Promoting urinary continence in postpartum women: 12-month follow-up data from a randomised controlled trial

Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women

BACKGROUND

About one-third of women have urinary incontinence (UI) and up to one-tenth have faecal incontinence (FI) after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both preventing and treating incontinence. This is an update of a Cochrane Review previously published in 2017.

OBJECTIVES

To assess the effects of PFMT for preventing or treating urinary and faecal incontinence in pregnant or postnatal women, and summarise the principal findings of relevant economic evaluations.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearched journals and conference proceedings (searched 7 August 2019), and the reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised or quasi-randomised trials in which one arm included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention. Populations included women who, at randomisation, were continent (PFMT for prevention) or incontinent (PFMT for treatment), and a mixed population of women who were one or the other (PFMT for prevention or treatment).

DATA COLLECTION AND ANALYSIS

We independently assessed trials for inclusion and risk of bias. We extracted data and assessed the quality of evidence using GRADE.

MAIN RESULTS

We included 46 trials involving 10,832 women from 21 countries. Overall, trials were small to moderately-sized. The PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Two participants in a study of 43 pregnant women performing PFMT for prevention of incontinence withdrew due to pelvic floor pain. No other trials reported any adverse effects of PFMT. Prevention of UI: compared with usual care, continent pregnant women performing antenatal PFMT probably have a lower risk of reporting UI in late pregnancy (62% less; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; moderate-quality evidence). Antenatal PFMT slightly decreased the risk of UI in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; high-quality evidence). There was insufficient information available for the late postnatal period (more than six to 12 months) to determine effects at this time point (RR 1.20, 95% CI 0.65 to 2.21; 1 trial, 44 women; low-quality evidence). Treatment of UI: compared with usual care, there is no evidence that antenatal PFMT in incontinent women decreases incontinence in late pregnancy (very low-quality evidence), or in the mid-(RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; low-quality evidence), or late postnatal periods (very low-quality evidence). Similarly, in postnatal women with persistent UI, there is no evidence that PFMT results in a difference in UI at more than six to 12 months postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; low-quality evidence). Mixed prevention and treatment approach to UI: antenatal PFMT in women with or without UI probably decreases UI risk in late pregnancy (22% less; RR 0.78, 95% CI 0.64 to 0.94; 11 trials, 3307 women; moderate-quality evidence), and may reduce the risk slightly in the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; low-quality evidence). There was no evidence that antenatal PFMT reduces the risk of UI at late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; moderate-quality evidence). For PFMT started after delivery, there was uncertainty about the effect on UI risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; moderate-quality evidence). Faecal incontinence: eight trials reported FI outcomes. In postnatal women with persistent FI, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (very low-quality evidence). In women with or without FI, there was no evidence that antenatal PFMT led to a difference in the prevalence of FI in late pregnancy (RR 0.64, 95% CI 0.36 to 1.14; 3 trials, 910 women; moderate-quality evidence). Similarly, for postnatal PFMT in a mixed population, there was no evidence that PFMT reduces the risk of FI in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, low-quality evidence). There was little evidence about effects on UI or FI beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it.

AUTHORS' CONCLUSIONS

This review provides evidence that early, structured PFMT in early pregnancy for continent women may prevent the onset of UI in late pregnancy and postpartum. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on UI, although the reasons for this are unclear. A population-based approach for delivering postnatal PFMT is not likely to reduce UI. Uncertainty surrounds the effects of PFMT as a treatment for UI in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women. It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches, and in certain groups of women. Hypothetically, for instance, women with a high body mass index (BMI) are at risk of UI. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups, and how much PFMT women in both groups do, to increase understanding of what works and for whom. Few data exist on FI and it is important that this is included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence. In addition to further clinical studies, economic evaluations assessing the cost-effectiveness of different management strategies for FI and UI are needed.

Smartphone-based reminder system to promote pelvic floor muscle training for the management of postnatal urinary incontinence: historical control study with propensity score-matched analysis

Background

The purpose of this study was to evaluate the efficacy of a smartphone-based reminder system in promoting pelvic floor muscle training (PFMT) to help postpartum women manage urinary incontinence (UI).

