About one‐third of women have urinary incontinence and up to one‐tenth have faecal
incontinence after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended
during pregnancy and after birth for both prevention and treatment of incontinence.
This is an update of a review previously published in 2012. To determine the effectiveness
of pelvic floor muscle training (PFMT) in the prevention or treatment of urinary and
faecal incontinence in pregnant or postnatal women. We searched the Cochrane Incontinence
Specialised Register (16 February 2017) and reference lists of retrieved studies.
Randomised or quasi‐randomised trials in pregnant or postnatal women. One arm of the
trial included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another
control condition, or an alternative PFMT intervention. Review authors independently
assessed trials for inclusion and risk of bias. We extracted data and checked them
for accuracy. Populations included: women who were continent (PFMT for prevention),
women who were incontinent (PFMT for treatment) at randomisation and a mixed population
of women who were one or the other (PFMT for prevention or treatment). We assessed
quality of evidence using the GRADE approach. The review included 38 trials (17 of
which were new for this update) involving 9892 women from 20 countries. Overall, trials
were small to moderate sized, and the PFMT programmes and control conditions varied
considerably and were often poorly described. Many trials were at moderate to high
risk of bias. Other than two reports of pelvic floor pain, trials reported no harmful
effects of PFMT. Prevention of urinary incontinence: compared with usual care, continent
pregnant women performing antenatal PFMT may have had a lower risk of reporting urinary
incontinence in late pregnancy (62% less; risk ratio (RR) for incontinence 0.38, 95%
confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; low‐quality evidence).
Similarly, antenatal PFMT decreased the risk of urinary incontinence in the mid‐postnatal
period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54
to 0.95; 5 trials, 673 women; moderate‐quality evidence). There was insufficient information
available for the late (more than six to 12 months') postnatal period to determine
effects at this time point. Treatment of urinary incontinence: it is uncertain whether
antenatal PFMT in incontinent women decreases incontinence in late pregnancy compared
to usual care (RR 0.70, 95% CI 0.44 to 1.13; 3 trials, 345 women; very low‐quality
evidence). This uncertainty extends into the mid‐ (RR 0.94, 95% CI 0.70 to 1.24; 1
trial, 187 women; very low‐quality evidence) and late (RR 0.50, 95% CI 0.13 to 1.93;
2 trials, 869 women; very low‐quality evidence) postnatal periods. In postnatal women
with persistent urinary incontinence, it was unclear whether PFMT reduced urinary
incontinence at more than six to 12 months' postpartum (RR 0.55, 95% CI 0.29 to 1.07;
3 trials; 696 women; very low‐quality evidence). Mixed prevention and treatment approach
to urinary incontinence: antenatal PFMT in women with or without urinary incontinence
(mixed population) may decrease urinary incontinence risk in late pregnancy (26% less;
RR 0.74, 95% CI 0.61 to 0.90; 9 trials, 3164 women; low‐quality evidence) and the
mid‐postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; very low‐quality
evidence). It is uncertain if antenatal PFMT reduces urinary incontinence risk late
postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; low‐quality evidence).
For PFMT begun after delivery, there was considerable uncertainty about the effect
on urinary incontinence risk in the late postnatal period (RR 0.88, 95% CI 0.71 to
1.09; 3 trials, 826 women; very low‐quality evidence). Faecal incontinence: six trials
reported faecal incontinence outcomes. In postnatal women with persistent faecal incontinence,
it was uncertain whether PFMT reduced incontinence in the late postnatal period compared
to usual care (RR 0.68, 95% CI 0.24 to 1.94; 2 trials; 620 women; very low‐quality
evidence). In women with or without faecal incontinence (mixed population), antenatal
PFMT led to little or no difference in the prevalence of faecal incontinence in late
pregnancy (RR 0.61, 95% CI 0.30 to 1.25; 2 trials, 867 women; moderate‐quality evidence).
