Siv Mørkved1, 2 , Signe Nilssen Stafne2, 3 and Hege Hølmo Johannessen4
(1)
Research Department, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
(2)
Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
(3)
Department of Clincal Services, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
(4)
Department of Physiotherapy, Ostfold Hospital Trust, Fredrikstad, Norway
Siv Mørkved
Email: siv.morkved@ntnu.no
Abstract
Pregnancy and childbirth are known risk factors for weakening and injury to the perineum and pelvic floor muscles. Stretch and rupture of peripheral nerves, connective tissue and pelvic floor muscles may cause pelvic floor dysfunctions such as urinary and anal incontinence. Controlled trials have found pelvic floor muscle training to be effective in both prevention and treatment of incontinence. Common factors for all trials reporting a positive effect of pelvic floor muscle exercises (PFMT) in pregnancy or postpartum are found to be thorough clinical assessment of the women’s ability to perform a voluntary pelvic floor muscle contraction, close individual or group follow-up, and high adherence to the exercise protocol. Symptoms of incontinence before or during pregnancy have been found to be the main risk factors for incontinence symptoms postpartum. Similarly, women with symptoms of incontinence in the first year after delivery have an increased risk of long term incontinence symptoms. The cost of incontinence-related illness is a substantial economic and human burden, highlighting the need for effective forms of prevention and management.
Keywords
PhysiotherapyPelvic floor muscle trainingUrinary incontinenceAnal incontinenceFaecal incontinence
Pregnancy and childbirth are known risk factors for weakening and injury to the perineum and pelvic floor muscles (PFM). Stretch and rupture of peripheral nerves, connective tissue and PFM may cause urinary (UI) and anal incontinence (AI), pelvic organ prolapse, sensory and emptying abnormalities of the lower urinary tract, defecation dysfunction, sexual dysfunction and chronic pain syndromes [1]. UI is defined as “any involuntary loss of urine” [2]. Anal incontinence (AI) is defined as “involuntary loss of faeces or flatus,” faecal incontinence as involuntary loss of faeces and flatal incontinence is the involuntary loss of flatus [2]. About 50 % of women lose some of the supporting function of the pelvic floor due to childbirth [3], and recent research using ultrasound and MRI report prevalence of major injuries to the PFM of 20–26 % following vaginal delivery [4–6]. Hence, vaginal delivery may be considered equivalent to a major sports injury, but unfortunately PFM injuries have not been given the same attention concerning prevention or treatment as their sports-related counterparts.
Pelvic Floor Muscle Training and Incontinence
Pelvic floor muscle training (PFMT) has been a part of exercise programs in Chinese Taoism for over 6000 years [7]. PFMT has been found to have a high cure rate as treatment for UI after being popularized by the American gynecologist Arnold Kegel in the late 1940s [8]. The concept of intensive PFMT was introduced by Bø and co-workers in the 1990s [9] and PFMT is now recommended as first line treatment for stress urinary incontinence (SUI), urge urinary incontinence as well as mixed urinary incontinence in the adult female population [7]. Compared to UI, there is scarce documentation on the general effect of PFMT on AI symptoms in pregnancy and postpartum [10–13].
The recommendations for effective strength training to increase general muscle cross-sectional area and strength are 3 sets of 8–12 close to maximum contractions 3–4 times per week [14]. The effect of an exercise regimen is also influenced by factors such as type of exercise, frequency, intensity and duration of the training, as well as adherence [9, 14]. Furthermore, the success of PFMT depends on the ability to effectively contract the PFM and it has been estimated that on the first attempt, 30 % of women are unable to contract the PFM [15, 16]. After a brief standardized verbal instruction, only 49 % were found able to perform an ideal voluntary pelvic floor muscle contraction (VPFMC) [15]. Dinc and co-workers (2009) [17], found that only 68 % of pregnant women were able to perform a correct VPMFC 1 week after thorough individual instruction. Vaginal palpation is the method most commonly used by physiotherapists to evaluate the function and strength of the PFM. However ultrasound is a more objective measure and is becoming an important clinical tool [18].
A variety of hypotheses have been suggested as to why PFMT might help prevent and treat incontinence in pregnancy and after delivery. Strength training of the PFM builds muscle volume, elevates the location of the PFM and pelvic organs, and closes the levator hiatus thus providing improved structural support for the pelvic floor as well as more optimal automatic function [19]. Neural adaptations and motor learning may explain increases in muscle function before hypertrophy occurs, as muscle function improves with increasing number of recruited motor units [20]. Morphological changes such as increased muscle thickness, narrowed resting area of the levator hiatus, reduced pubovisceral length and elevated resting position of the bladder and the rectal ampulla after PFMT have been documented after an intensive PFMT program in non-pregnant women [21]. The functional changes (elevated resting position of the bladder and rectum and the reduced pubovisceral length and hiatus size at maximum Valsalva) may be explained by increased “stiffness” in the muscle-connective tissue complex [21].
During pregnancy, the growing uterus will compress the bladder. Strengthening the PFM results in better structural support for the bladder neck and a strong contraction of the PFM ensures continence during an abrupt increase in the abdominal pressure [22]. Further, PFMT during pregnancy may also aid in counteracting the increased intra-abdominal pressure caused by the growing fetus, the hormonally mediated reduction in urethral pressure, and the increased laxity of fascia and ligament in the pelvic area [23]. The effect of PFMT as a successful treatment of incontinence may also be explained by behavior modification in addition to increased PFM strength. A total of 80 % of women with de novo SUI in pregnancy week 35 reported being able to reduce leakage during coughing by using the “Knack” maneuver (i.e., tightening of the PFM in preparation for a known leakage-provoking event), with 55 % eliminating leakage completely [24]. The rationale for teaching women how to perform a conscious contraction of the PFM before and during increases in abdominal pressure [24] is that the urethra and bladder base is prevented from descending [22].
