Urinary incontinence is a common problem costing more than 10 billion dollars each year in the United States alone.1 Among various types of incontinence, stress urinary incontinence is predominant, with prevalence rates of 15–52%.2 Incontinence is common during pregnancy, with prevalence estimated between 30% and 60%,3 and pelvic floor trauma owing to vaginal delivery is believed to be the major etiologic factor of impairment of urethral and anorectal sphincter function.4,5
Pelvic floor education assists women to exert better control over their urinary continence mechanisms by teaching them to improve the support of their bladder necks by increasing the strength and endurance of the paravaginal muscles. Many education techniques have been described, and pelvic floor exercises, biofeedback, and electrostimulation techniques are frequently used by physiotherapists skilled in urogynecology.
This is a prospective study to evaluate the usefulness of pelvic floor education in preventing stress urinary incontinence after vaginal delivery in nulliparous women.
Materials and Methods
One hundred seven white nulliparas, mean (± SD) age 29 ± 4 years, gave informed consent to enrollment, which was approved by the Ethics Committee of the University of Lausanne (approval number F-89/95). The enrollment period was 2 years. We excluded women with pregnancy complications (twin gestation, diabetes, or preterm labor, hemorrhage from low-lying placenta), those beginning labor, and those with histories of urinary infections. The acceptance rate was nearly 80%. Seventy-four percent of women enrolled from the private practice of the primary author, and the remaining 26% enrolled from outpatient obstetric clinics. The study population consisted of teachers and university researcher staff (15%), nurses and health-related professionals (14%), office workers and sales staff (42%), craftswomen (3%), and housewives (26%).
One gynecologist explained the purpose and methods involved in the study to each participant. We took careful histories emphasizing urinary infections, urinary incontinence (particularly stress urinary incontinence), and fecal incontinence. We repeated the questionnaire monthly to detect the appearance of new urinary or anorectal symptoms.
One investigator did a conventional clinical examination to evaluate the strength of pelvic floor muscular contraction using a subjective scale of 0–5.6 The same investigator performed a perineosonography to assess bladder neck position at rest and during the Valsalva maneuver and pelvic floor contraction, supine and standing, with the bladder containing 200–300 mL. The bladder volume was estimated: transverse diameter × horizontal diameter × sagittal diameter × 0.7.7 A curved linear array ultrasound scanner (Tosbee, Toshiba Corporation Medical Systems SA, Tokyo, Japan) with a 3.75-MHz transducer was placed on the vulva in a sagittal orientation to provide complete view of the bladder base and neck, urethra, and pubic symphysis. We used bladder neck localization as described by Schaer et al8 using a rectangular coordinate system, with the inferior border of the pubic symphysis serving as the reference point.
Each subject had conventional urodynamic testing of urethral sphincter function. A Microtip transducer (Gaeltec Microtip, 7F diameter; Gaeltec Manufactory, Isle of Sky, Scotland) placed at the 9 o'clock urethral position was used to record supine and standing stress urethral pressure profiles. Measurements included functional urethral length, maximum urethral closure pressure at stress, area of continence at stress (defined as the area [mm2] between the baseline and a line connecting each cough spike on the cough urethral closure pressure profile), and the mean value of the pressure transmission ratio in the central third of the functional urethral length. We measured intravaginal and intra-anal pressures during pelvic floor contraction using an air-inflated balloon connected to a microtip transducer (Sedia Se 250, SEDIA AG, Fribourg, Switzerland).
We performed initial examination between weeks 12 and 20 of pregnancy for 11 women, weeks 21 and 30 for 42 women, and weeks 31 and 39 for 54 women. The mean (± SD) gestational age at first examination was 29 ± 7 weeks. The examination was repeated on each patient 9 ± 2 weeks postpartum. Each woman was then assigned to one of two groups. A control group of 56 subjects did not receive any education until the third examination conducted 10 months postpartum. One group of 51 women received 6 weeks (12 sessions) of pelvic floor education that started 2 months postpartum and ended before the third examination, also conducted 10 months postpartum.
Each session consisted of pelvic floor exercise training, followed by 20 minutes of biofeedback and 15 minutes of electrostimulation with an electrode placed in the lower third of the vagina (stimulation characteristics: biphasic rectangular form; impulse width 200–400 microseconds; frequency 50 Hz; intensity 15–50 mA; contraction time 6 seconds; resting time 12 seconds; Compact Elite 2.7; Electronic Concept Lignon Innovation, Le Chambonsur Lignon, France).
The groups were similar in incidence of forceps deliveries (controls 16%, subjects 30%, P = .1), epidural analgesia (controls 51%, subjects 70%, P = .08), and infant's weight (controls 3280 ± 450 g, subjects 3260 ± 370 g, P = .8). The groups also were similar in population, which consisted of 15% teachers and university research staff, 14% nurses and health-related professionals, 42% office workers and sales staff, 3% crafts-women, and 26% housewives. Each patient was assigned at the beginning of the second examination. The investigators were masked to mode of delivery.
