Risk Of Bias In Included Studies
Due to brevity of reporting, it was difficult to assess the two trials that were published as conference abstracts.25, 43 Fifteen of the trials were small, with fewer than 25 women per comparison group.18, 21, 22, 23, 25, 26, 27, 30, 34, 35, 36, 37, 38, 39, 42 Ten were of moderate size, with around 2550 per group.24, 28, 31, 32, 33, 41, 45, 46, 47, 48 The other five allocated more than 50 women per group.19, 20, 31, 40, 44 Bidmead et al.43 randomized participants in a 2:1 ratio, with 40 in the PFMT group and 20 as controls.43 Eleven trials, including five recent ones, reported on a priori power calculation.19, 20, 23, 28, 31, 33, 34, 37, 39, 46, 48 Risk of bias assessment is illustrated in Fig. 2 and fully described in the complete Cochrane review.
Design Participants And Settings
This was a pragmatic non-randomized controlled trial that investigated the effectiveness of service and patient oriented physical therapy intervention for community women with UI symptoms delivered at health centers. Intervention program was service and patient oriented regarding to: participants preference about the setting to perform the intervention, either at health center or at home pelvic floor muscle contraction capacity evaluated by inspection over the underwear PFMT dose prescribed according to the participants PFM endurance bladder training according to the participants 24-h micturition diary.
All women who attended two primary care centers, from July 2010 to Oct 2011 were invited by community health agents or by nurses to answer the International Consultation on Incontinence Questionnaire-Short Form and signed the informed consent. In a second moment, women identified in the ICQ-SF as having UI, aged 18 years, and had never received physical therapy intervention for pelvic floor dysfunction were invited to participate in the study. Women who could not contract their PFM, were pregnant, presented symptoms of urinary infection, neurological disorders and/or difficulty understanding the treatment protocols were excluded and referred to the primary care physician for further consultation.
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What Is Pelvic Floor Muscle Therapy
Pelvic floor therapy is a type of physical therapy or exercise program that focuses on the pelvic floor, including the muscles and connective tissues that help hold the pelvic organs in place. PFMT, is a painless treatment option which comes with a 70-80 % success rate of significantly improving symptoms and has no side effects.
Pelvic floor therapy begins with a health assessment and an examination to determine the existing strength of the pelvic floor muscles and to decide which exercises will be most beneficial in achieving results. Patients are taught how to identify and focus on their pelvic floor muscles so exercises are more effective. Pelvic floor stimulation is then performed in our office with a vaginal and/or rectal sensor. A mild electrical stimulus is used to stimulate pelvic muscles and causes a comfortable, timed contraction of the pelvic floor muscles. This will feel like a gentle tapping sensation and you will feel the muscle contract.
Characteristics Of The Population Included In The Studies
The ages averaged between 71 and 79 years. Despite this study consider an elder a person over 60 years of age, the 3 articles chosen used the age of 65, following the criteria of inclusion proposed by the World Health Organization , which classifies elderly people as individuals with 65 years or more for developed countries and 60 years or more for undeveloped countries .
In 2 of the studies, the sample was composed by elderly women that live in a community. Only the Aslan et al study evaluated the training of the pelvic floor muscles in women living in long term institutions. According to the PEDro scale, all studies reached similar results in what concerned more important prognosis indicators.
When To Do Kegel Exercises
Most people prefer doing Kegel exercises while lying down on a bed or sitting in a chair. You can do them in any position you feel comfortable in. Doing Kegel exercises while standing can be very helpful because thats usually when urinary leakage happens.
To keep your urine from leaking, try to do a Kegel exercise before these activities:
- When standing up.
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Sensitivity And Subgroup Synthesis
Overall, out of 997 PFMT or PFMT + education patients, 504 patients showed improvement in urinary incontinence, and 218 became continent . In total, 62% of patients significantly reduced their urinary incontinence or cured it and improved their pelvic floor muscle contraction.
On the other hand, significant improvements in endurance, muscle contraction, and urinary leakage were observed in 49 patients , 168 patients , and 97 patients , respectively. However, the results across the outcome cannot be compared between the intervention groups, as the scales used for measuring the outcome varied across studies, except for urinary leakage.
Pelvic Floor Exercises And Stress Incontinence
Reviewed byDr Hannah Gronow
Pelvic floor exercises, also known as Kegel exercises, have numerous benefits and may help cure stress incontinence. Pelvic floor exercises are also useful to prevent incontinence for women who have had children. In addition, some people feel that having strong pelvic floor muscles heightens the pleasure when having sex.