Another hypothesis is that a trained muscle may be less prone to injury, and previously trained muscles may be easier to retrain after damage as the appropriate motor patterns are already learned. It may be that previously trained muscles has a greater reserve of strength so that injury to the PFM muscles, or the nerve supply, does not cause sufficient loss of muscle function to reach the threshold where reduced urethral pressure results in leakage [23]. Further, PFMT may in theory improve the mechanism maintaining anal continence and closure of the anal canal by improving the strength and function of the puborectalis, internal and external anal sphincter muscles in largely the same manner as indicated in the treatment of UI [7, 11]. However, it has been questioned whether it is possible to distinguish between a voluntary contraction of the external anal sphincter muscle as compared to a general VPFMC [13].
Due to the physiological and hormonal changes occurring during pregnancy as well as after delivery, it may be that the effect of PFMT differs between pregnant and postpartum women [11]. We have thus reviewed the evidence of PFMT and treatment efficacy in pregnancy and postpartum in current literature separately.
UI and PFMT in Pregnancy
In a systematic literature search on PubMed, two trials [25, 26] were found addressing primary prevention of UI during pregnancy including only continent women (Table 17.1), and five trials included a mixed population with both continent and incontinent women [12, 27–30]. Further, three trials assessed the effect of treatment of UI during pregnancy including only incontinent women (Table 17.2) [17, 31, 32]. Seven of the trials assessing PFMT during pregnancy found UI to be less prevalent in the intervention group [12, 17, 25, 28–30, 32], and three trials found no differences between groups [26, 27, 31]. One long-term follow-up study found that the difference in UI symptoms and quality of life (QoL) was not present 8 years after the index delivery [33]. Two of the trials [12, 27] included PFMT in a general fitness program for pregnant women with diverging results. In the trial by Stafne and co-workers (2012) [12], UI was found to be less prevalent in the intervention group. Bø and Haakstad (2011) [27] randomised sedentary pregnant women to either usual care or PFMT as part of a general fitness class twice weekly and found no difference in UI between groups. However, this trial was underpowered, included no assessment of the participants’ ability to perform a correct VPFMC, had high dropout rates and low adherence to the exercise training protocol. A recent Cochrane review of trials including continent as well as incontinent primiparae [23] concluded that PFMT may prevent UI up to 6 months postpartum. Further, PFMT was found to be an effective treatment option for women with persistent postpartum UI [11].
Table 17.1
Controlled trials assessing the effect of pelvic floor muscle training as primary prevention of UI during pregnancy and postpartum including women continent at inclusion only
|
Author |
Subjects |
Design/intervention |
Outcome |
Results (IG vs CG) |
Comment |
|
Mason et al. (2010) [26] |
N = 311 Nullipara No previous SUI Included between 11 and 14 weeks of pregnancy |
2 arm RCT single blind 1. Control: usual care and instructions in PFMT. 2. Intervention: attending a physiotherapy class (45 min) with PFMT 1×/month for 4 months and to perform daily PFMT at home (8–12 close to maximum PFMC each held 6–8 s twice daily). Individual assessment of correct VPFMC was performed in most women. |
Bristol Female Lower Urinary Tract Symptoms Questionnaire (BFLUTS) Leicester Impact Scale (LIS) Self-reported number of leakage episodes last 3 days |
36 weeks of pregnancy: UI: 24/60 (40 %) vs. 51/96 (53 %) (p = 0.14) 3 months PP: UI: 23/68 (33.8 %) vs. 33/80 (41.3 %) (p = 0.40) No sig difference in symptoms and episodes of UI between groups in late pregnancy and PP |
8 % were lost to follow-up. 23 % failed to return any of the questionnaires, and only 31 % completed all three sets of questionnaires Only 65 % of IG women attended ≥1 exercise class The trial was underpowered |
|
Reilly et al. (2002) [25] |
N = 268 Nullipara Continent with increased bladder neck mobility Included at 20 weeks of pregnancy |
2 arm RCT 1. Control: routine antenatal care likely to include verbal instructions in PFMT. 2. Intervention: Individual PFMT with physiotherapist at monthly intervals from 20 week’ of pregnancy until delivery, with additional home exercises. 3 sets of 8 contractions (each held for 6 s), repeated twice daily. At 34 weeks of pregnancy the number of contractions per set was increased from 8 to 12. Women were instructed to contract the PFM when coughing or sneezing. Performing PFMT was recorded in a personal training diary. |
Self-reported UI Symptom questionnaire Bladder neck mobility measured by ultrasound |
3 months PP: UI: 19 % vs. 33 % (p = 0.02) QoL: higher score in the exercise group (p = 0.004) Pad test: no difference Bladder neck mobility: no difference PFM strength: no difference |
Lost to follow-up: 14 % Adherence: 46 % IG women performed PFMT ≥28 days 51 % of CG did unsupervised PFMT |
|
Agur et al. (2008) [33] 8 year follow-up |
N = 164 |
Self-reported UI Performing PFMTSelf-reported UI Performing PFMT |
