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

International Urogynecology Journal volume 15, pages76–84(2004)Cite this 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.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

US$ 39.95

Tax calculation will be finalised during checkout.

Fig. 1.
Fig. 2.

References

  1. 1.

    Kegel AH (1948) Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol 56:238–249

    Google Scholar 

  2. 2.

    Chang S (1984) De indre øvelser (Internal exercises). Oslo: O.G.P.- OMRE A/S, Stuyvesant Publishing Co (English)

  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 351–358

  4. 4.

    Kegel AH (1952) Stress incontinence and genital relaxation. Ciba Clin Sympos 2:35–51

    Google 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, MD

    Google 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 571–624

  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, Oxford

  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 318:487–493

    CAS  PubMed  Google 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 62–63

  10. 10.

    Henalla S, Millar D, Wallace K (1990) Surgical versus conservative management for post-menopausal genuine stress incontinence of urine. Neurourol Urodyn 9:436–437

    Google 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 100:730–739

    Article  PubMed  Google 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 20:167–174

    Article  CAS  PubMed  Google 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 207:1–7

    Article  PubMed  Google 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 9:479–487

    Google 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 13:35–41

    CAS  PubMed  Google 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 12:27–30

    Google 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 20:31–42

    Article  CAS  PubMed  Google Scholar 

  18. 18.

    Neumann P, Gill V (2002) Pelvic floor and abdominal muscle interaction: EMG activity and intra-abdominal pressure. Int Urogynecol J 13:125–132

    Article  Google 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 41:269–274

    CAS  PubMed  Google 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 21:358–359

    Google 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 Urology

  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 137:131–133

    CAS  PubMed  Google 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 97:255–260

    Article  CAS  PubMed  Google Scholar 

  24. 24.

    Peschers U, Schaer G, Anthuber C, DeLancey J, Schussler B (1996) Changes in vesical neck mobility following vaginal delivery. Obstet Gynecol 88:1001–1006

    Google Scholar 

  25. 25.

    Small K, Wynne J (1990) Evaluating the pelvic floor in obstetric patients. Aust NZ J Obstet Gynaecol 30:41–45

    CAS  Google 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 95:535–540

    Article  CAS  PubMed  Google 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 165:322–329

    Google 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 21:486–490

    Article  CAS  PubMed  Google 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 8:3–7

    CAS  Google 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 46:870–874

    CAS  PubMed  Google Scholar 

  31. 31.

    Peschers U, Vodusek D, Fanger G, Schaer G, DeLancey J, Schussler B (2001) Pelvic muscle activity in nulliparous volunteers. Neurourol Urodyn 20:269–275

    Article  CAS  PubMed  Google Scholar 

  32. 32.

    Nygaard I, Thompson FL, Svengalis SL, Albright JP (1994) Urinary incontinence in elite nulliparous athletes. Obstet Gynecol 84:183–187

    CAS  PubMed  Google Scholar 

  33. 33.

    Bø K, Borgen J (2001) Prevalence of stress and urge urinary incontinence in elite athletes and controls. Med Sci Sports Exerc 33:1797–1802

    PubMed  Google Scholar 

  34. 34.

    Hay JG (1993) Citius, altius, longus (faster, higher, longer): The biomechanics of jumping for distance. J Biomechanics 26[Suppl 1]: 7–21

  35. 35.

    Kegel A (1948) The non-surgical treatment of genital relaxation. Annals West Med Surg 2:213–216

    Google 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 319–331

    Google Scholar 

  37. 37.

    DiNubile NA (1991) Strength training. Clin Sports Med 10:33–62

    CAS  PubMed  Google Scholar 

  38. 38.

    Stone M (2003) Implications for connective tissue and bone alterations resulting from resistance exercise training. Med Sci Sports Exerc 20:162–168

    Google 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 369–382

  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 279–290

  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 30:975–991

    PubMed  Google 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 22:265–274

    PubMed  Google 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 1030–1039

  44. 44.

    Bouchard C (2001) Physical activity and health: introduction to the dose-response symposium. Med Sci Sports Exerc 33:347–350

    Article  Google 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]: 351–358

  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 9:489–502

    Google Scholar 

  47. 47.

    Bernstein I (1997) The pelvic floor muscles. University of Copenhagen, Hvidovre Hospital, Department of Urology, PhD thesis

  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 253

  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 21:371–372

    Google Scholar 

  50. 50.

    Sapsford R (2001) The pelvic floor. A clinical model for function and rehabilitation. Physiother 87:620–630

    Google 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–E36

    Article  PubMed  Google Scholar 

  52. 52.

    Sapsford R, Hodges P (2001) Contraction of the pelvic floor muscles during abdominal maneuvers. Arch Phys Med Rehabil 82:1081–1088

    Article  CAS  PubMed  Google 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, 102

  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 22:543–544

    Google 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 22:582–588

    Article  PubMed  Google 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 389–424

  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 6:347–354

    Google Scholar 

  58. 58.

    Antonovsky A (1987) Unraveling the mystery of health. Jossey-Bass Inc, Publishers

  59. 59.

    Sale DG (1988) Neural adaptation to resistance training. Med Sci Sports Exerc 20:135–145

    Google 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 35:456–464

    PubMed  Google 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 94:575–582

    CAS  PubMed  Google 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 7:339–343

    CAS  Google 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 87:261–265

    Article  PubMed  Google 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 85:655–658

    CAS  PubMed  Google 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 113–120

  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 9:316–319

    CAS  PubMed  Google 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, Norway

  68. 68.

    Hahn I, Myrhage R (1999) Bekkenbotten. Bygnad, funktion och traning. AnaKomp AB, p 39

Download references

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.

Author information

Affiliations

  1. Norwegian University of Sport and Physical Education, PB 4014, Ullevål Stadion, 0806, Oslo, Norway

    Kari Bø

Authors
  1. Kari Bø
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kari Bø.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Bø, K. Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work?. Int Urogynecol J 15, 76–84 (2004). https://doi.org/10.1007/s00192-004-1125-0

Download citation

Keywords

  • Anatomy
  • Exercise
  • Pelvic floor muscles
  • Stress urinary incontinence
  • Training