Pelvic floor exercises and women

Pelvic floor muscle training has long been the treatment of choice for stress incontinence along with some other conditions, however with differing outcomes. Overall, it has been suggested that pelvic floor muscle training should be used as a first line conservative treatment and should be carried out over three months to be most effective in improving all incontinence types (Dumoulin C, Hay-Smith J, 2010). Many debates as to how these exercises should be taught, carried out and assessed for the best outcome are still ongoing. Stress incontinence alone seems to respond the best to pelvic floor muscle training (Dumoulin C, Hay-Smith J, 2010).

The pelvic floor is a broad sling of muscle which is suspended from the pubic bones right round to the base of the spine encompassing the bladder and rectum. It is well documented that many problems can occur when these muscles weaken and are no longer as effective in controlling the effects of gravity on the internal organs and controlling the bladder and bowel.

One of the main causes of weak pelvic floor muscles in women is pregnancy, however it is worth noting that men can have pelvic floor problems affecting the urinary and bowel systems. The pelvic floor is thought to co-contract with the transversus abdominus muscle and there is much evidence for using exercises reflecting core stability when strengthening this muscle (Dumoulin C, Hay-Smith J, 2010).

Historically pelvic floor exercises have been taught when patients present with urinary problems, however despite the research supporting their effectiveness, patient compliance can be very poor. Generally it is thought that doing pelvic floor exercises after childbirth will prevent the development of stress incontinence and prolapses later in life. The first step in the strengthening process is for the patient to have an awareness of the muscle and how it functions (Kegel, 1956).

To support the idea that pelvic floor muscle training is effective in improving stress incontinence, Largo-Jansseen T L M et al (1991) found that after three months 85% of women felt improved or was cured. This paper also highlighted that quality of life and psychological state not only improved as the symptoms improved but could be a factor where patients did not improve due to low motivation levels.

At present pelvic floor muscle training is the first call for patients as it is a simple and cost effective way to improve their symptoms before they need to be referred for further assessment and management.

Indications For Pelvic Floor Muscle Training:

• Pregnancy
• Prolapse
• Stress incontinence
• Urge incontinence
• Mixed incontinence
• Faecal incontinence
• Birth defects that weaken pelvic floor tissues
• Injuries/tumours that affect nerve supply
• Poor core stability and control
• Abdominal/Gynaecological surgery

Predictive factors in a successful pelvic floor programme
Outcome measures for pelvic floor strength programmes are well used and documented. Although many studies use a variety of measures, it is evident that they are centred round some main outcomes.

Subjective outcome measures seem to have focussed on how the patient’s report any improvement in quality of life and improvement of symptoms. Dumoulin C, Hay-Smith J, 2010, used the Incontinence Impact Questionnaire as an example of how quality of life can be improved. They also reported that adherence to treatment and adverse effects can be useful in determining if these had prevented more improvement in pelvic floor muscle strength.

Objectively, the number of leakage episodes and number of micturitions during the day and night can show immense improvement (Dumoulin C, Hay-Smith J, 2010, Largo-Janssen TLM et al, 1991). They both included pad and paper towel testing for amount of urine as a clear outcome measure.

Pelvic floor function can be measured very effectively by electromyography, vaginal squeeze pressure and length of contraction (Dumoulin C, Hay-Smith J, 2010) and this sometimes can improve patient participation and compliance as they can see the contraction on screen. Pelvic floor training in this way becomes much more interactive and the patient’s awareness of the muscle is realised when the contraction is seen on screen.

What are patients told to do ?
In order for patients to have be effective in complying with and optimising their pelvic floor research has shown that they need to have had a full explanation of where the pelvic floor muscles are and what they do (Dumoulin C, Hay-Smith J, 2010, Largo-Janssen TLM et al, 1991).

Prior to so much research, patients were told to practice contracting their pelvic floor muscles when they were urinating but this has found to encourage urine retention and is now made clear that this is not an ideal way of carrying out this exercise.