8 years after index delivery: UI: 35 % vs. 39 % (p = 0.75) Little or no difference in UI severity or QoL between groups. Performing PFMT >1/weekly: 38 % in IG, CG not reported. |
Drop-out: 34 % vs 23 % (p = .004) |
Abbreviations: IG intervention group, CG control group, PFM pelvic floor muscles, PFMC pelvic floor muscle contraction, PFMT pelvic floor muscle training, QoL quality of life, RCT randomized controlled trial, SUI stress urinary incontinence, UI urinary incontinence, VAS visual analogue scale, VPFMC voluntary pelvic floor muscle contraction
Table 17.2
Controlled trials assessing the effect of pelvic floor muscle training during pregnancy to prevent and treat incontinence including women with and without UI or AI at inclusion
|
Author |
Subjects |
Design/intervention |
Outcome |
Results (IG vs. CG) |
Comments |
|
Stafne et al. (2012) [12] |
N = 855 Nulli-/multiparae Continent/incontinent Included between 18 and 22 weeks of pregnancy |
2 arm RCT 1. Control: standard care (including written instructions in PFMT) 2. Intervention: attending weekly standard exercise program (60 min) and performing a home exercise twice weekly (45 min). The group and home exercise program consisted of aerobic activity and strength exercises including PFMT. Encouraged to perform 3 × 8–12 close to maximum PFMC each held for 6–8 s, 3 fast contractions added at the end of the contraction. Individual instruction on correct PFM, VPFMC checked Intervention period lasted 12 weeks |
Self-reported UI and FI |
After 12 weeks intervention (in pregnancy week 32–36): UI ≥1 times per week: 11 % vs. 19 % (p = 0.006) SUI ≥ 1 times per week: 7 % vs. 13 % (p = 0.03) FI: 3 % vs. 5 % (p = 0.24) |
Loss to follow-up: 11 % Adherence: 55 % adhered to the exercise protocol (exercising ≥3 times per week at the end of the intervention period) |
|
Sangsawang et al. (2011) [32] |
N = 70 Nulli-/multiparae SUI (≥1 episode of urinary leakage last month) Included between 20 and 30 weeks of pregnancy. |
Quasi-experimental study, pre-post test with control group 1. Control: usual nursing care (including written instructions in PFMT) 2. Intervention: written and individual oral instruction in correct VPFMC (no vaginal palpation, but instructions in “stop-test” i.e. trying to stop or slow urinary flow) and PFMT. PFMT (45 min) in groups every second week for 6 weeks. Home exercises, with 40 repetitions daily, 5×/week (slow contractions with 10 s holding time and 10 fast contractions at the end of holding time). Performing PFMT was recorded in a training diary. |
SUI severity (frequency and amount) SUI severity (VAS) |
After 6 weeks intervention: No leakage: 39 % vs. 0 % (p = 0.001) Frequency SUI: 2 ± 4 vs. 15 ± 10 (p < 0.001) Severity SUI (VAS): 1.3 ± 1.3 vs. 6.8 ± 2.2 (p < 0.001) |
Loss to follow up: 4 (IG) Adherence: 100 % in IG adhered to the exercise protocol (≥28 days of PFMT) Women in the IG were matched to CG women regarding age, parity and severity of SUI Women who failed to perform PFMC were categorized as dropout No assessment of correct VPFMC |
|
Bø and Haakstad (2011) [27] |
N = 105 Nulliparae Continent/incontinent Sedentary Included within 24 week of pregnancy |
2 arm RCT 1. Control 2. Intervention: attending aerobic fitness classes including PFMT, 2–3×/week, and performing 10 daily PFMC at home. The PFMT instructed in classes consisted of three sets of close to maximum contractions of 8–12 repetitions with holding periods of 6–8 s performed in different positions. Women were encouraged to be physically active ≥30 min daily. Intervention period lasted 12–16 weeks. |
UI and AI reported in a personal interview |
36–38 weeks of pregnancy: UI: 17/42 vs. 16/42 (p = 0.82) Flatus: 11/42 vs. 9/16 (p = 0.61) AI: 1/42 vs. 1/42 6–8 weeks postpartum: UI: 12/43 vs. 13/47 (p = 0.99) Flatus: 10/43 vs. 8/47 (p = 0.46) AI: 1/43 vs. 3/47 (p = 0.62) |
Loss to follow-up: 20 % Adherence: 40 % of IG women attended at least 80 % of the exercise sessions No assessment of correct VPFMC Classes led by an aerobic instructor, verbal instructions were given No data on level of exercise and PFMT in the CG |
|
Ko et al. (2011) [28] |
N = 300 Nulliparae Continent/incontinent Included between 16 and 24 week of pregnancy Performing PFMT was an exclusion criteria |
2 arm RCT 1. Control: received regular prenatal care. 2. Intervention: weekly PFMT in group led by a physiotherapist (45 min). And daily home exercises (3 repetitions of 8 contractions each held for 6 s) performed twice daily. Women were individually instructed in anatomy and correct VPFMC (by observation of inward movement of perineum during contraction). |
UI reported in a personal interview Incontinence Impact Questionnaire (IIQ-7) Urogenital Distress Inventory (UDI-6) |
36 weeks of pregnancy: UI: 34 % vs. 51 % (p < 0.01) 3 days postpartum: UI: 30 % vs. 41 % (p = 0.07) 6 weeks postpartum: UI: 2 % vs. 35 % (p = 0.06) 6 months postpartum: UI: 16 % vs. 27 % (p = 0.04) The IG had lower scores in total UDI-6 and IIQ-7 than CG in late pregnancy and postpartum No differences in pregnancy outcome |
Loss to follow-up: 0 Adherence (defined as performing ≥75 % of PFMT): 87 % |
|
Dinc et al. (2009) [17] |
N = 92 Nulli-/multiparae Incontinent (having complaints of stress/mixed UI in their history) Included between 20 and 34 weeks of pregnancy |
