Acta Obstet Gynecol Scand 2000; 79: 598–603 Copyright C Acta Obstet Gynecol Scand 2000

Printed in Denmark ¡ All rights reserved

Acta Obstetricia et
Gynecologica Scandinavica
ISSN 0001-6349

ORIGINAL ARTICLE

Randomized controlled trial on the effect of

pelvic floor muscle training on quality of life
and sexual problems in genuine stress
incontinent women
KARI BØ1, TRYGVE TALSETH2 AND ANNE VINSNES3

From the 1Norwegian University of Sport and Physical Education, Ullevål stadium, Oslo, the 2National Hospital of Norway,
Oslo, and the 3Institute of Nursing Science, Faculty of Medicine, University of Oslo, Norway

Acta Obstet Gynecol Scand 2000; 79: 598–603. C Acta Obstet Gynecol Scand 2000

Background. The purpose of the present study was to evaluate the effect of pelvic floor muscle
exercise on quality of life, lifestyle and sex-life variables in genuine stress incontinent women.
Methods. Fifty-nine women with clinically and urodynamically proven genuine stress inconti-
nence were randomized to either pelvic floor muscle exercise or an untreated control group.
The intervention group was asked to perform 8–12 close to maximum contractions in 3 series
per day. In addition they were exercising 45 minutes per week in groups. The intervention
period was 6 months, and the women in the exercise group met once a month for individual
assessment of pelvic floor muscle strength and motivation. Outcome measures were the Nor-
wegian version of the Quality of Life Scale (QoLS-N) and the Bristol Female Lower Urinary
Tract Symptoms (B-FLUTS) questionnaire.
Results. The results showed that general quality of life measured by the generic quality of life
questionnaire was not much affected by urinary incontinence. However, the disease specific
questionnaire demonstrated that ability to participate in physical activity and some sex-life
variables were affected by the condition. There was a statistically significant (p⬍0.01) reduc-
tion in number of women having problems with sex-life, social life, and physical activity in
the exercise group after six months of pelvic floor muscle exercise.
Conclusion. Pelvic floor muscle exercise showed some effect on quality of life and sex-life
variables.

Key words: genuine stress incontinence; pelvic floor muscle exercise; quality of life; sex-life;
strength training

