Advertisement

International Urogynecology Journal

, Volume 15, Issue 2, pp 76–84 | Cite as

Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work?

  • Kari Bø
Review Article

Abstract

To date several randomized controlled trials (RCT) have shown that pelvic floor muscle (PFM) training is effective in the treatment of female stress (SUI) and mixed urinary incontinence and, therefore, it is recommended as a first-line therapy. While the effectiveness of treatment is established, there are different theoretical rationales for why PFM training is effective. The aims of this article are to discuss the theories behind why PFM training is effective in treating SUI and to discuss each theory in the framework of new knowledge of functional anatomy and examples of results from RCTs. There are three proposed theories to explain the effectiveness of PFM training for SUI: 1) women learn to consciously pre-contract the PFMs before and during increases in abdominal pressure (such as coughing, physical activity) to prevent leakage; 2) strength training builds up long-lasting muscle volume and thus provides structural support; and 3) abdominal muscle training indirectly strengthens the PFM. The first can be placed in a behavioral construct, while the two latter both have the aim of changing neuromuscular function and morphology, thus making the PFM contraction automatic. To date there are RCTs and basic anatomy studies to support the first two concepts only.

Keywords

Anatomy Exercise Pelvic floor muscles Stress urinary incontinence Training 

Notes

Acknowledgements

Thanks to Ingrid Nygaard, MD, Professor of Obstetrics and Gynecology, University of Iowa College of Medicine, Iowa City, Iowa, for thorough English revision of the manuscript.

