyotonPRO.

RESULTS

The analysis of MyotonPRO data showed no significant improvements in all parameters. The PFDI-20 and PFIQ-7 questionnaire results showed a significant reduction in scores between T0 and T2.Results over time of the ANOVA values confirming the significant differences in the PFDI-20 and PFIQ-7 questionnaire results but not in the MyotonPRO variables.

CONCLUSIONS

Despite limitations and no significant results, this study demonstrated that the integration of manual and focused mechano-acoustic vibrations therapy improved the symptoms of UI and reduced its psychosocial impact. Further experience could be required to establish the place of this integrated approach in achieving long-term improvements in UI.