2 arm RCT 1. Control 2. Intervention: thorough instructions in correct PFMC and a home exercise programme with gradually increasing repetitions and holding time until 3 sets of 15 repetitions with 10 s holding time and fast contractions added, repeated 3×/day. |
Self-reported UI |
36–38 weeks of pregnancy: UI: 43 % vs. 71 % 6–8 weeks postpartum: UI: 17 % vs. 38 % Significant difference in episodes of UI, urgency, number of voids and amount of urine in pad test in favor of the IG both at 36–38 weeks pregnancy and at 6–8 weeks postpartum |
Loss to follow-up: 12 Correct VPFMC checked at enrolment in both groups |
|
Woldringh et al. (2006) [31] |
N = 264 Nulli-/multiparae Incontinent (≥2 episodes of loss of urine last month) Included between 17 and 20 weeks of pregnancy |
2 arm RCT 1. Control: routine care. 2. Intervention: four sessions of individual PFMT; three sessions (with 2 week interval) between 23 and 30 weeks of pregnancy and a fourth session 6 weeks PP. Written information including a detailed PFMT programme. |
Self-reported severity of UI Incontinence Impact Questionnaire (IIQ) |
No difference between IG and CG with respect to the severity of UI and impact of UI on daily life |
Lost to follow-up: 50 % Adherence: 37 % reported to exercise almost every day No vaginal palpation of VPFMC, but observation and palpation of the perineal body |
|
Mørkved et al. (2003) [29] |
N = 301 Nulliparae Continent/incontinent Included at 20 weeks of pregnancy |
2 arm RCT single blind 1. Control: customary information given by their midwife or general practitioner. Correct VPFMC checked at inclusion. 2. Intervention: 12 weeks of weekly PFMT in groups led by physiotherapist, with additional home exercises (10 close to maximum PFMC each held for 6 s, 3–4 fast contractions added on the last 4 exercises. Repeated 2×/day). Correct VPFMC checked at inclusion. Intervention period between 20 and 36 weeks of pregnancy |
Self-reported UI (women reporting UI ≥1/week were categorized as incontinent) |
36 weeks of pregnancy: UI: 32 % vs. 48 % (p = 0.07) 3 months postpartum: UI: 20 % vs. 32 % (p = 0.02) |
Dropout rate, 4 % Adherence: 81 % |
|
Sampselle et al. (1998) [30] |
N = 72 Nulliparae Continent/incontinent Included at 20 weeks of pregnancy |
2 arm RCT single blind 1. Control: routine care. 2. Intervention: PFMT tailored to the woman’s individual ability, with muscle identification exercises preceding strength-building efforts. 30 PFMC daily at maximum or near-maximum intensity was recommended for strength building. Correct VPFMC were checked. |
Self-reported UI (results reported as change in mean UI symptom score) |
35 weeks of pregnancy: Less UI symptoms were seen in the IG vs. CG (p = 0.04) 6 weeks postpartum: Less UI symptoms were seen in the IG vs. CG (p = 0.03) 6 months postpartum: Less UI symptoms were seen in the IG vs. CG (p = 0.04) |
Adherence 85 % Study participants were financially compensated, $150 |
Abbreviations: AI anal incontinence, IG intervention group, CG control group, PFMC pelvic floor muscle contraction, PFMT pelvic floor muscle training, RCT randomized controlled trial, SUI stress urinary incontinence, UI urinary incontinence, VAS visual analogue scale, VPFMC voluntary pelvic floor muscle contraction
AI and PFMT in Pregnancy
No randomised or quasi-randomised trials reporting on the effect of PFMT on primary prevention of AI/FI in pregnancy were identified. Two trials including both continent and incontinent women reported on AI/FI in pregnancy. Bø and Haakstad (2012) [27] found no differences in AI symptoms between intervention and control groups. Although not reaching statistical significance, Stafne and co-workers (2012) [12] found fewer women with FI in the intervention group. In a subgroup analysis, however, performing PFMT in the second half of pregnancy was shown to have a protective effect on late pregnancy FI in multiparous and not in primiparous women [12]. These findings indicate that even among women with potential weakening or injury to the PFM or obstetric anal sphincter injury from a previous pregnancy or delivery, specific training of the PFM may prevent or reduce the severity of incontinence in subsequent pregnancies. However, as FI was not the primary outcome measure of these studies, both were underpowered to assess FI.
UI and PFMT Postpartum
In a systematic literature search on PubMed, ten randomised trials were found where six trials included a mixed population of continent and incontinent women [34–39] and four trials included incontinent women only [40–43] (Table 17.3). All four trials assessing the effect of PFMT in treatment of urinary incontinence postpartum had significant reductions in UI among intervention group women. Kim and co-workers (2012) [40] compared a PFMT programme with abdominal strengthening exercises and trunk stabilisation with or without supervision and found reductions in clinical symptoms of UI, including QoL measures in both groups. The improvements were greater in the supervised group, however, this was a pilot study and included only 20 postpartum women. In addition, two studies reported on 6 and 7 years follow up. Glazener and co-workers (2005) [44] found no differences between groups in UI after 6 years, whereas Dumoulin and co-workers (2013) [45] found that over 50 % of the women in the PFMT groups were still continent after 7 years.
