There were no differences in any outcome measure between nonoperated women originally assigned to either the intensive or home exercise intervention groups. Of the 10 nonoperated women in the intensive exercise group, 5 and 8 reported urinary leakage during the last month during physical activity and coughing and sneezing, respectively, compared with 4 and 7, respectively, of the 13 nonoperated women in the home exercise group. There was also no difference in satisfaction between nonoperated groups (80% in the intensive exercise compared with 76.9% in the home exercise group reported being satisfied or almost satisfied).
The marked benefit of intensive pelvic floor muscle training seen short-term was not maintained 15 years later. Urinary symptoms and severity were similar regardless of group assignment, whether or not operated women were included in the analysis. Pelvic floor muscle training adherence also did not differ between the 2 programs and 15 years later; only roughly one quarter of women exercised regularly. Fifty percent in each group had interval stress urinary incontinence surgery. At the time of our questionnaire, operated and nonoperated women reported no difference in most urinary symptoms, satisfaction, or training adherence. However, more operated women reported severe incontinence and leakage that interfered with daily life than did nonoperated women.
Strengths of our study include the high response rates for both treatment groups, the long follow-up period, the use of validated instruments appropriate for questionnaire studies, high data quality, and outcome collection by a nonbiased research assistant. The main limitations include the small sample size and lack of clinical data.
Studies of pelvic floor muscle training with more than 5 years follow-up that include clinical or urodynamic assessment are limited by reporting results for either 1 group only or for a smaller proportion of subjects.14,22–24 This may reflect difficulties in tracing women after several years or motivating participants to undergo urodynamic assessment. Our high follow-up rate is likely partly due to the questionnaire nature of our study design. Although subjects did not undergo urodynamics or other objective tests, we chose questionnaire instruments with excellent test characteristics when compared with urodynamics or pad testing.15,16,18 Our original study was powered to find significant differences between groups with 30 patients and did show significant differences in all parameters comparing 23 and 29 patients.13 However, 15 years later, half of the women in each of the original groups had stress urinary incontinence surgery, creating small sample sizes for comparisons between the nonoperated women in the intensive and home exercise groups. Hence, the nonsignificant differences found in analysis of the nonoperated women may be due to small sample sizes. Similarly, although statistically significant, small group sizes in the subgroups of the severity index call for caution in interpreting the results.
In our population, at variable years removed from surgery, the group of women that underwent surgery did not have fewer urinary symptoms than the group that did not. It is likely that in the short-term after surgery, operated women were more continent than those not operated, but our study design does not allow us to do survival analysis of outcomes. Further, this study was not a randomized trial comparing the outcomes of pelvic floor muscle training and surgery, and those who chose surgery may have had more severe incontinence to begin with. Indeed, women that “fail” pelvic floor muscle training are likely different from those who respond well to physical therapy and may represent a group at high risk of failure no matter what treatment they undergo. Surgeons may be perplexed by the apparent low success rate of surgery in our group. It is of interest to note that long-term follow-up studies of incontinence surgeries show quite different results when surgeons’ own patients are followed up compared to results when a community sample is queried. For example, Diokno et al25 recently reported in a cross-sectional questionnaire study that of 967 women who had a history of continence surgery, 73% reported leakage in the preceding month and 53% wore pads. Satisfaction was not well correlated with leakage. Our results are in line with these. Consistent with our initial study, other short-term studies found that intensive pelvic floor muscle training with close follow-up is more effective than home training or exercise with less follow-up.26–28 This corresponds with results from general strength training studies showing a dose–response relationship in effect.29 After the training period the women in our study were left alone to continue exercising on their own. Although some researchers have found that women find it difficult to adhere to pelvic floor muscle training,30 we followed up our intensive exercise group 5 years after the intervention and found that 70% were still exercising regularly.14 We expected that because these women were improved of stress urinary incontinence, motivated, and independently exercising 5 years after the trial, they would continue to exercise. However, 15 years is a long time, and illnesses and other physical, psychological, and social changes may have made regular exercises harder to do. Studies from exercise science have shown that a 5–10% reduction in muscle strength per week can be expected after strength training is discontinued.31 Even training 1–2 times per week at high intensity is often enough to maintain muscle strength.29,31,32 However, in the present study only 28% were exercising at a frequency required to maintain muscle strength.33
We asked subjects about whether they precontracted the pelvic floor muscles because of evidence suggesting that this “bracing” is another mechanism, in addition to strengthening, by which pelvic muscle training improves leakage. In the original study protocol, we did not specifically instruct women to precontract.13 One fourth of our subjects precontracted the pelvic floor muscles before and during coughing and sneezing, and some believed this to be the main or partial mechanism for their improvement or cure. Adding conscious precontractions to both short- and long-term protocols for pelvic floor muscle training may enhance the effect of this treatment34 and should be studied further. Not surprisingly, women who were originally continent or almost continent after pelvic floor muscle training were less likely to have undergone surgery during the follow-up period than those still wet. Similarly, Cammu et al35 reported that 16 of 24 successful patients after physiotherapy remained satisfied after 10 years, and only 8% had undergone surgery compared with 62% of women that did not initially respond to pelvic floor muscle training.
