The aim of this commentary is to summarize and discuss from a rehabilitation point of view the published Cochrane Review “Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women” by Dumoulin et al.1 (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005654.pub4/full?cookiesEnabled), in collaboration with Cochrane Incontinence. This Cochrane Corner is produced in agreement with the American Journal of Physical Medicine & Rehabilitation by Cochrane Rehabilitation.
Urinary incontinence (UI), defined by the International Continence Society as the complaint of any involuntary loss of urine, affects approximately a quarter to a third of women in their lifetime. Three common types of nonneurogenic UI are observed: stress UI (SUI), urgency UI (UUI), and mixed UI (MUI). Stress UI is characterized by an involuntary loss of urine during increased intra-abdominal pressure (effort or physical exertion); UUI is present when a woman reports involuntary leakage associated with or immediately preceded by a sudden and strong need to void (urgency); MUI is observed when women have both symptoms and signs of SUI and UUI.2
A wide range of treatments have been used in the management of UI, including conservative interventions, medication, and surgery.
This review focuses on one of the most used conservative interventions, specifically pelvic floor muscle training (PFMT) that is a program of exercises to improve pelvic floor muscle (PFM) function.3,4 Generally, after achieving PFM awareness and correct motor learning, both strength and fatigue resistance of PFM improve in response to an exercise program, that contemplates low numbers of repetitions with high loads to improve muscle strength and high numbers of repetitions or prolonged contractions with low to moderate loads to improve muscle endurance. In addition, we have to mention coordination training consisting of PFM contraction in response to a specific situation (eg, before cough, “the knack theory”).5
The biological rationale for PFMT for SUI and MUI is twofold: with the PFM contraction (a) increasing the urethral pressure and (b) providing support for the pelvic floor organs (ie, reducing bladder neck displacement). The biological rationale for PFMT for UUI is based on the observation by Godec et al.6 that a detrusor muscle contraction can be inhibited by a PFM contraction; thereby, voluntary PFM contractions could be used to control the urgency to void, allowing the woman to reach the toilet in time to prevent urine leakage.1
PELVIC FLOOR MUSCLE TRAINING VERSUS NO TREATMENT, OR INACTIVE CONTROL TREATMENTS, FOR UI IN WOMEN
(Dumoulin et al., 2018)
What Was the Aim of This Cochrane Review?
The aim of this Cochrane Review was to assess the effects of PFMT for women with UI in comparison with no treatment, placebo drug or sham electrical stimulation, or other inactive control treatments (anti-incontinence device, incontinence pads, general education class, access to an educational pamphlet).1
What Was Studied in This Cochrane Review?
The population addressed in this review was women with UI and diagnosed as having SUI, UUI, or MUI on the basis of symptoms, signs, or urodynamic study; trials of women whose UI due to factors outside the lower urinary tract or to pregnancy or postnatal period were excluded. Other common exclusion criteria were urinary tract infection, significant postmicturition residual volume, neurological disorders, and cognitive impairments.
The interventions included PFMT in comparison with no treatment, or inactive treatments. Pelvic floor muscle training was a program of repeated voluntary PFM contractions taught and generally supervised by a healthcare professional.
The outcomes of interest in the review were as follows:
- (a) primarily, symptomatic cure or improvement of UI, symptom-, and condition-specific quality-of-life (QoL) measures, and
- (b) secondarily, longer-term symptomatic cure or improvement of UI, satisfaction and need for further treatment, number of leakage episodes in 24 hrs on bladder diary, amount of leakage from a short or long pad-test, and general QoL.
Search Methodology and Up-to-Dateness of the Cochrane Review
The review authors searched for studies published up to February 12, 2018.
What Were the Main Results of This Cochrane Review?
The review included 31 trials (10 of which were new for this update) involving 1817 women from 14 countries. The trials included women with SUI, UUI, MUI, or UI all types. The women were allocated randomly to either receive or not receive PFMT, and the effects were compared.
Symptomatic Cure of UI
Women with SUI in the PFMT groups were, on average, eight times more likely to report being cured, whereas women with UI all types were, on average, five times to report being cured.
Symptomatic Cure or Improvement of UI
Women with SUI in PFMT groups were, on average, six times more likely to report that they were cured or improved. Women with UI all types were roughly twice as likely to report that they were cured or improved.
Urinary Incontinence–Specific Symptoms and Condition-Specific QoL
Women with SUI and UI all types in the PFMT groups were more likely to report significant improvement in UI symptoms and condition-specific QoL. One small trial for women with MUI reported better QoL.
Leakage Episodes in 24 hrs
Pelvic floor muscle training reduced leakage episodes by one in 24 hrs in women with SUI and UI all types. Pelvic floor muscle training seemed to reduce urine loss in women with UUI alone.
Leakage on Short (up to 1 hr) Clinic-Based Pad Test
Women with SUI and UI all types in the PFMT groups lost significantly less urine in short pad tests than controls.
Women in the PFMT groups were also more satisfied with treatment and their sexual outcomes were better. Women in control groups were more likely to seek further treatments.
Adverse events were very rare and promptly resolved.
The evidence was generally downgraded to moderate on methodological grounds with the exception of “participant-perceived cure” in women with SUI, which was rated as high quality.
What Were the Authors’ Conclusions?
Pelvic floor muscle training can cure or improve symptoms of SUI reducing the number of leakage episodes, the quantity of leakage on the short pad tests, and symptoms on UI-specific symptom questionnaires. A similar pattern is seen in studies that recruit women with all types of UI (SUI, MUI, and UUI) rather one specific type of UI.
The long-term effectiveness of PFMT needs to be further researched.
What Are the Implications of the Cochrane Evidence for Practice in Rehabilitation?
The Cochrane review indicates that PFMT should be included in first-line conservative management for women with UI.
Rehabilitation professionals should get involved in this field because UI is a frequent and bothersome condition and the efficacy of this rehabilitation intervention (PFMT) is supported by high level of evidence.
Although the PFMT is useful to reduce or cure UI, there are some unresolved issues.
The proposed PFMT programs differed in terms of type and number of voluntary PFM contractions, duration of holding and rest time, body positions, and treatment length. Thus, optimal program has not yet been identified. However, it could also be argued that this heterogeneity in exercise content adds to the robust nature of the evidence; then, the finer detail of program content may be less important.
As said before, there is no strong evidence of the long-term effects of PFMT. Research is needed to identify strategies, which may allow patients to maintain the positive treatment outcomes.
We thank the authors of Cochrane Review (Chantale Dumoulin, Licia Cacciari, and Jean Hay-Smith), the Cochrane Rehabilitation and Cochrane Incontinence Group for reviewing the Contents of the Cochrane Corner.
1. Dumoulin C, Cacciari LP, Hay-Smith EJC: Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women (Review). Cochrane Database Syst Rev
2. Abrams P, Cardozo L, Wagg A, et al: (eds): Incontinence
, 6th ed 2017. Tokyo, 6th International Consultation on Incontinence, 2016
3. Kegel AH: Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol
4. Bø K: Pelvic floor muscle training for stress urinary incontinence. In: Bø K, Berghmans B, Mørkved S, Van Kampen M (eds): Evidence-Based Physical Therapy for the Pelvic Floor. Bridging Science and Clinical practice
. Philadelphia, PA, Butterworth Heinemann Elsevier, 2007
5. Dumoulin C, Glazener C, Jenkinson D: Determining the optimal pelvic floor muscle training regimen for women with stress urinary incontinence. NeurourolUrodyn
6. Godec C, Cass AS, Ayala GF: Bladder inhibition with functional electrical stimulation. Urology