Table 17.3
Controlled trials assessing the effect of pelvic floor muscle training postpartum to prevent and treat incontinence including women with and without UI or AI at inclusion
|
Author |
Subjects |
Design/intervention |
Outcome |
Results (IG vs CG) |
Comment |
|
Urinary incontinence as primary outcome measure |
|||||
|
Hilde et al. (2013) [34] |
N = 175 Primiparae with no 3rd or 4th grade perineal tear Continent/incontinent Included at 6 weeks after vaginal delivery, stratified by major levator ani muscle defects |
2-arm RCT, single blind 1. Control: oral and written instruction on how to perform correct PFMC at inclusion, no further intervention 2. Intervention: weekly PMFT, in group led by physiotherapist. Daily home exercises: 3 sets of 8–12 close to maximum PFMC each held for 6–8 s, 3 fast contractions added on the last 4 exercises. Intervention period was 16 weeks. VPFMC checked at inclusion in both groups. Exercise diary of home exercises, group attendance recorded by physiotherapist. |
Self-reported UI (ICI-Q UI SF) Pad test |
Baseline: UI: 39 % vs 50 % 6 months postpartum: UI: 35 % vs 39 %, effect size: 0.89 (95 % CI: 0.6–1.3) Similar results in stratum with or without major leavtor ani defects, effect size: 0.89 (95 % CI: 0.5–.16) vs 0.90 (95 % CI: 0.5–1.5), respectively. No sign differenced in pad test between groups. |
Loss to follow up: 8.6 %; Higher drop-out rate in IG: 12/87 vs. 3/88 96 % adhered to the exercise protocol (≥80 % of class sessions and daily home training Number of women performing PFMT at baseline: 35 % vs 50 % (p = .10) |
|
Kim et al. (2012) [40] |
N = 20 Parous women Incontinent Included <6 weeks after normal vaginal delivery. |
2-arm RCT, pilot study 1. Control: Unsupervised PFMT 2. Intervention: Supervised PFMT Intervention period was 8 weeks. VPFMC checked at inclusion in both groups. Both groups were instructed to perform PFMT daily. All women received a booklet and exercise diary. |
UI (Bristol female lower urinary tract symptoms) Vaginal squeeze pressure |
Significant difference in UI and vaginal squeeze pressure in favour of the supervised PFMT group on after the intervention period. |
Loss to follow up: 2/20 Adherence: not stated |
|
Ewings et al. (2005) [35] |
N = 234 Parous women Continent/incontinent |
Nested RCT 1. Control: usual postnatal care including verbal promotion of postnatal PFMT and leaflet explaining how to do PFMT. 2. Intervention: taught one to one with physiotherapist in hospital, with intervention to attend PFMT group at 2 and 4 months after delivery. No details of PFMT programme given. |
UI |
6 months postpartum: UI: 60 % vs 47 % (p = .10) |
Loss to follow-up: 19 % (27/90 vs 17/100) Adherence to PFMT in the intervention group: 5/90 (5.6 %) |
|
Dumoulin et al. (2004) [41] |
N = 64 Parous women Weekly SUI at ≥3 months after their last delivery Recruited during annual gyenaecological visit |
3-arm RCT 1. Control: 8 weekly sessions of massage 2. PFM rehabilitation: Weekly sessions supervised by physiotherapist for 8 weeks: 15-minutes electrical stimulation (biphasic rectangular form; frequency 50 Hz; pulse with 250 ms; duty cycle, 6 s on and 18 s off for the first 4 weeks and 8 s on and 24 s off for the last 4 weeks; maximal tolerated current intensity) + 25 min PFMT with biofeedback + home training 5 days per week. 1. PFM rehabilitation (as group 2) + 30 min deep abdominal muscle training |
Pad test Self-reported weekly UI |
Less than 2 g urine on pad test after intervention period: CG: 0/19 PFM rehabilitation: 14/20 PFM rehabilitation + deep abdominal muscle training: 17/23 Significant difference in favour of the intervention groups (p = 0.001) Non-significant difference between the two intervention groups Incontinence Impact Questionnaire: Significant difference in favour of the intervention groups PFM strength: Non-significant difference between groups. |
Drop-out rate: 6 % High adherence |
|
Dumoulin et al. (2013) [45] 7 year follow-up |
N = 35 Combination of the previous two intervention groups |
Pad test Self-reported UI |
Less than 2 g urine on pad test (performed by 26 out of 35 women): 14/26 (53 %) Incontinence Impact Questionnaire: Significantly better than at baseline |
61.4 % of the participants from the original studies agreed to participate in the follow-up study Percentage performing any PFMT: 54 % |
|
|
Chiarelli & Cockburn (2002) [36] |
N = 720 Primi-/multiparae Continent/incontinent Postnatal women following forceps or ventouse delivery, or birthweight 4000 g or more Included while in hospital postpartum |
2-arm parallel group 1. Control: usual care, leaflet on PFMT 2. Intervention: continence promotion. One contact with physiotherapist on postnatal ward and another at 8 weeks postpartum (correct VPFMC checked at second visit). Intervention included individually tailored PFMT, use of transversus abdominus contraction, the ‘Knack’, techniques to minimise perineal descent, postpartum wound management. Written and verbal information. |
Self-reported UI Urinary diary (3 days) |
Baseline: UI: 18 % vs 17 % 3 months postpartum: UI: 31 % vs 38 % (p = .04) |
Drop-out rate: 6 % in each group Adherence: 84 % vs 58 % (p = .001) |
|
Chiarelli et al. (2004) [47] 12 month follow-up |
Self-reported UI (telephone interview) |
12 months postpartum: No significant difference in UI status IG significantly more likely to perform PFMT at adequate levels, continued adherence predictive of continence at 12 months postpartum |
Drop-out rate: 30 % |
||
|
Glazener et al. (2001) [42] |
