Women's knowledge, practises, and intentions regarding correct pelvic floor exercises

Pelvic floor muscle exercise and training for coping with urinary incontinence

The pelvic floor consists of levator ani muscles including puborectalis, pubococcygeus and iliococcygeus muscles, and coccygeus muscles. Pelvic floor muscle exercise (PFME) is defined as exercise to improve pelvic floor muscle strength, power, endurance, relaxation, or a combination of these parameters. PFME strengthens the pelvic floor muscles to provide urethral support to prevent urine leakage and suppress urgency. This exercise has been recommended for urinary incontinence since first described by Kegel. When treating urinary incontinence, particularly stress urinary incontinence, PFME has been recommended as first-line treatment. This article provides clinical application of PFME as a behavioral therapy for urinary incontinence. Clinicians and physical therapist should understand pelvic floor muscle anatomy, evaluation, regimen, and instruct patients how to train the muscles properly.

Pregnant women's experiences with a pelvic floor muscle training program in Nepal

BACKGROUND

In Nepal, pelvic floor disorders affect about 24% of the women in reproductive age whereof 10% suffer from pelvic organ prolapse (POP). Still, many do not seek health care. Strengthening exercises for the pelvic floor muscles for prevention and treatment of POP has shown strong evidence internationally, but for women in Nepal surgery is primarily offered. To amend this, a novel pelvic floor muscle training (PFMT) program for pregnant women was introduced.

OBJECTIVE

To learn about how the PFMT-program was received by the participating women, their understanding of the importance of doing the exercises, and the constraints of daily life for performing the program.

METHODS

A qualitative study design based on a sub-sample (N = 10) from a strategic sample (N = 235) who participated in the PFMT-program. Ten semi-structured in-depth interviews were interpreted according to a phenomenological analytical tradition.

RESULTS

The 10 women were representative for the women who had participated in the PFMT-program with regard to urban residence, socioeconomic, and educational standing. The program was well received and compliance satisfactory. In line with the PFMT's learning outcomes, the women described risk factors, showed knowledge about the pelvic floor muscles, and understood the importance of doing the exercises. They had managed to fit the exercises into their busy daily routines. Meeting peers in exercise groups and understanding from family were positive factors for compliance.

CONCLUSION

The Nepalese women appear interested in self-care and are making an effort to fit the exercises into their busy schedule. Although the communicative validity was satisfactory, the pragmatic validity cannot be generalized to women in rural areas and under less fortunate socioeconomic and educational circumstances.

Narrative review of pelvic floor muscle training for childbearing women-why, when, what, and how

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is prevalent during pregnancy and postpartum. UI in pregnancy strongly predicts UI postpartum and later in life. UI reduces women's wellbeing and quality of life and presents a significant burden to healthcare resource.

METHODS

A narrative review summarizing quantitative and qualitative evidence about pelvic floor muscle training (PFMT) for prevention and treatment of UI for childbearing women.

RESULTS

There are clinically important reductions in the risk of developing UI in pregnancy and after delivery for pregnant women who start PFMT during pregnancy, and PFMT offers additional benefits preventing prolapse and improving sexual function. If women develop UI during pregnancy or postpartum then PFMT is an appropriate first-line treatment. For novice exercisers, a programme comprising eight contractions, with 8-s holds, three times a day, 3 days a week, for at least 3 months is a reasonable minimum and 'generic' prescription. All women need clear accurate verbal instruction in how to do PFMT. Incontinent women, and women who cannot do a correct contraction, require referral for pelvic floor rehabilitation. Behavioural support from maternity care providers (MCPs)-increasing women's opportunity, capability, and motivation for PFMT-is as important as the exercise prescription.

CONCLUSION

PFMT is effective to prevent and treat UI in childbearing women. All pregnant and postpartum women, at every contact with a MCP, should be asked if they are continent. Continent women need exercise prescription and behavioural support to do PFMT to prevent UI. Incontinent women require appropriate referral for diagnosis or treatment.