With a proposed sample size of 55 in each group and a two-tailed alpha error of .05, this study had a power of 78.5 to produce a statistically significant result. We assumed a difference of 0.17 (specifically 0.22 versus 0.05) in proportions. We used Student's paired two-tailed t test for comparison of same-patient measures and Student's unpaired two-tailed t test for comparison of between-group measures. Dichotomous variables were compared using two-sided Fisher's exact test. Within-group changes for dichotomous variables were evaluated by, McNemar's test and within-group changes for continuous variables were evaluated by Student's paired two-tailed t test. An alpha error of < .05 was used. Calculations were performed using Statview version 4.5 (Abacus Concepts Inc., Berkeley, CA) and SPSS version 9.0 (SPSS Inc., Chicago, IL).
Effect of pelvic floor education on stress urinary incontinence complaints are shown in Table 1. The women who underwent education experienced significant reduction in the incidence of stress urinary incontinence compared with women who did not receive this education; however, incidence of fecal incontinence was similar in both groups. Table 2 shows that the incidence of women who recovered normal pelvic floor contraction, as measured by digital testing of pelvic floor muscle strength, was similar between groups.
When compared 10 months postpartum, the two groups had similar bladder neck positions in the upright position and similar bladder neck mobility during Valsalva maneuver when supine (Table 3), similar urodynamic parameters (Table 4), and similar intravaginal and intra-anal pressures during pelvic floor muscle contraction (Table 5). Pelvic floor strength assessed by intra-anal pressure recordings during pelvic floor voluntary contraction was not statistically different between groups (Figure 1).
Trauma during vaginal delivery might result in a variety of pelvic floor complaints; stress urinary incontinence and fecal incontinence are the most frequent and long-lasting. Stress urinary incontinence is observed in 20–34% of women after vaginal delivery, 3% with daily or more frequent leakage.9,10 Stress urinary incontinence persists postpartum in 29% of women in whom it appeared during pregnancy and presents de novo in 16% of pregnancy-continent women.11 Fecal incontinence is seen in 4–7% of primiparous women, and transanal ultrasonography demonstrates occult anal sphincter lesions in 35% of primiparas.12 Pelvic floor education using exercises, electrical stimulation, and biofeedback has gained acceptance during the past 15 years and might cure (30–50%) or decrease (60–90%) the incidence of stress urinary incontinence.13 The efficacy of these different techniques used separately is controversial because the treatment protocol and the duration of the rehabilitation period differ between studies.14 We found 11 randomized controlled trials that show that exercises are effective in reducing symptoms of stress urinary incontinence and that effectiveness increased variably when combined with biofeedback or electrostimulation.
The efficacy of these techniques in the prevention of stress urinary incontinence is uncertain.15 Therefore, we used a combination of therapeutic modalities and an education period of 6 weeks (two sessions/wk) to compare pelvic floor characteristics of women receiving pelvic floor education with women who did not receive education. The results described in the few studies with control groups are varied and conflicting. Norton and Baker16 studied primiparas assigned to pelvic floor exercise, cone, and control groups and found that those groups 6 months postpartum improved to a common endpoint when their pelvic floor muscle functions were assessed by perineometry and digitally. In a small cohort of women with persisting stress urinary incontinence 3 months postpartum, Dumoulin et al17 found that pelvic floor electrostimulation results in a significant increase in vaginal pressure and a significant reduction in stress urinary incontinence, but that study lacked control subjects. In a prospective comparison of 99 matched pairs of mothers divided into a trained group and a control group, Morkved and Bo18 found that pelvic floor muscle exercises performed for 8 weeks starting 8 weeks postpartum significantly reduced urinary incontinence and significantly increased pelvic floor muscle strength in the trained group. Wilson and Herbison19 performed a similar study that compared 1 year postpartum 113 women trained and monitored regularly by a physiotherapist with 117 women using standard postnatal pelvic floor exercises. They found that the prevalence of incontinence was significantly lower in the physiotherapist-trained group than in the other, with no significant differences in perineometry measurements.
We found similar effects of pelvic floor rehabilitation on the incidence of stress urinary incontinence, which was reduced by 19% in the women receiving pelvic floor education and by only 2% in the control group (P = .03). In agreement with Wilson and Herbison but not with Morkved and Bo, we were unable to find a significant increase in perineometry measures in the trained group, despite using the same technique of intravaginal balloons in both studies. Those conflicting results might be explained by differences in perineometry techniques, populations of women studied (Scandinavian versus Swiss) and the extent to which these women practiced their pelvic floor techniques.
Pelvic floor education with biofeedback techniques has demonstrated benefit in 89% of women with residual fecal incontinence after sphincteroplasty20 and in 67% of women with fecal incontinence after vaginal delivery.21 Likewise, electrostimulation has been used successfully in 46% of women with fecal incontinence, particularly those with moderate fecal incontinence.22 In our study, 4% of women demonstrated moderate fecal incontinence that was unchanged after pelvic floor education. However, the number of women was too small to make significant conclusions.