N = 747 Primi-/multiparae UI at 3 months postpartum |
2-arm RCT 1. Control: no visit 2. Intervention: assessment of UI by nurses, with conservative advice on PFM exercises (80–100 fast/slow contractions daily) 5, 7, and 9 months after delivery supplemented by bladder training if appropriate at 7 and 9 months |
Self-reported UI and FI PFMT |
3 months postpartum (baseline): Severe UI: 57 % vs 54 % FI: 16 % vs 15 % 12 months postpartum: Any UI: 60 % vs 69 % (p = .037) Severe UI: 20 % vs 32 % (p = .002) Any FI: 4 % vs 11 % (p = .012) Severe FI: 2 % vs 5 % (p = .075) |
Loss to follow-up at 12 months postpartum: 25 % vs 35 % |
|
Glazener et al. (2005) [44] 6 year follow-up |
N = 516 |
6 years postpartum: Severe UI: 58 % vs 51 % Any FI: 14 % vs 14 % |
Loss to follow-up at 6 years postpartum: 30 % (263/371 vs 253/376) Percentage performing any PFMT at 6 years postpartum: 50 % vs 50 % |
||
|
Meyer et al. (2001) [37] |
N = 107 Nulliparae Continent/incontinent Recruited between 12 and 39 weeks postpartum (mean 29 ± 7 weeks) |
2-arm controlled study, assigned in alternating manner 1. Control: no PFM education until after intervention period 2. Intervention: 12 sessions of PFMT, followed by 20 min biofeedback and 15 min electrical stimulation. Intervention period was between 2 and 10 months postpartum. VPFMC was checked prior to intervention. |
Self-reported UI and FI |
Base line: UI: 14/51 vs 18/56 AI: 0/51 vs 0/56 10 months postpartum: UI: 6/51 vs 8/56 AI: 2/5| vs 3/56 Cure rate: 19 % vs. 2 % (p = 0.002) |
Loss to follow up, drop-out or adherence to PFMT protocol not reported. PFMT protocol not reported |
|
Wilson and Herbison (1998) [43] |
N = 230 Primi-/multiparae Incontinent at 3 months postpartum. Stratified by parity, UI severity and mode of delivery. |
2-arm RCT 1. Control: standard post natal PFMT taught by physiotherapist while in hospital 2. Intervention: 4 sessions (3, 4, 6, 9 months postpartum) with PFME instructed by physiotherapist. IG further randomised into 3 groups; (a) PFMT (8–10 sessions of a total of 80–100 daily PFMC + biofeedback with vaginal perionometer); (b) PFMT & cone weights (PFMT + 15 min training with vaginal cone weight daily) (c) Cone group (15 min training with vaginal cones) daily |
Self-reported UI and FI Home pad test PFMT in the past months |
Baseline: UI: 89 % vs 89 % PFMT in last month: 79 % vs 77 % 12 months postpartum: UI: 50 % vs 76 %* FI: 22 % vs 22 % PFMT in last month: 89 % vs 65 % 24–44 months postpartum: PFMT in last month: 58 % vs 54 % |
Loss to follow up: 85/230 (IG: 59/113 CG: 26/117) *Significantly less UI in IG, however due to high drop-out rate in IG, results must be interpreted with caution |
|
Mørkved and Bø (1997) [38] |
N = 198 Primi-/multiparae Continent/incontinent |
Prospective matched control study 1. Control: customary written postpartum instructions from the hospital. Not discouraged from performing PFM exercises on their own. Correct VPFMC checked at enrolment. 2. Intervention: 8 weeks of intensive pelvic floor muscle training (in a group) led by physiotherapist with additional home exercises. The intervention started 8 weeks postpartum. Correct VPFMC checked. |
Self-reported SUI Pad test Urodynamics |
16 weeks postpartum: UI: 14 % vs 28 % (p = .015) Pad test: 3 % vs 13 % (p = .009) PFM strength improvement: 5.3 vs 0.8 (p = <.01) |
Drop-out IG: 7/99 Percentage performing PFMT between 8 and 16 weeks postpartum: 100 % vs 65 % |
|
Mørkved and Bø (2000) [46] One year follow-up |
N = 180 |
Self-reported UI Pad test PFM strength in women performing PFMT less or more than 3 times per week |
12 months postpartum: UI: 17 % vs 38 % (p < .003) Pad test: 3 % vs 13 % (p < .001) Change in PFM strength in women performing PFMT 3 times or more per week: 4.9 (95 % CI: 3.7–6.2) vs. performing PFMT less or more than 3 times per week: 1.8 (95 % CI: 0.8–2.7) |
Drop-out: 18 pairs Percentage performing PFMT between 16 weeks and 1 year postpartum: 53 % vs 24 % |
|
|
Sleep and Grant (1987) [39] |
N = 1800 Continent/incontinent Recruited within 24 h of vaginal delivery |
2 arm RCT 1. Control: Current standard antenatal and postnatal care. Recommended to do VPFMC as often as remember and mid stream urine stop. 4 week health diary 2. Intervention: As above plus one individual session daily while in hospital with midwifery co-ordinator. Four weeks health diary including additional section recommending a specific PFMT task each week (all tasks related to integrating VPFMC with usual daily activity). |
Self-reported UI |
3 months postpartum: UI: 22 % vs 22 % |
Drop-out rate: 107/900 vs 84/900 Performing PFMT at 3 months postpartum: 58 % vs 42 % |
|
Anal or faecal incontinence as primary outcome measure |
|||||
|
Peirce et al. (2013) [74] |
N = 120 Continent/incontinent Primiparae recruited prior to discharge home from hospital postpartum |
2-arm RCT 1. Home PFMT: Standard PFMT 5 min twice daily for 3 months 2. Early EMG biofeedback + PFMT: use of home biofeedback programme (5 s hold, 10 s rest × 10) twice daily and PFMT as for group 1 Participants recorded adherence to PFMT protocol in an training diary |
Self-reported FI (Jorge Wexner score) QoL (Fecal Incontinence QoL scale) Anal resting and squeeze pressures (Manometry) |
After 3 months of treatment: No differences in incontinence scores, QoL scores or anal resting/squeeze pressures between groups. |
Drop-out: 0 Adherence: 7/30 did not use ES as per protocol due to lack of time and absence of FI symptoms. Adherence not reported in BF group. |
|
Mahony et al. (2004) [48] |