Methods

Forty-nine and 212 postpartum women in the intervention and control groups, respectively, received PFMT guidance using a leaflet and verbal instruction as the standard care at an obstetrics clinic in Japan. Women in the intervention group also received PFMT support using the smartphone-based reminder system between January and August 2014. For analysis, they were compared with historical controls between February 2011 and January 2012, who did not receive such support and were chosen by propensity score matching. The outcomes examined were PFMT adherence and UI prevalence. The former consisted of implementation rate (i.e., the percentage of women who reported performing PFMT during the intervention period), training intensity (i.e., the number of pelvic floor muscle contractions (PFMCs) per day), and training frequency (i.e., the number of days PFMT was performed per week); the latter consisted of self-reported UI prevalence at baseline and at the end of the eight-week intervention period.

Result

Propensity score matching resulted in 58 postpartum women (n = 29 per group). The intervention group exhibited better PFMT adherence than the control group, in terms of PFMT implementation rate (69 vs. 31%, p = 0.008), median training intensity (15 vs. 1 PFMC reps/day, p = 0.006), and training frequency (7 vs. 3 days/week, p < 0.001). UI prevalence was not different between the groups at baseline, but was significantly reduced in the intervention group at eight weeks (0 vs. 24%, p = 0.004).

Conclusion

Our smartphone-based reminder system appears promising in enhancing PFMT adherence and managing postpartum UI in postpartum women. By enhancing PFMT adherence and improving women’s ability to manage the condition, the reminder system could improve the health-related quality of life of postpartum women with UI.

The effectiveness of post-partum interventions to prevent urinary incontinence: a systematic review

ABSTRACT Objective: to assess the effectiveness of post-partum interventions to prevent urinary incontinence: a systematic review. Method: systematic review of randomized controlled studies conducted in the MEDLINE, Cochrane, Scopus and the Virtual Library on Health (Biblioteca Virtual em Saúde, BVS) databases. Results: six articles were included in this review. All studies used the Pelvic Floor Muscle Training as the main procedure to prevent urinary incontinence. The results pointed to a positive and effective intervention in the post-partum period. Conclusion: there is evidence that programs of exercise of the pelvic floor musculature performed both in the immediate and late post-partum result in a significant increase in muscle strength and contribute to prevent urinary incontinence.

Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women

BACKGROUND

About one-third of women have urinary incontinence and up to one-tenth have faecal incontinence after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both prevention and treatment of incontinence.This is an update of a review previously published in 2012.

OBJECTIVES

To determine the effectiveness of pelvic floor muscle training (PFMT) in the prevention or treatment of urinary and faecal incontinence in pregnant or postnatal women.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register (16 February 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trial included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed trials for inclusion and risk of bias. We extracted data and checked them for accuracy. Populations included: women who were continent (PFMT for prevention), women who were incontinent (PFMT for treatment) at randomisation and a mixed population of women who were one or the other (PFMT for prevention or treatment). We assessed quality of evidence using the GRADE approach.

MAIN RESULTS

The review included 38 trials (17 of which were new for this update) involving 9892 women from 20 countries. Overall, trials were small to moderate sized, and the PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Other than two reports of pelvic floor pain, trials reported no harmful effects of PFMT.Prevention of urinary incontinence: compared with usual care, continent pregnant women performing antenatal PFMT may have had a lower risk of reporting urinary incontinence in late pregnancy (62% less; risk ratio (RR) for incontinence 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; low-quality evidence). Similarly, antenatal PFMT decreased the risk of urinary incontinence in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; moderate-quality evidence). There was insufficient information available for the late (more than six to 12 months') postnatal period to determine effects at this time point.Treatment of urinary incontinence: it is uncertain whether antenatal PFMT in incontinent women decreases incontinence in late pregnancy compared to usual care (RR 0.70, 95% CI 0.44 to 1.13; 3 trials, 345 women; very low-quality evidence). This uncertainty extends into the mid- (RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; very low-quality evidence) and late (RR 0.50, 95% CI 0.13 to 1.93; 2 trials, 869 women; very low-quality evidence) postnatal periods. In postnatal women with persistent urinary incontinence, it was unclear whether PFMT reduced urinary incontinence at more than six to 12 months' postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; very low-quality evidence).Mixed prevention and treatment approach to urinary incontinence: antenatal PFMT in women with or without urinary incontinence (mixed population) may decrease urinary incontinence risk in late pregnancy (26% less; RR 0.74, 95% CI 0.61 to 0.90; 9 trials, 3164 women; low-quality evidence) and the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; very low-quality evidence). It is uncertain if antenatal PFMT reduces urinary incontinence risk late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; low-quality evidence). For PFMT begun after delivery, there was considerable uncertainty about the effect on urinary incontinence risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; very low-quality evidence).Faecal incontinence: six trials reported faecal incontinence outcomes. In postnatal women with persistent faecal incontinence, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (RR 0.68, 95% CI 0.24 to 1.94; 2 trials; 620 women; very low-quality evidence). In women with or without faecal incontinence (mixed population), antenatal PFMT led to little or no difference in the prevalence of faecal incontinence in late pregnancy (RR 0.61, 95% CI 0.30 to 1.25; 2 trials, 867 women; moderate-quality evidence). For postnatal PFMT in a mixed population, there was considerable uncertainty about the effect on faecal incontinence in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, very low-quality evidence).There was little evidence about effects on urinary or faecal incontinence beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it. We found no data on health economics outcomes.