References

  1. 1.
    Kegel AH (1948) Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol 56:238–249Google Scholar
  2. 2.
    Chang S (1984) De indre øvelser (Internal exercises). Oslo: O.G.P.- OMRE A/S, Stuyvesant Publishing Co (English)Google Scholar
  3. 3.
    Mantle J (2001) Physiotherapy for incontinence. In: Cardozo L, Staskin D (eds) Textbook of female urology and urogynecology. London: Isis Medical Media Ltd, pp 351–358Google Scholar
  4. 4.
    Kegel AH (1952) Stress incontinence and genital relaxation. Ciba Clin Sympos 2:35–51Google Scholar
  5. 5.
    Fantl JA, Newman DK, Colling J, DeLancey J, Keeys C, Loughery R, et al (1996) Urinary incontinence in adults: acute and chronic management. 2, update [96–0682], 1–154. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. Clinical Practice Guideline, Rockville, MDGoogle Scholar
  6. 6.
    Wilson PD, Bø KH-SJ, Nygaard I, Staskin D, Wyman J, Bourchier A (2002) Conservative treatment in women. In: Abrams P, Cardozo L, Khoury S, Ein A (eds) Incontinence. Plymbridge Ltd, Health Publication Ltd, Plymouth, pp 571–624Google Scholar
  7. 7.
    Hay-Smith E, Bø K, Berghmans L, Hendriks H, deBie R, van Waalwijk van Doorn ESC (2001) Pelvic floor muscle training fur urinary incontinence in women (Cochrane review). [3]. The Cochrane Library, OxfordGoogle Scholar
  8. 8.
    Bø K, Talseth T, Holme I (1999) Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 318:487–493PubMedGoogle Scholar
  9. 9.
    Wong K, Fung B, Fung, LCW, Ma S (1997) Pelvic floor exercises in the treatment of stress urinary incontinence in Hong Kong Chinese women. Papers to be read by title, ICS 27th annual Meeting, Yokohama, Japan, pp 62–63Google Scholar
  10. 10.
    Henalla S, Millar D, Wallace K (1990) Surgical versus conservative management for post-menopausal genuine stress incontinence of urine. Neurourol Urodyn 9:436–437Google Scholar
  11. 11.
    Mørkved S, Bø K, Fjørtoft T (2002) Is there any additional effect off adding biofeedback to pelvic floor muscle training? A single-blind randomized controlled trial. Obstet Gynecol 100:730–739CrossRefPubMedGoogle Scholar
  12. 12.
    Bø K, Lilleås F, Talseth T, Hedlund H (2001) Dynamic MRI of pelvic floor muscles in an upright sitting position. Neurourol Urodyn 20:167–174CrossRefPubMedGoogle Scholar
  13. 13.
    Ashton-Miller J, Howard D, DeLancey J (2001) The functional anatomy of the female pelvic floor and stress continence control system. Scand J Urol Nephrol Suppl 207:1–7CrossRefPubMedGoogle Scholar
  14. 14.
    Bø K, Kvarstein B, Hagen R, Larsen S (1990) Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: II. Validity of vaginal pressure measurements of pelvic floor muscle strength and the necessity of supplementary methods for control of correct contraction. Neurourol Urodyn 9:479–487Google Scholar
  15. 15.
    Bø K, Stien R (1994) Needle EMG registration of striated urethral wall and pelvic floor muscle activity patterns during cough, valsalva, abdominal, hip adductor, and gluteal muscles contractions in nulliparous healthy females. Neurourol Urodyn 13:35–41PubMedGoogle Scholar
  16. 16.
    Peschers U, Gingelmaier A, Jundt K, Leib B, Dimpfl T (2001) Evaluation of pelvic floor muscle strength using four different techniques. Int Urogynecol J 12:27–30Google Scholar
  17. 17.
    Sapsford R, Hodges P, Richardson C, Cooper D, Markwell S, Jull G (2001) Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourol Urodyn 20:31–42CrossRefPubMedGoogle Scholar
  18. 18.
    Neumann P, Gill V (2002) Pelvic floor and abdominal muscle interaction: EMG activity and intra-abdominal pressure. Int Urogynecol J 13:125–132CrossRefGoogle Scholar
  19. 19.
    Hahn I, Milsom I, Ohlson BL, Ekelund P (1996) Comparative assessment of pelvic floor function using vaginal cones, vaginal digital palpation and vaginal pressure measurement. Gynecol Obstet Invest 41:269–274PubMedGoogle Scholar
  20. 20.
    Mørkved S, Salvesen K, Bø K, Eik-Nes S (2002) Pelvic floor muscle strength and thickness in continent and incontinent nulliparous women. Neurourol Urodyn 21:358–359Google Scholar
  21. 21.
    Gunnarsson M (2002) Pelvic floor dysfunction. A vaginal surface EMG study in healthy and incontinent women. PhD thesis. Lund University, Faculty of Medicine, Department of UrologyGoogle Scholar
  22. 22.
    Bernstein I, Juul N, Grønvall S, Bonde B, Klarskov P (1991) Pelvic floor muscle thickness measured by perineal ultrasonography. Scand J Urol Nephrol Suppl 137:131–133PubMedGoogle Scholar
  23. 23.
