Physiotherapy for female stress urinary incontinence: individual therapy at the outpatient clinic versus home-based pelvic floor training: a 5-year follow-up study

Supervised versus unsupervised pelvic floor muscle training in the treatment of women with urinary incontinence - a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

This study synthesized the effects of supervised and unsupervised pelvic floor muscle training (PFMT) programs on outcomes relevant to women's urinary incontinence (UI).

METHODS

Five databases were searched from inception to December 2021, and the search was updated until June 28, 2022. Randomized and non-randomized control trials (RCTs and NRCTs) comparing supervised and unsupervised PFMT in women with UI and reported urinary symptoms, quality of life (QoL), pelvic floor muscles (PFM) function/ strength, the severity of UI, and patient satisfaction outcomes were included. Risk of bias assessment of eligible studies was performed by two authors through Cochrane risk of bias assessment tools. The meta-analysis was conducted using a random effects model with the mean difference or standardized mean difference.

RESULTS

Six RCTs and one NRCT study were included. All RCTs were assessed as "high risk of bias", and the NRCT study was rated as "serious risk of bias" for almost all domains. The results showed that supervised PFMT is better than unsupervised for QoL and PFM function of women with UI. There was no difference between supervised and unsupervised PFMT for urinary symptoms and improvement of the severity of UI. Results of patient satisfaction were inconclusive due to the sparse literature. However, supervised and unsupervised PFMT with thorough education and regular reassessment showed better results than those for unsupervised PFMT without educating patients about correct PFM contractions.

CONCLUSIONS

Supervised and unsupervised PFMT programs can both be effective in treating women's UI if training sessions and regular reassessments are provided.

Analysis of the status quo of pelvic floor muscle and the effect of pelvic floor muscle training in second pregnant women

OBJECTIVE

This study aims to investigate the current situation of pelvic floor muscle (PFM) in the second trimester postpartum 42 days by detecting the electrophysiological indexes of PFM on pelvic floor rehabilitation after 2 months.

METHODS

In total, 198 cases of second child puerpera were selected, who were delivered in our hospital between June 1, 2020, and December 10, 2020, and underwent outpatient reexamination 42 days after delivery.

RESULTS

Except for the rest post-baseline stage values, the pelvic floor surface electromyography evaluation values significantly differed from each other at the considered time points in group A, P < .05; on day 72 in group B, no obvious improvement in the evaluation values was observed as than those on day 42 (P > .05) except for the endurance contractions stage values. However, on day 102, all values were markedly different at each considered time point (P < .05). On day 102 postpartum, the evaluation values of group A in the rest pre-baseline stage, the time before and after peak of phasic (flick) contractions stage, and the endurance contractions stage were significantly improved to those in group B with all P < .05. On day 42 after parturition, each index of the tonic contractions stage was higher after spontaneous labor than that after cesarean; the differences were all significant, P < .05, but on day 102 postpartum, all of the values exhibited no difference between the 2 modes. In only the phasic (flick) contractions stage at 42th, were the values of younger mothers obviously higher, P = .025; the other stage values for different ages of women during different time periods were not statistically significant, P > .05.

CONCLUSIONS

In the short term, the effect of biofeedback plus electrical stimulation on the PFM function in second pregnant women was better than that of the Kegel exercise, but with time, there was no significant difference between the 2 training methods on the recovery of the PFM.

Pelvic floor muscle function in the standing position in women with pelvic floor dysfunction

INTRODUCTION AND HYPOTHESIS

Clinical assessment of the pelvic floor muscles (PFMs) in a standing position may provide a more valid representation of PFM function experienced by patients in daily life than assessment in the lying position. The primary aim of this study was to examine PFM function in a standing versus a lying position in parous women with any type of urinary incontinence and/or pelvic organ prolapse.

METHODS

In this exploratory cross-sectional study, participant symptom status was determined using the Australian Pelvic Floor Questionnaire. Pelvic floor muscle function was assessed in standing and lying positions with a randomised order of testing. The primary outcome measure was vaginal squeeze pressure (VSP) using intra-vaginal manometry. Secondary outcomes included vaginal resting pressure, total PFM work and digital muscle testing. The difference between PFM function in a standing position compared with a lying position was analysed using paired t test or Wilcoxon's signed rank test.