AUTHORS' CONCLUSIONS

Targeting continent antenatal women early in pregnancy and offering a structured PFMT programme may prevent the onset of urinary incontinence in late pregnancy and postpartum. However, the cost-effectiveness of this is unknown. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on urinary incontinence, although the reasons for this are unclear. It is uncertain whether a population-based approach for delivering postnatal PFMT is effective in reducing urinary incontinence. Uncertainty surrounds the effects of PFMT as a treatment for urinary incontinence in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women.It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches and in certain groups of women. Hypothetically, for instance, women with a high body mass index are at risk factor for urinary incontinence. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups and how much PFMT women in both groups do, to increase understanding of what works and for whom.Few data exist on faecal incontinence or costs and it is important that both are included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence.

What Are the Characteristics of Home Exercise Programs That Older Adults Prefer?: A Cross-Sectional Study

OBJECTIVE

The aim of this study was to examine the preferences of older adults toward the structure and delivery of home exercise programs for the prevention of falls as well as the perceived benefits of and barriers to program adherence.

METHODS

A two-wave cross-sectional telephone survey of community-dwelling older adults was conducted in Victoria, Australia. Respondents were categorized as current, previous, or nonparticipants of a home exercise program in the last 6 yrs. Thematic analysis of open-response questions examining the preferences of current and previous participants toward participation in, and delivery of, home exercise programs for falls preventions was performed.

RESULTS

A total of 245 respondents completed the follow-up survey. The respondents were classified as current (n = 54), previous (n = 22), or nonparticipants (n = 169) of a home exercise program in the last 6 yrs. Program adherence was influenced by the perceived effect of programs on physical and mental health, participant autonomy, and how well the program structure complemented individual exercise and lifestyle preferences.

CONCLUSIONS

Adherence to home exercise programs for falls prevention is influenced by personal preferences toward program structure and delivery as well as perceived benefits of and barriers to program participation. To optimize participant adherence, service providers need to consider personal preferences and some flexibility in the program being delivered.

[Effect of Kegel exercise to prevent urinary and fecal incontinence in antenatal and postnatal women: systematic review]

PURPOSE

The aim of this study was to review the literature to determine whether intensive pelvic floor muscle training during pregnancy and after delivery could prevent urinary and fecal incontinence.

METHODS

Randomized controlled trials (RCT) of low-risk obstetric populations who had done Kegel exercise during pregnancy and after delivery met the inclusion criteria. Articles published between 1966 and 2012 from periodicals indexed in Ovid Medline, Embase, Scopus, KoreaMed, NDSL and other databases were selected, using the following keywords: 'Kegel, pelvic floor exercise'. The Cochrane's Risk of Bias was applied to assess the internal validity of the RCT. Fourteen selected studies were analyzed by meta-analysis using RevMan 5.1.

RESULTS

Fourteen RCTs with high methodological quality, involving 6,454 women were included. They indicated that Kegel exercise significantly reduced the development of urinary and fecal incontinence from pregnancy to postpartum. Also, there was low clinical heterogeneity.

CONCLUSION

There is some evidence that for antenatal and postnatal women, Kegel exercise can prevent urinary and fecal incontinence. Therefore, a priority task is to develop standardized Kegel exercise programs for Korean pregnant and postpartum women and make efficient use of these programs.

