Pelvic floor muscle training for incontinence and postpartum recovery: what the evidence shows

Urinary incontinence, or the accidental leakage of urine, is a common concern for many women. It can happen at different life stages, including during and after pregnancy. Pelvic floor muscle training (PFMT) is a common approach recommended to help with these issues.

This article looks at what the research says about how effective PFMT is for urinary incontinence in women. We will cover its use in the general population, as well as specifically for women during and after pregnancy. The evidence discussed here mostly focuses on women.

What is Pelvic Floor Muscle Training (PFMT)?

Your pelvic floor muscles form a sling-like support at the bottom of your pelvis. These muscles help support your bladder, bowel, and uterus. They also play a role in controlling when you urinate and have bowel movements.

Pelvic floor muscle training involves specific exercises to strengthen these muscles. These exercises focus on contracting and relaxing the pelvic floor muscles correctly. It's more than just "doing Kegels." Proper technique is important to get the most benefit.

A pelvic health physiotherapist can guide you through PFMT. They can: * Assess your pelvic floor muscles: This often includes an internal examination to check muscle strength, endurance, and coordination. This type of assessment is always done with your full consent. You can discuss other assessment options with your physiotherapist if you prefer. * Teach you the correct technique: They can help you identify and contract the right muscles. * Develop a personalized exercise program: This program will be tailored to your specific needs and goals. * Provide feedback: They can help you monitor your progress and adjust your exercises as needed.

You can learn more about finding the right support by reading about choosing a physiotherapist and whether you need a referral for physiotherapy in Canada.

PFMT for Urinary Incontinence in Women (General Population)

A large review of studies, published in 2018, looked at PFMT compared to no treatment or inactive control treatments for women with urinary incontinence [1]. This review included 31 trials with 1817 women. The studies were generally small to moderate in size, with most follow-ups lasting less than 12 months. The quality of the evidence varied [1].

The review looked at different types of urinary incontinence: * Stress Urinary Incontinence (SUI): Leakage when you cough, sneeze, laugh, or exercise. * Urgency Urinary Incontinence (UUI): A sudden, strong urge to urinate that is hard to hold back, leading to leakage. * Mixed Urinary Incontinence (MUI): A combination of both SUI and UUI.

Here's what the review found for different types of incontinence. One note on wording first: "cure" below is the review's own outcome category — it means women reported their leakage had resolved during the study period. It is the trials' measurement language, not a promise about any individual's result.

For Stress Urinary Incontinence (SUI)

• Reported "cure": Women who did PFMT were eight times more likely to report their SUI had resolved compared to those who received no treatment or inactive control treatments (56% versus 6%). This was based on 4 trials involving 165 women, with high-quality evidence [1].
• Reported "cure or improvement": Women in PFMT groups were six times more likely to report their SUI had resolved or improved (74% versus 11%). This was based on 3 trials involving 242 women, with moderate-quality evidence [1].
• Symptoms and Quality of Life: PFMT groups were more likely to report significant improvement in SUI symptoms (7 trials, 376 women; moderate-quality evidence) and in their quality of life related to SUI (6 trials, 348 women; low-quality evidence) [1].
• Leakage Episodes: PFMT reduced the number of leakage episodes by about one per day in women with SUI (7 trials, 432 women; moderate-quality evidence) [1].

For Any Type of Urinary Incontinence (SUI, UUI, or MUI combined)

• Reported "cure": Women doing PFMT were five times more likely to report their incontinence had resolved (35% versus 6%). This was based on 3 trials involving 290 women, with moderate-quality evidence [1].
• Reported "cure or improvement": PFMT groups were two times more likely to report their incontinence had resolved or improved (67% versus 29%). This was based on 2 trials involving 166 women, with moderate-quality evidence [1].
• Symptoms and Quality of Life: PFMT groups were more likely to report significant improvement in UI symptoms (1 trial, 121 women; moderate-quality evidence) and in their quality of life (4 trials, 258 women; moderate-quality evidence) [1].
• Leakage Episodes: PFMT reduced the number of leakage episodes by about one per day across all types of UI (4 trials, 349 women; moderate-quality evidence) [1].

For Urgency Urinary Incontinence (UUI) and Mixed Urinary Incontinence (MUI)

The review found very limited data for UUI and MUI alone. There was only one small study for women with MUI (12 women) which reported better quality of life. For UUI alone, there was only one study, and it did not provide data on symptom resolution, improvement, or the number of leakage episodes [1].

