Pelvic floor dysfunction includes urinary and fecal incontinence, pelvic organ prolapse (POP), sensory and emptying abnormalities of the lower urinary tract, defecatory dysfunction, sexual dysfunction, and chronic pain syndromes.¹ This chapter will focus on the effect of physiotherapy on urinary and fecal incontinence, POP, sexual disorders, and chronic pain syndromes in women.

In 1999 the member states of the World Confederation for Physical Therapy (WCPT) approved a position statement describing the nature and process of physiotherapy/physical therapy.² It is stated that physical therapy involves “using knowledge and skills unique to physical therapists, and is the service only provided by, or under the direction and supervision of a physical therapist.” The physical therapy process includes assessment, diagnosis, planning, intervention, and evaluation.² Physiotherapy for pelvic floor dysfunction involves thorough history taking and clinical evaluation of the patient’s total function and specific function of the PFMs before setting up an individual treatment plan.² Up to 30% of women with pelvic floor dysfunction may be unable to voluntarily contract the pelvic floor muscle (PFM); therefore, individual instruction and feedback is essential.³ Physiotherapy treatments for the pelvic floor may include bladder training, PFM training with or without biofeedback, use of vaginal cones, electrostimulation, or other adjuncts to pelvic floor training. The actual training can be done individually or in groups.^4,5 Supervised training is often followed by an individualized home training program.

There are both therapeutic and preventative indications for pelvic floor physical therapy. As outlined below, physical therapy is used to both treat and prevent the development of stress urinary incontinence (SUI), plays a role in the treatment of urgency incontinence and overactive bladder, and has been shown to have modest effects on the treatment of prolapse. Because of its central role in treatment paradigms, PFM training is indicated in any woman with incontinence or prolapse who can learn to voluntarily contract the pelvic floor.

SUI is the involuntary leakage of urine associated with increases in intra-abdominal pressure, such as occurs with cough, laugh, or sneeze. It is attributed to the inability of the urethra to withstand increases in bladder pressure. The two main theories on how pelvic floor muscle training (PFMT) may be effective in prevention and treatment of SUI⁶ are supported by basic research and case–control studies.^6,7 The first is that women learn to consciously contract before and during increases in abdominal pressure, and continue to perform such contractions as a behavior modification to prevent descent of the pelvic floor. The second theory is that women who perform regular strength training over time build up “stiffness” and structural support of the pelvic floor. In addition to these main theories two other theories have been proposed: Sapsford⁸ claimed that the PFM was effectively trained indirectly by contraction of the internal abdominal muscles, especially the transversus abdominal (TrA) muscle. There are no randomized controlled trials (RCTs) supporting this theory.⁹ On the contrary, a single RCT showed no additional effect of adding TrA training to a PFMT program.¹⁰ Finally, “functional training of the PFM” has been proposed where women are asked to conduct a PFM contraction during different tasks of daily living.¹¹ There are no RCTs to support this training schedule.⁴

Efficacy for Pelvic Floor Muscle Training

In 1948 Kegel was the first to report PFMT to be effective in treatment of female urinary incontinence (UI).4,5 In spite of his reports of cure rates of more than 84%, surgery soon became the first choice of treatment, and it was not until the 1980s that renewed interest in nonsurgical treatments evolved. This new interest for conservative treatment may have developed because of higher awareness among women regarding incontinence and health and fitness activities, increasing costs of surgery, and morbidity, complications, and relapses reported after surgical procedures.⁴

The numerous reports by Kegel with more than 80% cure rate comprised uncontrolled studies with the inclusion of a variety of incontinence types and no measurement of urinary leakage before and after treatment. However, since then, several RCTs have demonstrated that PFM training is more effective than no treatment to treat SUI.^5,12,13 In addition, a number of RCTs have compared PFM training alone with the use of vaginal resistance devices, biofeedback, or vaginal cones.^5,14 Out of the RCTs on SUI, only 1 did not show any significant effect of PFM training on UI.¹⁴ Interestingly, in this study there was no check of the women’s ability to contract, adherence to the training protocol was poor, and the placebo group contracted gluteal muscles and external rotators of the hips, activities that may be associated with co-contractions of the PFM.⁴

It is often reported that PFM training is more commonly associated with improvement of symptoms, rather than a complete cure. However, short-term cure rates of 44% to 80%, defined as ≤2 g of leakage on different pad tests, have been found after PFM training for SUI.¹⁵ The highest cure rates were shown in RCTs of high methodological quality.^4,16 The participants had thorough individual instruction by a trained physical therapist (PT), combined training with biofeedback or electrical stimulation, and close follow-up at least every two weeks. In studies that have shown efficacy, adherence was high and dropout low.