When teaching how to contract the pelvic floor muscle without testing digitally, most therapists will ask the patient to imagine they are trying to stop themselves passing wind from the back passage and urinating form the front passage without tensing their stomach, buttocks or thighs. They are then told that they should feel a lifting sensation within their lower stomach (Patient UK, 2009).

Generally the patients are told that they can lie or sit to do the exercises and when more effective at them to link them to an everyday activity like making a cup of tea so that they make sure they do them regularly enough.

There are two types of contraction that should be taught to each patient to practice. The slow pull up where the pelvic floor is activated and the contraction is maintained for up to 10 seconds builds strength and stamina. The fast pull up and quick release contraction should be repeated 10 times also which allows the pelvic floor to be activated at short notice for example, when the patient coughs, sneezes or runs (Patient UK, 2009).

Once the patient has practiced these for a period of about 8-12 weeks they are normally told to try to contract their pelvic floor before standing up, whilst walking and whilst lifting.

What do patients actually do?
Patients tend to find that because the pelvic floor muscles are not visible, it is difficult to know if they are doing them correctly. Commonly, the stomach, buttocks and thighs all contract when patients try to activate the pelvic floor. This is mainly because of the patients’ lack of awareness of the muscle but sometimes due to weakness (Largo T L M et al, 1991).

Another reason that these exercises could be ineffective is that health professionals sometimes lack time to give patients the information and background that they need to understand why these exercises are important and therefore compliance and motivation can prevent regular practice (Dumoulin C, Haye-Smith J, 2010).

Sometimes patients are able to contract their pelvic floor very well but do not have the strength to hold it for long enough to prevent fatigue. These patients are the ones who if not encouraged could give up as they see little or no improvement and this highlights that unless the pelvic floor muscles are digitally assessed there is no real way of telling effectiveness.

Unfortunately many patients are just given the exercises on a sheet and talked through them which contributes to the compliance rates and hence a decrease in effectiveness. Many patients claim to have heard about these exercises yet have never been shown or taught them apart from after having their children. Many researchers have found that if a patient has strong pelvic floor muscles this aids the delivery of their baby whilst helping to prevent incontinence post delivery (Kegel A H, 1956). Perhaps pelvic floor exercises should be given to women much earlier on in life.

Supplementary measures or devices to optimise pelvic floor exercise and the use of biofeedback
Other measures to improve the function of the pelvic floor or to help patients learn how to locate and contract them are available. Sometimes patients struggle with this and therapists can only explain how to contract the pelvic floor to a certain extent and such measures can work very well.

Electrical stimulation is aimed to improve muscle function by restoring the functional nerve/muscle connections and resynchronising muscle activity. This is particularly useful after childbirth and a lot of heavy lifting where nerve damage may have occurred as controlled stimulation may force alternate dormant pathways to be ‘opened up’. A selection of probes can be used such as anal, vaginal or unilateral (as one side of the vaginal wall may be insensitive).

Biofeedback can help patients to locate and contract the correct muscles by inserting a probe in to the anus or vagina and then trying to contract. If the patient contracts correctly it will be seen on the screen which is visible to the patient. Many patients find it easier to feel the anal sphincter contracting and therefore when beginning with pelvic floor contractions the probe may be inserted anally. Biofeedback and neurostimulation can be effective when used together.

Vaginal cones are small plastic devices that patients can insert in to the vagina and practice contracting the pelvic floor muscles. Each cone is weighted differently so the strength of the muscle can be increased as the patient can hold a cone for the normal 10 second contraction. These are particularly useful when treatment is to be carried over when the patient is at home.

Although there is little evidence to demonstrate how effective these other devices are in strengthening the pelvic floor, it has been found that they should be used in addition to the standard pelvic floor exercises already described.

Patients who have had some individual treatment and are contracting their pelvic floor effectively may be invited to a class to strengthen their muscles further. The class may teach specific pelvic floor muscle exercises and core stability with mat work or a gym ball. It may also begin to link pelvic floor contractions with activities of daily living and other cardiovascular exercises. The class will also teach relaxation which is extremely important in those who cannot ‘switch off’ their contraction once activated.