N = 60 Incontinent Primi-/multiparae recruited 12 weeks following obstetric injury |
2-arm RCT, single blind 1. BF: weekly intra-anal biofeedback (alternating slow twitch (hold 5 s, relax 8 s) and fast twitch (3 rapid maximum VPFMC for 5 s, relax 8 s) for 10 min) with physiotherapist for 12 weeks. Daily PFMT home exercises. 2. BF + ES: weekly intra-anal electrical stimulation (35 Hz, 20 % ramp modulation, 5 s on/8 s off for 20 min, intensity eliciting contraction of the external anal sphincter muscle) and intra-anal biofeedback (as for group 1) for 12 weeks |
Self-reported AI (Jorge Wexner score) QoL (Fecal Incontinence QoL scale) Mean maximum anal squeeze and resting pressures Endoanal ultrasound |
After 12 weeks of treatment: Continent (FI): 8/28 (BF + ES) vs 6/26 (BF) Significant reductions in incontinence scores and QoL scores in both groups after treatment. Significant improvement in anal squeeze pressure and anal squeeze pressure increments in both groups. No change in anal resting pressures. 3 % had a normal endoanal ultrasound scan. |
Loss to follow-up: 6/60 (BF + ES: 2; BF: 4) Adherence to PFMT not reported |
|
Fynes et al. (1999) [49] |
N = 40 Incontinent Primi-/multiparae consecutively recruited from perineal clinic following obstetric anal sphincter injury |
2-arm RCT 1. Sensory BF: weekly sessions of sensory vaginal biofeedback PFMT (20 short maximum PFMC of 6–8 s hold, 10 s relax and 30 s hold PFMC) + Standard home PFMT 2. Augmented BF: weekly anal electrical stimulation (20 % ramp modulation and 20 Hz 5 s on/8 s off for 10 min followed by 50 Hz, 8 s on/30 rest for 10 min) and EMG biofeedback (PFMC alternating between hold 5 s and rapid maximum squeezes during 5 s and 8 s relax for 15 min) + Standard home PFMT |
Self-reported FI PFM strength (manometry) |
After 12 weeks of treatment: Median FI: 0 (AugBF) vs 4 (SensBF) (p < .0001) Asymptomatic FI: 15/20 (AugBF) vs 7/19 (SensBF) Significant increases in the mean maximum resting and squeeze pressures and squeeze increments in AugBF group. No significant difference in SensBF group Poorer outcome in participants with full thickness defects of the external anal sphincter muscle. |
Loss to follow-up: 1/40 |
Abbreviations: AI anal incontinence, BF biofeedback, CI confidence interval, EMG electromyography, ES electrical stimulation, FI faecal incontinence, IG intervention group, CG control group, PFM pelvic floor muscles, PFMCpelvic floor muscle contraction, PFMT pelvic floor muscle training, RCT randomized controlled trial, SUI stress urinary incontinence, UI urinary incontinence, VAS visual analogue scale, VPFMC voluntary pelvic floor muscle contraction
In the trials with a mixed population, an improvement in UI was found in three out of six studies [36–38]. Mørkved and Bø (2000) [46] reported that the effect of PFMT was still present 1 year after the cessation of the training programme, while Chiarelli and Cockburn (2004) [47] found no persistent effect after 1 year. However, they found that continued adherence to PFMT at 12 months was predictive of UI at that time. Three trials found no differences between intervention and control group [34, 35, 39], however, in two of the trials there was little distinction between the intervention offered and the care given to the control group [35, 39]. The trial by Hilde and co-workers (2013) [34] included primiparous women 6 weeks postpartum. All participants were given thorough instructions in correct VPFMC, with both ultrasonography and digital palpation prior to randomisation to either usual care or weekly PFMT class and home PFM exercises. After the 16 weeks of intervention period, there were no differences between groups with regards to prevalence of UI or effect size.
AI and PFMT Postpartum
In the three studies reporting on mixed prevention and treatment of FI/AI postpartum, there was no evidence favouring PFMT over standard or usual care [27, 39] or no PFMT [37]. However, none of these studies were designed with FI or AI as the main outcome measure, the confidence intervals tended to be wide, indicating that the trials may have been underpowered in order to evaluate the effect of the intervention on postpartum FI/AI. In the study by Sleep and Grant (1987) [39], both study groups received standard instructions of home PFMT prior to discharge home from hospital after delivery, and one group also received reinforcement of these instructions during home visits by community midwives during the first 4 weeks postpartum. The effect of these interventions was assessed 2 months later and revealed no differences in UI or FI between groups [39]. Two trials have reported on the prevalence of AI/FI and the treatment effect of PFMT in women with UI at inclusion. In the study by Wilson and co-workers (1998) [43], more than half of the women randomized to the intervention groups receiving reinforced PFMT with or without cone weights withdrew before the end of the study, and the study was thus underpowered in order to show any differences in prevalence of AI between groups. The findings in the study by Glazener and co-workers (2001) [42] suggest that PFMT may reduce co-existing AI in patients referred with UI. Further, a significant difference in the number of daily PFM contractions performed was found, favouring the PFMT group [42]. At 6 years postpartum, however, these group differences did not persist, as the number of women who reported performing daily PFM contractions was halved, and the prevalence of FI/AI was similar in the PFMT and the control groups [44].
