Discover Portal

Woman doing pelvic floor exercises

NIHR Signal Pelvic floor muscle training can improve symptoms of urinary incontinence

Published on 2 January 2019

doi: 10.3310/signal-000702

Two-thirds of women with any type of urinary incontinence who have pelvic floor muscle training see improvement or cure compared with only a third of women who receive no treatment or inactive treatments. It is even more effective for women with stress incontinence, with three-quarters of women reporting improvement or resolution of symptoms, such as episodes of leakage.

This systematic review included 31 trials and 1,817 women with any type of incontinence; stress, urgency or mixed urinary incontinence.

Findings support current guidelines to offer pelvic floor exercises as first-line conservative management in women with urinary incontinence. Long-term effectiveness and cost-effectiveness require further evaluation.

Share your views on the research.

Why was this study needed?

The prevalence of urinary incontinence for women living in the UK is approximately 34%. However, prevalence is likely to be higher as embarrassment and other factors lead to underreporting. Incontinence can affect women of all ages and has a serious impact on quality of life.

Urinary incontinence is the involuntary leakage of urine. The two main causes are overactive bladder, resulting in urge incontinence, and weakness of the pelvic floor and urethral sphincter leading to stress incontinence.

There are various non-surgical options to help reduce incontinence including pelvic floor muscle training (PFMT). However, there is uncertainty about the effects of PFMT, specifically the size of effect. This review is an update of a previous Cochrane review done in 2014 and aims to assess the effects of PFMT for women with urinary incontinence in comparison to no treatment, placebo or sham treatments.

What did this study do?

This systematic review included 31 randomised controlled trials involving 1,817 women from 14 countries. Two trials were based in the UK. The studies included women with stress, urgency or mixed urinary incontinence. Women were randomly allocated to pelvic floor muscle training, no treatment, or other inactive control treatments. On average, trials followed up patients for less than 12 months.

Overall, trials included were of moderate quality, and outcomes appeared to be consistent. However, most trials failed to include a clear description of the training or its intensity which could influence the outcomes. Few trials had long-term follow up.

What did it find?

  • Cure was eight times more likely to be reported by women with stress incontinence who were in the intervention group (56% vs 6% with control; risk ratio [RR] 8.38, 95% confidence interval [CI] 3.68 to 19.07; 4 trials, 165 women).
  • Cure was five times more likely to be reported by women with any type of urinary continence in the intervention groups (35% vs 6% with control; RR 5.34, 95% CI 2.78 to 10.26; 3 trials; 290 women).
  • Improvement or cure was reported six times more frequently in women with stress urinary incontinence who were in the intervention groups (74% vs 11% with control; RR 6.33, 95% CI 3.88 to 10.33; 3 trials, 242 women).
  • Improvement or cure was twice as likely to be reported by women with any type of urinary incontinence in the intervention groups (67% vs 29% with control; RR 2.39, 95% CI 1.64 to 3.47; 2 trials; 166 women).
  • Women with stress urinary incontinence in the pelvic floor muscle training groups had one fewer leakage episodes over 24 hours (mean difference [MD] 1.23 lower, 95% CI 1.78 lower to 0.68 lower; 7 trials, 432 women) and in women with all types of urinary incontinence (MD 1.00 lower, 95% CI 1.37 lower to 0.64 lower; 4 trials, 349 women).

What does current guidance say on this issue?

NICE guidance updated in 2015 advises a trial of supervised pelvic floor muscle training for at least three months as first-line treatment for women with stress or mixed urinary incontinence. The training should involve at least eight contractions three times per day. This exercise programme should continue for longer if PFMT is beneficial.

General NHS advice is for all women to perform pelvic floor exercises throughout their lives.

What are the implications?

This study confidently concludes that pelvic floor muscle training can resolve symptoms or improve stress incontinence and other types of urinary incontinence.

Overall, women were more likely to report better quality of life, and PFMT may reduce the number and quantity of leakage episodes. Women should be encouraged to perform pelvic floor exercises on a daily basis to prevent and manage urinary incontinence.

Citation and Funding

Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018;(10):CD005654.

This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure, Cochrane Programme Grant or Cochrane Incentive funding to the Cochrane Incontinence Group.

Bibliography

Dumoulin C, Hay‐Smith EJ, Mac Habée‐Séguin G. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2014;(5):CD005654.

Guy’s and St Thomas’ NHS Foundation Trust. Pelvic floor exercises for women. London: Guy’s and St Thomas’ NHS Foundation Trust; 2017.

NICE. Urinary incontinence in women: management. CG171. London: National Institute for Health and Care Excellence. 2013 (updated 2015).

 

Why was this study needed?