Female urinary incontinence during pregnancy and after delivery: Clinical impact and contributing factors

Urinary incontinence (UI) is a common condition affecting adult women of all ages and it could have a negative influence on quality of life. The etiology of UI is multifactorial, but some of the most important risk factors are obesity and ageing, as well as adverse obstetric events. Pregnancy and delivery per se have been implicated in the etiology of UI. Although several studies have demonstrated a direct association between UI and vaginal delivery in short, medium and long-term, the role of childbirth on the risk of UI remains controversial. The mechanical strain during delivery may induce injuries to the muscle, connective and neural structures. Vaginal birth can be associated with relaxation or disruption of fascial and ligamentous supports of pelvic organs. Parity, instrumental delivery, prolonged labor and increased birth weights have always been considered risk factors for pelvic floor injury. Also genetic factors have been recently raised up but still there are not appropriate guidelines or measures to reduce significantly the incidence of UI. The role of pelvic floor muscle training (PFMT) in the prevention and treatment of UI is still unclear. However, PFMT seems to be useful when supervised training is conducted and it could be incorporated as a routine part of women’s exercise programmes during pregnancy and after childbirth.

Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review

BACKGROUND

Urinary incontinence (UI) is a common condition in women causing reduced quality of life and withdrawal from fitness and exercise activities. Pregnancy and childbirth are established risk factors. Current guidelines for exercise during pregnancy have no or limited focus on the evidence for the effect of pelvic floor muscle training (PFMT) in the prevention and treatment of UI.

AIMS

Systematic review to address the effect of PFMT during pregnancy and after delivery in the prevention and treatment of UI.

DATA SOURCES

PubMed, CENTRAL, Cochrane Library, EMBASE and PEDro databases and hand search of available reference lists and conference abstracts (June 2012).

METHODS

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) and quasiexperimental trials published in the English language.

PARTICIPANTS

Primiparous or multiparous pregnant or postpartum women.

INTERVENTIONS

PFMT with or without biofeedback, vaginal cones or electrical stimulation.

STUDY APPRAISAL AND SYNTHESIS METHODS

Both authors independently reviewed, grouped and qualitatively synthesised the trials.

RESULTS

22 randomised or quasiexperimental trials were found. There is a very large heterogeneity in the populations studied, inclusion and exclusion criteria, outcome measures and content of PFMT interventions. Based on the studies with relevant sample size, high adherence to a strength-training protocol and close follow-up, we found that PFMT during pregnancy and after delivery can prevent and treat UI. A supervised training protocol following strength-training principles, emphasising close to maximum contractions and lasting at least 8 weeks is recommended.

CONCLUSIONS

PFMT is effective when supervised training is conducted. Further high-quality RCTs are needed especially after delivery. Given the prevalence of female UI and its impact on exercise participation, PFMT should be incorporated as a routine part of women's exercise programmes in general.

Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women

BACKGROUND

About a third of women have urinary incontinence and up to a 10th have faecal incontinence after childbirth. Pelvic floor muscle training is commonly recommended during pregnancy and after birth both for prevention and the treatment of incontinence.

OBJECTIVES

To determine the effect of pelvic floor muscle training compared to usual antenatal and postnatal care on incontinence.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which includes searches of CENTRAL, MEDLINE, MEDLINE in Process and handsearching (searched 7 February 2012) and the references of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trial needed to include pelvic floor muscle training (PFMT). Another arm was either no PFMT or usual antenatal or postnatal care.

DATA COLLECTION AND ANALYSIS

Trials were independently assessed for eligibility and methodological quality. Data were extracted then cross checked. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions. Three different populations of women were considered separately, women dry at randomisation (prevention); women wet at randomisation (treatment); and a mixed population of women who might be one or the other (prevention or treatment). Trials were further divided into those which started during pregnancy (antenatal); and those started after delivery (postnatal).

MAIN RESULTS

Twenty-two trials involving 8485 women (4231 PFMT, 4254 controls) met the inclusion criteria and contributed to the analysis.Pregnant women without prior urinary incontinence (prevention) who were randomised to intensive antenatal PFMT were less likely than women randomised to no PFMT or usual antenatal care to report urinary incontinence up to six months after delivery (about 30% less; risk ratio (RR) 0.71, 95% CI 0.54 to 0.95, combined result of 5 trials).Postnatal women with persistent urinary incontinence (treatment) three months after delivery and who received PFMT were less likely than women who did not receive treatment or received usual postnatal care to report urinary incontinence 12 months after delivery (about 40% less; RR 0.60, 95% CI 0.35 to 1.03, combined result of 3 trials). It seemed that the more intensive the programme the greater the treatment effect.The results of seven studies showed a statistically significant result favouring PFMT in a mixed population (women with and without incontinence symptoms) in late pregnancy (RR 0.74, 95% CI 0.58 to 0.94, random-effects model). Based on the trial data to date, the extent to which mixed prevention and treatment approaches to PFMT in the postnatal period are effective is less clear (that is, offering advice on PFMT to all pregnant or postpartum women whether they have incontinence symptoms or not). It is possible that mixed prevention and treatment approaches might be effective when the intervention is intensive enough.There was little evidence about long-term effects for either urinary or faecal incontinence.