Submitted 25 October, 1999

Accepted 18 January, 2000

Randomized controlled trials (RCT) have demon-
strated that pelvic floor muscle (PFM) training is
more effective than no treatment (1–4) and more
effective than both electrical stimulation (1,2) and
vaginal cones (2) in treatment of genuine stress in-
continence (GSI). In a former published RCT we
Abbreviations:
GSI: genuine stress incontinence; PFM: pelvic floor muscles;
QoL: quality of life; UI: urinary incontinence; RCT: ran-
domized controlled trials.
C Acta Obstet Gynecol Scand 79 (2000)
reported the results of such training on PFM func-
tion and strength, urodynamic variables, and uri-
nary leakage. After the 6 month intervention
period 56% in the exercise group reported that the
condition was unproblematic compared to 3.3% in
the control group (2). The exercise group signifi-
cantly reduced urinary leakage from mean 38.6
grams (95% CI: 25.1–52.1) to 8.4 (95% CI: 3.9–
12.9) (p⬍0.001). PFM strength was increased from
11 cm H2O (95% CI: 7.7–14.3) to 19.2 cm H2O
(95% CI.15.3–23.1) (p⬍0.001). There were no sig-
 Pelvic floor muscle exercise, lifestyle and sex-life
nificant changes in the untreated control group (2).
The World Health Organization (WHO) has de-
veloped a system for outcome measures in rehabili-
tation interventions, named the International
Classification of Impairment, Disability, and
Handicap/Participation (ICIDH) (5). According to
this system pelvic floor muscle function and
strength can be either at the patho-physiological
or the impairment level. Urinary leakage is at the
disability level. Interference with quality of life,
lifestyle, and sexual matters can be classified at the
Handicap/Participation level.
Urinary incontinence has been shown to in-
fluence quality of life issues (6, 7) and it has
been recommended to add quality of life and
life-style issues as outcome variables when evalu-
ating the effect of all intervention trials for uri-
nary incontinence (8,9). Several authors have
found that urinary incontinence (UI) affects
women’s sexlife (10–12). Hilton (12) reported that
24% of women referred to a gynecological urol-
ogy clinic experienced urinary leakage during in-
tercourse, and Clark and Romm (10) showed
that 66% of urinary incontinent women experi-
enced incontinence, urgency or frequency during
sexual activity. On the other hand, other studies
found that urinary incontinence did not severely
influence women’s sexuality in a negative way
(13–15).
Some authors have claimed that PFM strength
training can be effective in improving women’s sex-
life (16, 17). However, methodological issues re-
lated to appropriate control groups have been re-
quested (18). To our knowledge, to date, no RCT
has been conducted to evaluate the effect of PFM
strength training on reducing leakage during inter-
course or sexual matters in GSI women.
The aim of the present study was to compare the
effect of a 6 month intensive PFM training pro-
gram on quality of life, lifestyle, and sex-life vari-
ables in women with GSI and to compare it with
a randomized untreated control group.
Material and methods
Thirty women with clinically and urodynamically
proven GSI were randomized to the control group
and 29 to the training group after stratification on
degree of leakage measured by a provocative pad
test with standardized bladder volume (2). The
power calculation of the study was based on the
power estimation and the results of a previous
RCT designed to detect differences of 1 s.d. with
a power of 80% and an a of 5% (2, 19).
Randomization schemes stratified by degree of
incontinence (Æ20 grams and ⬎20 grams of leak-
age) were constructed by using computer generated
599
random numbers. Information for decoding ran-
domization was kept locked in the statisticians’ of-
fice. Inclusion criteria were history of stress uri-
nary incontinence and ⬎4 grams of leakage meas-
ured by the pad test. Exclusion criteria were
urinary incontinence other than GSI, involuntary
detrusor contractions exceeding 10 cm H2O on cy-
stometry, residual urine ⬎50 ml , maximal uroflow
⬍15 ml/s, previous surgery for GSI, neurological
or psychiatric disease, ongoing urinary tract infec-
tions, other diseases that could interfere with par-
ticipation, use of concomitant treatments during
the trial, and inability to understand instructions
given in Norwegian. The study was approved by
the local ethics committee, and all women gave
written consent. Background variables for the two
groups are given in Table I. There were no statisti-
cally significant differences between groups at
baseline (2).
Intervention
The training group was asked to perform 8–12
close to maximum contractions in 3 series per day.
In addition they were attending a 45 minute PFM
strength training class once a week with an experi-
enced physiotherapist. In the exercise class motiva-
tion for maximum contraction of the PFM during
every attempt was emphasized. PFM exercise was
performed in lying, standing, kneeling, and sitting
positions with legs apart to emphasize specific
strength training of the PFM. Participants aimed
at holding each contraction for 6–8 seconds, 3–4
fast contractions were then added. The rest period
between contractions was approximately 6 sec-
onds. A total of 8–12 contractions were completed
in each position. Body awareness, breathing, relax-
ation, exercises, and strength training for the ab-
dominal, back, and thigh muscles were performed
to music between positions. The participants were
encouraged to perform equally intensive contrac-
tions at home, and an audiotape with verbal guid-
ance was available for home training. A training
diary was kept.
The women met the physiotherapist once a
month for individual assessment of PFM strength
Table I. Background variables for the training and control groups before treat-
ment. Mean and s.d. Non significant differences between groups
Training Control
Mean age (years) 49.6 (10.0) 51.7 (8.8)
BMI (kg/m2) 25.1 (2.8) 25.8 (3.7)
Parity 2.3 (0.8) 2.4 (0.9)
Duration of symptoms (years)
Stress pad test (grams)
10.2
38.6
(7.7)
(34.7)
9.9
51.4
(7.8)
(48.2)
C Acta Obstet Gynecol Scand 79 (2000)
600 K. Bø et al.

Table II. Percentage of women with ‘a little’, ‘some’, and ‘much’ problems in sex-life variables before and after 6 months intervention measured by B-FLUTS

Difference between groups Cochran-Mantel-

PFM exercise Control after treatment Haenszel

Problems because of avoiding places and situations Before 37.5% 36.7% ⬍0.54
After 28.0% 34.4%
Problems with interference with social life Before 28.6% 33.3% ⬍0.01 ⬍0.02
After 3.7% 40.7%
Problem with interference with physical activity Before 87.5% 85.7% ⬍0.01 ⬍0.01
After 43.5% 79.3%
Overall interference with life Before 61.9% 86.2% ⬍0.1 ⬍0.02
After 56.0% 82.1%
Unsatisfied if you had to spend the rest of your Before 20.8% 33.3% ⬍0.1 ⬍0.03
life with symptoms as now After 4.0% 37.9%

Table III. Percentage of women with ‘little’, ‘some’, and ‘much’ problems in sex-life variables before and after 6 months intervention measured by B-FLUTS