Kegel A H (1948) found that pelvic floor exercise training could help up to 84% of the women with various types of incontinence. Many more studies have been conducted on the different available treatments but due to small sample sizes most have been inconclusive.

Bo K, Talseth T & Holme I (1999) compared the effect of pelvic floor exercises, electrical stimulation, vaginal cones and no treatment with genuine stress incontinence. They described no adverse effects with pelvic floor exercises alone but with electrical stimulation – tenderness, bleeding and discomfort were reported. It was found that pelvic floor training alone was a more effective treatment for genuine stress incontinence than electrical stimulation or vaginal cones. They also found that a more structured programme for pelvic floor exercise is more effective than that carried out at home.

Voluntary pelvic floor contractions have been found to be more effective than electrically stimulated ones (Bo K, Talseth T, 1997). The results of a similar study showed that exercises were superior to vaginal cones in increasing muscle strength and reducing urinary leakage (Bo K, Talseth T, Holme I, 1999). Here they also suggested no difference between vaginal cones and electrical stimulation but agree that they were more effective than with no exercise at all and that women found these methods more difficult. More research is needed to decide if electrical stimulation is useful in other conditions such as nerve damage.

The long term results of pelvic floor muscle training also need to be measured for this study. However, Bo K & Talseth T (1996) found that pelvic floor exercise programmes are beneficial after five years and preventing surgery in a lot of cases.

Other treatments can useful to improve the pelvic floor such as lifestyle/behavioural interventions for example bladder retraining, voiding regimes and urge suppression (Dumoulin C, Haye-Smith J, 2010). Pharmaceutical and surgical interventions can also provide further improvement when physiotherapy is not sufficient.

Which is more effective: Antenatal or postnatal pelvic floor exercises?
Pelvic floor exercises are currently recommended to prevent and treat incontinence during and after the birth. In fact about a third of women have urine leakage and up to a tenth faecal leakage after childbirth (Hay-Smith J et al, 2009). In their review study, Hay-Smith et al (2009) found that pelvic floor muscle training for women having their first baby can reduce urinary incontinence in late pregnancy and early post partum. The authors could not tell whether this continued after three months of delivery. It is also not known whether women who have had more than one baby benefit from these exercises. A pelvic floor exercise regime could be important to help those who are at risk of post natal incontinence and the prevention of post natal incontinence with the use of ante natal exercises. It still remains the choice of treatment for women with persistent urinary or faecal after delivery.

Hay-Smith et al (2009) were less clear on whether teaching all post natal women pelvic floor exercises could decrease the prevalence of incontinence after childbirth. It has been suggested that post natal pelvic floor muscle training offered on an individual basis to women at greater risk of post natal incontinence due to forceps or vaginal delivery of a large baby is most effective. Hay-Smith et al (2009) seem to suggest the need for more intense programmes of strengthening to decrease the prevalence of post natal urinary and faecal incontinence. They also recognise the limited resources available to carry out such a task and that perhaps those at greater risk should be targeted in smaller groups. More evidence is needed to explore the longer term effects.

It seems that both pelvic floor muscle training ante and post natally can be affective in decreasing incontinence after the birth. More evidence is needed to find out exactly which strength training programme is most effective and to measure its long term effects.

When to stop pelvic floor exercise
Pelvic floor exercise is an important type to continue with throughout your life and none of research suggests stopping its use. It has been found to decrease the prevalence of urinary and faecal incontinence in most subjects (Dumoulin C, Hay-Smith J, 2010). Although it is a very difficult muscle to locate, feel and train, it has been found useful even when surgery or pharmaceutical interventions are needed (Largo-Janssen T L M et al, 1991). Many patients come back to have pelvic floor training with electrical stimulation and biofeedback after their surgery and in fact more gastroenterologists are referring male and female patients with faecal incontinence.

