Current Urology Reports

, Volume 14, Issue 5, pp 457–464

Update on Behavioral and Physical Therapies for Incontinence and Overactive Bladder: The Role of Pelvic Floor Muscle Training

Lower Urinary Tract Symptoms and Voiding Dysfunction (G Badlani and H Goldman, Section Editors)

Abstract

Behavioral and physical therapies have been used for many years to treat incontinence and overactive bladder (OAB). This paper focuses on programs that include pelvic floor muscle training (PFMT) as a component in treatment for women or men. PFMT was long used almost exclusively for treatment of stress incontinence. When it became evident that voluntary pelvic floor muscle contraction can be used to control bladder function, PFMT was also integrated into the treatment of urge incontinence and OAB as part of a broader behavioral urge suppression strategy. PFMT has evolved over decades, both as a behavioral therapy and a physical therapy, combining principles from behavioral science, nursing, and muscle physiology into a widely recommended conservative treatment. The collective literature indicates that PFMT is effective for incontinence, as well as urgency, frequency, and nocturia. It can be combined with all other treatment modalities and holds potential for prevention of bladder symptoms.

Keywords

Pelvic floor muscle training Behavioral treatment Physical therapy Biofeedback Behavioral medicine Combination therapy Urinary incontinence Overactive bladder Pelvic floor disorders Urgency Urinary frequency Nocturia Lower urinary tract symptoms 