For postnatal PFMT in a mixed population, there was considerable uncertainty about
the effect on faecal incontinence in the late postnatal period (RR 0.73, 95% CI 0.13
to 4.21; 1 trial, 107 women, very low‐quality evidence). There was little evidence
about effects on urinary or faecal incontinence beyond 12 months' postpartum. There
were few incontinence‐specific quality of life data and little consensus on how to
measure it. We found no data on health economics outcomes. Targeting continent antenatal
women early in pregnancy and offering a structured PFMT programme may prevent the
onset of urinary incontinence in late pregnancy and postpartum. However, the cost‐effectiveness
of this is unknown. Population approaches (recruiting antenatal women regardless of
continence status) may have a smaller effect on urinary incontinence, although the
reasons for this are unclear. It is uncertain whether a population‐based approach
for delivering postnatal PFMT is effective in reducing urinary incontinence. Uncertainty
surrounds the effects of PFMT as a treatment for urinary incontinence in antenatal
and postnatal women, which contrasts with the more established effectiveness in mid‐life
women. It is possible that the effects of PFMT might be greater with targeted rather
than mixed prevention and treatment approaches and in certain groups of women. Hypothetically,
for instance, women with a high body mass index are at risk factor for urinary incontinence.
Such uncertainties require further testing and data on duration of effect are also
needed. The physiological and behavioural aspects of exercise programmes must be described
for both PFMT and control groups and how much PFMT women in both groups do, to increase
understanding of what works and for whom. Few data exist on faecal incontinence or
costs and it is important that both are included in any future trials. It is essential
that future trials use valid measures of incontinence‐specific quality of life for
both urinary and faecal incontinence. Review question To assess whether doing pelvic
floor muscle exercises (PFME) during pregnancy or after birth reduces incontinence.
This is an update of a review published in 2012. Background More than one‐third of
women experience unintentional (involuntary) loss of urine (urinary incontinence)
in the second and third trimesters of pregnancy and about one‐third leak urine in
the first three months after giving birth. About one‐quarter of women have some involuntary
loss of flatus (wind) or faeces (anal incontinence) in late pregnancy and one fifth
leak flatus or faeces one year after birth. PFME are commonly recommended by health
professionals during pregnancy and after birth to prevent and treat incontinence.
The muscles are strengthened and kept strong with regular PFME. Muscles are contracted
several times in a row, more than once a day, several days a week and continued indefinitely.
How up‐to‐date is this review? The evidence is current to 16 February 2017. Study
characteristics We included 38 trials (17 new to this update) involving 9892 women
from 20 countries. The studies included pregnant women or women who had delivered
their baby within the last three months. Women reported leakage of urine, faeces,
both urine or faeces, or no leakage. They were allocated randomly to receive PFME
(to try and prevent incontinence or as a treatment for incontinence) or not and the
effects were compared. Study funding sources Nineteen studies were publicly funded.
One received grants from public and private sources. Three studies received no funding
and 15 did not declare funding sources. Key results Pregnant women without urine leakage
who did PFME to prevent leakage: women may report less urine leakage in late pregnancy
and three to six months after childbirth. There was not enough information to determine
whether these effects continued beyond the first year after the baby's birth. Women
with urine leakage, pregnant or after birth, who did PFME as a treatment: it was
uncertain whether doing PFME during pregnancy reduced leakage in late pregnancy or
in the year following childbirth. It was unclear if doing PFME helped women with leakage
after giving birth. Women with or without urine leakage (mixed group), pregnant or
after birth, who did PFME to either prevent or treat leakage: women who began exercising
during pregnancy were less likely to report leakage in late pregnancy and up to six
months after birth, but it was uncertain if the effect lasted at one year following
birth. For women who started PFME after delivery, the effect on leakage one year after
birth was uncertain. Leakage of faeces: few studies (only six) had evidence about
leakage of faeces. One year after delivery, it was uncertain if PFME helped decrease
leakage of faeces in women who started exercising following childbirth. It was also
uncertain if women with or without leakage of faeces (mixed group) who started PFME
while pregnant were less likely to leak faeces in late pregnancy or up to one year
after birth. There was little information about how PFME may affect leakage‐related
quality of life. There were two reports of pelvic floor pain but no other harmful
effects of PFME were noted. It is unknown if PFMEs offer value for money because no
study had a health economics analysis. It is unknown if PFME offer value for money
as no health economics data were identified. Quality of the evidence Overall, studies
were not large and most had design problems, including limited details on how women
were randomly allocated into groups, and poor reporting of measurements. Some of the
problems were expected because it was impossible to blind health professionals or
women to whether they were exercising or not. The PFME differed considerably between
studies and were often poorly described. Evidence quality was generally low to very
low.