AUTHORS' CONCLUSIONS

There is some evidence that for women having their first baby, PFMT can prevent urinary incontinence up to six months after delivery. There is support for the widespread recommendation that PFMT is an appropriate treatment for women with persistent postpartum urinary incontinence. It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches and in certain groups of women (for example primiparous women; women who had bladder neck hypermobility in early pregnancy, a large baby, or a forceps delivery). These and other uncertainties, particularly long-term effectiveness, require further testing.

[Urinary incontinence 6 months after childbirth]

BACKGROUND AND OBJECTIVE

Urinary incontinence initiated before and right after delivery and persisting 3 months after delivery tends to become chronic. We intended to estimate the persistence of urinary incontinence 6 months postpartum and to analyse the different factors associated with it.

PATIENTS AND METHODS

Follow-up study 6 months after delivery of women presenting urinary incontinence symptoms in gestation or in the first 2 months of postpartum. The dependent variable was the persistence and the independent variables were grouped in obstetric and non-obstetric. Odds ratio (OR) were calculated with their confidence interval at 95% (IC 95%) in the bivariate analysis. The variables that showed an important risk of persistence of incontinence were used to perform a multivariate model of logistic regression.

RESULTS

The persistence of incontinence 6 months after delivery was 21.4% (CI 95% 16-26.7). The risk of persistence increased with the Kristeller maneuver (OR 7.89, CI 95% 3.04-20.49), not weight recovery (OR 3.64, CI 95% 1.10-12.02), not practising pelvic floor muscle exercises in postpartum (OR 9.36, CI 95% 2.71-32.33), appearance of incontinence after delivery (OR 6.66, CI 95% 2.37-18.68) and the weight of the newborn>3.5 kg (OR 6.76, CI 95% 2.54-18.03), all of them explaining 58% of the variability of persistence.

CONCLUSION

21.4% of women with urinary incontinence caused by pregnancy/delivery will continue to have it 6 months postpartum. An important part of this persistence is associated with some factors easy to modify.

Adherence to behavioral interventions for urge incontinence when combined with drug therapy: adherence rates, barriers, and predictors

BACKGROUND

Behavioral intervention outcomes for urinary incontinence (UI) depend on active patient participation.

OBJECTIVE

The purpose of this study was to describe adherence to behavioral interventions (pelvic-floor muscle [PFM] exercises, UI prevention strategies, and delayed voiding), patient-perceived exercise barriers, and predictors of exercise adherence in women with urge-predominant UI.

DESIGN

This was a prospectively planned secondary data analysis from a 2-stage, multicenter, randomized clinical trial.

PATIENTS AND INTERVENTION

Three hundred seven women with urge-predominant UI were randomly assigned to receive either 10 weeks of drug therapy only or 10 weeks of drug therapy combined with a behavioral intervention for UI. One hundred fifty-four participants who received the combined intervention were included in this analysis.

MEASUREMENTS

Pelvic-floor muscle exercise adherence and exercise barriers were assessed during the intervention phase and 1 year afterward. Adherence to UI prevention strategies and delayed voiding were assessed during the intervention only.

RESULTS

During intervention, 81% of women exercised at least 5 to 6 days per week, and 87% performed at least 30 PFM contractions per day. Ninety-two percent of the women used the urge suppression strategy successfully. At the 12-month follow-up, only 32% of the women exercised at least 5 to 6 days per week, and 56% performed 15 or more PFM contractions on the days they exercised. The most persistent PFM exercise barriers were difficulty remembering to exercise and finding time to exercise. Similarly, difficulty finding time to exercise persisted as a predictor of PFM exercise adherence over time.

LIMITATIONS

Co-administration of medication for UI may have influenced adherence.