Effects of pelvic floor muscle training in pregnant women

Objective:

The aim is to verify the effectiveness of the pelvic floor muscle training (PFMT) program in pregnant women, by analyzing the amount of urine leakage.

Design:

Experimental study.

Location:

Care units in the Vila Real district, Portugal.

Participants:

Forty-three pregnant women divided into an experimental group (EG) (n = 22) and a control group (CG) (n = 21).

Interventions:

Both groups were evaluated in a predelivery stage (initial) and 6 months after delivery (final). The EG was given a PFMT exercise protocol with a duration of 6 weeks, applicable in classes and at home, another PFMT protocol for 9 weeks.

Main measurements:

The strength of the pelvic floor muscle was measured by the Oxford Grading Scale and the amount of urine was assessed with a Pad test. Quality of life was measured by the King's Health Questionnaire and self-efficacy by the Broome Pelvic Muscle Self-Efficacy Scale.

Results:

The loss of urine, significantly reduced from 0.86 ± 0.83 to 0.50 ± 0.67 in the EG (P = .021), whereas in the CG no significant change was observed. The degree of muscle contraction increased by 4.82 ± 0.39 in EG and 3.95 ± 0.67 in CG. The quality of life observed significant improvements in both groups (P < .05). As for self-efficacy, for the EG it improved significantly – initial (P = .001), final (P = .031), and for the CG the values remained the same.

Conclusions:

This PFMT protocol reduced urinary incontinence in pregnant women. The program allowed significant improvement in the quantity of urinary leakage and an increase in the strength of the pelvic floor muscle.

Performance of self-reported and unsupervised antenatal pelvic floor muscle training and its effects on postpartum stress urinary incontinence among Chinese women: a cohort study

OBJECTIVES

We investigated performance of antenatal pelvic floor muscle training (PFMT) among Chinese pregnant women, to explore its effects on postpartum stress urinary incontinence (SUI).

METHODS

We conducted a prospective cohort study in Shenzhen, China among 815 singleton pregnant women age ≥18 years, who were continent before pregnancy. Telephone follow-up was conducted at 6 weeks postpartum. Logistic univariable and multivariable regression analyses were used to estimate effects of antenatal PFMT (frequency and duration) on SUI postpartum among subgroups defined by SUI during pregnancy. The interactions of antenatal PFMT and PFMT duration on SUI postpartum were tested.

RESULTS

Among 798 women included in the analysis, 127 (15.91%) had SUI at 6 weeks postpartum. Only 157 (19.67%) women performed antenatal PFMT, none under supervision. After adjusting potential confounders, neither frequency (odds ratio (OR) = 1.08, 95% confidence interval (CI) 0.89-1.32) nor duration (OR = 1.03, 95% CI 0.87-1.23) of antenatal PFMT was a significant factor in postpartum SUI. No interactions of antenatal PFMT and PFMT duration on SUI postpartum were found in any participants or subgroups.

CONCLUSION

No effect of self-reported, unsupervised, self-initiated antenatal PFMT on SUI 6 weeks postpartum was found. Low doses and no supervision may have contributed to the negative results.

"Are you doing your pelvic floor?" An ethnographic exploration of the interaction between women and midwives about pelvic floor muscle exercises (PFME) during pregnancy

OBJECTIVE

Many women experience urinary incontinence (UI) during and after pregnancy. Pelvic floor muscle exercises (PFME) can prevent and reduce the symptoms of UI. The objective of the study was to explore challenges, opportunities and concerns for women and health care professionals (HCPs), related to the implementation of PFME training for women in current antenatal care.

DESIGN

An ethnographic study design was used. Researchers also formed and collaborated with a public advisory group, consisting of seven women with recent experiences of pregnancy, throughout the study.

PARTICIPANTS

Seventeen midwife-woman interactions were observed in antenatal clinics. In addition, 23 midwives and 15 pregnant women were interviewed. Repeat interviews were carried out with 12 of the women postnatally. Interviews were also carried out with other HCPs; four physiotherapists, a linkworker/translator and two consultant obstetricians. Additional data sources included field notes, photographs, leaflets, policy and other relevant documents.