Due to lack of resources in the NHS and length of time it takes for the pelvic floor muscles to strengthen, patients normally only have a relatively short period of treatment which may not be effective and therefore more research is needed to find out if ceasing training is detrimental or not.

In conclusion, there is a lot of controversy around whether pelvic floor muscle training is beneficial. However, the majority of research agrees that these exercises are beneficial with patients who have mainly stress incontinence but can improve other types of incontinence (Dumoulin C, Hay-Smith J, 2010). Many factors can influence improvement such as patient compliance, anxiety caused by the incontinence or personal stress and how well they have been taught to contract the muscle in the first place ((Kegel, 1956). It is clear that even if objective markers are only affected slightly, psychological markers and quality of life can be improved immensely Largo-Jansseen T L M et al (1991) and this is vital within the changing NHS.

It has been shown that pelvic floor muscle training needs to be taught carefully so that the patient is more likely to maintain compliance and this may involve setting individual programmes with regular check ups. There is a need for further research to find out whether a longer more continued strength programme is more useful in decreasing the effects of incontinence permanently. If this is the case, many treatment settings may struggle with the increased and prolonged need for treatments.

The use of devices to help contract the pelvic floor seem to have been approved as an adjunct to treatment with active contractions. However, active pelvic floor contractions still seem to achieve better results with less side effects than with other devices especially when the exercises have been taught properly in the first place. Again more research would be useful to determine if the use of devices is more effective for other problematic conditions. It may also be useful to look at whether pelvic floor muscle training improves in conjunction with other treatments like pharmaceutical interventions or behavioural training.

Hay-Smith et al (2009) suggested that women having their first baby could prevent or improve stress incontinence by performing pelvic floor exercises during late pregnancy and therefore, clinically we may need to be targeting these women at early pregnancy or even earlier. They also highlighted the possible need to target the groups of women who are at high risk in order to be most effective and to keep costs down.

Pelvic floor muscle training is becoming a more recognisable treatment with growing referrals from gastroenterologists which is heightening awareness that Physiotherapy can make improvements to strength, control and quality of life to these patients. There is now more evidence that male patients can benefit from the same treatments for bladder and bowel conditions and at present the leading research is following this path. In the future a more seamless approach to pelvic floor muscle training which is more cost effective but targets the higher risk groups when needed may change the services delivered to our patients. Services will also incorporate male patients as at present very little provision is in place to offer them the same standard of care that females receive.

References

• Bo K, Talseth T. Long term effect of pelvic floor muscle exercise five years after cessation of organised training Obstet Gynecol 1996; 87: 261-265
• Bo K, Talseth T. Change in urethral pressure during voluntary pelvic floor muscle contraction and vaginal electrical stimulation Int Urogynecol J 1997;8: 3-7
• Bo K, Talseth T, Holme I. Single blind randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment management of genuine stress incontinence in women. British Medical Journal 1999; 318 (7182): 487-493
• Dumoulin C, Haye-Smith J. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews 2010; Issue 1. Art. No.: CD005654.DOI:10.1002/14651858. CD005654.pub2.
• Hay-Smith J, Morkved S, Fairbrother K A & Herbison G P. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women (Review) Cochrane Database of Systematic Reviews 2008; Issue 4. Art. No.: CD007471. DOI: 10.1002/14651858.CD007471
• Largo-Janssen T L M, Debruyne F M J, Smits A J A, Van Weel C. Controlled trial of pelvic floor exercises in the general treatment of urinary stress incontinence in general practice. Br J General Practice 1991; 41: 445-449
• Kegel AH. Progressive resistance exercise in the functional resto- ration of the perineal muscles. Am J Obstet Gynecol 1948; 56:238-249
• Kegel A H. Stress incontinence of urine in women: physiologic treatment. J Int Coll Surg 1956; 25: 487-499
• Patient UK (2009). Pelvic floor exercises (online) Available at: http://www.patient.co.uk/health/Pelvic-Floor-Exercises.htm. (Ac- cessed 21 January 2011)

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