Thus, responders to pelvic floor muscle training can be sorted out relatively quickly, leaving surgery for those that do not respond to muscle training. For pelvic floor muscle training responders, an important issue is how to organize and finance long-term training. Women in the present study had participated in a program combining individual instruction and monthly assessment with weekly group training and home training.6,13 Group training is a time saving and cost-beneficial way to organize pelvic floor muscle training. Women who have been treated successfully may benefit from the opportunity to continue with group training to maintain muscle function. Another way to organize maintenance training is to incorporate pelvic floor muscle training into general fitness programs for women. Strength training of the pelvic floor muscles should be considered as important as training of abdominal, back, leg, and arm muscles. Because more than 30% of incontinent women are not able to contract the pelvic floor muscles correctly initially,5 proper individual instruction with feedback is essential before embarking on group sessions.
Further work is needed to better understand factors associated with long-term effectiveness of both pelvic floor muscle training and surgery for stress urinary incontinence. Given the high prevalence of stress urinary incontinence and high social burden, it is vital to develop and test intervention models that aim to increase long-term adherence to pelvic floor muscle training.
1. Hunskaar S, Burgio K, Diokno A, Herzog A, Hjaelmås K, Lapitan M. Epidemiology and natural history of urinary incontinence in women. Urology 2003;62(suppl):16–23.
2. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardization of terminology of lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Neurourol Urodyn 2002;21:167–78.
3. Fantl JA, Newman DK, Colling J, DeLancey J, Keeys C, Loughery R, et al. Urinary incontinence in adults: acute and chronic management. 2, update [96–0682] Clinical Practice Guideline.. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1996. p. 1–154.
4. Wilson PD, Bo KH-SJ, Nygaard I, Staskin D, Wyman J, Bourchier A. Conservative treatment in women. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence. Plymouth (UK): Health Publication Ltd; 2002. p. 571–624.
5. Hay-Smith E, Bo K, Berghmans L, Hendriks H, deBie R, van Waalwijk van Doorn ESC. Pelvic floor muscle training fur urinary incontinence in women (Cochrane review). In: The Cochrane Library, Issue 3, 2001. Oxford: Update Software.
6. Bo K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 1999;318:487–93.
7. Henalla S, Millar D, Wallace K. Surgical versus conservative management for post-menopausal genuine stress incontinence of urine. Neurourol Urodyn 1990;9:436–7.
8. Morkved S, Bo K, Fjortoft T. Is there any additional effect off adding biofeedback to pelvic floor muscle training? A single-blind randomized controlled trial. Obstet Gynecol 2002;100:730–9.
9. Dumoulin C, Lemieux MC, Bourbonnais D, Gravel D, Bravo G, Morin M. Physiotherapy for persistent postnatal stress urinary incontinence: a randomized controlled trial. Obstet Gynecol 2004;104:504–10.
10. Balmforth J, Cardozo L. Trends toward less invasive treatment of female stress urinary incontinence. Urology 2003;62(suppl):52–60.
11. Black NA, Downs SH. The effectiveness of surgery for stress incontinence in women: a systematic review. Br J Urol 1996;78:497–510.
12. Smith T, Daneshgari F, Dmochowski R, Ghoniem G, Jarvis G, Nitti V, et al. Surgical treatment of incontinence in women. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence. Plymouth (UK): Health Publication Ltd; 2002. p. 823–63.