References

  1. 1.
    NIH Consensus Conference. Urinary incontinence in adults. JAMA. 1989;261:2685–96.CrossRefGoogle Scholar
  2. 2.
    Hartmann KE, McPheeters ML, Biller DH et al. Treatment of Overactive Bladder in Women. Evidence Report/Technology Assessment Number 187 (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2007-10065-I). Agency for Healthcare Research and Quality (AHRQ); 2009.Google Scholar
  3. 3.
    Fantl JA, Newman DK, Colling J, et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline, No. 2 1996 Update; Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No.96-0682.Google Scholar
  4. 4.
    Gormley EA, Lightner DJ, Burgio KL, Chai TC, Clemens JQ, Culkin DJ, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol. 2012;188:2455–63.PubMedCrossRefGoogle Scholar
  5. 5.
    Hay Smith J, Berghmans B, Burgio K, Dumoulin C, Hagen S, Moore K, et al. Adult conservative management. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence, 4th international consultation on incontinence. Paris: Health Publications Ltd; 2009. p. 1101–227.Google Scholar
  6. 6.
    Kaya S, Akbayrak T, Beksac S. Comparison of different treatment protocols in the treatment of idiopathic detrusor overactivity: a randomized controlled trial. Clin Rehabil. 2011;25:327.PubMedCrossRefGoogle Scholar
  7. 7.
    Arruda RM, Castro RA, Sousa GC, et al. Prospective randomized comparison of oxybutynin, functional electrostimulation, and pelvic floor training for treatment of detrusor overactivity in women. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:1055.PubMedCrossRefGoogle Scholar
  8. 8.
    Colombo M, Zanetta G, Scalambrino S, et al. Oxybutynin and bladder training in the management of female urge urinary incontinence: a randomized study. Int Urogynecol J. 1995;6:63.CrossRefGoogle Scholar
  9. 9.
    Burgio KL, Goode PS, Johnson 2nd TM, Hammontree L, Ouslander JG, Markland AM, et al. Behavioral versus drug treatment for overactive bladder in men: the male overactive bladder treatment in veterans (MOTIVE) trial. J Am Geriatr Soc. 2011;59:2209–16.PubMedCrossRefGoogle Scholar
  10. 10.
    Subak LL, Wing R, West DS, et al. Weight loss to treat urinary incontinence in overweight and obese women. NEJM. 2009;360:481.PubMedCrossRefGoogle Scholar
  11. 11.
    Burgio KL, Locher JL, Goode PS, Hardin JM, McDowell BJ, Dombrowski M, et al. Behavioral versus drug treatment for urge incontinence in older women: a randomized clinical trial. JAMA. 1998;23:1995–2000.CrossRefGoogle Scholar
  12. 12.
    Goode PS, Burgio KL, Locher JL, et al. Urodynamic changes associated with behavioral and drug treatment of urge incontinence in older women. J Am Geriatr Soc. 2002;50:808.PubMedCrossRefGoogle Scholar
  13. 13.
    Song C, Park JT, Heo KO, et al. Effects of bladder training and/or tolterodine in female patients with overactive bladder syndrome: a prospective, randomized study. J Korean Med Sci. 2006;21:1060.PubMedCrossRefGoogle Scholar
  14. 14.
    Kafri R, Langer R, Dvir Z, et al. Rehabilitation vs drug therapy for urge urinary incontinence: short-term outcome. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:407.PubMedCrossRefGoogle Scholar
  15. 15.
    Johnson TM, Burgio KL, Goode PS, et al. Effects of behavioral and drug therapy on nocturia in older incontinent women. J Am Geriatr Soc. 2005;53:846.PubMedCrossRefGoogle Scholar
  16. 16.
    Johnson TM, Markland AD, Goode PS, Vaughan CP, Colli J, Ouslander JG, et al. Efficacy of adding behavioral treatment or antimuscarinic drug therapy to alpha-blocker therapy in men with nocturia. BJU Int. 2013;112(1):100–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol. 1948;56:238–48.PubMedGoogle Scholar
  18. 18.
    Kegel AH. Stress incontinence of urine in women: physiologic treatment. J Int Coll Surg. 1956;25:487–99.PubMedGoogle Scholar
  19. 19.
    Goode PS, Burgio KL, Locher JL, Roth DL, Umlauf MG, Richter HE, et al. Effect of behavioral training with or without pelvic floor electrical stimulation on stress incontinence in women: a randomized controlled trial. JAMA. 2003;290:345–52.PubMedCrossRefGoogle Scholar
  20. 20.
    Bourcier AP, Juras JC, Jacquetin B. Urinary incontinence in physically active and sportswomen. In: Appell RA, Bourcier AP, La Torre F, editors. Pelvic floor dysfunction: investigations and conservative treatment. Rome: C.E.S.I.; 1999. p. 9–17.Google Scholar