Because of use of different outcome measures and instruments to measure PFM function and strength, it is impossible to combine results between studies, and it is difficult to conclude which training regimen is the most effective. Also, the exercise dosage of PFMT including the type, frequency, duration, and intensity of exercises varies significantly between studies.^4,5 A Cochrane systematic review¹⁴ of outcomes following treatment for SUI documented this variety in approach. In the review, the length of interventions varied between six weeks and six months, intensity (measured as holding time) varied between 3 and 40 seconds, and number of repetitions per day between 36 and >200. Frequency of training was daily in all included RCTs.

It has been shown that instructor follow-up training is significantly more effective than home exercise.⁴ In one study, individual assessment and teaching of how to correctly contract the pelvic floor musculature was combined with strength training in groups in a six-month training program. Women were randomized to either an intensive training program consisting of seven individual sessions with a PT, combined with 45 minutes weekly PFM training classes, and Three sets of 8 to 12 contractions per day at home or the same program without weekly intensive exercise classes. The results showed better improvement in both muscle strength and urinary leakage in the intensive exercise group. In the intensive exercise group 60% of women reported that they were continent/almost continent compared with 17% in the less intensive intervention group. A significant reduction of urinary leakage, measured by pad test performed at a standardized bladder volume, was demonstrated only in the intensive exercise group (Figure 20-1).

This study was the first to demonstrate that a large difference in outcome can be expected according to the intensity and follow-up of the training program, and that very little effect can be expected after training without close follow-up. It is worth noting that the lesser intervention group in this study had seven visits with a skilled PT, and that adherence to the home training program was high. Nevertheless, the effect was only 17%. To date, more intensive training has also shown to be more effective in other RCTs and systematic reviews. ^4,5,12,13,16 A dose–response effect has been seen in a variety of training regimens.^4,17 Hence, one reason for disappointing effects shown in some clinical practices or clinical trials may be insufficient supervision and low dosage. If low-dosage programs are chosen as one arm in a RCT comparing PFM training with other methods, PFM training is bound to be less effective.

Efficacy of Pelvic Floor Muscle Training with Biofeedback

Biofeedback has been defined as “a group of experimental procedures where an external sensor is used to give an indication on bodily processes, usually in the purpose of changing the measured quality.”⁴ Biofeedback equipment has been developed within the area of psychology, mainly for measurement of sweating, heart rate, and blood pressure during different forms of stress. Kegel based his training protocol on thorough instruction of correct contraction using vaginal palpation and clinical observation. He combined PFM training with use of vaginal squeeze pressure measures as a form of biofeedback during exercise. Today, a variety of biofeedback apparatuses are commonly used in clinical practice to assist with PFM training (Figure 20-2).

In urology or urogynecology textbooks the term “biofeedback” is often used to designate a treatment that is distinct from PFM training. However, biofeedback is not a treatment on its own. It is an adjunct to PFMT, measuring the response from a single PFM contraction. Vaginal and anal surface electromyography (EMG), and urethral and vaginal squeeze pressure measurements have been utilized for the purpose of making patients more aware of muscle function, and to enhance and motivate patients’ effort during training.⁴ However, erroneous attempts of PFM contractions such as those that occur with straining may be registered by manometers and dynamometers, and contractions of muscles other than the PFM may affect surface EMG activity. Hence, EMG, manometers, and dynamometers cannot be used without other assessments to register a correct PFM contraction. MRI and ultrasound are newer methods that can be used for biofeedback and they overcome these challenges.

Since Kegel first presented his results, several RCTs have shown that PFM training without biofeedback is more effective than no treatment for SUI.^5,16 In women with stress or mixed incontinence, all but two RCTs failed to show any additional effect of adding biofeedback to the training protocol for SUI. One⁴ demonstrated quicker progress in the biofeedback group. Another⁴ demonstrated a positive effect of biofeedback in addition to PFMT; however, this study was confounded by a difference in training frequency between groups, and the effect might be due to a double training dosage, the use of biofeedback, or both.

Very few of the studies comparing PFMT with and without biofeedback have used the exact same training dosage in the two randomized intervention groups. For example, Pages et al.⁴ compared 60 minutes of group training five days a week with 15 minutes of individual biofeedback training five days a week, and found that the individualized biofeedback training protocol was more effective as assessed by women’s report and measurement of PFM strength. When the two groups under comparison receive different dosage of training in addition to biofeedback, it is impossible to conclude what is causing a possible effect. Moreover, since PFM training is effective without biofeedback, a large sample size is needed to show any beneficial effect of adding biofeedback to an already effective training protocol. In most of the published studies comparing PFMT with PFMT combined with biofeedback, the sample sizes are small, and type II error may have been the reason for negative findings.⁵ However, in the two largest RCTs published, no additional effect was demonstrated from adding biofeedback.⁵

Many women may not like to undress, go to a private room, and insert a vaginal or rectal device in order to exercise. On the other hand, some women find it motivating to use biofeedback to control and enhance the strength of the contractions when training. Any factor that may stimulate adherence to intensive training should be recommended in purpose of enhancing the effect of a training program. Hence, when available, biofeedback should be given as an option for home training, and the physiotherapist should use any sensitive, reliable, and valid tool to measure the contraction force at office follow-up.