PFMT for Incontinence in Pregnant and Postnatal Women

Another comprehensive review, updated in 2020, looked specifically at PFMT for preventing and treating urinary and faecal incontinence in women during pregnancy (antenatal) and after childbirth (postnatal) [2]. This review included 46 trials with 10,832 women. The studies varied widely in their PFMT programs and control conditions. Many trials had a moderate to high risk of bias [2].

Here's what the review found:

Preventing Urinary Incontinence (UI)

• During Pregnancy: Continent pregnant women who did antenatal PFMT probably had a lower risk of reporting UI in late pregnancy (62% less risk). This was based on 6 trials involving 624 women, with moderate-quality evidence [2].
• Mid-Postnatal Period (3 to 6 months after birth): Antenatal PFMT slightly decreased the risk of UI in the mid-postnatal period (29% less risk). This was based on 5 trials involving 673 women, with high-quality evidence [2].
• Late Postnatal Period (more than 6 to 12 months after birth): There was not enough information to determine the effects at this time point (1 trial, 44 women; low-quality evidence) [2].

Treating Urinary Incontinence (UI)

• Antenatal PFMT for Incontinent Women: There was no evidence that antenatal PFMT in women who were already incontinent decreased incontinence in late pregnancy, or in the mid- or late postnatal periods (very low to low-quality evidence) [2].
• Postnatal PFMT for Incontinent Women: For women with ongoing UI after childbirth, there was no evidence that PFMT made a difference in UI more than six to 12 months postpartum (3 trials, 696 women; low-quality evidence) [2].

Mixed Prevention and Treatment Approach for UI (Antenatal PFMT for women with or without UI)

• During Pregnancy: Antenatal PFMT in women, whether they had UI or not, probably decreased UI risk in late pregnancy (22% less risk). This was based on 11 trials involving 3307 women, with moderate-quality evidence [2].
• Mid-Postnatal Period: It may slightly reduce the risk in the mid-postnatal period. This was based on 5 trials involving 1921 women, with low-quality evidence [2].
• Late Postnatal Period: There was no evidence that antenatal PFMT reduced the risk of UI at late postpartum (2 trials, 244 women; moderate-quality evidence) [2].
• PFMT Started After Delivery (Mixed Population): For PFMT started after delivery in a mixed group of women, there was uncertainty about its effect on UI risk in the late postnatal period (3 trials, 826 women; moderate-quality evidence) [2].

Faecal Incontinence (FI)

Eight trials in the review reported outcomes for faecal incontinence [2]. * Postnatal Women with Persistent FI: It was uncertain whether PFMT reduced faecal incontinence in the late postnatal period compared to usual care (very low-quality evidence) [2]. * Antenatal PFMT (Mixed Population): There was no evidence that antenatal PFMT led to a difference in the prevalence of faecal incontinence in late pregnancy (3 trials, 910 women; moderate-quality evidence) [2]. * Postnatal PFMT (Mixed Population): Similarly, for postnatal PFMT in a mixed population, there was no evidence that PFMT reduced the risk of faecal incontinence in the late postnatal period (1 trial, 107 women; very low-quality evidence) [2].

Limitations of the Research

It's important to understand the limitations of these studies when interpreting the findings: * Blinding is difficult: It's hard for participants and researchers to be "blinded" to whether someone is doing PFMT or not. This can sometimes influence reported outcomes [1, 2]. * Varied protocols: The PFMT programs in the studies differed greatly in how they were taught, how long they lasted, and how often exercises were done [1, 2]. This makes it hard to compare results directly. * Follow-up periods: Many studies had follow-up periods of less than a year [1]. This means we have less information on the long-term effects of PFMT. * Risk of bias: Many trials had a moderate to high risk of bias, which can affect the certainty of the findings [1, 2]. * Small to moderate study sizes: Many individual trials were not very large [1, 2].

What this means for you

The evidence suggests that pelvic floor muscle training can be helpful for women experiencing stress urinary incontinence and, to a lesser extent, general urinary incontinence. For pregnant women who are continent, antenatal PFMT may help prevent urinary incontinence during late pregnancy and in the mid-postnatal period.

If you are experiencing urinary or faecal incontinence, or if you are pregnant or have recently given birth, a licensed pelvic health physiotherapist can assess your individual situation. They can help determine if PFMT is a suitable approach for you. They can also teach you how to perform the exercises correctly and create a program tailored to your needs. Remember, any internal examination is always conducted with your informed consent.