  21. 21.
    Miller JM, Ashton-Miller JA, DeLancey JOL. A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatr Soc. 1998;46:870.PubMedGoogle Scholar
  22. 22.
    Hay-Smith EJC, Dumoulin C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2010;1, CD005654.PubMedGoogle Scholar
  23. 23.
    Shamliyan TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med. 2008;148(6):459–73.PubMedCrossRefGoogle Scholar
  24. 24.
    Wells TJ, Brink CA, Diokno AD, Wolfe R, Gillis GL. Pelvic muscle exercise for stress urinary incontinence in elderly women. J Am Geriatr Soc. 1991;39:785–91.PubMedGoogle Scholar
  25. 25.
    Berghmans LCM, Frederiks CMA, de Bie RA. Efficacy of biofeedback when included with pelvic floor muscle exercise treatment for genuine stress incontinence. Neurourol Urodyn. 1996;15:37–52.PubMedCrossRefGoogle Scholar
  26. 26.
    Nygaard IE, Kreder KJ, Lepic MM, Fountain KA, Rhomberg AT. Efficacy of pelvic floor muscle exercises in women with stress, urge, and mixed urinary incontinence. Am J Obstet Gynecol. 1996;174:120–5.PubMedCrossRefGoogle Scholar
  27. 27.
    Bo K, Talseth T. Single blind randomized controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ. 1999;318:487–93.PubMedCrossRefGoogle Scholar
  28. 28.
    Wilson PD, Herbison GP. A randomized controlled trial of pelvic floor muscle exercises to treat postnatal urinary incontinence. Int Urogynecol J. 1998;9:257–64.CrossRefGoogle Scholar
  29. 29.
    Wilson PD, Herbison GP, Glazener CMA, Lang G, Gee H, MacArthur C. Postnatal incontinence: a multicenter, randomized controlled trial of conservative treatment. Neurourol Urodyn. 1997;16:349–50.Google Scholar
  30. 30.
    Glazener CM, Herbison GP, Wilson PD, MacArthey C, Lang GD, Gee H, et al. Conservative management of persistent postnatal urinary and faecal incontinence: a randomized controlled trial. BMJ. 2001;323:1–5.CrossRefGoogle Scholar
  31. 31.
    Burns PA, Pranikoff K, Nochajski TH, Hadley EC, Levy KJ, Ory MG. A comparison of effectiveness of biofeedback and pelvic muscle exercise treatment of stress incontinence in older community-dwelling women. J Gerontol. 1993;48:167–74.CrossRefGoogle Scholar
  32. 32.
    Morkved S, Bo K. Effect of postpartum pelvic floor muscle training in prevention and treatment of urinary incontinence: a one-year follow-up. Br J Obstet Gynaecol. 2000;107:1022–8.CrossRefGoogle Scholar
  33. 33.
    Glazener C, Boachie C, Buckley B, Cochran C, Dorey G, Grant A, et al. Conservative treatment for urinary incontinence in Men After Prostate Surgery (MAPS): two parallel randomised controlled trials. Health Technol Assess. 2011;15(24):1–296.PubMedGoogle Scholar
  34. 34.
    Manassero F, Traversi C, Ales V, et al. Contribution of early intensive prolonged pelvic floor exercises on urinary continence recovery after bladder necksparing radical prostatectomy: results of a prospective controlled randomized trial. Neurourol Urodyn. 2007;26(7):985–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Van Kampen M, De Weerdt W, Van Poppel H, De Ridder D, Feys H, Baert L. Effect of pelvic-floor reeducation on duration and degree of incontinence after radical prostatectomy: a randomised controlled trial. Lancet. 2000;355(9198):98–102.PubMedCrossRefGoogle Scholar
  36. 36.
    Ribeiro LH, Prota C, Gomes CM, de Bessa Jr J, Boldarine MP, Dall’Oglio MF, et al. Long-term effect of early postoperative pelvic floor biofeedback on continence in men undergoing radical prostatectomy: a prospective, randomized, controlled trial. J Urol. 2010;184(3):1034–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Burgio KL, Stutzman RE, Engel BT. Behavioral training for post-prostatectomy urinary incontinence. J Urol. 1989;141:303–6.PubMedGoogle Scholar
  38. 38.
    Goode PS, Burgio KL, Johnson 2nd TJ, Clay OJ, Roth DL, Markland AD, et al. Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for persistent post-prostatectomy incontinence—a randomized controlled trial. JAMA. 2011;305:151–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Burgio KL, Whitehead WE, Engel BT. Urinary incontinence in the elderly: bladder-sphincter biofeedback and toileting skills training. Ann Intern Med. 1985;104:507–15.CrossRefGoogle Scholar
  40. 40.
