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 stren