RESULTS

Vaginal squeeze pressure assessed with manometry was higher in a standing than in a lying position (p = 0.001): standing (mean [SD]) 24.90 [12.67], lying 21.15 [14.65]. In contrast, PFM strength on digital muscle testing was lower in a standing position than in a lying position.

CONCLUSIONS

This study has demonstrated that PFM function in a standing position is different from that in a lying position in women with pelvic floor dysfunction. Whether the higher VSP observed in a standing position reflects a true difference in strength between positions, or a higher pressure reading due to incorrect PFM contraction technique in a standing position is uncertain. Further research with larger cohorts and a measurement tool that can accurately distinguish a rise in intra-vaginal pressure from PFM contraction rather than increasing intra-abdominal pressure is required to confirm this difference, and the clinical significance of any difference.

Effectiveness of pelvic floor muscle training and bladder training for women with urinary incontinence in primary care: a pragmatic controlled trial

BACKGROUND

Although the efficacy of pelvic floor muscle training (PFMT) and bladder training are well established, there is a paucity of patient centered models using these interventions to treat women with UI at primary level of health assistance in Brazil.

OBJECTIVE

To investigate the effectiveness of a physical therapy intervention to treat women with UI in primary health centers.

METHODS

Pragmatic non-randomized controlled trial in which women with UI from the community participated in a supervised physical therapy program consisting of bladder training plus 12 weeks of PFMT, performed either at home or in the health center. Outcome measures were amount and frequency of urine loss measured by the 24-h pad-test and the 24-h voiding diary; secondary outcome was the impact of UI on quality of life measured by the ICIQ-SF. Outcomes were measured at baseline, at the 6th and 12th weeks of the intervention and 1 month after discharge.

RESULTS

Interventions reduced the amount (pad-test, p=0.004; d=0.13, 95% CI=-0.23 to 0.49) and frequency of urine loss (voiding diary, p=0.003; d=0.51, 95%CI=0.14 to 0.87), and the impact of UI on quality of life (ICIQ-SF, p<0.001; d=1.26, 95%CI=0.87 to 1.66) over time, with positive effects from the 6th week up to 1 month for both intervention setting (home and health center), and no differences between them.

CONCLUSION

Interventions were effective, can be implemented in primary health centers favoring the treatment of a greater number of women who do not have access to specialized physical therapy.

TRIAL REGISTRATION

RBR-8tww4y.

Pelvic floor muscle training protocol for stress urinary incontinence in women: A systematic review

Summary Introduction: Strengthening exercises for pelvic floor muscles (SEPFM) are considered the first approach in the treatment of stress urinary incontinence (SUI). Nevertheless, there is no evidence about training parameters. Objective: To identify the protocol and/or most effective training parameters in the treatment of female SUI. Method: A literature research was conducted in the PubMed, Cochrane Library, PEDro, Web of Science and Lilacs databases, with publishing dates ranging from January 1992 to March 2014. The articles included consisted of English-speaking experimental studies in which SEPFM were compared with placebo treatment (usual or untreated). The sample had a diagnosis of SUI and their age ranged between 18 and 65 years. The assessment of methodological quality was performed based on the PEDro scale. Results: Seven high methodological quality articles were included in this review. The sample consisted of 331 women, mean age 44.4±5.51 years, average duration of urinary loss of 64±5.66 months and severity of SUI ranging from mild to severe. SEPFM programs included different training parameters concerning the PFM. Some studies have applied abdominal training and adjuvant techniques. Urine leakage cure rates varied from 28.6 to 80%, while the strength increase of PFM varied from 15.6 to 161.7%. Conclusion: The most effective training protocol consists of SEPFM by digital palpation combined with biofeedback monitoring and vaginal cones, including 12 week training parameters, and ten repetitions per series in different positions compared with SEPFM alone or a lack of treatment.

Non-face-to-face treatment of stress urinary incontinence: predictors of success after 1 year

Introduction and hypothesis

The objective was to determine predictors of long-term success in women with stress urinary incontinence (SUI) treated with a 3-month pelvic floor muscle training (PFMT) program delivered via the Internet or a brochure.

Methods

We included 169 women with SUI ≥1 time/week who completed the 1-year follow-up (n = 169, mean age 50.3, SD 10.1 years). Three outcome variables defined success after 1 year: Patient Global Impression of Improvement (PGI-I), International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF), and sufficient treatment. Using logistic regression, we analyzed data from the baseline, and from the 4-month and 1-year follow-ups, for potential predictors of success.

