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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.

  •   Gynaecological disorders, Renal and urogenital disorders, Primary care, Physical therapy, Acute and general medicine
Pelvic floor muscle training can improve symptoms of urinary incontinence

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).

 

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