Efficacy of Pelvic Floor Muscle Training with Vaginal Weighed Cones

Vaginal cones are weights that are put into the vagina above the levator plate (Figure 20-3). The cones were developed in 1985. The theory behind the use of cones in strength training is that the PFM are contracted reflexively or voluntary when the cone is perceived to slip out. The weight of the cone is supposed to give a training stimulus and make the women contract more forcefully with progressively increasing weights. A Cochrane review, combining studies including patients with both SUI and mixed incontinence, concluded that training with vaginal cones is more effective than no treatment.¹⁸

Five RCTs have been found comparing PFMT with and without vaginal cones for SUI.^4,18 Bø⁴ found that PFMT was significantly more effective than training with cones to both improve muscle strength and reduce urinary leakage. In other studies no differences were observed between PFMT with and without cones.^4,18 Others^4,18 reported very low adherence with the use of vaginal cones and therefore did not recommend their use. Others have reported that women have motivational problems with the use of cones with dropout rates of 33%.

The use of cones can also be questioned from an exercise science perspective. Holding the cone for as long as 15 to 20 minutes may cause decreased blood supply, decreased oxygen consumption, muscle fatigue, and pain. In addition, in order to retain the vaginal cone women may recruit contraction of other muscles instead of the PFM. Moreover, many women report that they dislike using cones.⁴ On the other hand, the cones may add benefit to the training protocol if used correctly: subjects can be asked to contract around the cone and simultaneously try to pull it out in lying or standing position, repeating this 8 to 12 times in three series per day, or they can use the cones during progressively graded activities of daily living. In this way, general strength training principles are followed, and progression can be added to the training protocol. The effect of these methods, however, needs to be evaluated in high-quality RCTs. Use of “vaginal balls” following general strength training was more effective in reducing urinary leakage than regular PFMT.^4,18

Efficacy of Electrical Stimulation for Treatment of SUI

Physiotherapists are the only health professional group that has formal training in use of electrical stimulation in their undergraduate curricula. Nevertheless, the effect of electrical stimulation is much disputed in physiotherapy, and the use of electrical stimulation differs between countries. According to Herbert et al.¹⁹ the effect of electrical stimulation in the general musculoskeletal area is not impressive. Interestingly, however, there has been much interest in electrical stimulation in treatment of incontinence and other pelvic floor dysfunctions, especially among general practitioners and gynecologists.^20,21

Considerable controversy regarding the effect of electrical stimulation to treat SUI exists.^5,15,21 Many of the electrical stimulation studies are flawed with small numbers, and future RCTs with better methodological quality should be undertaken.^5,15,21 Electrical stimulation has been shown to have side effects²⁰ and to be less tolerable to women than PFM training. In addition, Bø and Talseth⁵ found that voluntary PFM contraction increases urethral pressure significantly more than electrical stimulation, and several consensus statements have concluded that strength training is more effective than electrical stimulation in humans. There are no studies on long-term effect of electrical stimulation for the treatment of SUI.

Complications

Few, if any, adverse effects have been found after PFMT.^{4,5,12,13,15,16} One study reported^4,5 found that one woman reported pain with exercise and three had an uncomfortable feeling during the exercises. Aukee et al.^4,5 reported no side effects in the training group but found that two women interrupted the use of home biofeedback apparatus because they found the vaginal probe uncomfortable. Both of these women were postmenopausal. In other studies no side effects have been found.⁵

Long-term Outcomes

Several studies have reported long-term effect of PFMT.^4,5,13. However, usually women in the nontreatment or less effective intervention groups have gone on to receive other treatments after cessation of the study period, confounding follow-up. Follow-up data are therefore usually reported for either all women or only the group with the best short-term effect. As for surgery, there are only few long-term studies that include clinical examination.⁴ A study of 88 out of 110 women with stress, urgency, or mixed incontinence five years after cessation of training found that 67% remained satisfied with the treatment of their condition. Only 7 of 110 had been treated with surgery. Moreover, satisfaction was closely related to compliance to training and type of incontinence, with mixed incontinent women being most likely to report loss of treatment effect. SUI women had the best long-term effect, but only 39% of women were exercising daily or “when needed.”

In a five-year follow-up, Bø and Talseth⁴ examined only the intensive exercise group and found that urinary leakage was significantly increased after cessation of organized training. Three of 23 women had been treated with surgery. Fifty-six percent of the women had a positive closure pressure during cough and 70% had no visible leakage during cough at five-year follow-up. Seventy percent of the intensive exercise group were still satisfied with the results and did not desire other treatment options.