Results

Of the participants, 77 % (129 out of 169) were successful in ≥1 of the outcomes, 23 % (37 out of 160) were successful in all 3. Participants with successful short-term results were more likely to succeed in the corresponding outcome at 1 year than those without successful short-term results (adjusted odds ratios [ORs]: PGI 5.15, 95 % confidence interval [CI] 2.40–11.03), ICIQ-UI SF 6.85 (95 % CI 2.83–16.58), and sufficient treatment 3.78 (95 % CI 1.58–9.08). Increasing age predicted success in PGI-I and sufficient treatment (adjusted OR 1.06, 95 % CI 1.02–1.10, and 1.08, 95 % CI, 1.03–1.13 respectively). Compared with not training regularly, regular PFMT at 1 year predicted success for PGI and sufficient treatment (adjusted OR 2.32, 95 % CI 1.04–5.20, and 2.99, 95 % CI 1.23–7.27 respectively).

Conclusion

The long-term success of a non-face-to-face treatment program for SUI with a focus on PFMT can be predicted by successful short-term results, increasing age, and the performance of regular PFMT after 1 year.

Topography and landmarks for the nerve supply to the levator ani and its relevance to pelvic floor pathologies

The aim of this study was to explore the anatomical variations of the nerve to the levator ani (LA) and to relate these findings to LA dysfunction. One hundred fixed human female cadavers were dissected using transabdominal, gluteal, and perineal approaches, resulting in two hundred dissections of the sacral plexus. The pudendal nerve and the sacral nerve roots were traced from their origin at the sacral foramina to their termination. All nerves contributing to the innervation of the LA were considered to be the nerve to the LA. Based on the spinal nerve components, the nerve to the LA was classified into the following categories: 50% (n = 100) originated from S4 and S5 (type I); 19% (n = 38) originated from S5 (type II); 16% (n = 32) originated from S4 (type III); 11% (n = 22) originated from S3 and S4 (type IV); 4% (n = 8) originated from S3, S4, and S5 (type V). Two patterns of nerve termination were observed. In 42% of specimens, the nerve to the LA penetrated the coccygeus muscle and assumed an external position along the inferior surface of the LA muscle. In the remaining 58% of specimens, the nerve crossed the superior surface of the coccygeus muscle and continued along the superior surface of the iliococcygeus muscle. Damage to the nerve to LA has been associated with various pathologies. In order to minimize injuries during surgical procedures, a thorough understanding of the course and variations of the nerve to the LA is extremely important.

Strategies to enhance self-efficacy and adherence to home-based pelvic floor muscle exercises did not improve adherence in women with urinary incontinence: a randomised trial

QUESTION

Do strategies to enhance self-efficacy and exercise mastery affect adherence to home-based pelvic floor muscle exercises in women with urinary incontinence?

DESIGN

Two-arm, parallel, randomised, controlled trial with intention-to-treat analysis. Randomisation was performed using computer-generated random numbers in five blocks of 20 women.

PARTICIPANTS

Eighty-six women with stress, urgency or mixed urinary incontinence.

INTERVENTION

All participants underwent three individual physiotherapy clinic visits at Day 0, 15 and 30, and 2 further months of home-based pelvic floor muscle exercises. The experimental group also received self-efficacy enhancing interventions, including a structured discussion on accomplishments and goals, a 9-minute video with testimonials, and a reminder.

OUTCOME MEASURES

The primary outcome - adherence to at least 20 fast and 20 slow contractions every day - was evaluated with a structured questionnaire at 15, 30 and 90 days after enrolment and completion of a daily diary. A validated questionnaire was used to assess urinary incontinence. Self-efficacy and pelvic floor muscle function were also measured.

RESULTS

Seven women withdrew from each group before the Day-30 assessment. There was no difference in adherence to pelvic floor muscle exercises at 90 days between the groups (MD 0.5 points, 95% CI -1.1 to 2.1) on the questionnaire, which was scored from 2 to 21. At Day 90, 56% of the experimental group and 44% of the control group were performing the exercises every day. Adherence scores of both groups decreased during the 2-month follow-up period without any supervised physiotherapy session (p<0.05). The groups did not differ on the remaining secondary outcomes.

CONCLUSION

Discussion of accomplishments and goals, a testimonial video and a reminder did not increase exercise adherence more than exercise mastery.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials UTN:U1111-1128-8684.