    Miller J, Perucchini D, Carchidi L, DeLancey J, Ashton-Miller J (2001) Pelvic floor muscle contraction during a cough and decreased vesical neck mobility. Obstet Gynecol 97:255–260CrossRefPubMedGoogle Scholar
  24. 24.
    Peschers U, Schaer G, Anthuber C, DeLancey J, Schussler B (1996) Changes in vesical neck mobility following vaginal delivery. Obstet Gynecol 88:1001–1006Google Scholar
  25. 25.
    Small K, Wynne J (1990) Evaluating the pelvic floor in obstetric patients. Aust NZ J Obstet Gynaecol 30:41–45Google Scholar
  26. 26.
    Howard D, Miller J, DeLancey J, Ashton-Miller J (2000) Differential effects of cough, valsalva, and continence status on vesical neck movement. Obstet Gynecol 95:535–540CrossRefPubMedGoogle Scholar
  27. 27.
    Bump R, Hurt WG, Fantl JA, Wyman JF (1991) Assessment of Kegel exercise performance after brief verbal instruction. Am J Obstet Gynecol 165:322–329Google Scholar
  28. 28.
    Theofrastous J, Wyman J, Bump R, McClish D, Elser D, Bland D, et al (2002) Effects of pelvic floor muscle training on strength and predictors of response in the treatment of urinary incontinence. Neurourol Urodyn 21:486–490CrossRefPubMedGoogle Scholar
  29. 29.
    Bo K, Talseth T (1997) Change in urethral pressure during voluntary pelvic floor muscle contraction and vaginal electrical stimulation. Int Urogyn J 8:3–7Google Scholar
  30. 30.
    Miller JM, Ashton-Miller JA, DeLancey J (1998) A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatr Soc 46:870–874PubMedGoogle Scholar
  31. 31.
    Peschers U, Vodusek D, Fanger G, Schaer G, DeLancey J, Schussler B (2001) Pelvic muscle activity in nulliparous volunteers. Neurourol Urodyn 20:269–275CrossRefPubMedGoogle Scholar
  32. 32.
    Nygaard I, Thompson FL, Svengalis SL, Albright JP (1994) Urinary incontinence in elite nulliparous athletes. Obstet Gynecol 84:183–187PubMedGoogle Scholar
  33. 33.
    Bø K, Borgen J (2001) Prevalence of stress and urge urinary incontinence in elite athletes and controls. Med Sci Sports Exerc 33:1797–1802PubMedGoogle Scholar
  34. 34.
    Hay JG (1993) Citius, altius, longus (faster, higher, longer): The biomechanics of jumping for distance. J Biomechanics 26[Suppl 1]: 7–21Google Scholar
  35. 35.
    Kegel A (1948) The non-surgical treatment of genital relaxation. Annals West Med Surg 2:213–216Google Scholar
  36. 36.
    Frontera W, Meredith C (1989) Strength training in the elderly. In: Harris R, Harris S (eds) Physical activity, aging and sports. Vol 1: Scientific and medical research. Center for the Study of Aging, Albany, NY, pp 319–331Google Scholar
  37. 37.
    DiNubile NA (1991) Strength training. Clin Sports Med 10:33–62PubMedGoogle Scholar
  38. 38.
    Stone M (2003) Implications for connective tissue and bone alterations resulting from resistance exercise training. Med Sci Sports Exerc 20:162–168Google Scholar
  39. 39.
    Vailas A, Vailas J (1994) Physical activity and connective tissue. In: Bouchard C, Shephard R, Stephens T (eds) Physical Activity, Fitness and Health. International Proceedings and Consensus Statement. Human Kinetics Publishers, Champaign, IL, pp 369–382Google Scholar
  40. 40.
    Stone M (1992) Connective tissue and bone response to strength training. In: Komi P (ed) Strength and power in sport. Blackwell Science Ltd, Oxford, pp 279–290Google Scholar
  41. 41.
    Pollock ML, Gaesser GA, Butcher JD, Despres JP, Dishman RK, Franklin BA, et al (1998) The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 30:975–991PubMedGoogle Scholar
  42. 42.
    American College of Sports Medicine Position Stand (1990) The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Med Sci Sports Exerc 22:265–274PubMedGoogle Scholar
  43. 43.
    Haskel W (1994) Dose-response issues from a biological perspective. In: Bouchard C, Shephard RJ, Stephens T (eds) Physical activity, fitness, and health. International proceedings and consensus statement. Human Kinetics Publishers, Champaign, IL, pp 1030–1039Google Scholar
  44. 44.
    Bouchard C (2001) Physical activity and health: introduction to the dose-response symposium. Med Sci Sports Exerc 33:347–350CrossRefGoogle Scholar
  45. 45.
    Kesaniemi Y, Danforth E, Jensen M, Kopelman P, Lefebvre P, Reeder B (2001) Dose-response issues concerning physical activity and health: an evidence-based symposium. Med Sci Sports Exerc 33[Suppl 6]: 351–358Google Scholar
  46. 46.
    Bø K, Hagen RH, Kvarstein B, Jørgensen J, Larsen S (1990) Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: III. Effects of two different degrees of pelvic floor muscle exercise. Neurourol Urodyn 9:489–502Google Scholar
  47. 47.