13. Bo K, Hagen RH, Kvarstein B, Jorgensen J, Larsen S. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: III. Effects of two different degrees of pelvic floor muscle exercise. Neurourol Urodyn 1990;9:489–502.
14. Bo K, Talseth T. Long term effect of pelvic floor muscle exercise five years after cessation of organized training. Obstet Gynecol 1996;87:261–5.
15. Sandvik H, Seim A, Vanvik A, Hunskaar S. A severity index for epidemiological surveys of female urinary incontinence: comparison with 48-hour pad-weighing tests. Neurourol Urodyn 2000;19:137–45.
16. Avery K, Donovan J, Peters T, Shaw C, Gotoh M, Abrams P. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn 2004;23:322–30.
17. Sandvik H, Hunskaar S, Seim A, Hermstad R, Vanvik A, Bratt H. Validation of a severity index in female urinary incontinence and its implementation in an epidemiological survey. J Epidemiol Community Health 1993;47:497–9.
18. Sandvik H, Hunskaar S, Vanvik A, Bratt H, Seim A, Hermstad R. Diagnostic classification of female urinary incontinence: an epidemiological survey corrected for validity. J Clin Epidemiol 1995;48:339–43.
19. Donovan J, Badia X, Corcos J, Gotoh M, Kelleher CJ, Naughton M, et al. Symptom and quality of life assessment. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence. Plymouth (UK): Health Publication Ltd; 2002. p. 267–316.
20. Bo K. Reproducibility of instruments designed to measure subjective evaluation of female stress urinary incontinence. Scand J Urol Nephrol 1994;28:97–100.
21. Fleiss JL, Levin B, Paik MC. Statistical methods for rates and proportions. 3rd ed. Hoboken (NJ): Wiley; 2003. p. 250.
22. Klarskov P, Nielsen KK, Kromann-Andersen B, Maegaard E. Long-term results of pelvic floor training for female genuine stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1991;2:132–5.
23. Lagro-Janssen T, van Weel C. Long-term effect of treatment of female incontinence in general practice. Br J Gen Pract 1998;48:1735–8.
24. Kiss G, Rehder P, Pilloni S, Helfer R, Madersbacher H. 6-years long term results of pelvic floor reeducation training in women with urinary stress incontinence. Neurourol Urodyn 2004;21:319–20.
25. Diokno AC, Burgio K, Fultz H, Kinchen KH, Obenchain R, Bump RC. Prevalence and outcomes of continence surgery in community dwelling women. J Urol 2003;170:507–11.
26. Wilson PD, Samarrai TAL, Deakin M, Kolbe E, Brown ADG. An objective assessment of physiotherapy for female genuine stress incontinence. Br J Obstet Gynaecol 1987;94:575–82.
27. Glavind K, Nohr S, Walter S. Biofeedback and physiotherapy versus physiotherapy alone in the treatment of genuine stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:339–43.
28. Goode P, Burgio KL, Locher JL, Roth S, Umlauf M, Richter H, et al. Effect of behavioral training with or without pelvic floor electrical stimulation on stress incontinence in women: a randomized controlled trial. JAMA 2003;290:345–52.
29. Kraemer WJ. Progression models in resistance training for healthy adults. Med Sci Sports Exerc 2002;34:364–80.
30. Ashworth P, Hagan M. Some social consequences of noncompliance with pelvic floor exercises. Physiotherapy 1993;79:465–71.
31. DiNubile NA. Strength training. Clin Sports Med 1991;10:33–62.
32. Graves J, Pollock ML, Legget S, Braith R, Carpenter D, Bishop L. Effect of reduced training frequency on muscular strength. Int J Sports Med 1988;9:316–9.
33. Pollock ML, Gaesser GA, Butcher JD, Despres JP, Dishman RK, Franklin BA, et al. The recommeneded quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998;30:975–91.
34. Bo K. Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work? Int Urogynecol J Pelvic Floor Dysfunct 2004;15:76–84.
35. Cammu H, Van Nylen M, Amy J. A ten-year follow-up after Kegel pelvic floor muscle exercises for genuine stress incontinence. BJU Int 2000;85:655–8.