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Where Can I Find Out More Or Get Help
If there is a problem with bladder or bowel control, it is important to be properly assessed as weak pelvic floor muscles are just one of the many causes of incontinence.
You can also contact the National Continence Helpline on . The National Continence Helpline is staffed by Nurse Continence Specialists who offer free and confidential information, advice and support. They also provide a wide range of continence-related resources and referrals to local services.
How Is It Diagnosed
Your physical therapist will perform a thorough examination to identify the causes of your urinary incontinence, and will ask you to describe your symptoms and your daily experiences. They may assess the muscles of your pelvis, hip, and low back, as well as the coordination, strength, and flexibility of the muscles of your pelvic floor.
Your physical therapist also may refer you to a physician for additional tests, such as urodynamic testing, diagnostic ultrasound, or MRI to show any pelvic-floor muscle problems, to ensure an accurate diagnosis.
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Data Extraction Quality Assessment Data Synthesis
Data extraction was performed in Microsoft Excel after reviewing all the final included studies. The data that were extracted from all the studies were the studies first author, year of publication, study design, inclusion criteria, intervention groups sample size, drop out, study duration, study outcome. During data extraction, no authors were contacted. Quality assessment of the studies was carried out using, The Cochrane risk of bias 2 tool. The quality of the studies was based on the following questions: randomization, deviation from interventions, missing outcome reporting, measuring the outcomes, and selective reporting of outcomes. Based on the following questions, studies were marked as low, medium, or high risk of bias. Following the data extraction, narrative synthesis was performed. Heterogeneity tests and meta-analysis of the studies were not performed.
How To Do Kegel Exercises
Before you start your Kegel exercises, make sure to urinate so your bladder is empty.
When youre ready, follow these steps:
Your pelvic floor muscles may get tired during this exercise. If this happens, stop and do the exercise later.
Do not use your stomach, leg, or buttock muscles when doing this exercise. Exercising these muscles will not help you get back urinary control or improve your sexual health.
As you continue to practice these exercises, increase the time you hold and rest your pelvic floor muscles. Start with 5 seconds, and slowly build up the time each week. Do this until youre holding in and resting for 10 seconds.
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Pelvic Floor Muscle Training
Pelvic floor exercises can help strengthen some of the muscles that control the flow of urine. These exercises are used to treat urge or stress incontinence. To do Kegel exercises:
- Squeeze your muscles as if you were trying not to pass gas. Or squeeze your muscles as if you were stopping the flow of urine. Your belly, legs, and buttocks shouldn’t move.
- Hold the squeeze for 3 seconds, then relax for 5 to 10 seconds.
- Start with 3 seconds, then add 1 second each week until you are able to squeeze for 10 seconds.
- Repeat the exercise 10 times a session. Do 3 to 8 sessions a day.
If you are having trouble finding out what muscles to squeeze, you can try stopping the flow of urine a few times. But don’t make it a practice to do Kegels while urinating.
If doing these exercises causes pain, stop doing them and talk with your doctor. Sometimes people have pelvic floor muscles that are too tight. In these cases, doing Kegel exercises may cause more problems.
If you aren’t sure how to do these exercises, talk to your doctor about getting a referral to a pelvic floor physical therapist.
Kegel exercises are often combined with biofeedback techniques to teach the proper exercise methods and to make sure the exercise is working. To be effective, pelvic floor exercises with or without biofeedback techniques require a high level of motivation and frequent repetition.
Overall Quality And Risk Of Bias Assessing Of Studies
Quality assessment of the studies was conducted using the Cochrane ROB2 tool, as shown in Figure 2 and Figure 3 and Table 3. The studies were classified as at low risk of bias, some concerns, or high risk of bias. Overall, 7 studies reported a low risk of bias, 3 studies reported a high risk of bias, while the remaining 5 studies reported medium , or some risk of bias, as represented in Figure 3. Almost half of the studies had a low risk of bias in terms of the randomization process, missing outcome data, and selection of reported result, as shown in Figure 2. Around 76.9%, 69.2%, 84.6%, 61.5%, and 76.9% across all the studies reported low risk of bias in terms of the randomization process, deviation of intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result, respectively. Only 20% across all the studies reported a high risk of bias in terms of measurement of the outcome.
Cochrane risk of bias for each component across all the studies.