    Bernstein I (1997) The pelvic floor muscles. University of Copenhagen, Hvidovre Hospital, Department of Urology, PhD thesisGoogle Scholar
  48. 48.
    Miller J, Ashton-Miller J, Carchidi L, DeLancey J (1997) Does a three-month pelvic muscle exercise intervention improve the effectiveness of the knack in reducing cough-induced urine loss on standing stress test? Int Urogynecol J 253Google Scholar
  49. 49.
    Hay-Smith E, Herbison G, Wilson P (2002) Pelvic floor muscle training for women with symptoms of stress urinary incontinence: a randomized trial comparing strengthening and motor relearning approaches. Neurourol Urodyn 21:371–372Google Scholar
  50. 50.
    Sapsford R (2001) The pelvic floor. A clinical model for function and rehabilitation. Physiother 87:620–630Google Scholar
  51. 51.
    Moseley G, Hodges P, Gandevia S (2002) Deep and superficial fibers of the lumbar multifidus muscle are differentially active during voluntary arm movements. Spine 27:E29–E36CrossRefPubMedGoogle Scholar
  52. 52.
    Sapsford R, Hodges P (2001) Contraction of the pelvic floor muscles during abdominal maneuvers. Arch Phys Med Rehabil 82:1081–1088CrossRefPubMedGoogle Scholar
  53. 53.
    Sapsford R, Markwell SJ, Clarke B (1998) The relationship between urethral pressure and abdominal muscle activity. Abstract from the 7 th national CFA conference on incontinence, 102Google Scholar
  54. 54.
    Dumolin C, Lemieux M, Bourbonnais D, Morin M (2003) Conservative management of stress urinary incontinence: a single-blind, randomized controlled trial of pelvic floor rehabilitation with or without abdominal muscle rehabilitation compared to the absence of treatment. Neurourol Urodyn 22:543–544Google Scholar
  55. 55.
    Bø K, Sherburn M, Allen T (2003) Transabdominal ultrasound measurement of pelvic floor muscle activity when activated directly or via transversus abdominis muscle contraction. Neurourol Urodyn 22:582–588CrossRefPubMedGoogle Scholar
  56. 56.
    Fowler C, Benson J, Craggs M, Vodusek D, Yang C, Podnar S (2002) Clinical neurophysiology. In: Abrams P, Cardozo L, Khoury S, Wein A (eds) Incontinence. Plymbridge Distributors Ltd, Plymouth, pp 389–424Google Scholar
  57. 57.
    Danneels L, Cools A, Vanderstraeten G, Cambier D, Witvrouw E, Burgois J, et al (2001) The effects of three different training modalities on the cross-sectional area of the paravertebral muscles. Scand J Med Sci Sports 6:347–354Google Scholar
  58. 58.
    Antonovsky A (1987) Unraveling the mystery of health. Jossey-Bass Inc, PublishersGoogle Scholar
  59. 59.
    Sale DG (1988) Neural adaptation to resistance training. Med Sci Sports Exerc 20:135–145Google Scholar
  60. 60.
    Rhea M, Alvar B, Burkett L, Ball S (2003) A meta-analysis to determine the dose response for strength development. Med Sci Sports Exerc 35:456–464PubMedGoogle Scholar
  61. 61.
    Wilson PD, Samarrai TAL, Deakin M, Kolbe E, Brown ADG (1987) An objective assessment of physiotherapy for female genuine stress incontinence. Br J Obstet Gynaecol 94:575–582PubMedGoogle Scholar
  62. 62.
    Glavind K, Nøhr S, Walter S (1996) Biofeedback and physiotherapy versus physiotherapy alone in the treatment of genuine stress urinary incontinence. Int Urogynecol J 7:339–343Google Scholar
  63. 63.
    Bø K, Talseth T (1996) Long term effect of pelvic floor muscle exercise five years after cessation of organized training. Obstet Gynecol 87:261–265CrossRefPubMedGoogle Scholar
  64. 64.
    Cammu H, Van Nylen M, Amy J (2000) A ten-year follow-up after Kegel pelvic floor muscle exercises for genuine stress incontinence. BJU Int 85:655–658PubMedGoogle Scholar
  65. 65.
    Constantinou CE, Govan DE (1981) Contribution and timing of transmitted and generated pressure components in the female urethra. Female incontinence. Allan R Liss Inc, New York, pp 113–120Google Scholar
  66. 66.
    Graves J, Pollock ML, Legget S, Braith R, Carpenter D, Bishop L (1988) Effect of reduced training frequency on muscular strength. Int J Sports Med 9:316–319PubMedGoogle Scholar
  67. 67.
    Bø K (1990) Pelvic floor muscle exercise for the treatment of female stress urinary incontinence. Methodological studies and clinical results. Doctoral thesis, The Norwegian University of Sport and Physical Education, Oslo, NorwayGoogle Scholar
  68. 68.
    Hahn I, Myrhage R (1999) Bekkenbotten. Bygnad, funktion och traning. AnaKomp AB, p 39Google Scholar

Copyright information

© International Urogynecological Association 2004

Authors and Affiliations

  1. 1.Norwegian University of Sport and Physical EducationOsloNorway

Personalised recommendations