SETTING

Data were collected in three geographical areas of the UK spanning rural, urban and suburban areas. Data collection took place in antenatal clinics, in primary and secondary care settings, and the majority of women were interviewed in their homes.

FINDINGS

Three broad and inter-related themes of "ideological commitment", "confidence" and "assumptions, stigma and normalisation" were identified. The challenges, opportunities and concerns regarding PFME implementation were explored within these themes.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Although HCPs and some women knew that PFME were important, they were not prioritised and the significant benefits of doing PFME may not have been communicated by midwives or recognised by women. There was a lack of confidence amongst midwives to teach PFME and manage UI within the antenatal care pathway and amongst women to ask about PFME or UI. A perceived lack of consistent guidelines and policy at local and national levels may have impeded clear communication and prioritisation of PFME. Furthermore, assumptions made by both women and midwives, for example, women regarding UI as a normal outcome of pregnancy, or midwives' perception that certain women were more likely to do PFME, may have exacerbated this situation. Training for midwives to help women in the antenatal period to engage in PFME could address challenges and concerns and to help prevent opportunities for women to learn about PFME from being missed.

Exercise Professionals Improve Their Poor Skills in Contracting Pelvic-Floor Muscles: A Randomized Controlled Trial

A quick, well-timed pelvic-floor muscle contraction during physical effort is recommended for active women to prevent urine leakage.

PURPOSE

We address two research questions: how well do future female exercise professionals contract the pelvic-floor muscles, and whether the biofeedback session is necessary to train them to contract pelvic-floor muscles?

METHOD

Participants were 84 nulliparous future exercise professionals (age 23 ± 3 years, mean ± SD), randomly allocated into biofeedback (n = 27), usual-advice (n = 26), and control (no advice, n = 21) groups. Contraction of pelvic-floor muscles on a 4-point scale (1 = incorrect through 4 = correct) was assessed in all groups by surface electromyography (sEMG) with a vaginal probe before and after 6 weeks of intervention.

RESULTS

In pretest, almost one in five participants (17%) could not activate the pelvic floor and less than half of them (45%) presented correct technique. The technique score for the three groups was 3.1 ± 1.1 (mean ± SD). After training, both intervention groups presented better technique score by 0.6 (90% confidence limits ± 0.5) relative to the control group, and two-thirds (65%) of the intervention groups presented the correct technique.

CONCLUSIONS

Future exercise professionals displayed poor skills in contracting pelvic-floor muscles. Both training interventions (with and without biofeedback) were effective for this study group.

High-Low Impact Exercise Program Including Pelvic Floor Muscle Exercises Improves Pelvic Floor Muscle Function in Healthy Pregnant Women - A Randomized Control Trial

Background: Pregnancy and high-impact activity are considered as risk factors for pelvic floor dysfunctions, including urinary incontinence.

Aim: To investigate whether a structured exercise program, including high- and low-impact aerobics and supported by pelvic floor muscle exercises, improves the neuromuscular activity of the pelvic floor and does not reduce the quality of life in terms of urinary incontinence in healthy pregnant women.

Methods: This was a randomized control trial among 97 Caucasian healthy nulliparas in uncomplicated pregnancies (age 30 ± 4 years, 21 ± 5 weeks of gestation; mean ± SD). Women were assessed for pelvic floor muscle functions with surface electromyography (EMG) using vaginal probes and using the Incontinence Impact Questionnaire (IIQ). Only women able to contract pelvic floor muscles and with good quality of life based on IIQ were included for the study. Seventy women in the experimental group took part in a supervised exercise program including high-low impact aerobics and pelvic floor muscle exercises three times a week. Twenty-seven controls did not receive any exercise intervention. After 6 weeks both groups were re-tested with EMG and IIQ. Post- and pre-exercise program changes in each group were analyzed using a repeated-measures ANOVA.