Two studies have compared the effect of postpartum PFMT in conjunction with other treatment aids such as biofeedback and electrical stimulation in women with AI/FI postpartum [48, 49]. Both studies had a low drop-out rate and the results show an increased ability to perform VPFMC and a reduction of FI/AI symptoms following PFMT [48, 49]. Mahony and co-workers (2004) [48] offered women experiencing AI symptoms postpartum PFMT with biofeedback or PFMT with biofeedback and a standardised electrical stimulation programme for 12 weeks. Due to ethical reasons, the study included no control group. A total of 85 % of participants reported improvements in FI symptoms and 26 % became asymptomatic. Further, participants reported significant improvements in QoL scores. Both groups showed a significant improvement in median PFM squeeze pressure, however, a larger increment was found in the group performing PMFT with biofeedback and no electrical stimulation. Similar results were found by Fynes and co-workers (1999) [49], who compared PFMT and vaginal biofeedback to PFMT and anal biofeedback augmented by a standardised electrical stimulation programme during a 12 week treatment period. Continence scores improved in both treatment groups, however, more participants became asymptomatic in the group receiving PFMT and biofeedback augmented with electrical stimulation and only the women in the augmented biofeedback group had increased resting and squeeze pressures.
Cost of Incontinence
The cost of incontinence-related illness is a substantial economic and human burden, highlighting the need for effective forms of prevention and management [50]. Symptoms of UI or AI before or during pregnancy have been found to be the main risk factors for incontinence symptoms postpartum [51–62]. In a 12 year prospective study, Viktrup and co-workers (2006) [57] reported that women with onset of UI in pregnancy or shortly after their first delivery had increased risk of long-lasting symptoms. Among women who were continent during their first pregnancy and the postpartum period, the prevalence of UI 12 years after the first delivery was 33 % compared to 66 % in women who became incontinent during their first pregnancy and the postpartum period [63]. Similarly, women with AI symptoms in the first year after delivery have an increased risk of long term AI symptoms [64, 65]. Experiencing UI or AI/FI 6 months postpartum has been found to have a negative impact on health related QoL [66], and poorer QoL has been reported among women experiencing severe symptoms or both UI and AI/FI in pregnancy and postpartum [66–68].
Using 1995 estimates, the direct annual cost of UI in women was similar to the annual expenditures of other chronic diseases, and estimated to be $12.4 billion [69]. It has been estimated that the financial burden of incontinence for patients as well as society is relatively large. Furthermore, the financial burden may increase in the future due to an aging population and direct costs related to medical care and treatment, as well as indirect costs related to factors such as the loss of productivity [69–72]. Increasing costs of FI have been shown to be associated with symptom severity and female gender, whereas age was found to be associated with reduced costs among patients experiencing AI for more than 1 year [70]. Among older patients with longstanding FI, loss of productivity in paid and unpaid work accounted for half the estimated total cost of FI [71]. Considering that incontinence symptoms in pregnancy and the first year postpartum have been found to be strongly associated with incontinence symptoms in the long term, identifying women with AI symptoms affecting QoL in the first year postpartum may reduce the long term adverse effect of AI both with regards to personal as well as societal costs.
Criteria for Successful Treatment Outcomes and Recommendations
In the current literature, there are insufficient details on the PFMT protocols in order to assess their potential to improve PFM function and subsequently reduce UI and AI/FI [11]. However, common factors for all trials reporting a positive effect of PFMT in pregnancy or postpartum were found to be thorough clinical assessment of the participants’ ability to perform VPFMC, close individual or group follow-up, and high adherence to the exercise protocol [11, 34]. In contrast, trials with little or no effect tended to have an inadequate training dosage, infrequent or no follow up of participants during the intervention period or low adherence to the exercise protocols. Further, considering the spontaneous changes occurring to the PFM during the first 6 months postpartum [73], it may be that the duration of the intervention in some of these studies was insufficient and introduced as well as assessed too early postpartum in order to result in any clinical improvement in PFM strength and function [34, 74].
Furthermore, it is suggested that individual and supervised PFMT interventions may be more successful than group-based interventions in women with severe incontinence symptoms, major levator ani or sphincter ani muscle defects or reduced ability to perform PFM contractions [34]. Nevertheless, the effect of PFMT during pregnancy to prevent UI and AI appears to still be open to question [23, 75, 76]. There is a lack of trials investigating the effect of implementing PFMT in a more general training program for pregnant women. Boyle and co-workers (2012) [11] strongly recommend that all future trials of PFMT during pregnancy or postpartum should collect data on AI as well as UI, and highlight the need for large, pragmatic trials with population-based approaches, using adequate PFMT intensity. Further, considering the complex and multifactorial pathophysiology of AI/FI in particular, multifactorial interventions have been recommended in future trials on the effect of PFMT on reducing AI/FI symptoms in pregnancy and postpartum aiming at reducing the frequency of AI/FI, improving rectal sensibility and changing stool quality [77].
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