Effectiveness of a pelvic floor muscle exercise program on urinary incontinence following childbirth

EXECUTIVE SUMMARY: Objectives  The primary objective of this review was to determine, from the available evidence, the effectiveness of an antenatal and/or a post-natal program of pelvic floor muscle exercises (PFME) compared with usual care on preventing, reducing or resolving the incidence and severity of stress incontinence, urge incontinence or mixed stress and urge urinary incontinence following childbirth. Secondary objectives were included to examine the effectiveness of a PFME program on pelvic floor muscle strength and on encouraging adherence to an exercising program.

TYPES OF STUDIES: Randomised controlled trials and non-randomised controlled trials were included in the review if, in relation to urinary incontinence, and/or adherence to a PFME program, and/or pelvic floor muscle strength, the following had been explored: • antenatal PFME compared with usual care; • post-natal PFME compared with usual care; • a PFME program compared with usual care. Usual care is commonly used to describe the care women normally receive from health professionals in the antenatal and/or post-natal period. In some cases usual care includes a standard information package given to all women attending the health service and in others it is advice about performing PFME.

Participants included women who experienced a spontaneous onset of labour and who subsequently delivered at more than 20 weeks gestation either vaginally, both spontaneous and assisted, or by non-elective caesarean section.

• women who delivered by elective caesarean section; • women experiencing post-partum overflow urinary incontinence.

1 Pelvic floor muscle exercises. 2 PFME instruction and a PFME program's components, such as educational materials, feedback (including biofeedback, e.g. information about strength of pelvic floor muscle contractions by various means) and number of PFME.

• electrical stimulation of pelvic floor muscles; • vaginal cones; or • other adjunct therapies. In studies that included a subgroup treated with one of these interventions, the results of the subgroup were excluded from the review's analysis.

Outcomes that were of interest: • non-occurrence of urinary incontinence following childbirth; • a change in the frequency, duration or severity (as appropriate) of urinary incontinence up to 12 months following childbirth. • a change in the strength of pelvic floor muscle contractions; • period of time PFME continued after initial instruction; • frequency of PFME undertaken; • women's awareness of the importance of PFME; • satisfaction with PFME instruction. Search strategy  All major electronic sources of information relevant to the topic (e.g. PubMed, CINAHL and the Cochrane Library) were searched to identify published and unpublished studies and previous work in the field. Printed journals were hand-searched and reference lists checked for potentially useful research. The review included any studies undertaken between 1981 and 2003. The search did not attempt to locate unpublished research before 1991. Assessment of quality  An independent Review Panel carried out quality assessment of studies. Two members of the panel, using quality assessment checklists developed for the review, reviewed each study. Disagreements between reviewers were resolved through discussion or a third reviewer examining a study. Data extraction and analysis  A data extraction tool was developed to extract data relating to participant characteristics, study methods, interventions and outcomes. Two reviewers independently extracted the required data. Randomised controlled trials included in the review were pooled in several meta-analyses using RevMan software program. Heterogeneity between studies was determined to ensure that they were sufficiently similar to allow for the pooling of their results. Non-randomised controlled trials were discussed in narrative comparisons. Results  Six randomised controlled trials met the inclusion criteria for the primary objective of the systematic review. The results of this review indicate that antenatal PFME and post-natal PFME are effective in resolving or reducing urinary incontinence following childbirth. There was insufficient evidence to conclude that PFME can prevent urinary incontinence in post-partum women. In most of these studies women were selected randomly and therefore included women without urinary incontinence and women with urinary incontinence. Two randomised controlled trials selected their sample on the criteria of existing post-partum urinary incontinence. A subgroup analysis of these studies showed that post-natal PFME also have a significant effect on reducing or resolving urinary incontinence in women with existing post-partum urinary incontinence. Seven randomised controlled trials and three non-randomised controlled trials met the inclusion criteria for the secondary objectives of the review. Findings of the studies included in the review suggest a PFME program will improve the frequency with which women perform PFME. Two studies found that women receiving the intervention (a PFME program) and who were performing PFME regularly in the month before data collection were significantly less likely to have any incontinence. The review's results support previous findings showing there is little evidence that a high-intensity PFME program is more effective than a low-intensity PFME regimen of exercising. No conclusions about the effectiveness of feedback to a woman about pelvic floor muscle strength, for example, perineometer measures, as part of a PFME program can be reached. The mixed results of this review mean that no conclusions can be reached about the effectiveness of a PFME program, antenatal or post-natal, on improving pelvic floor muscle strength. A number of studies reported a high percentage of women lost to follow-up and the data collected in most of the studies relied on self-reports relating to urinary incontinence and/or frequency of exercising. These factors may have affected the overall results of the review. However, wherever possible, tests for heterogeneity were carried out to determine if studies should be combined in meta-analyses and in other cases the results' limitations are acknowledged. Implications for practice  In terms of the effectiveness of PFME programs, the results of this review indicate that urinary incontinence following childbirth can be improved by performing PFME and that any form of a specific PFME program appears to improve exercising frequency. However, the value of individual components of PFME programs, such as take-home materials, reminder telephone calls and feedback of exercising effectiveness, is less clear. • Encourage women to undertake both antenatal and post-natal PFME (E1). • Pay particular attention to women with antenatal and post-natal urinary incontinence in providing advice and PFME instruction (E1). • To encourage adherence and continuation, PFME education programs should be multifaceted with a number of components, rather than only supplying an information booklet (E4). • Include PFME as a specific program in all antenatal and post-natal care, incorporating at least two individual instruction sessions into the program (E1). • Provide post-partum contact, particularly for those discharged early, either by telephone, electronic or home visits (E4). • Design pelvic floor muscle home exercise programs that are realistic given the demands on a mother and that can be incorporated into her daily routine in terms of number and frequency. Two or more training sessions per week are recommended (E4). • Health professionals working with women in the post-partum period should ask about symptoms of incontinence to ensure assistance is offered to those experiencing urinary incontinence (E4).