Results: Women in the experimental group improved the neuromuscular activity of the pelvic floor in some motor tasks without any adverse outcomes of the intervention. After the exercise program we observed in the experimental group significantly higher EMG amplitude in the pelvic floor muscles during 3-s contractions (p = 0.014). We also noticed a beneficial trend in the increase of neuromuscular activity during 10- and 60-s contractions, but the changes were not statistically significant. The exercising women substantially improved their abilities for relaxation following 3- and 10-s contractions (p = 0.013 and p < 0.001). In controls, we reported no statistically significant improvement in either of the motor tasks. All study participants maintained good quality of life related to urinary incontinence.

Conclusion: Prenatal exercise programs that include high- and low-impact aerobics and are supported by pelvic floor muscle exercises should be recommended for pregnant women, especially those who are accustomed to higher exercise intensity before pregnancy. Nevertheless, these recommendations can be directed to continent women who can properly contract pelvic floor muscles.

ISRCTN. DOI: 10.1186/ISRCTN92265528: “Pelvic floor muscle training with surface electromyography”, retrospectively registered on the 25th of July, 2016.

Pelvic Floor Muscle Exercise Education and Factors Associated with Implementation among Antenatal Women in Hospital Universiti Sains Malaysia

Background

Pelvic floor muscle exercise is effective for pelvic floor muscle dysfunction. Despite the high prevalence of pelvic floor muscle dysfunction in women in the community, pelvic floor muscle exercise recognition is low in Malaysian society; thus, this intervention is not frequently used . This study assessed the knowledge of, attitudes towards, and use of pelvic floor muscle exercise among antenatal women before and after educational classes. The study also determined factors associated with exercise practice.

Methods

An interventional study was conducted in 121 antenatal women selected through systematic random sampling between June and December 2010. Baseline knowledge of, attitude towards, and practice of pelvic floor muscle exercise were assessed using self-administered validated questionnaires at first visit and at 2 months post-partum. All participants attended two exercise education classes on their next two visits before delivery. A paired t-test and multivariate analysis were used for data evaluation.

Results

The mean pre-intervention scores for knowledge, attitudes, and practice were 24.98, 24.25, and 3.51, respectively, with statistically significant mean score increments after intervention (P<0.001). The mean differences were 4.67 (95% confidence interval [CI], 3.86–5.49), 3.77 (95% CI, 3.05–4.50) and 3.45 (95% CI, 2.90–4.00) for knowledge, attitudes, and practice, respectively. Lack of baseline information on pelvic floor muscle exercise was significantly associated with practice change following an educational class.

Conclusion

Education is effective in improving knowledge of, attitude towards, and practice of pelvic floor muscle exercise. There is a need for greater effort to increase exercise awareness in our community, especially during antenatal class.

Evaluation of applying Kinesio taping in children with urinary incontinence

INTRODUCTION

Physiotherapeutic methods, used in patients with urinary incontinence, are recommended and acknowledged treatment methods. They include pelvic floor muscle exercises, electrical stimulation, magnetic field, acupuncture, and biofeedback. However, the influence of Kinesio taping (KT) applications is not known. The aim of this work was to assess the influence of the KT method on the number of incontinence incidents in children. Additionally, children included in the research were given a depression level test to assess their mental state and how it is influenced by incontinence.

MATERIAL AND METHODS

The study included 62 children (37 boys and 25 girls), aged 7-14 years, diagnosed as having night urinary incontinence and frequent daytime incontinence (daytime wetting). Study participants were randomly allocated to the research group, in which KT was applied, or the control group in which a placebo was used. The main outcome measure was the number of incontinence incidents.

RESULT

The analysis of study results indicated that there was a statistically significant decrease (p < 0.001) in the number of incontinence incidents after KT was applied among children in the research group compared with those in the control group. After 4 days of KT application the number decreased by half within 24 h (Figure).

DISCUSSION

As can be seen from the analysis of the literature on urinary incontinence therapy, several physiotherapeutic methods are described. They are not merely based on a single strategy but include combinations of methods. To our knowledge, the method described in our work is a pioneer method, previously not applied on its own. It is, however, limited by a relatively small number of research participants, although it took 29 months to gather the group for the research. Additionally, the research based on the principle that children with up to threw incontinence episodes per day were given KT applications every 3 days (72 h per session), whereas children with more frequent incontinence episodes were given KT applications every day (24 h per session). It seems that the principle should be that all children are given KT applications with the same frequency. Perhaps it could be interesting to compare the effects between groups with different frequency. Nevertheless, we believe that the results obtained in this research are of interest in the context of possibility to use KT for urinary incontinence in children.