Difference between groups Cochran-Mantel-

PFM exercise Control after intervention Haenszel

Sex-life spoilt by urinary symptoms Before 40.0% 46.2%

After 16.7% 50.0% 0.03 0.9
Problem with sex-life spoilt by urinary symptoms Before 33.3% 52.2%
After 11.1% 50.0% 0.02 0.02
Problem with pain in intercourse Before 33.4% 20%
After 10.5% 33.3% 0.1 ⬍0.05
UI with intercourse Before 20.0% 45.8%
After 10.5% 41.7% 0.02

and motivation for training (2, 19). The inter-
vention period was 6 months. The control group
had no contact during the intervention period.
However, they were offered the opportunity to use
the Continence Guard (Coloplast A/S) (2).
Outcome measures
In order to relate the QoL-score in women diag-
nosed with GSI to other groups we decided to use
a generic QoL instrument. Hence the Norwegian
version of the Quality of Life Scale (QoLS-N) was
used to assess general health and quality of life
(20). The scale is a 16 item scale adapted and
modified for use in chronic illness population by
Burckhardt et al. (21). The Norwegian version uses
a 7 point satisfaction scale (20, 21).
We also wanted to specifically assess the impact
of GSI on QoL. Hence the Bristol Female Lower
Urinary Tract Symptoms (B-FLUTS) ques-
tionnaire was used as a condition specific quality
of life questionnaire before and after treatment
(22, 23). This instrument has been specifically de-
signed to subjectively quantify urinary inconti-
nence and to assess how degree of ‘bother’ influ-
ence the impact of quality of life. The instrument
C Acta Obstet Gynecol Scand 79 (2000)
has been tested for reliability and validity and was
found to have acceptable reproducibility and valid-
ity (23). It also correlates well with objective meas-
ures of fluid loss (23). Only those questions related
to lifestyle (question nos 28–31, 33) and sex-life
(question nos 21–24) will be reported here.
Those women using the Continence guard
answered two questionnaires, one that applied for
the condition without the guard and another with
use of the guard. The present results are reported
without the guard.
Statistical analysis
Generic QoL scores using the QoLS-N are given as
mean and SEM before and after the intervention.
Results of the B-FLUTS are reported as frequen-
cies and positive findings are grouped together (‘a
little, somewhat, a lot’ or ‘a bit of a problem, quite
a problem, a serious problem’).
Wilcoxon two-sample rank test corrected for ties
was used to compare the groups before and after
treatment. Cochran-Mantel-Haenszel test was
used to adjust for pre-values. Significance level was
set to 5%.
 Pelvic floor muscle exercise, lifestyle and sex-life
Results
There were four drop-outs in the training group,
two due to causes outside the intervention and two
due to lack of motivation. There were no drop-outs
in the control group. In the control group the score
on the generic QoLS-N changed from 82.3 (SEM
2.6) to 85.2 (SEM 2.2). For the exercise group pre-
treatment score was 85.3 (SEM 1.6), and post-
treatment 90.1 (SEM 1.9). Neither changes were
statistically significant. There was no significant
difference between groups either before (pΩ0.57)
or after (pΩ0.16) the intervention.
Differences between groups on B-FLUTS vari-
ables after the 6 months treatment period are
shown in Tables II and III. There were no signifi-
cant differences in any variables before the treat-
ment period. Five women in each group reported
that they did not have a sex-life at present. Table
II shows that there was significantly fewer women
reporting problems in all quality of life and life-
style variables, except avoiding places and situ-
ations, in the training group compared to control
after treatment. Table III shows that the number of
women with sex related problems was significantly
lower in the training group compared to the con-
trol after treatment, except for the variable pain
during intercourse.
When controlling for pre-values the variables:
‘sex-life spoilt by urinary incontinence’, ‘urinary
incontinence with intercourse’ and ‘having prob-
lems because of avoiding places and situations’ no
longer reached ‘statistical significance’.
Discussion
The results of the present study demonstrated a
significant improvement from PFM training in sev-
eral life-style, QoL, and sex-life variables com-
pared with an untreated control group.
The sample size of 25 and 30 women, with five
women in each group not having a sex-life at pres-
ent, may have contributed to non significant results
when correcting for pre-test values. The effect may
therefore be underestimated, and the results should
be interpreted with some caution. Although this
sample of women had substantial GSI measured
by stress pad test (2), it did not make many women
avoid places and situations in general. Other
studies have documented that, even though pa-
tients express some negative feelings about their
UI, they use a variety of strategies to live their lives
in a manner that enables them to feel normal (14,
24, 25).
It has been documented that co-morbidity is not
a determinant of UI (15), which leads to the con-
clusion that ‘middle aged’ women with UI often
601
have good health. It is also documented that