CONCLUSIONS

Most women adhered to exercise during supervised intervention; however, adherence declined over the long term. Interventions to help women remember to exercise and to integrate PFM exercises and UI prevention strategies into daily life may be useful to promote long-term adherence.

Pelvic floor muscle function in women presenting with pelvic floor disorders

INTRODUCTION AND HYPOTHESIS

This observational study was undertaken to determine knowledge, prior instruction, frequency of performance, and ability to perform pelvic floor muscle exercises in a group of women presenting for evaluation of pelvic floor disorders.

METHODS

Three hundred twenty-five women presenting for evaluation of pelvic floor disorders were questioned concerning knowledge and performance of pelvic floor muscle exercises (PMEs) and then examined to determine pelvic floor muscle contraction strength.

RESULTS

The majority of women (73%) had heard of PMEs, but only 42% had been instructed to perform them and 62.5% stated they received verbal instruction only. Only 23.4% of patients could perform pelvic muscle contractions with Oxford Scale 3, 4, or 5 strengths. Increased age, parity, and stage of prolapse were associated with lower Oxford scores.

CONCLUSIONS

Although most women with pelvic floor disorders are familiar with PMEs, less than one fourth could perform adequate contractions at the time of initial evaluation.

Atendimento de puérperas pela fisioterapia em uma maternidade pública humanizada

O objetivo foi descrever o perfil de puérperas atendidas pela fisioterapia em uma maternidade pública de Betim, MG, e o atendimento a elas prestado, visando contribuir para a assistência fisioterapêutica obstétrica. Foi feito um levantamento de 215 fichas de avaliação fisioterapêutica de puérperas, contendo dados demográficos e clínicos, além dos registros específicos da fisioterapia. A maioria da puérperas era jovem, do lar, casadas, multíparas e de Betim. Quanto à avaliação das mamas, a maioria apresentou mamas simétricas, secretantes, mamilos protrusos, tendo sido observados poucos traumas mamilares ou dificuldade na amamentação; 62,3% das puérperas apresentavam diafragma normocinético, 85,1% som timpânico à percussão abdominal, involução uterina dentro da normalidade, 87,9% contração do assoalho pélvico presente, 30,3% edema em membros inferiores; a diástase dos músculos reto-abdominais foi de 2±1 e 1±1 dedos supra e infra-umbilical, respectivamente. As condutas adotadas foram: exercícios respiratórios diafragmáticos, abdominais isométricos, contração do assoalho pélvico; exercícios circulatórios de membros inferiores, manobras de eliminação de flatos, deambulação e orientação. O perfil das puérperas atendidas correspondeu ao esperado, encontrando-se elas em estado de recuperação puerperal. A conduta proposta pela fisioterapia foi realizada pela grande maioria das puérperas.

Continence and quality-of-life outcomes 6 months following an intensive pelvic-floor muscle exercise program for female stress urinary incontinence: a randomized trial comparing low- and high-frequency maintenance exercise

BACKGROUND AND OBJECTIVES

Few studies have examined the effectiveness of pelvic-floor muscle (PFM) exercises to reduce female stress urinary incontinence (SUI) over the long term. This study: (1) evaluated continence and quality-of-life outcomes of women 6 months following formalized therapy and (2) determined whether low- and high-frequency maintenance exercise programs were equivalent in sustaining outcomes.

SUBJECTS AND METHODS

Thirty-six women with SUI who completed an intensive PFM exercise intervention trial were randomly assigned to perform a maintenance exercise program either 1 or 4 times per week. Urine leaks per week, volume of urine loss, quality of life (Incontinence Impact Questionnaire [IIQ] score), PFM strength (Brink score), and prevalence of urodynamic stress incontinence (USI) were measured at a 6-month follow-up for comparison with postintervention status. Parametric and nonparametric statistics were used to determine differences in outcome status over time and between exercise frequency groups.

RESULTS

Twenty-eight women provided follow-up data. Postintervention status was sustained at 6 months for all outcomes (mean [SD] urine leaks per week=1.2+/-2.1 versus 1.4+/-3.1; mean [SD] urine loss=0.2+/-0.5 g versus 0.2+/-0.8 g; mean [SD] IIQ score=17+/-20 versus 22+/-30; mean [SD] Brink score=11+/-1 versus 11+/-1; and prevalence of USI=48% versus 35%). Women assigned to perform exercises once or 4 times per week similarly sustained their postintervention status.