The effect of pelvic floor muscle training in urinary incontinent elderly women: a sistematic review

Introduction The International Continence Society (ICS) determines that the pelvic floor muscles training (PFMT) is the first-choice treatment of urinary symptoms in women. Objective The aim of this study was to systematize randomized controlled clinical trials that address the effects of PFMT in the treatment of urinary symptoms in older women using objective outcome measures. Method Systematic review search was performed eletronic the following databases: Medline, Pubmed, Lilacs, PEDro and manual research conducted in the references of the studies. Were considered eligible women aged over 60 years who performed PFMT in isolation, without the involvement of another technique. The PFMT performed in clinic or at home, with or without the supervision of a therapist and with or without the use of biofeedback as an adjunct. Considered as outcome measures urodynamic studies, voiding diary that assesses daytime urinary frequency, nocturnal urinary frequency, urinary incontinence and exchange absorbent, and, finally, the absorbent test that quantifies loss urinary grams. The assessment of methodological quality of the studies was conducted by PEDro scale. Results Three studies were reviewed in full. Only one trial was rated high methodological quality. There was significant improvement in urinary symptoms after treatment proposed in the three selected studies. Conclusion Considering the studies available so far are weak the evidence for the use of PFMT in the treatment of urinary symptoms in elderly women.

Effect of home-based Kegel exercises on quality of life in women with stress and mixed urinary incontinence

The aim of this study was to assess the effects of home-based Kegel exercises in women with stress and mixed urinary incontinence. A total of 90 women with urodynamically proven urinary stress (SUI) and mixed (MUI) incontinence awaiting anti-incontinence surgery were recruited in the urogynaecology clinic of Ankara Zekai Tahir Burak Women's Health Research and Education Hospital. Of these, 18 women were excluded due to low compliance and the remaining 72 were divided into two groups according to urodynamic diagnosis (SUI group, n = 38; MUI group, n = 34). Age, BMI, menopausal status and medical history of the women were recorded. The women took Kegel exercise, consisting of 10 sets of contractions/day; each set included 10 repetitions, for at least 8 weeks. To evaluate the pelvic floor muscle strength, the modified Oxford grading system was used before and after Kegel exercising. The Incontinence Impact Questionnaire (IIQ-7); Urogenital Distress Inventory (UDI-6) and the Patient Global Impression of Improvement (PGI-I) questions were compared before and after 8 weeks of Kegel exercising. The age, BMI, gravidity, menopausal status, macrosomic fetus history, hypertension and asthma were similar between the groups. There were statistically significant lower scores in both IIQ-7 and UDI-6 before and after Kegel exercises within each group (p < 0.001). The mean change of the IIQ-7 and UDI-6 score was statistically significantly higher in the SUI group than in the MUI group (p = 0.023 and p = 0.003, respectively). Results of the Oxford scale were also statistically significantly higher after Kegel exercises within each group (p = < 0.001). In total, 68.4% of the women in the SUI group and 41.2% of the women in the MUI group reported improvements which were statistically significant (p = 0.02). We conclude that home-based Kegel exercises, with no supervision, have been found effective in women with SUI and MUI. The improvement was more prominent in women with SUI.

Effect of vaginal spheres and pelvic floor muscle training in women with urinary incontinence: a randomized, controlled trial

AIMS

To compare the efficacy and safety of Kegel exercises performed with or without, vaginal spheres as treatment for women with urinary incontinence.

METHODS

Multicentre parallel-group, open, randomized controlled trial. Women were allocated to either a pelvic floor muscle-training program consisting of Kegel exercises performed twice daily, 5 days/week at home, over 6 months with vaginal spheres, or to the same program without spheres. The primary endpoint was women's report of urinary incontinence at 6 months using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI-SF). Secondary outcome measures were the 1 hr pad-test, King's Health Questionnaire (KHQ) and a five-point Likert scale for subjective evaluation. Adherence was measured with the Morisky-Green test.

RESULTS

Thirty-seven women were randomized to the spheres group and 33 to the control group. The primary endpoint was evaluated in 65 women (35 in the spheres group vs. 30 controls). ICIQ-UI-SF results improved significantly at 1-month follow-up in the spheres group (P < 0.01) and at 6 months in the controls. The 1 hr pad-test improved in the spheres group but not in the control group. No significant differences were found in the KHQ results or in the subjective evaluation of efficacy and safety. Adherence was higher in the spheres group but differences were not significant. Mild transient side effects were reported in four patients in the spheres group and one in the control group.