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Selection Of Sources Of Evidence
Lists of potential articles were combined and de-duplicated. In the first stage of review, the first author screened abstracts and titles and retained only those that met inclusion criteria. In the second stage of review, the first author reviewed full texts and retained only those that met inclusion criteria. Disagreements were rare and were resolved through discussion.
We included all articles that met inclusion criteria. Nearly all included articles did not have a stated purpose of testing the mechanism of action of the intervention. Thus, it seemed inappropriate to employ traditional approaches to complete risk of bias in ratings. Rigorously performed trials specific to their specified trial outcomes for the intervention would have rated poorly when considering the purpose of this reviewlinking analysis of purported mechanism to intervention outcomes.
Ological Quality Of The Studies
The methodological quality evaluation performed by the PEDro scale showed an average score of 06 :1191-85 Buckley BS, Lapitan MCM Epidemiology Committee of the Fourth International Consultation on Incontinence, Paris, 2008. Prevalence of urinary incontinence in men, women, and children current evidence: findings of the Fourth International Consultation on Incontinence. Urology. 2010 76:265-70.6 Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardization of terminology of lower urinary tract function: report from the Standardization Sub-Committee of the International Continence Society. Neurourol Urodyn. 2002 21:167-78.7 Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol. 1948 56:238-48.-88 Fantl JA, Newman DK, Colling J. Urinary incontinence in adults: Acute and chronic management . Rockville: Department of Health and Services 1996.). Table 2 shows in details the methodological quality evaluation of the studies. Two studies compared the PFMT with a control group :317-24.,8383 Aslan E, Komurcu N, Beji NK, Yalcin O. Bladder training and Kegel exercises for women with urinary complaints living in a rest home. Gerontology. 2008 54:224-31.) and one article compared the TMAP with the intra-vaginal electro stimulation :1043-8.).
Potential Impact Of A Pfm Tear On Theorized Mechanisms
None of the articles evaluated birth-related nonrepairable tears of the critical urethral support provided by the pubovisceral portion of the levator ani muscle . Such tears were suspected as early as 1943 and irrefutable evidence suggests they are permanent .
Suggested psychometrically sound methods to diagnose PFM tear include various clinical appraisal estimates using one or more fingers for palpatory assessment, MRI, and three- or four-dimensional ultrasound for imaging assessment . Importantly, though PFMT targets this very muscle whether women had a tear was not assessed in any of the articles. For these women, PFMT may strengthen the urethral striated muscle as an alternative mechanism explaining its effects on UI.
More evidence is needed, particularly given that 5% to 15% of women who have delivered vaginally have at least a partial tear of the pubovisceral muscle origin at the pubic bone . In addition, our previous study found that postpartum women with PFM tears were more likely to have lower urethral closure pressure during Kegel exercises . More research is needed to account for the effect of PFM tear on theorized mechanisms as well as its effects of PFMT on reducing UI.
How To Do Pelvic Floor Exercises
Each time you do a series of slow pull-ups, you might try to hold each pull-up for a little longer. And each time you do a series of fast pull-ups try to do more.
However, especially when you first start to perform these exercises correctly, you will need to be able to concentrate fully on doing them so ideally try to set aside a quiet time to do them, they dont take long!
Pelvic Floor Exercise Tips
If you are not used to doing pelvic floor exercises then perhaps do the exercises as often as described above for the first three months or so. This will strengthen up the pelvic floor muscles. Thereafter, a five-minute spell of pelvic floor exercises once or twice a day should keep the muscles strong and toned up which may help to prevent incontinence from developing in later life.
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Policy Implications And Conclusions
Overall, the trial findings are consistent with national guidelines and confirm the recommendation that electromyographic biofeedback should not be routinely offered as part of PFMT.2
In this large multicentre trial with long term follow-up of electromyographic biofeedback as an adjunct to PFMT, we found no evidence of benefit from routinely adding biofeedback to PFMT. Supervised PFMT is effective in the management of urinary incontinence, although further research is needed into how to maximise its benefits.
What is already known on this topic
The 2011 Cochrane review assessing the benefit of adding feedback to PFMT for female urinary incontinence included 16 trials, but seven reported more PFMT supervision in the biofeedback group
The results differed depending on whether trial groups had comparable PFMT programmes it was concluded that biofeedback might provide benefit but further research was needed
Since then a meta-analysis including 11 trials concluded no benefit from adding biofeedback to PFMT, whereas two subsequent small single centre trials found some benefit of biofeedback immediately post-treatment
What this study adds
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