CONCLUSION

The KT method may serve as an effective complementary form of physiotherapy for children with urinary incontinence.

Women's experiences, beliefs and knowledge of urinary symptoms in the postpartum period and the perceptions of health professionals: a grounded theory study

Aim This study aimed to explore, describe and enhance understanding of women's experiences, beliefs and knowledge of urinary symptoms in the postpartum period and also sought to understand the perceptions of health professionals of these issues.

BACKGROUND

Women often take no action with regard to urinary symptoms particularly in the postnatal period, which can lead to the adoption of coping mechanisms or normalisation of symptoms. The true prevalence is difficult to assess due to differing age groups and time spans in studies. There is only a small body of work available to try to understand the lack of action on the part of the women, and even less around the attitudes of health professionals.

METHODS

Grounded theory was selected for a qualitative inductive approach, to attempt to understand the social processes involved and generate new knowledge by examining the different interactions. Recruitment was by theoretical sampling. In total, 15 women were interviewed and two focus groups of health professionals were undertaken. In addition, an antenatal clinic and a postnatal mothers group were observed. All information was analysed manually using constant comparison. Findings The findings revealed that at times poor communication, lack of clear education and the power of relative's stories of the past were barriers to help seeking, and were disempowering women, creating a climate for normalisation. Women were willing to talk but preferred the health professional to initiate discussion. In addition, health professionals were concerned about a lack of time and knowledge and were uncertain of the effect of pelvic floor muscle exercises due to some research indicating improvement may not be maintained over time. The core category was; 'overcoming barriers to facilitate empowerment', indicating that improving communication and education could reduce barriers and enable them to seek help.

Opportunities, challenges and concerns for the implementation and uptake of pelvic floor muscle assessment and exercises during the childbearing years: protocol for a critical interpretive synthesis

BACKGROUND

Pregnancy and childbirth are important risk factors for urinary incontinence (UI) in women. Pelvic floor muscle exercises (PFME) are effective for prevention of UI. Guidelines for the management of UI recommend offering pelvic floor muscle training (PFMT) to women during their first pregnancy as a preventive strategy. The objective of this review is to understand the relationships between individual, professional, inter-professional and organisational opportunities, challenges and concerns that could be essential to maximise the impact of PFMT during childbearing years and to effect the required behaviour change.

METHODS

Following systematic searches to identify sources for inclusion, we shall use a critical interpretive synthesis (CIS) approach to produce a conceptual model, mapping the relationships between individual, professional, inter-professional and organisational factors and the implementation, acceptability and uptake of PFME education, assessment and training during the childbearing years. Purposive sampling will be used to identify potentially relevant material relating to topics or areas of interest which emerge as the review progresses. A wide range of empirical and non-empirical sources will be eligible for inclusion to encompass the breadth of relevant individual, professional, inter-professional and organisational issues relating to PFME during childbearing years. Data analysis and synthesis will identify key themes, concepts, connections and relationships between these themes. Findings will be interpreted in relation to existing frameworks of implementation, attitudes and beliefs of individuals and behaviour change. We will collate examples to illustrate relationships expressed in the conceptual model and identify potential links between the model and drivers for change.

DISCUSSION

The CIS review findings and resulting conceptual model will illustrate relationships between factors that might affect the implementation, acceptability and uptake of PFME education, assessment and training during the childbearing years. The model will inform the development and evaluation of a training package to support midwives with implementation and delivery of effective PFME during the antenatal period. The review forms part of the first phase of the United Kingdom National Institute for Health Research funded 'Antenatal Preventative Pelvic floor Exercises And Localisation (APPEAL)' programme (grant number: RP-PG-0514-20002) to prevent poor health linked to pregnancy and childbirth-related UI.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42016042792.