CONCLUSIONS

Both treatments improved urinary incontinence but women who performed the exercises with vaginal spheres showed an earlier improvement. Vaginal spheres were well tolerated and safe.

Weighted vaginal cones for urinary incontinence

BACKGROUND

For a long time pelvic floor muscle training (PFMT) has been the most common form of conservative (non-surgical) treatment for stress urinary incontinence (SUI). Weighted vaginal cones can be used to help women to train their pelvic floor muscles. Cones are inserted into the vagina and the pelvic floor is contracted to prevent them from slipping out.

OBJECTIVES

The objective of this review is to determine the effectiveness of vaginal cones in the management of female urinary stress incontinence (SUI).We wished to test the following comparisons in the management of stress incontinence: 1. vaginal cones versus no treatment; 2. vaginal cones versus other conservative therapies, such as PFMT and electrostimulation; 3. combining vaginal cones and another conservative therapy versus another conservative therapy alone or cones alone; 4. vaginal cones versus non-conservative methods, for example surgery or injectables.Secondary issues which were considered included whether:1. it takes less time to teach women to use cones than it does to teach the pelvic floor exercise; 2. self-taught use is effective;3. the change in weight of the heaviest cone that can be retained is related to the level of improvement;4. subgroups of women for whom cone use may be particularly effective can be identified.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 19 September 2012), MEDLINE (January 1966 to March 2013), EMBASE (January 1988 to March 2013) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing weighted vaginal cones with alternative treatments or no treatment.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for inclusion and trial quality. Data were extracted by one reviewer and cross-checked by the other. Study authors were contacted for extra information.

MAIN RESULTS

We included 23 trials involving 1806 women, of whom 717 received cones. All of the trials were small, and in many the quality was hard to judge. Outcome measures differed between trials, making the results difficult to combine. Some trials reported high drop-out rates with both cone and comparison treatments. Seven trials were published only as abstracts.Cones were better than no active treatment (rate ratio (RR) for failure to cure incontinence 0.84, 95% confidence interval (CI) 0.76 to 0.94). There was little evidence of difference for a subjective cure between cones and PFMT (RR 1.01, 95% CI 0.91 to 1.13), or between cones and electrostimulation (RR 1.26, 95% CI 0.85 to 1.87), but the confidence intervals were wide. There was not enough evidence to show that cones plus PFMT was different to either cones alone or PFMT alone. Only seven trials used a quality of life measures and no study looked at economic outcomes.Seven of the trials recruited women with symptoms of incontinence, while the others required women with urodynamic stress incontinence, apart from one where the inclusion criteria were uncertain.

AUTHORS' CONCLUSIONS

This review provides some evidence that weighted vaginal cones are better than no active treatment in women with SUI and may be of similar effectiveness to PFMT and electrostimulation. This conclusion must remain tentative until larger, high-quality trials, that use comparable and relevant outcomes, are completed. Cones could be offered as one treatment option, if women find them acceptable.

Randomised controlled trial comparing early home biofeedback physiotherapy with pelvic floor exercises for the treatment of third-degree tears (EBAPT Trial)

OBJECTIVE

To compare early home biofeedback physiotherapy with pelvic floor exercises (PFEs) for the initial management of women sustaining a primary third-degree tear.

DESIGN

Single centre, randomised trial.

SETTING

National Maternity Hospital, Dublin, Ireland.

POPULATION

A total of 120 women sustaining a primary third-degree tear.

METHODS

Women were randomised in a one to three ratio: 30 to early postpartum home biofeedback physiotherapy and 90 to PFEs.

MAIN OUTCOME MEASURES

Differences in anorectal manometry results, Cleveland Clinic continence scores and Rockwood faecal incontinence quality of life scale scores after 3 months of postpartum treatment.

RESULTS

The mean anal resting pressure was 39 ± 13 mmHg in the early biofeedback physiotherapy group and 43 ± 17 mmHg in the PFE group. The mean anal squeeze pressure was 64 ± 17 mmHg in the biofeedback group and 62 ± 23 mmHg in the PFE group. There was no significant difference in anal resting and squeeze pressure values between the groups (P = 0.123 and P = 0.68, respectively). There were no differences in symptom score and quality of life measurements between the groups.

