Pelvic Floor Exercises and Urinary Incontinence in Women
Background Urinary incontinence (UI) is a common condition in women causing reduced quality of life and withdrawal from fitness and exercise activities. Pregnancy and childbirth are established risk factors. Current guidelines for exercise during pregnancy have no or limited focus on the evidence for the effect of pelvic floor muscle training (PFMT) in the prevention and treatment of UI.
Aims Systematic review to address the effect of PFMT during pregnancy and after delivery in the prevention and treatment of UI.
Data sources PubMed, CENTRAL, Cochrane Library, EMBASE and PEDro databases and hand search of available reference lists and conference abstracts (June 2012).
Methods Study eligibility criteria: Randomised controlled trials (RCTs) and quasiexperimental trials published in the English language. Participants: Primiparous or multiparous pregnant or postpartum women. Interventions: PFMT with or without biofeedback, vaginal cones or electrical stimulation. Study appraisal and synthesis methods: Both authors independently reviewed, grouped and qualitatively synthesised the trials.
Results 22 randomised or quasiexperimental trials were found. There is a very large heterogeneity in the populations studied, inclusion and exclusion criteria, outcome measures and content of PFMT interventions. Based on the studies with relevant sample size, high adherence to a strength-training protocol and close follow-up, we found that PFMT during pregnancy and after delivery can prevent and treat UI. A supervised training protocol following strength-training principles, emphasising close to maximum contractions and lasting at least 8 weeks is recommended.
Conclusions PFMT is effective when supervised training is conducted. Further high-quality RCTs are needed especially after delivery. Given the prevalence of female UI and its impact on exercise participation, PFMT should be incorporated as a routine part of women's exercise programmes in general.
Current exercise guidelines recommend all pregnant women to be physically active on preferably all weekdays throughout pregnancy and to conduct both cardiovascular and strength-training exercise. The prescription for exercise is more detailed for the cardiovascular component of training than the strength-training component. This may, to some extent, be explained by the fact that there are fewer published clinical trials on strength-training programmes for pregnancy and birth outcomes than endurance training.
Pregnancy and childbirth are known risk factors for weakening and injury to the perineum and pelvic floor. Stretch and rupture of peripheral nerves, connective tissue and muscles may cause urinary and faecal incontinence, pelvic organ prolapse, sensory and emptying abnormalities of the lower urinary tract, defecation dysfunction, sexual dysfunction and chronic pain syndromes. About 50% of women lose some of the supporting function of the pelvic floor due to childbirth, and recent research using ultrasound and MRI reports the prevalence of major injuries to the pelvic floor muscles of 20–26% following vaginal delivery. Hence, vaginal childbirth can be considered equivalent to a major sport injury, but has not been given the same attention concerning prevention or treatment.
Urinary incontinence is the most prevalent symptom of pelvic floor dysfunction, with the prevalence rates varying between 32% and 64%. Stress urinary incontinence (UI) is defined as a 'complaint of involuntary loss of urine during on effort or physical exertion (eg, sporting activities), or on sneezing and coughing' and is the most common form of UI in all age groups. Prevalence rates between 4.5% (swimming) and 80% (trampoline jumping) have been found in young elite athletes. In the general female population, UI causes withdrawal from exercise and fitness activities and is a barrier to regular participation in physical activities. Surprisingly, strength training of the pelvic floor muscles is not mentioned at all in the Guidelines of the American College of Obstetricians and Gynecologists and only briefly mentioned in the British and Canadian guidelines. Furthermore, there are no or few references to evidence from clinically controlled trials in the existing guidelines.
Two important questions are whether UI and other pelvic floor disorders can be prevented by training the pelvic floor muscles (PFM) before problems arise (primary prevention), or whether women at risk at an early stage can be identified with a view to secondary prevention using PFM training (PFMT). Reviews on PFMT in prevention of UI report inconsistent results and there seems to be some doubt about the effect. This may be due to the use of different inclusion criteria of studies and different criteria to classify studies as either prevention or treatment interventions. Some authors do not separate between antenatal or postpartum interventions, and there seems to be little attention paid to dose–response issues in the training protocols. The aims of the present systematic review were to answer the following questions.