[Severe post-obstetric perineal tears: Medium-term consequences on women's quality of life]

AIMS

To assess the prevalence of anal (AI) and urinary (UI) incontinence at medium term after 3rd and 4th degree anal sphincter tears and their impact on sexuality and women's quality of life.

MATERIAL

It is a case-control, single center study. Sixty-eight primiparous women delivered with severe anal sphincter tear (exposed group) were compared to 136 women without (control group). Questionnaires on anal and urinary incontinence, sexual function and quality of life, using validated scores, were sent between two and five years after the first delivery. Maternal and obstetric data were collected retrospectively on the medical files.

RESULTS

The answer rate was 22.5% (46/204) of which 30.9% (21/68) in the exposed group and 18.4% (25/136) in the unexposed group. In case of severe anal sphincter tear, 57.1% of women reported an AI vs 48% in the control group (P=0.76). The rate of AI for liquid stool was significantly higher in the exposed group (P=0.05). Patients with severe perineal tears reported a greater impact of symptoms on their quality of life but the difference with the control group was not significant.

CONCLUSIONS

The severity of symptoms related to anal sphincter tears is common and underestimated. Preventive measures must be improved in order to maintain women's quality of life.

LEVEL OF EVIDENCE

4.

Pelvic floor awareness and the positive effect of verbal instructions in 958 women early postdelivery

INTRODUCTION AND HYPOTHESIS

It is uncertain how reliable a personal belief is about the ability to do pelvic floor muscle (PFM) contractions early postdelivery and how instructional feedback affects pelvic floor muscle contraction (PFMC) performance. We hypothesize that many women do not have a reliable idea about PFMC and that instructional feedback can help improve their control.

METHODS

Prospective observational study in 958 women (median 30 years) early postdelivery PFMC was evaluated with visual observation: an inward movement of the perineum was accepted as sign of good contraction. The women who could not show PFMC three consecutive times got verbal instructions, and re-evaluation was afterward.

RESULTS

In 500 women, no inward movement of the perineum was observed: 275 women (29%) showed no movement at all, and 225 women (24%) showed some movement but no inward displacement. In 33.4%, the personal conviction to be able or not to perform PFMC proved false. After verbal instructions, 74% improved their PFMC.

CONCLUSIONS

The belief of doing correct PFM contraction was false in at least one of five postpartum women. Verbal instructions have a positive effect on performing PFMC in 73.6% of women.

Continence and pelvic floor status in nulliparous women at midterm pregnancy

INTRODUCTION AND HYPOTHESIS

A Cochrane review recommends antenatal pelvic floor muscle training (PFMT) in urinary incontinence (UI) prevention. The aim of the study was to investigate nulliparous pregnant women's knowledge about and practising of PFMT, their pelvic floor muscle (PFM) function, and ability to contract correctly. It was hypothesized that continent women had higher PFM strength and endurance than women with UI.

METHODS

Three hundred nulliparous women at gestational week 18-22 were included in a cross-sectional study. Vaginal resting pressure, maximum voluntary contraction, and PFM endurance were measured by manometer. UI was assessed by International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI-SF). Comparisons of PFM function in continent women and women with UI were analyzed using independent-samples t test. Mean differences with 95 % confidence interval (CI) are presented.

RESULTS

Of 300 women, 89 % had heard of PFMT at mid pregnancy, and 35 % performed PFMT once or more a week. After thorough instruction 4 % were unable to contract correctly. Thirty-five percent reported UI, of whom 48 % performed PFMT once or more a week. Continent women had significantly higher PFM strength and endurance when compared with women having UI, with mean differences of 6.6 cmH(2)O (CI 2.3-10.8, p = 0.003), and 41.5 cmH(2)Osec (CI 9.8-73.1, p = 0.010), respectively. No difference was found for vaginal resting pressure (p = 0.054).

CONCLUSIONS

Most nulliparous pregnant women knew about PFMT. Thirty-five percent performed PFMT once or more a week. Incontinent nulliparous pregnant women had weaker PFM than their continent counterparts. More emphasis on information regarding PFM function and PFMT is warranted during pregnancy.