women between 20–49 years of age have less QoL
impairment, and they are more likely to seek treat-
ment (11). Hence, relevant improvement in lower
urinary tract symptomatology (disability level)
may not produce significant improvement in gen-
eral health score (participation level).
The overall QoL-score in our group was quite
high at pre-test. Statistically significant changes, by
means of an overall QoL improvement, may there-
fore both be difficult to achieve and unrealistic to
suppose. Also another study, using both generic
and condition-specific instruments, found the
same; the QoL improvement that was noted with
a condition-specific instrument, was not supported
with a generic QoL instrument (26). Previous
studies have shown that GSI has less impact on
generic QoL outcomes than urge incontinence (7,
27). Our results may reflect the fact that we only
included women with GSI.
Participation in physical activity was greatly
affected. This corresponds with former studies
showing that women with GSI withdraw from
physical activities and have problems especially
during high impact activities (28, 29). Since partici-
pation in regular moderate physical activity is im-
portant to good health and in prevention of e.g.
coronary heart disease, high blood pressure, obes-
ity, osteoporosis, anxiety and depression, with-
drawal from regular physical activity can be a
threat to women’s health (30). In general, GSI may
be more noticeable in the active woman than in the
sedentary, and therefore GSI may be more difficult
to treat in physically active women. However, the
results of the present study correspond with other
studies demonstrating that it is possible to improve
GSI women’s ability to participate in physical ac-
tivity by PFM strength training (19, 28).
In the present study more than 40% of the
women reported that their sex-life was spoilt by
urinary leakage. This corresponds with results
from other studies (10–12). On the other hand,
some research groups have not found such associ-
ations. Berglund & Fugl-Meyer found that neither
the magnitude of the leakage nor the duration of
the GSI influenced the women’s sexual experiences
significantly (13). Klemm & Creason found that
none of the women they included in their study
felt differently about themselves sexually, or as a
woman, because of their UI (14). Samuelsson et
al. did not find a statistically significant difference
between continent and incontinent women on a
generic QoL instrument (15).
It has been claimed that PFM training is im-
portant for female sexuality, and PFM exercise are
often recommended if women have sexual prob-
lems (16, 17). These recommendations seem to be
C Acta Obstet Gynecol Scand 79 (2000)
602 K. Bø et al.
based more on anecdotal stories than scientific evi-
dence, and the theoretical background for how and
why the training should improve women’s sexual
function is rather vague. It is not easy to under-
stand whether the authors are referring to women’s
ability to achieve orgasm, length and strength of
orgasm, number of orgasms, perception in the va-
gina during intercourse, a more general feeling of
well-being and self-esteem, or even whether it is
referred to male or female perception. Some
authors have shown that there is no link with PFM
strength and female orgasm (31, 32).
In the present study fewer women in the PFM
exercise group reported their sex-life to be spoilt
by urinary leakage than in the control group after
treatment. However, this significance disappeared
when corrected for pre-values. Larger sample sizes
may change this in favor of training. The number
of women reporting this to be a problem for them
was, however, significantly fewer in the exercise
group. This is different from the findings of Wilson
and Herbison (33). However, they used another
questionnaire and were investigating a population
of postnatal women. A direct comparison of re-
sults cannot, therefore, be done.
Our results point to the value of PFM exercise
on some sex-life issues. However, the results of the
present study should be interpreted with caution.
The small number of women having a sex-life bias
the interpretation of the results. A more in-depth
information about dysfunction related to the sex-
ual response cycle is necessary in order to under-
stand the complexity of women’s sexuality. We
need further information about the occurrence of
UI during intercourse, e.g. whether the leakage oc-
curs during the penetration movements or whether
the occurrence of UI during intercourse is related
to one of the phases: desire, excitement, orgasm or
resolution phases.
Acknowledgments
We thank Ingar Holme, Professor in Biostatistics, for valuable
help with the statistical analyses.
This research was funded by The Norwegian Fund for Post-
graduate Studies in Physiotherapy and The Norwegian Re-
search Council. In addition, Coloplast AS gave financial sup-
port to the study.
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Address for correspondence:
Professor Kari Bø, PT., Ex.Sci., Ph.D.
Norwegian University of Sport and Physical Education
PB. 4014, Ullevål Stadion
0806 Oslo
Norway
C Acta Obstet Gynecol Scand 79 (2000)