CONCLUSIONS

This study demonstrates no added value in using early home biofeedback physiotherapy in the management of women sustaining third-degree tears. Poor compliance may have contributed because women found it difficult to designate time to using biofeedback.

Nonsurgical outpatient therapies for the management of female stress urinary incontinence: long-term effectiveness and durability

Objective. To evaluate long-term effectiveness and safety of conservative and minimally invasive outpatient treatments for female stress urinary incontinence (SUI) through a review of the literature. Methods. PubMed was searched for reports on prospective clinical trials with at least 12-month follow-up of minimally invasive treatments, pelvic floor rehabilitation, or pharmacotherapy in women with SUI. Each report was examined for long-term rates of effectiveness and safety. Results. Thirty-two clinical trial reports were included. Prospective long-term studies of pelvic floor rehabilitation were limited but indicated significant improvements with treatment adherence for at least 12 months. Poor initial tolerability with duloxetine resulted in substantial discontinuation. Most patients receiving transurethral radiofrequency collagen denaturation or urethral bulking agents reported significant long-term improvements, generally good tolerability, and safety. Conclusions. Conservative therapy is an appropriate initial approach for female SUI, but if therapy fails, radiofrequency collagen denaturation or bulking agents may be an attractive intermediate management step or alternative to surgery.

Improvement of quality of life, anxiety and depression after surgery in patients with stress urinary incontinence: results of a longitudinal short-term follow-up

Objective

The objective of this study was to compare the effect of incontinence surgery and pelvic floor training on quality of life (QOL), anxiety and depression in patients with stress urinary incontinence (SUI).

Methods

In a prospective longitudinal study, females with proven SUI were asked to complete a set of standardized questionnaires (sociodemographic data sheet, FACT-G, I-QOL, HADS) before and eight weeks after treatment. The comparison groups consisted of a surgical treatment group and a conservative group that underwent supervised pelvic floor training for eight weeks.

Results

From the 67 female patients included in the study a number of 53 patients completed both assessment time points (mean age 57.4, mean years of SUI 7.6). The surgical treatment group consisted of 32 patients of which 21 patients received a modified Burch colposuspension and 11 patients a tension-free mid-urethral tape suspension. The 21 patients in the conservative group attended eight once-weekly supervised pelvic floor training sessions.

After treatment the surgical intervention group showed a significantly higher improvement of QOL (FACT-G and I-QOL) and anxiety (HADS) than the pelvic floor training group.

Conclusion

For female patients with SUI surgery yielded a better outcome than pelvic floor training with regard to quality of life and anxiety.

Innervation of the levator ani muscles: description of the nerve branches to the pubococcygeus, iliococcygeus, and puborectalis muscles

We described the innervation of the levator ani muscles (LAM) in human female cadavers. Detailed pelvic dissections of the pubococcygeus (PCM), iliococcygeus (ICM), and puborectalis muscles (PRM) were performed on 17 formaldehyde-fixed cadavers. The pudendal nerve and the sacral nerves entering the pelvis were traced thoroughly, and nerve branches innervating the LAM were documented. Histological analysis of nerve branches entering the LAM confirmed myelinated nerve tissue. LAM were innervated by the pudendal nerve branches, perineal nerve, and inferior rectal nerve (IRN) in 15 (88.2%) and 6 (35.3%) cadavers, respectively, and by the direct sacral nerves S3 and/or S4 in 12 cadavers (70.6%). A variant IRN, independent of the pudendal nerve, was found to innervate the LAM in seven (41.2%) cadavers. The PCM and the PRM were both primarily innervated by the pudendal nerve branches in 13 cadavers (76.5%) each. The ICM was primarily innervated by the direct sacral nerves S3 and/or S4 in 11 cadavers (64.7%).

Long-term results of the pelvic floor muscle training for female urinary incontinence: An 8-year transition tree and predictive parameters

AIMS

The pelvic floor muscle (PFM) training is effective in alleviating the symptoms of urinary incontinence, but there are very few reports available on its long-term effectiveness. Therefore, 8-year follow-up data have been prospectively analyzed.

MATERIALS AND METHODS

Originally 123 women with stress or mixed urinary incontinence participated in an 8-week intensive PFM training program. The training comprised repeated muscle contractions of the pelvic floor and the timely locking of the perineum. An average of 8 years (6-10) had elapsed between the time of present assessment and the completion of the original training. Seventy-nine women were subjected to the present analysis. Self-reported responses of "completely cured" and "more than 50% improved" were regarded as treatment success (TS). An 8-year transition tree and predictive parameters were analyzed.