The prevalence of urinary incontinence for women living in the UK is approximately 34%. However, prevalence is likely to be higher as embarrassment and other factors lead to underreporting. Incontinence can affect women of all ages and has a serious impact on quality of life.

Urinary incontinence is the involuntary leakage of urine. The two main causes are overactive bladder, resulting in urge incontinence, and weakness of the pelvic floor and urethral sphincter leading to stress incontinence.

There are various non-surgical options to help reduce incontinence including pelvic floor muscle training (PFMT). However, there is uncertainty about the effects of PFMT, specifically the size of effect. This review is an update of a previous Cochrane review done in 2014 and aims to assess the effects of PFMT for women with urinary incontinence in comparison to no treatment, placebo or sham treatments.

What did this study do?

This systematic review included 31 randomised controlled trials involving 1,817 women from 14 countries. Two trials were based in the UK. The studies included women with stress, urgency or mixed urinary incontinence. Women were randomly allocated to pelvic floor muscle training, no treatment, or other inactive control treatments. On average, trials followed up patients for less than 12 months.

Overall, trials included were of moderate quality, and outcomes appeared to be consistent. However, most trials failed to include a clear description of the training or its intensity which could influence the outcomes. Few trials had long-term follow up.

What did it find?

  • Cure was eight times more likely to be reported by women with stress incontinence who were in the intervention group (56% vs 6% with control; risk ratio [RR] 8.38, 95% confidence interval [CI] 3.68 to 19.07; 4 trials, 165 women).
  • Cure was five times more likely to be reported by women with any type of urinary continence in the intervention groups (35% vs 6% with control; RR 5.34, 95% CI 2.78 to 10.26; 3 trials; 290 women).
  • Improvement or cure was reported six times more frequently in women with stress urinary incontinence who were in the intervention groups (74% vs 11% with control; RR 6.33, 95% CI 3.88 to 10.33; 3 trials, 242 women).
  • Improvement or cure was twice as likely to be reported by women with any type of urinary incontinence in the intervention groups (67% vs 29% with control; RR 2.39, 95% CI 1.64 to 3.47; 2 trials; 166 women).
  • Women with stress urinary incontinence in the pelvic floor muscle training groups had one fewer leakage episodes over 24 hours (mean difference [MD] 1.23 lower, 95% CI 1.78 lower to 0.68 lower; 7 trials, 432 women) and in women with all types of urinary incontinence (MD 1.00 lower, 95% CI 1.37 lower to 0.64 lower; 4 trials, 349 women).

What does current guidance say on this issue?

NICE guidance updated in 2015 advises a trial of supervised pelvic floor muscle training for at least three months as first-line treatment for women with stress or mixed urinary incontinence. The training should involve at least eight contractions three times per day. This exercise programme should continue for longer if PFMT is beneficial.

General NHS advice is for all women to perform pelvic floor exercises throughout their lives.

What are the implications?

This study confidently concludes that pelvic floor muscle training can resolve symptoms or improve stress incontinence and other types of urinary incontinence.

Overall, women were more likely to report better quality of life, and PFMT may reduce the number and quantity of leakage episodes. Women should be encouraged to perform pelvic floor exercises on a daily basis to prevent and manage urinary incontinence.

Citation and Funding

Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018;(10):CD005654.

This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure, Cochrane Programme Grant or Cochrane Incentive funding to the Cochrane Incontinence Group.

Bibliography

Dumoulin C, Hay‐Smith EJ, Mac Habée‐Séguin G. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2014;(5):CD005654.

Guy’s and St Thomas’ NHS Foundation Trust. Pelvic floor exercises for women. London: Guy’s and St Thomas’ NHS Foundation Trust; 2017.

NICE. Urinary incontinence in women: management. CG171. London: National Institute for Health and Care Excellence. 2013 (updated 2015).

 

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women

Published on 6 October 2018

Dumoulin, C.,Cacciari, L. P.,Hay-Smith, E. J. C.

