Pelvic floor muscle training (PFMT) is a first‐line conservative treatment for urinary
incontinence in women. Other active treatments include: physical therapies (e.g. vaginal
cones); behavioural therapies (e.g. bladder training); electrical or magnetic stimulation;
mechanical devices (e.g. continence pessaries); drug therapies (e.g. anticholinergics
(solifenacin, oxybutynin, etc.) and duloxetine); and surgical interventions including
sling procedures and colposuspension. This systematic review evaluated the effects
of adding PFMT to any other active treatment for urinary incontinence in women To
compare the effects of pelvic floor muscle training combined with another active treatment
versus the same active treatment alone in the management of women with urinary incontinence.
We searched the Cochrane Incontinence Group Specialised Register, which contains trials
identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE,
MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and
conference proceedings (searched 5 May 2015), and CINAHL (January 1982 to 6 May 2015),
and the reference lists of relevant articles. We included randomised or quasi‐randomised
trials with two or more arms, of women with clinical or urodynamic evidence of stress
urinary incontinence, urgency urinary incontinence or mixed urinary incontinence.
One arm of the trial included PFMT added to another active treatment; the other arm
included the same active treatment alone. Two review authors independently assessed
trials for eligibility and methodological quality and resolved any disagreement by
discussion or consultation with a third party. We extracted and processed data in
accordance with the Cochrane Handbook for Systematic Reviews of Interventions. Other
potential sources of bias we incorporated into the 'Risk of bias' tables were ethical
approval, conflict of interest and funding source. Thirteen trials met the inclusion
criteria, comprising women with stress urinary incontinence (SUI), urgency urinary
incontinence (UUI) or mixed urinary incontinence (MUI); they compared PFMT added to
another active treatment (585 women) with the same active treatment alone (579 women).
The pre‐specified comparisons were reported by single trials, except bladder training,
which was reported by two trials, and electrical stimulation, which was reported by
three trials. However, only two of the three trials reporting electrical stimulation
could be pooled, as one of the trials did not report any relevant data. We considered
the included trials to be at unclear risk of bias for most of the domains, predominantly
due to the lack of adequate information in a number of trials. This affected our rating
of the quality of evidence. The majority of the trials did not report the primary
outcomes specified in the review (cure or improvement, quality of life) or measured
the outcomes in different ways. Effect estimates from small, single trials across
a number of comparisons were indeterminate for key outcomes relating to symptoms,
and we rated the quality of evidence, using the GRADE approach, as either low or very
low. More women reported cure or improvement of incontinence in two trials comparing
PFMT added to electrical stimulation to electrical stimulation alone, in women with
SUI, but this was not statistically significant (9/26 (35%) versus 5/30 (17%); risk
ratio (RR) 2.06, 95% confidence interval (CI) 0.79 to 5.38). We judged the quality
of the evidence to be very low. There was moderate‐quality evidence from a single
trial investigating women with SUI, UUI or MUI that a higher proportion of women who
received a combination of PFMT and heat and steam generating sheet reported a cure
compared to those who received the sheet alone: 19/37 (51%) versus 8/37 (22%) with
a RR of 2.38, 95% CI 1.19 to 4.73). More women reported cure or improvement of incontinence
in another trial comparing PFMT added to vaginal cones to vaginal cones alone, but
this was not statistically significant (14/15 (93%) versus 14/19 (75%); RR 1.27, 95%
CI 0.94 to 1.71). We judged the quality of the evidence to be very low. Only one trial
evaluating PFMT when added to drug therapy provided information about adverse events
(RR 0.84, 95% CI 0.45 to 1.60; very low‐quality evidence). With regard to condition‐specific
quality of life, there were no statistically significant differences between women
(with SUI, UUI or MUI) who received PFMT added to bladder training and those who received
bladder training alone at three months after treatment, on either the Incontinence
Impact Questionnaire‐Revised scale (mean difference (MD) ‐5.90, 95% CI ‐35.53 to 23.73)
or on the Urogenital Distress Inventory scale (MD ‐18.90, 95% CI ‐37.92 to 0.12).
A similar pattern of results was observed between women with SUI who received PFMT
plus either a continence pessary or duloxetine and those who received the continence
pessary or duloxetine alone. In all these comparisons, the quality of the evidence
for the reported critical outcomes ranged from moderate to very low. This systematic
review found insufficient evidence to state whether or not there were additional effects
by adding PFMT to other active treatments when compared with the same active treatment
alone for urinary incontinence (SUI, UUI or MUI) in women. These results should be
interpreted with caution as most of the comparisons were investigated in small, single
trials. None of the trials in this review were large enough to provide reliable evidence.
Also, none of the included trials reported data on adverse events associated with
the PFMT regimen, thereby making it very difficult to evaluate the safety of PFMT.
Pelvic floor muscle training added to another active treatment versus the same active
treatment alone for urinary incontinence in women Background Involuntary leakage of
urine (urinary incontinence) affects women of all ages, particularly older women who
live in residential care, such as nursing homes. Some women leak urine during exercise
or when they cough or sneeze (stress urinary incontinence). This may occur as a result
of weakness of the pelvic floor muscles, which may be a result of factors such as
damage during childbirth. Other women leak urine before going to the toilet when there
is a sudden and compelling need to pass urine (urgency urinary incontinence). This
may be caused by involuntary contraction of the bladder muscle. Mixed urinary incontinence
is the combination of both stress and urgency urinary incontinence. Pelvic floor muscle
training is a supervised treatment that involves muscle‐clenching exercises to strengthen
the pelvic floor muscles. It is a common treatment used by women to stop urine leakage.
Other treatments are also available, which can be used either alone, or in combination
with pelvic floor muscle training. The main findings of the review In this review,
we included 13 trials that compared a combination of pelvic floor muscle training
and another active treatment in 585 women with the same active treatment alone in
579 women to treat all types of urine leakage. There was not enough evidence to say
whether or not the addition of pelvic floor muscle training to another active treatment
would result in more reports of a cure or improvement in urine leakage and better
quality of life, when compared to the same active treatment alone. Adverse effects
There was also insufficient evidence to evaluate the adverse events associated with
the addition of PFMT to other active treatment as none of the included trials reported
data on adverse events associated with the PFMT regimen. Limitations of the review
Most of the comparisons were investigated by single trials, which were small. None
of the trials included in this systematic review were large enough to answer the questions
they were designed to answer. The quality of the evidence was rated as either low
or very low for the outcomes of interest. The main limitations of the evidence were
poor reporting of study methods, and lack of precision in the findings for the outcome
measures.