RESULTS

The success rate of the training was 39% at the 8-year follow-up. The transition tree demonstrated that the continence/incontinence status has been varying in 42% of the women, while it was stable in 58% throughout the follow-up period. The 6-year incidence and remission rates of incontinence were 34% and 18%, respectively. The higher pressure difference in the vaginal contraction strength between the baseline and strength at the end of the training is a predictive parameter of the long-term TS.

CONCLUSIONS

The results suggest that the 8-year TS rate was 39% and that the altered patterns of the continence status and incidence and remission rates of incontinence were similar to those observed in the general population.

Short-term efficacy of group pelvic floor training under intensive supervision versus unsupervised home training for female stress urinary incontinence: A randomized pilot study

AIMS

Current management guidelines propose pelvic floor muscle training (PFMT) as first line treatment for female stress urinary incontinence (SUI). The aim of this study is to compare the efficacy of group PFMT under intensive supervision to that of individual home therapy in women with SUI.

MATERIAL AND METHODS

Thirty women with clinical and urodynamic diagnosis of SUI were randomized in two equal-number groups. Following a common demonstration course, Group A women received a detailed schedule for home training, while Group B in addition attended a weekly hospital group visit. At 12 weeks both groups were assessed for changes in subjective and objective outcomes.

RESULTS

Twenty-two women, (10 Group A, 12 Group B) with a mean age of 47.3 years completed the study. Although significant (P<0.05) improvements were noted in both groups in quality of life scores, number of incontinence episodes/week, 24-hr frequency, and endurance, repetitions and fast contractions upon vaginal assessment of the PFMs, comparative analysis at the end of the study demonstrated significantly better results for women in Group B, who also improved in daily pad usage, underwear wetting, modified Oxford grading of the PFMs and hold with cough. Consequently, significantly more women in Group B reported improvement in their continence (100% vs. 20% in Group A).

CONCLUSIONS

Group PFMT under intensive supervision produced significantly better improvements in primary and secondary outcomes in the short-term compared to individual, unsupervised home application of PFMT.

Pelvic floor muscle training and adjunctive therapies for the treatment of stress urinary incontinence in women: a systematic review

BACKGROUND

Stress urinary incontinence (SUI) is a prevalent and costly condition which may be treated surgically or by physical therapy. The aim of this review was to systematically assess the literature and present the best available evidence for the efficacy and effectiveness of pelvic floor muscle training (PFMT) performed alone and together with adjunctive therapies (eg biofeedback, electrical stimulation, vaginal cones) for the treatment of female SUI.

METHODS

All major electronic sources of relevant information were systematically searched to identify peer-reviewed English language abstracts or papers published between 1995 and 2005. Randomised controlled trials (RCTs) and other study designs eg non-randomised trials, cohort studies, case series, were considered for this review in order to source all the available evidence relevant to clinical practice. Studies of adult women with a urodynamic or clinical diagnosis of SUI were eligible for inclusion. Excluded were studies of women who were pregnant, immediately post-partum or with a diagnosis of mixed or urge incontinence. Studies with a PFMT protocol alone and in combination with adjunctive physical therapies were considered. Two independent reviewers assessed the eligibility of each study, its level of evidence and the methodological quality. Due to the heterogeneity of study designs, the results are presented in narrative format.

RESULTS

Twenty four studies, including 17 RCTs and seven non-RCTs, met the inclusion criteria. The methodological quality of the studies varied but lower quality scores did not necessarily indicate studies from lower levels of evidence. This review found consistent evidence from a number of high quality RCTs that PFMT alone and in combination with adjunctive therapies is effective treatment for women with SUI with rates of 'cure' and 'cure/improvement' up to 73% and 97% respectively. The contribution of adjunctive therapies is unclear and there is limited evidence about treatment outcomes in primary care settings.

CONCLUSION

There is strong evidence for the efficacy of physical therapy for the treatment for SUI in women but further high quality studies are needed to evaluate the optimal treatment programs and training protocols in subgroups of women and their effectiveness in clinical practice.