    Burgio KL, Pearce KL, Lucco AJ. Staying dry: a practical guide to bladder control. Baltimore: Johns Hopkins University Press; 1989.Google Scholar
  41. 41.
    Burgio KL, Goode PS, Locher JL, Umlauf MG, Roth DL, Richter HE, et al. Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: a randomized controlled trial. JAMA. 2002;288:2293–9.PubMedCrossRefGoogle Scholar
  42. 42.
    Fantl JA, Wyman JF, McClish DK, et al. Efficacy of bladder training in older women with urinary incontinence. JAMA. 1991;265:609–13.PubMedCrossRefGoogle Scholar
  43. 43.
    Floratos DL, Sonke GS, Rapidou CA, Alivizatos GJ, Deliveliotis C, Constantinides CA, et al. Biofeedback vs verbal feedback as learning tools for pelvic muscle exercises in the early management of urinary incontinence after radical prostatectomy. BJU Int. 2002;89(7):714–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Moore KN, Valiquette L, Chetner MP, Byrniak S, Herbison GP. Return to continence after radical retropubic prostatectomy: a randomized trial of verbal and written instructions versus therapist-directed pelvic floor muscle therapy. Urology. 2008;72(6):1280–6.PubMedCrossRefGoogle Scholar
  45. 45.
    Opsomer RJ, Castille Y, Abi-Add AS, Van Cangh PJ. Urinary incontinence after radical prostatectomy: is professional pelvic floor training necessary? Neurourol Urodyn. 1994;13(4):382–4.Google Scholar
  46. 46.
    Herderschee R, Hay-Smith EJ, Herbison GP, Roovers JP, Heineman MJ. Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev. 2011;7, CD009252.PubMedGoogle Scholar
  47. 47.
    Knight S, Laycock J, Naylor D. Evaluation of neuromuscular electrical stimulation in the treatment of genuine stress incontinence. Physiotherapy. 1998;84:61–71.CrossRefGoogle Scholar
  48. 48.
    Sand PK, Richardson DR, Staskin SE, Swift SE, Appell RA, Whitmore KE, et al. Pelvic floor stimulation in the treatment of genuine stress incontinence: a multicenter placebo-controlled trial. Am J Obstet Gynecol. 1995;173:72–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Yamanishi T, Yasuda K, Sakakibara R, Hattori T, Ito H, Marakami S. Pelvic floor electrical stimulation in the treatment of stress incontinence: an investigational study and a placebo controlled double-blind trial. J Urol. 1997;158:2127–31.PubMedCrossRefGoogle Scholar
  50. 50.
    Burgio KL, Kraus SR, Menefee S, Borello-France D, Corton M, Johnson HW, et al. Behavior therapy to enable drug discontinuation in the treatment of urge incontinence: a randomized controlled trial. Ann Intern Med. 2008;149:161–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Mattiasson A, Blaakaer J, Hoye K, Wein AJ, Tolterodine Scandinavian Study Group. Simplified bladder training augments the effectiveness of tolterodine in patients with an overactive bladder. BJU Int. 2003;91:54–60.PubMedCrossRefGoogle Scholar
  52. 52.
    Mattiasson A, Masala A, Morton R, et al. Efficacy of simplified bladder training in patients with overactive bladder receiving a solifenacin flexible-dose regimen: results from a randomized study. BJU Int. 2010;105(8):1126–35.PubMedCrossRefGoogle Scholar
  53. 53.
    Burgio KL, Locher JL, Goode PS. Combined behavioral and drug therapy of urge incontinence in older women. J Am Geriatr Soc. 2000;48:370–4.PubMedGoogle Scholar
  54. 54.
    Ghoniem GM, van Leeuwen JS, Elser DM, Freeman RM, Zhao YD, Yalcin I, et al. A randomized controlled trial of duloxetine alone, pelvic floor muscle training alone, combined treatment, and no active treatment in women with stress urinary incontinence. J Urol. 2005;173:1647–53.PubMedCrossRefGoogle Scholar
  55. 55.
    Jarvis SK et al. Peri-operative physiotherapy improves outcomes for women undergoing incontinence and or prolapse surgery: results of a randomised controlled trial. Aust N Z J Obstet Gynaecol. 2005;45(4):300–3.PubMedCrossRefGoogle Scholar
  56. 56.
    Frawley HC, Phillips BA, Bo K, Galea MP. Physiotherapy as an adjunct to prolapse surgery: an assessor-blinded randomized controlled trial. Neurourol Urodynam. 2010;29(5):719–25.Google Scholar
  57. 57.
    Barber MD, Brubaker L, Menefee S, Norton P, Borello-France D, et al. Operations and pelvic muscle training in the management of apical support loss (OPTIMAL) trial: design and methods. Contemp Clin Trials. 2009;30:178–89.PubMedCrossRefGoogle Scholar
  58. 58.