Which women do pelvic floor muscle exercises six months' postpartum?

OBJECTIVES

This study was undertaken to estimate the association between pelvic floor muscle training and demographic and health related factors that may influence pelvic floor muscle training postpartum.

STUDY DESIGN

This analysis includes the first 17,978 women enrolled in the Norwegian Mother and Child Cohort Study who answered questions about pelvic floor muscle training (n = 17,744). We used logistic regression analyses, and the results are presented as crude and adjusted odds ratios with 95% CI.

RESULTS

Women doing regular pelvic floor muscle training were more educated, likely to participate in general fitness activities, and had more children. Women experiencing urinary leakage and pelvic girdle pain postpartum were also more likely to do pelvic floor muscle training (adjusted odds ratio = 1.26, 95% CI 1.18-1.35; adjusted odds ratio = 1.31, 95% CI 1.23-1.39). Those who smoked daily or were delivered by cesarean were less likely to do pelvic floor muscle training (adjusted odds ratio = 0.81, 95% CI 0.72-0.91; adjusted odds ratio = 0.56, 95% CI 0.51-0.61).

CONCLUSION

There is a need for more research concerning effective strategies to enhance postpartum pelvic floor muscle training.

Unassisted pelvic floor exercises for postnatal women: a systematic review

AIM

This paper is a report of a systematic review on unassisted pelvic floor exercises for postnatal stress incontinence to identify effective interventions and highlight areas for further research.

BACKGROUND

Stress incontinence is a common and embarrassing problem. Childbirth is a major cause and problems can be persistent for some. However women are often reluctant to seek help.

METHOD

We conducted a systematic literature search in December 2006 using the CINAHL, Medline and Cochrane Library databases, hand-searching of selected textbooks, checking reference lists and contacting experts. There were no date restrictions. The review included randomized controlled trials, published in English, of unassisted pelvic floor exercises in postnatal women. Two reviewers independently extracted data and assessed study quality. Main outcomes were reduction in symptoms of incontinence, patient satisfaction and quality of life.

RESULTS

Four randomized controlled trials met the inclusion criteria. Interventions ranged from written information to structured exercise classes, while usual care varied from a leaflet to group sessions with a midwife. Three out of four studies demonstrated short-term improvement in incontinence symptoms, which was statistically significant in two. However, at later follow-up there was no longer a statistically significant effect on continence. All trials found that women in the intervention group were more likely to do the exercises.

CONCLUSION

We found few trials, quality was variable, and comparisons were difficult because of variations in interventions and outcomes measured. Further high quality evaluations are needed, using standardized interventions and outcome measures, patient-relevant outcomes such as quality of life, and follow-up periods that enable evaluation of long-term effectiveness.

A cross-sectional study of knowledge and practice of pelvic floor exercises during pregnancy and associated symptoms of stress urinary incontinence in North-East Scotland

OBJECTIVES

to establish levels of knowledge about pelvic floor exercises during pregnancy; reported practice of pelvic floor exercises in pregnancy; and prevalence of stress urinary incontinence in a sample of women in the third trimester of pregnancy.

DESIGN

structured cross-sectional interview survey.

PARTICIPANTS

pregnant women over the age of 16 years and more than 30 weeks gestation attending antenatal clinics in North-East Scotland. Of 350 women who agreed to participate, 289 (82.6%) were interviewed between July 1999 and March 2000.

FINDINGS

225 women (77.9%) reported being given or obtaining information about pelvic floor exercises in the current pregnancy. Books were the most frequently mentioned source of information. Midwives were the health professionals most likely to give information about pelvic floor exercises. Younger women, first-time mothers and those from more deprived backgrounds were less likely to report having information about the exercises. A third of women (n=90, 31.1%) said that they would have liked more information about the exercises. Practice of the exercises during pregnancy was reported by just over half the sample (n=156, 54.0%) and more than once a day by 26.3% (n=76). Younger women, and those from more deprived backgrounds, were less likely to report the practice of exercises. No difference was found in reported practice according to parity. More than half (n=157, 54.3%) of the women reported incontinence during the current pregnancy. No relationship was found between reported practice of pelvic floor exercises and stress urinary incontinence.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

the number of women who indicated a desire for more information and the low number who reported practice of the exercises suggest that improvements could be made. The gaps in information provision and practice suggest areas for future health promotion about the exercises, particularly by midwives, as not all women are seen by a physiotherapist during pregnancy. Reported levels of incontinence during pregnancy confirm previous findings and highlight the prevalence of incontinence in pregnancy.