Abstract and Introduction
Abstract
Background Urinary incontinence (UI) is a common condition in women causing reduced quality of life and withdrawal from fitness and exercise activities. Pregnancy and childbirth are established risk factors. Current guidelines for exercise during pregnancy have no or limited focus on the evidence for the effect of pelvic floor muscle training (PFMT) in the prevention and treatment of UI.
Aims Systematic review to address the effect of PFMT during pregnancy and after delivery in the prevention and treatment of UI.
Data sources PubMed, CENTRAL, Cochrane Library, EMBASE and PEDro databases and hand search of available reference lists and conference abstracts (June 2012).
Methods Study eligibility criteria: Randomised controlled trials (RCTs) and quasiexperimental trials published in the English language. Participants: Primiparous or multiparous pregnant or postpartum women. Interventions: PFMT with or without biofeedback, vaginal cones or electrical stimulation. Study appraisal and synthesis methods: Both authors independently reviewed, grouped and qualitatively synthesised the trials.
Results 22 randomised or quasiexperimental trials were found. There is a very large heterogeneity in the populations studied, inclusion and exclusion criteria, outcome measures and content of PFMT interventions. Based on the studies with relevant sample size, high adherence to a strength-training protocol and close follow-up, we found that PFMT during pregnancy and after delivery can prevent and treat UI. A supervised training protocol following strength-training principles, emphasising close to maximum contractions and lasting at least 8 weeks is recommended.
Conclusions PFMT is effective when supervised training is conducted. Further high-quality RCTs are needed especially after delivery. Given the prevalence of female UI and its impact on exercise participation, PFMT should be incorporated as a routine part of women's exercise programmes in general.
Introduction
Current exercise guidelines recommend all pregnant women to be physically active on preferably all weekdays throughout pregnancy and to conduct both cardiovascular and strength-training exercise. The prescription for exercise is more detailed for the cardiovascular component of training than the strength-training component. This may, to some extent, be explained by the fact that there are fewer published clinical trials on strength-training programmes for pregnancy and birth outcomes than endurance training.
Pregnancy and childbirth are known risk factors for weakening and injury to the perineum and pelvic floor. Stretch and rupture of peripheral nerves, connective tissue and muscles may cause urinary and faecal incontinence, pelvic organ prolapse, sensory and emptying abnormalities of the lower urinary tract, defecation dysfunction, sexual dysfunction and chronic pain syndromes. About 50% of women lose some of the supporting function of the pelvic floor due to childbirth, and recent research using ultrasound and MRI reports the prevalence of major injuries to the pelvic floor muscles of 20–26% following vaginal delivery. Hence, vaginal childbirth can be considered equivalent to a major sport injury, but has not been given the same attention concerning prevention or treatment.
Urinary incontinence is the most prevalent symptom of pelvic floor dysfunction, with the prevalence rates varying between 32% and 64%. Stress urinary incontinence (UI) is defined as a 'complaint of involuntary loss of urine during on effort or physical exertion (eg, sporting activities), or on sneezing and coughing' and is the most common form of UI in all age groups. Prevalence rates between 4.5% (swimming) and 80% (trampoline jumping) have been found in young elite athletes. In the general female population, UI causes withdrawal from exercise and fitness activities and is a barrier to regular participation in physical activities. Surprisingly, strength training of the pelvic floor muscles is not mentioned at all in the Guidelines of the American College of Obstetricians and Gynecologists and only briefly mentioned in the British and Canadian guidelines. Furthermore, there are no or few references to evidence from clinically controlled trials in the existing guidelines.
Two important questions are whether UI and other pelvic floor disorders can be prevented by training the pelvic floor muscles (PFM) before problems arise (primary prevention), or whether women at risk at an early stage can be identified with a view to secondary prevention using PFM training (PFMT). Reviews on PFMT in prevention of UI report inconsistent results and there seems to be some doubt about the effect. This may be due to the use of different inclusion criteria of studies and different criteria to classify studies as either prevention or treatment interventions. Some authors do not separate between antenatal or postpartum interventions, and there seems to be little attention paid to dose–response issues in the training protocols. The aims of the present systematic review were to answer the following questions.
Is there evidence that pregnant women should be advised to do PFMT to prevent or treat UI?
Is there evidence that postpartum women should be advised to do PFMT to prevent or treat UI?
What is the most optimal training dosage for effective antenatal and postpartum PFMT in the prevention and treatment of UI?
What is the long-term effect of PFMT during pregnancy and after childbirth?
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