Cochrane Database Syst Rev Volume 10 , 2018

BACKGROUND: Pelvic floor muscle training (PFMT) is the most commonly used physical therapy treatment for women with stress urinary incontinence (SUI). It is sometimes also recommended for mixed urinary incontinence (MUI) and, less commonly, urgency urinary incontinence (UUI).This is an update of a Cochrane Review first published in 2001 and last updated in 2014. OBJECTIVES: To assess the effects of PFMT for women with urinary incontinence (UI) in comparison to no treatment, placebo or sham treatments, or other inactive control treatments; and summarise the findings of relevant economic evaluations. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register (searched 12 February 2018), which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, handsearching of journals and conference proceedings, and the reference lists of relevant articles. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials in women with SUI, UUI or MUI (based on symptoms, signs or urodynamics). One arm of the trial included PFMT. Another arm was a no treatment, placebo, sham or other inactive control treatment arm. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed trials for eligibility and risk of bias. We extracted and cross-checked data. A third review author resolved disagreements. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions. We subgrouped trials by diagnosis of UI. We undertook formal meta-analysis when appropriate. MAIN RESULTS: The review included 31 trials (10 of which were new for this update) involving 1817 women from 14 countries. Overall, trials were of small-to-moderate size, with follow-ups generally less than 12 months and many were at moderate risk of bias. There was considerable variation in the intervention's content and duration, study populations and outcome measures. There was only one study of women with MUI and only one study with UUI alone, with no data on cure, cure or improvement, or number of episodes of UI for these subgroups.Symptomatic cure of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were eight times more likely to report cure (56% versus 6%; risk ratio (RR) 8.38, 95% confidence interval (CI) 3.68 to 19.07; 4 trials, 165 women; high-quality evidence). For women with any type of UI, PFMT groups were five times more likely to report cure (35% versus 6%; RR 5.34, 95% CI 2.78 to 10.26; 3 trials, 290 women; moderate-quality evidence).Symptomatic cure or improvement of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were six times more likely to report cure or improvement (74% versus 11%; RR 6.33, 95% CI 3.88 to 10.33; 3 trials, 242 women; moderate-quality evidence). For women with any type of UI, PFMT groups were two times more likely to report cure or improvement than women in the control groups (67% versus 29%; RR 2.39, 95% CI 1.64 to 3.47; 2 trials, 166 women; moderate-quality evidence).UI-specific symptoms and quality of life (QoL) at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT group were more likely to report significant improvement in UI symptoms (7 trials, 376 women; moderate-quality evidence), and to report significant improvement in UI QoL (6 trials, 348 women; low-quality evidence). For any type of UI, women in the PFMT group were more likely to report significant improvement in UI symptoms (1 trial, 121 women; moderate-quality evidence) and to report significant improvement in UI QoL (4 trials, 258 women; moderate-quality evidence). Finally, for women with mixed UI treated with PFMT, there was one small trial (12 women) reporting better QoL.Leakage episodes in 24 hours at the end of treatment: PFMT reduced leakage episodes by one in women with SUI (mean difference (MD) 1.23 lower, 95% CI 1.78 lower to 0.68 lower; 7 trials, 432 women; moderate-quality evidence) and in women with all types of UI (MD 1.00 lower, 95% CI 1.37 lower to 0.64 lower; 4 trials, 349 women; moderate-quality evidence).Leakage on short clinic-based pad tests at the end of treatment: women with SUI in the PFMT groups lost significantly less urine in short (up to one hour) pad tests. The comparison showed considerable heterogeneity but the findings still favoured PFMT when using a random-effects model (MD 9.71 g lower, 95% CI 18.92 lower to 0.50 lower; 4 trials, 185 women; moderate-quality evidence). For women with all types of UI, PFMT groups also reported less urine loss on short pad tests than controls (MD 3.72 g lower, 95% CI 5.46 lower to 1.98 lower; 2 trials, 146 women; moderate-quality evidence).Women in the PFMT group were also more satisfied with treatment and their sexual outcomes were better. Adverse events were rare and, in the two trials that did report any, they were minor. The findings of the review were largely supported by the 'Summary of findings' tables, but most of the evidence was downgraded to moderate on methodological grounds. The exception was 'participant-perceived cure' in women with SUI, which was rated as high quality. AUTHORS' CONCLUSIONS: Based on the data available, we can be confident that PFMT can cure or improve symptoms of SUI and all other types of UI. It may reduce the number of leakage episodes, the quantity of leakage on the short pad tests in the clinic and symptoms on UI-specific symptom questionnaires. The authors of the one economic evaluation identified for the Brief Economic Commentary reported that the cost-effectiveness of PFMT looks promising. The findings of the review suggest that PFMT could be included in first-line conservative management programmes for women with UI. The long-term effectiveness and cost-effectiveness of PFMT needs to be further researched.

Expert commentary

Over half the women from the trials reported complete resolution of their incontinence, with nearly three quarters reporting either complete resolution or improvement.

Because there were few trials specifically looking at urge incontinence (related to a strong urge to empty the bladder), or mixed incontinence, it is more difficult to extrapolate for these groups, and further research would be useful for these conditions.

However, overall pelvic floor muscle training is low risk and, once women are confident with the technique, is easy to perform. Therefore women can undertake supervised pelvic floor exercises confident that the majority of them will see improvements in symptoms and quality of life.

Carolyn Lindsay, Lead Senior Physiotherapist, Chesterfield Royal Hospital NHS Foundation Trust

The commentator declares no conflicting interests