Do pregnant women exercise their pelvic floor muscles?

The aims of the present study were to assess the number of women performing pelvic floor muscle training (PFMT) during pregnancy and to compare the background variables in those exercising and in those who did not. Four hundred and sixty-seven pregnant women (response rate 84%), mean age 31.5 years (range 20-49), answered a questionnaire on general physical activity level during pregnancy including PFMT. The questionnaire was sent out in week 32 of gestation and answered within week 36. Twenty-four percent reported problems with urinary incontinence and 9% flatus/fecal incontinence. The percentages of pregnant women performing PFMT at least once a week before pregnancy and during trimesters 1, 2, and 3 were 7, 12.9, 17.6, and 17.4%, respectively. More women with lower prepregnancy BMI and with present and past pelvic girdle pain were performing regular PFMT. No significant differences were found in any other background variables. It is concluded that relatively few women perform regular PFMT during pregnancy. In conclusion, only 17% of pregnant Norwegian women reported performing PFMT during pregnancy.

Initial management of stress urinary incontinence: pelvic floor muscle training and duloxetine

Stress urinary incontinence (SUI) is common among women of all ages and can have a negative impact on quality of life (QoL). Often, women refrain from seeking treatment due to the fear that surgery might be the only option, or that no other treatments exist. SUI symptoms can often be treated with simple measures such as pelvic floor muscle training (PFMT), weight loss, devices, etc. However, PFMT has low compliance rates, and few continue long term. More recently, another treatment option has been introduced, i.e. the relatively balanced serotonin and noradrenaline reuptake inhibitor (SNRI) duloxetine. PFMT and/or SNRI are recommended as a first-line therapy for the initial management of SUI in women in the guidelines of the third International Consultation on Incontinence. SNRI have received a grade A recommendation. As PFMT and duloxetine target different areas (i.e. pelvic floor muscle and distal urethral sphincter/rhabdosphincter, respectively), combined therapy might provide additional benefit. A recent study comparing the effect of combined treatment with no active treatment found that combination therapy was significantly better for all outcomes, including frequency of SUI episodes, pad use, improvements in QoL and global impression of improvement scores. The data suggest that combination therapy might provide another treatment option for SUI symptoms in women.

Pelvic floor muscle training effect on urinary incontinence knowledge, attitudes, and severity: An experimental study

This study of Taiwanese women investigated effects of pelvic floor muscle training (PFMT) on urinary incontinence (UI) severity and on participants' knowledge and attitudes regarding UI and PFMT. Of 114 participants in a 4-h PFMT program, 55 suffering from UI completed 2 questionnaires, 1 before and 1 after the program. Among them, 78% reported experiencing UI under increased abdominal pressure, and 82% had suffered the condition for more than 1 year. Participants achieved reductions in UI severity after PFMT; and the program produced a significant difference in their knowledge about, though not in their attitudes toward, both UI and PFMT.

Rehabilitation of pelvic floor muscles utilizing trunk stabilization

The pelvic floor muscles (PFM) are part of the trunk stability mechanism. Their function is interdependent with other muscles of this system. They also contribute to continence, elimination, sexual arousal and intra-abdominal pressure. This paper outlines some aspects of function and dysfunction of the PFM complex and describes the contribution of other trunk muscles to these processes. Muscle pathophysiology of stress urinary incontinence (SUI) is described in detail. The innovative rehabilitation programme for SUI presented here utilizes abdominal muscle action to initiate tonic PFM activity. Abdominal muscle activity is then used in PFM strengthening, motor relearning for functional expiratory actions and finally impact training.