A review of questionnaires completed by study participants showed that 57% of the pelvic floor-educated women described themselves as feeling that they had greatly improved pelvic floor function control, whereas 22% and 21% assessed themselves as moderately improved and unimproved, respectively. In contrast, 27% of the women in the control group described themselves as waiting impatiently to begin the rehabilitation program, and 23% felt it unnecessary to begin a rehabilitation program because they had no pelvic floor complaints.
1. Consensus Conference. Urinary incontinence in adults (review). JAMA 1989;261:2685–90.
2. Locher JL, Burgio KL. Epidemiology of incontinence. In: Ostergard DR, Bent AE, eds. Uroygynecology and urodynamics. Theory and practice. 4th ed. Baltimore: Williams & Wilkins, 1996:67–75.
3. Burgio KL, Locher JL, Zyczynski H, Hardin JM, Singh K. Urinary incontinence during pregnancy in a racially mixed sample: Characteristics and predisposing factors. Int Urogynecol J 1996;7:69–73.
4. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal sphincter disruption during vaginal delivery. N Engl J Med 1993;329:1905–11.
5. Ryhammer AM, Bek KM, Lourberg S. Multiple vaginal deliveries increase the risk of permanent incontinence of flatus urine in normal premenopausal women. Dis Colon Rectum 1995;38:1206–9.
6. Wall LL. Conservative management of stress incontinence. In: Wall LL, Norton PA, De Lancey JOL, eds. Practical urogynecology. 1st ed. Baltimore: William & Wilkins, 1993:140–52.
7. Rosenzweig BA. Radiologic studies of the lower urinary tract. In: Walters MD, Karram MM, eds. Clinical urogynecology. Boston: Mosby, 1993:132–47.
8. Schaer GN, Koechli OR, Schuessler B, Haller U. Perineal ultrasound for evaluating the bladder neck in urinary stress incontinence. Obstet Gynecol 1995;85:220–4.
9. Wilson PD, Herbison RM, Herbison GP. Obstetric practice and the prevalence of urinary incontinence three months after delivery. Br J Obstet Gynaecol 1996;103:154–61.
10. MacArthur C, Lewis M, Knox EG. Health after childbirth. Br J Obstet Gynaecol 1991;98:1193–5.
11. Meyer S, Schreyer A, De Grandi P, Hohlfeld P. The effects of birth on urinary continence mechanisms and other pelvic-floor characteristics. Obstet Gynecol 1998;92:613–8.
12. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal sphincter disruption during vaginal delivery. N Engl J Med 1993;329:1905–11.
13. Yamanishi T, Yasuda K. Electrical stimulation for stress incontinence. Int Urogynecol J Pelvic Floor Disord 1998;9:281–90.
14. Miller K, Richardson A, Siegel SW, Karram M, Blackwood NB, Sand PK. Pelvic floor electrical stimulation for genuine stress incontinence: Who will benefit and when? Int Urogynecol J Pelvic Floor Disord 1998;9:265–70.
15. Berghmans LC, Hendriks HJ, Bo K, Hay-Smith EJ, de Bie RA, van Waalwijk van Doorn ES. Conservative treatment of stress urinary incontinence in women: A systematic review of randomised trials. Br J Urol 1998;82:181–91.
16. Norton P, Baker J. Randomised prospective control trial of vaginal cones versus pelvic floor exercises in post-partum primiparous women. Neurourol Urodyn 1990;9:85–7.
17. Dumoulin C, Seaborne DE, Quirion-De Girardi C, Sullivan SJ. Pelvic floor rehabilitation, part 2: Pelvic floor reeducation with interferential currents and exercise in the treatment of genuine stress incontinence in post-partum women, a cohort study. Phys Ther 1995;75:1075–81.
18. Morkved S, Bo K. The effect of postpartum pelvic floor muscle exercise in the prevention and treatment of urinary incontinence. Int Urogynecol J 1997;8:217–22.
19. Wilson PD, Herbison GP. A randomised controlled trial of pelvic floor muscle exercises to treat postnatal urinary incontinence. Int Urogynecol J Pelvic Floor Disord 1998;9:257–64.
20. Jensen LL, Lowry AC. Biofeedback improves functional outcome after sphincteroplasty. Dis Colon Rectum 1997;40:197–200.
21. Rieger NA, Wattchow DA, Sarre RG, Cooper SJ, Rich CA, Saccone GT, et al. Prospective trial of pelvic floor retraining in patients with fecal incontinence. Dis Colon Rectum 1997;40:821–6.
22. Leroi AM, Dorival MP, Lecouturier MF, Saiter C, Welter ML, Touchais JY, et al. Pudendal neuropathy and severity of incontinence but not presence of an anal sphincter defect may determine the response to biofeedback therapy in fecal incontinence. Dis Colon Rectum 1999;42:762–9.
© 2001 The American College of Obstetricians and Gynecologists
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