DISCUSSION AND CONCLUSION

Benefits of an initial intensive intervention program for SUI were sustained over 6 months. However, only 15 of the 28 women provided documentation of their exercise adherence, limiting conclusions regarding the need for continued PFM exercise during follow-up intervals of Collapse

Key Words Collapse

MESH Headings

• Adult
• Aged
• Exercise Therapy
• Female
• Humans
• Middle Aged
• Parity
• Patient Compliance
• Pelvic Floor/physiopathology
• Postmenopause
• Pregnancy
• Quality of Life
• Treatment Outcome
• Urinary Incontinence, Stress/rehabilitation

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Grants

• R15 AG15488-03 NIA NIH HHS

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Affiliation(s)

Diane F Borello-France Department of Physical Therapy, Duquesne University, 111 Health Sciences Bldg, Pittsburgh, PA 15282, USA.
Patricia A Downey
Halina M Zyczynski
Christine R Rause

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Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women

BACKGROUND

About a third of women have urinary incontinence and up to a tenth have faecal incontinence after childbirth. Pelvic floor muscle training is commonly recommended during pregnancy and after birth both for prevention and treatment of incontinence.

OBJECTIVES

To determine the effect of pelvic floor muscle training compared to usual antenatal and postnatal care on incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 24 April 2008) and the references of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trials needed to include pelvic floor muscle training (PFMT). Another arm was either no pelvic floor muscle training or usual antenatal or postnatal care. The pelvic floor muscle training programmes were divided into either: intensive; or unspecified if training elements were lacking or information was not provided. Reasons for classifying as intensive included one to one instruction, checking for correct contraction, continued supervision of training, or choice of an exercise programme with sufficient exercise dose to strengthen muscle.

DATA COLLECTION AND ANALYSIS

Trials were independently assessed for eligibility and methodological quality. Data were extracted then cross checked. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. Three different populations of women were considered separately: women dry at randomisation (prevention); women wet at randomisation (treatment); and a population-based approach in women who might be one or the other (prevention or treatment). Trials were further divided into: those which started during pregnancy (antenatal); and after delivery (postnatal).

MAIN RESULTS

Sixteen trials met the inclusion criteria. Fifteen studies involving 6181 women (3040 PFMT, 3141 controls) contributed to the analysis. Based on the trial reports, four trials appeared to be at low risk of bias, two at low to moderate risk, and the remainder at moderate risk of bias.Pregnant women without prior urinary incontinence who were randomised to intensive antenatal PFMT were less likely than women randomised to no PFMT or usual antenatal care to report urinary incontinence in late pregnancy (about 56% less; RR 0.44, 95% CI 0.30 to 0.65) and up to six months postpartum (about 30% less; RR 0.71, 95% CI 0.52 to 0.97).Postnatal women with persistent urinary incontinence three months after delivery and who received PFMT were less likely than women who did not receive treatment or received usual postnatal care (about 20% less; RR 0.79, 95% CI 0.70 to 0.90) to report urinary incontinence 12 months after delivery. It seemed that the more intensive the programme the greater the treatment effect. Faecal incontinence was also reduced at 12 months after delivery: women receiving PFMT were about half as likely to report faecal incontinence (RR 0.52, 95% CI 0.31 to 0.87).Based on the trial data to date, the extent to which population-based approaches to PFMT are effective is less clear (that is, offering advice on PFMT to all pregnant or postpartum women whether they have incontinence symptoms or not). It is possible that population-based approaches might be effective when the intervention is intensive enough.There was not enough evidence about long-term effects for either urinary or faecal incontinence.

AUTHORS' CONCLUSIONS

There is some evidence that PFMT in women having their first baby can prevent urinary incontinence in late pregnancy and postpartum. In common with older women with stress incontinence, there is support for the widespread recommendation that PFMT is an appropriate treatment for women with persistent postpartum urinary incontinence. It is possible that the effects of PFMT might be greater with targeted rather than population-based approaches and in certain groups of women (for example primiparous women; women who had bladder neck hypermobility in early pregnancy, a large baby, or a forceps delivery). These and other uncertainties, particularly long-term effectiveness, require further testing.

