Keeping leakage at bay

February 2015 Vol 15 (1)

Is one-off advice on pelvic floor exercises enough to keep urinary incontinence at bay? This edition’s critically appraised topic (CAT) looks at whether pelvic floor muscle training makes a difference.

Pelvic floorCLINICAL BOTTOM LINE:

Pelvic floor muscle training (both during pregnancy and after delivery) can prevent and treat urinary incontinence in pregnant or postpartum women. To be most effective, a supervised 8-week training programme is recommended so that women are supported to do the exercises correctly and often.

 

CLINICAL SCENARIO:

It is very common for women to experience urinary incontinence as a complication of pregnancy and childbirth. In your antenatal classes you advise women to do pelvic floor muscle exercises but wonder if a structured programme is needed. You decide to review the evidence for the effectiveness of pelvic floor muscle training (PFMT) for preventing and treating urinary incontinence in this group of women.

 

CLINICAL QUESTION:

What effect does pelvic floor muscle training during pregnancy and after childbirth have on the prevention and treatment of urinary incontinence?

 

SEARCH STRATEGY:

PubMed Clinical Queries (therapy, narrow): “pelvic floor muscle training” AND pregnancy

 

CITATION:

Morkved, S., & Bo, K. (2014). Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review. Br J Sports Med, 48(4), 299-310. doi: 10.1136/bjsports-2012-091758

 

STUDY SUMMARY:

A systematic review testing the effect of PFMT for preventing or treating urinary incontinence (UI) in pregnant or postpartum women. Inclusion criteria for studies assessed in the review are:

  • Type of study: Randomised controlled trials (RCTs) and quasi-experimental studies involving primiparous/multiparous pregnant or
  • postpartum women
  • Intervention: A structured programme of pelvic floor muscle training
  • Control: Usual care (such as advice only about pelvic floor exercises) or no PFMT
  • Outcomes: Urinary incontinence (outcome measures not specified).

 

STUDY VALIDITY:

Electronic databases searched were PubMed (12 June 2012), the Cochrane Central Register of Controlled Trials (12 June 2012), EMBASE
(1980 to 2012, week 24) and Physiotherapy Evidence Database (12 June 2012). In addition, reference lists of included studies and meeting abstract books published by the World Confederation of Physical Therapy (1993–2011), International Continence Society and International Urogynecology Association (1990–2011) were manually searched. Language of publication was restricted to English or Scandinavian.

Both review authors independently reviewed, grouped, assessed study quality, and qualitatively synthesised the trials but inclusion criteria, and processes for study selection, data extraction were not described. Disagreement between authors was solved by consensus.

A 10pt PEDro rating scale was used to assess the quality of included studies. The publication bias was not formally assessed.

There was a lack of detail for some review methods but overall a high-quality review of mixed-quality studies.

 

STUDY RESULTS:

After the removal of duplicates, 117 references were initially reviewed, from which 22 studies were selected as meeting the review criteria. Within these 22 studies there was considerable variation in the PFMT programme (intervention) offered and also considerable variation in the study population and the outcome measures used. Interventions were structured PFMT programmes with or without biofeedback, vaginal cones or electrical stimulation. All involved at least one supervised training session. Control groups received either usual care consisting of self-motivated PFMT supported only by one-off instruction or advice, no advice, or were instructed not to exercise pelvic floor muscles.

Because of the high heterogeneity of the studies the numerical study results were not combined using meta-analysis. A detailed qualitative synthesis of study results was provided for four pre-specified review questions (table). Interpretation of the results involved careful analysis of study quality, study size, PFMT programme content and adherence. Based on this analysis, the review’s overall conclusion was that high adherence to a supervised programme of intensive pelvic floor muscle strength training during pregnancy and after delivery can prevent and treat UI. No adverse events were reported.

 

COMMENTS:

  • This review adds to the evidence of the effectiveness of PFMT in women with UI.
  • In particular, a strong dose-response relationship was observed.
  • The PFMT intervention in studies reporting significant improvements in UI involved supervised training sessions, optimal dosage (8-12 maximum contractions, 3-4 times a week) and programme duration of at least eight weeks.
  • Studies showing little or no effect of PFMT programmes involved inadequate training dosages, minimal supervision of training and had had large dropout rates in the intervention group.
  • Long-terms effects and optimum maintenance dose of PFMT remains difficult to establish. :

 

Reviewer:

Cynthia Wensley RN MHSc is a PhD candidate at Deakin University. She also works at the School of Nursing, The University of Auckland as an honorary professional teaching fellow.

 

EBP table Feb 2015

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