Others⁴ used a postal questionnaire and medical files to evaluate the long-term effectiveness of treatment in 52 women who had participated in an individual course of PFMT for SUI. Eighty-seven percent were suitable for analysis. Thirty-three percent had undergone surgery after ten years. However, only 8% had undergone surgery in the group originally successful after training, whereas 62% had undergone surgery in the group initially dissatisfied with training. Successful results were maintained after ten years in two-thirds of the patients originally classified as successful.

Bø et al.²² reported current status of lower urinary tract symptoms (LUTS) from questionnaire data 15 years after cessation of organized training. They found that the short-term significant effect of intensive training was no longer present. Fifty percent from both groups had interval surgery for SUI; however, more women in the less intensive training group had surgery within the first five years after ending the training program. There were no differences in reported frequency or amount of leakage between nonoperated and operated women, and women who had surgery reported significantly more severe leakage and were more bothered by UI during daily activities than those not operated.

The general recommendations for maintaining muscle strength are a single set of eight to 12 contractions twice a week.¹⁷ The intensity of the contraction seems to be more important than frequency of training. So far, no studies have evaluated how many contractions subjects must perform to maintain PFM strength after cessation of organized training. In a study by Bø⁴ PFM strength was maintained five years after cessation of organized training with 70% exercising more than once a week. However, number and intensity of exercises varied considerably between successful women. One series of 8 to 12 contractions could easily be instructed in aerobic dance classes or recommended as part of women’s general strength training programs.

Others have identified the timing of PFM contractions to be important for long-term efficacy. In one study⁴ the long-term effect of PFM training appeared to be attributed to learning the timing of pelvic floor contraction before sudden increases in intra-abdominal pressure, and not to regular strength training. Muscle strength was not measured in their study. Although not taught in the original program, several women in the study of Bø et al.²² also had performed precontractions of the PFM before and during rise in abdominal pressure during the long-term follow-up period. The contribution of timing and strength exercising seems to exhibit independent contributions to continence; performance of precontractions did not increase muscle strength in a recently published RCT.⁷

RCTs with high methodological quality and several systematic reviews have concluded that there is high-level evidence that PFMT is more effective than no treatment, sham, or placebo treatment for SUI. PFMT is recommended as first-line treatment for SUI. Addition of biofeedback, electrical stimulation, or vaginal cones has not been shown to improve outcomes compared with performance of PFMT alone. More intensive PFM training, meaning supervised training, is more effective than nonsupervised training. A recommended protocol is 8 to 12 contractions three times per day following individual teaching and assessment of ability to perform a correct contraction and weekly supervised training either individually or in groups.

In clinical practice, many patients with overactive bladder symptoms including frequency, urgency, nocturia, and urgency incontinence are treated with PFM training with and without biofeedback, electrical stimulation, bladder training, or medication, and often many of these interventions are combined.⁵ When different methods are combined, it is not possible to analyze the cause/effect of the different interventions. In addition, in many systematic reviews evaluating the effect of PFM training in treatment of UI, studies including patients with symptoms or urodynamic diagnosis of SUI, urgency incontinence, and mixed incontinence are combined. This makes it impossible to understand the real effect of the different interventions on overactive bladder symptoms.²³

Bladder Training

According to Wyman²⁴ bladder training has been advocated as treatment of OAB since the late 1960s. The goal is to restore normal bladder function through patient education along with a voiding regimen that gradually increases the time interval between voids.

Wyman²⁴ lists several explanations of why bladder training may work including improved cortical inhibition over involuntary detrusor contractions, urethral closure during bladder filling, central modulation of afferent sensory impulses, and the individual becoming more knowledgeable and aware of the circumstances causing incontinence, which therefore increases the ability of the individual to change behavior in ways that increase the reserve capacity of the lower urinary system.

Efficacy of Bladder Training on OAB

Based on a systematic review of RCTs on bladder training to treat OAB, Wyman²⁴ concludes that there is only weak evidence to judge the effectiveness. However, bladder training has no known side effects and can be used safely as first-line treatment for OAB in women.

Pelvic Floor Muscle Training

New theories suggest PFM dysfunction is a common cause of both SUI and urgency incontinence²⁵; the mechanisms behind PFM dysfunction in each of these diagnoses are not yet thoroughly understood. Optimally, the physiotherapy intervention should relate to the underlying pathophysiological condition. PFMT may have different cure and improvement rates for SUI and urgency incontinence, and the combination of heterogeneous patient groups in systematic reviews and meta-analysis may dilute the effectiveness of the intervention rate for each diagnosis. In other words, an optimal PFMT protocol may be different for the two conditions due to a different theoretical rationale. In this overview, only RCTs applying PFM training and including patients with symptoms/diagnosis of overactive bladder will be reported.