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 contextual model of pelvic floor muscle defects in female stress urinary incontinence: a rationale for physiotherapy treatment

On the basis of the current literature, we describe a model of structural defects in stress urinary incontinence (SUI) and how physiotherapy for SUI can affect each component of the model with reference to the relevant anatomy and pathophysiology. This model of SUI involves four primary structural defects: (1) increased tonic stress on the pelvic fascia due to pelvic floor muscle (PFM) tears; (2) fascial tearing due to PFM denervation; (3) fascial weakness resulting from tears; and (4) inefficient PFM contraction due to altered motor control. These four components interact to collectively weaken urethral closure and allow urine leakage under conditions of increased intra-abdominal pressure. Physiotherapy can strengthen the PFM and may improve the efficiency and/or timing of PFM contractions to reduce or eliminate SUI. It is worthwhile for motivated women with SUI to try PFM exercise therapy as a first approach to treatment. Women need to be individually instructed to ensure that they correctly perform PFM contractions and that they can monitor their own performance. Long-term, high-intensity exercise, including home exercise, is necessary to achieve maximum effect. Under these conditions the improvement in urinary continence with PFM exercise can be complete and enduring.

Postnatal pelvic floor muscle training for preventing and treating urinary incontinence: where do we stand?

PURPOSE OF REVIEW

Postnatal pelvic floor muscle training aims to rehabilitate the pelvic floor muscles. To be effective, a certain exercise dosage must be respected. Recent trials evaluated the effect of different programs on prevention/treatment of urinary incontinence immediately after delivery and in treatment of persistent incontinence.

RECENT FINDINGS

Only three systematic reviews, six trials, and four follow-up studies have been published in the past two decades. High heterogeneity in postnatal pelvic floor muscle training programs is observed throughout the literature, making comparisons difficult. In the prevention/treatment of postnatal urinary incontinence immediately after delivery and in persistent incontinence, supervised intensive programs prove more effective than standard postnatal care. Longer-term results have yet to show advantages for postnatal training programs.

SUMMARY

Although a certain exercise dosage must be respected for a postnatal pelvic floor muscle training program to be effective, a few randomized controlled trials present such dosage. Randomized controlled trials should study the effect of supervised, intensive training protocols with adherence aids. As standard care does not seem to reduce the prevalence of postnatal urinary incontinence, obstetrics services must address delivery of postnatal pelvic floor muscle training.

Physiotherapy for female stress urinary incontinence: a multicentre observational study

BACKGROUND

No previous data are available on the effectiveness of physiotherapy management of urinary stress incontinence with relevance to the Australian health system.

AIMS

To evaluate Australian ambulatory physiotherapy management of stress urinary incontinence.

METHODS

Observational multicentre clinical study of physiotherapy management of female stress urinary incontinence between February 1999 and October 2000, with 1-year follow-up. Outcome measures were a stress test and a 7-day diary of incontinent episodes (pretreatment and at every visit) and a condition-specific quality of life (QoL) questionnaire (pre- and post-treatment). Subjects were followed-up 1 year after treatment by questionnaire with a 7-day diary, QoL questionnaire, and assessment of subjective outcome, subjective cure, satisfaction and need for surgery.

RESULTS

Of the 274 consenting subjects, 208 completed an episode of physiotherapy care consisting of a median (IQ range) of five (four to six) visits. At the end of the episode, 84% were cured and 9% improved on stress testing, whilst 53% were cured and 25% improved according to the 7-day diary. Mean volume of urine loss on stress testing reduced from 2.4 (2.5) mL to 0.1(0.4) mL after treatment. There was a significant improvement in all QoL domains. Median (interquartile range) incontinent episodes per week were reduced from five (three to 11) to zero (zero to two) (P < 0.05) after treatment and to one (zero to four) at 1 year (P < 0.05). At 1 year, approximately 80% of respondents had positive outcomes on all outcome measures.

CONCLUSIONS

Physiotherapy management in Australian clinical settings is an effective treatment option for women with stress urinary incontinence.

[Differential diagnosis in descending perineum syndrome]

Clinical symptoms in descending perineum syndrome show considerable variations, ranging from obstructed defecation to combined fecal and urinary incontinence and including different types of prolapse. Differential diagnosis has to compete with this complexity. Common pelvic floor disorders associated with descending perineum are rectocele, rectal prolapse, enterocele, and sigmoidocele. Standardized diagnostic tools include detailed history and clinical examination with proctorectoscopy as well as anorectal manometry, endoanal ultrasound, defecography, and dynamic MR of the pelvic floor. The diagnosis and proposed therapy have to be developed within an interdisciplinary concept.