    Diokno AC, Sampselle CM, Herzog AG, et al. Prevention of urinary incontinence by behavioral modification program: a randomized controlled trial among older women in the community. J Urol. 2004;171:1161–4.CrossRefGoogle Scholar
  59. 59.
    Morkved S, Bo K. The effect of postpartum pelvic floor muscle exercise in the prevention and treatment of urinary incontinence. Int Urogynecol J. 1997;8:217–22.CrossRefGoogle Scholar
  60. 60.
    Mørkved S, Bø K, Schei B, Salvesen KA. Pelvic floor muscle training during pregnancy to prevent urinary incontinence: a single-blind randomized controlled trial. Obstet Gynecol. 2003;101(2):313–9.PubMedCrossRefGoogle Scholar
  61. 61.
    Ko PC, Liang CC, Chang SD, Lee JT, Chao AS, Cheng PJ. A randomized controlled trial of antenatal pelvic floor exercises to prevent and treat urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2011;22(1):17–22.CrossRefGoogle Scholar
  62. 62.
    Mason L, Roe B, Wong H, Davies J, Bamber J. The role of antenatal pelvic floor muscle exercises in prevention of postpartum stress incontinence: a randomised controlled trial. J Clin Nurs. 2010;19:2777–86.PubMedCrossRefGoogle Scholar
  63. 63.
    Hay-Smith J, Morkved S, Fairbrother KA, Herbison GP. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2008;4, CD007471.PubMedGoogle Scholar
  64. 64.
    Burgio KL, Goode PS, Urban DA, Umlauf MG, Locher JL, Bueschen A, et al. Preoperative biofeedback-assisted behavioral training to reduce post-prostatectomy incontinence: a randomized controlled trial. J Urol. 2006;175:196–201.PubMedCrossRefGoogle Scholar
  65. 65.
    Mathewson-Chapman M. Pelvic muscle exercise/biofeedback for urinary incontinence after prostatectomy: an education program. J Cancer Educ. 1997;12:218–23.PubMedGoogle Scholar
  66. 66.
    Sueppel C, Kreder K, See W. Improved continence outcomes with preoperative pelvic floor muscle strengthening exercises. Urol Nurs. 2001;21:201–10.PubMedGoogle Scholar
  67. 67.
    Parekh AR, Feng MI, Kirages D, Bremner H, Kaswick J, Aboseif S. The role of pelvic floor exercises on post-prostatectomy incontinence. J Urol. 2003;170:130–3.PubMedCrossRefGoogle Scholar
  68. 68.
    Centemero A, Rigatti L, Giraudo D, Lazzeri M, Lughezzani G, Zugna D, et al. Preoperative pelvic floor muscle exercise for early continence after radical prostatectomy: a randomised controlled study. Eur Urol. 2010;57(6):1039–43.PubMedCrossRefGoogle Scholar
  69. 69.
    Overgård M, Angelsen A, Lydersen S, Morkved S. Does physiotherapist-guided pelvic floor muscle training reduce urinary incontinence after radical prostatectomy? A randomised controlled trial. Eur Urol. 2008;54(2):438–48.PubMedCrossRefGoogle Scholar
  70. 70.
    Wille S, Sobottka A, Heidenreich A, Hofmann R. Pelvic floor exercises, electrical stimulation and biofeedback after radical prostatectomy: results of a prospective randomized trial. J Urol. 2003;170(2 Pt 1):490–3.PubMedCrossRefGoogle Scholar
  71. 71.
    Filocamo MT, Li Marzi V, Del Popolo G, et al. Effectiveness of early pelvic floor rehabilitation treatment for post-prostatectomy incontinence. Eur Urol. 2005;48(5):734–8.PubMedCrossRefGoogle Scholar
  72. 72.
    Subak LL, Quesenberry CP, Posner SF, Cattolica E, Soghikian K. The effect of behavioral therapy on urinary incontinence: a randomized controlled trial. Obstet Gynecol. 2002;100:72–8.PubMedCrossRefGoogle Scholar
  73. 73.
    Sampselle CM, Wyman JF, Thomas KK, Newman DK, Gray M, Dougherty M, et al. Continence for women: a test of AWHONN’s evidence-based protocol in clinical practice. JOGNN. 2000;29:18–26.PubMedCrossRefGoogle Scholar
  74. 74.
    Bo K, Haakstad LA. Is pelvic floor muscle training effective when taught in a general fitness class in pregnancy? A randomized controlled trial. Physiotherapy. 2011;97:190–5.PubMedCrossRefGoogle Scholar
  75. 75.
    Pereira VS, Correia GN, Driusso P. Individual and group pelvic floor muscle training versus no treatment in female stress urinary incontinence: a randomized controlled pilot study. Eur J Obstet Gynecol Reprod Biol. 2011;159:465–71.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York (outside the USA) 2013

Authors and Affiliations

  1. 1.University of Alabama at BirminghamBirminghamUSA
  2. 2.Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Department of Veterans AffairsBirminghamUSA
  3. 3.BirminghamUSA

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