Medium-term efficacy of pelvic floor muscle training for female urinary incontinence in daily practice

The purpose of this paper is to assess the efficacy of physiotherapy and quality of life in women treated for urinary incontinence by specialized physiotherapists in daily community-based practices. Three hundred and fifty-five women were treated in five physiotherapy practices between January 2000 and December 2004. After a minimum follow-up of 12 months, these women received a questionnaire at home. With the questionnaire, we collected demographic data, data on the efficacy of treatment, satisfaction with the result, and the Urogenital Distress Inventory, and Incontinence Impact Questionnaire. Additional information was derived from the medical files. One hundred and eighty-seven women responded. Fifty percent of women were satisfied with the result of physiotherapy. After a mean follow-up of 32 months, 123 out of 130 women (94.6%), who only had physiotherapy, recorded to experience incontinence episodes daily to several times a week. Women who underwent additional incontinence surgery after insufficient physiotherapy recorded significantly less urinary incontinence symptoms and a better quality of life. Pelvic floor muscle training for urinary incontinence is effective in half of the women. If not successful, women seem to benefit significantly from incontinence surgery.

Effect of test position on pelvic floor muscle assessment

The aims of this study were to analyse the effect of different body positions on pelvic floor muscle (PFM) assessment using digital muscle testing, manometry and transabdominal ultrasound. In addition, subject acceptance of each testing position was recorded. Subjects were 20 women's health physiotherapists. The testing protocol included the best of three maximum voluntary contractions tested in each of four positions (crook lying, supine, sitting and standing). Significant differences in muscle strength and subject acceptance between positions were found with each tool, most often between lying and upright positions. Digital muscle testing and vaginal squeeze-pressure scores were highest in the lying position, and vaginal resting pressure and transabdominal ultrasound scores were highest in the standing position. Subjects preferred the lying positions for internal examinations. The clinical significance of these differences and the reasons for these variations require further investigation.

Conservative strategies for the treatment of stress urinary incontinence

The conservative treatment of stress urinary incontinence for women has many facets. Each intervention may have value and patients may benefit from simple, reversible recommendations and techniques versus invasive surgery. Starting with a thorough history, lifestyle modifications may lead to decreased incontinence. Depending on the patient's goals and clinical situation, they may benefit from a pessary or anti-incontinence device. Finally, the use of pelvic floor muscle exercises has been shown to benefit a significant number of patients. Regardless of the degree of stress urinary incontinence, conservative strategies should be considered a fundamental part of the treatment plan.

Weighted vaginal cones for urinary incontinence

BACKGROUND

Pelvic floor muscle training has long been the most common form of conservative treatment for stress urinary incontinence. Weighted vaginal cones can be used to help women to train their pelvic floor muscles. Cones are inserted into the vagina and the pelvic floor is contracted to prevent them slipping out.

OBJECTIVES

To evaluate the effects of weighted vaginal cones in the treatment of women with urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised register (to February 2001), MEDLINE (January 1966 to August 2001), EMBASE (January 1988 to August 2001) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing weighted vaginal cones with alternative treatments or no treatment in women with urinary incontinence.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed studies for inclusion and trial quality. Data was extracted by one reviewer and cross checked by the others. Study authors were contacted for extra information.

MAIN RESULTS

Fifteen studies, involving 1126 women of whom 466 received cones, were included. All of the trials were small and in many the quality was hard to judge. Outcome measures differed between studies, making the results difficult to combine. Some studies reported high drop out rates with both cone and comparison treatments. Four of the studies recruited women with symptoms of stress incontinence without urodynamic confirmation. Six trials were only published as abstracts. Cones were better than no active treatment (RR for failure to cure incontinence 0.74, 95% CI 0.59 to 0.93). There was little evidence of difference between cones and PFMT (RR 1.09, 95% CI 0.86 to 1.38) or electrostimulation (RR 1, 95% CI 0.89 to 1.13), but the confidence intervals were wide. There was not enough evidence to show that that cones plus PFMT was different to either cones alone or PFMT alone. Only two studies used a Quality of Life measure and no study looked at economic outcomes.

REVIEWER'S CONCLUSIONS

This review provides some evidence that weighted vaginal cones are better than no active treatment in women with stress urinary incontinence and may be of similar effectiveness to PFMT and electrostimulation. This conclusion must remain tentative until further larger high quality studies are carried out using comparable and relevant outcome measures. Some women treated with cones, pelvic floor muscle training or electrostimulation drop out of treatment early. Therefore, cones should be offered as one option so that if women find them unacceptable they know there are other treatments available.