EVIDENCE-BASED PHYSIATRY: COCHRANE CORNER
Can Pelvic Floor Muscle Training Versus No Treatment or Inactive
Control Treatments Reduce or Cure Urinary Incontinence in
Women?
A Cochrane Review Summary With Commentary
Paolo Di Benedetto, MD
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he aim of this commentary is to summarize and discuss
T from a rehabilitation point of view the published Cochrane
Review “Pelvic floor muscle training versus no treatment,
or inactive control treatments, for urinary incontinence in
women” by Dumoulin et al.1 (https://www.cochranelibrary.
com/cdsr/doi/10.1002/14651858.CD005654.pub4/full?
cookiesEnabled), in collaboration with Cochrane Incontinence.
This Cochrane Corner is produced in agreement with the
American Journal of Physical Medicine & Rehabilitation by
Cochrane Rehabilitation.
BACKGROUND
Urinary incontinence (UI), defined by the International
Continence Society as the complaint of any involuntary loss
of urine, affects approximately a quarter to a third of women
in their lifetime. Three common types of nonneurogenic UI
are observed: stress UI (SUI), urgency UI (UUI), and mixed
UI (MUI). Stress UI is characterized by an involuntary loss
of urine during increased intra-abdominal pressure (effort or
physical exertion); UUI is present when a woman reports invol-
untary leakage associated with or immediately preceded by a
sudden and strong need to void (urgency); MUI is observed
when women have both symptoms and signs of SUI and UUI.2
A wide range of treatments have been used in the manage-
ment of UI, including conservative interventions, medication,
and surgery.
This review focuses on one of the most used conservative
interventions, specifically pelvic floor muscle training (PFMT)
that is a program of exercises to improve pelvic floor muscle
(PFM) function.3,4 Generally, after achieving PFM awareness
and correct motor learning, both strength and fatigue resistance
From the Friuli Riabilitazione Centre, Roveredo in Piano (Pordenone), Italy.
All correspondence should be addressed to: Paolo Di Benedetto, MD, Friuli
Riabilitazione Centre, 42 G. Carducci St, 33080 Roveredo in Piano
(Pordenone), Italy.
This summary is based on a Cochrane Review previously published in the Cochrane
Database of Systematic Reviews 2018, Issue 10, Art. No.: CD005654, DOI:
10.1002/14651858.CD005654.pub4 (see http://www.cochranelibrary.com for
information). Cochrane Reviews are regularly updated as new evidence emerges
and in response to feedback, and Cochrane Database of Systematic Reviews
should be consulted for the most recent version of the review.
The views expressed in the summary with commentary are those of the Cochrane
Corner author(s) and do not represent the Cochrane Library or Wiley.
Financial disclosure statements have been obtained, and no conflicts of interest have
been reported by the authors or by any individuals in control of the content of
this article.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115
DOI: 10.1097/PHM.0000000000001347
178 www.ajpmr.com American Journal of Physical Medicine & Rehabilitation • Volume 99, Number 2, February 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
of PFM improve in response to an exercise program, that
contemplates low numbers of repetitions with high loads
to improve muscle strength and high numbers of repetitions
or prolonged contractions with low to moderate loads to
improve muscle endurance. In addition, we have to men-
tion coordination training consisting of PFM contraction
in response to a specific situation (eg, before cough, “the
knack theory”).5
The biological rationale for PFMT for SUI and MUI is
twofold: with the PFM contraction (a) increasing the urethral
pressure and (b) providing support for the pelvic floor organs
(ie, reducing bladder neck displacement). The biological ratio-
nale for PFMT for UUI is based on the observation by Godec
et al.6 that a detrusor muscle contraction can be inhibited by
a PFM contraction; thereby, voluntary PFM contractions could
be used to control the urgency to void, allowing the woman to
reach the toilet in time to prevent urine leakage.1
PELVIC FLOOR MUSCLE TRAINING VERSUS NO
TREATMENT, OR INACTIVE CONTROL
TREATMENTS, FOR UI IN WOMEN
(Dumoulin et al., 2018)
What Was the Aim of This Cochrane Review?
The aim of this Cochrane Review was to assess the ef-
fects of PFMT for women with UI in comparison with no
treatment, placebo drug or sham electrical stimulation, or
other inactive control treatments (anti-incontinence device,
incontinence pads, general education class, access to an ed-
ucational pamphlet).1
What Was Studied in This Cochrane Review?
The population addressed in this review was women
with UI and diagnosed as having SUI, UUI, or MUI on the
basis of symptoms, signs, or urodynamic study; trials of
women whose UI due to factors outside the lower urinary
tract or to pregnancy or postnatal period were excluded.
Other common exclusion criteria were urinary tract infec-
tion, significant postmicturition residual volume, neurologi-
cal disorders, and cognitive impairments.
The interventions included PFMT in comparison with no
treatment, or inactive treatments. Pelvic floor muscle training
was a program of repeated voluntary PFM contractions taught
and generally supervised by a healthcare professional.
Volume 99, Number 2, February 2020
The outcomes of interest in the review were as follows:
(a) primarily, symptomatic cure or improvement of UI,
symptom-, and condition-specific quality-of-life (QoL)
measures, and
(b) secondarily, longer-term symptomatic cure or improve-
ment of UI, satisfaction and need for further treatment,
number of leakage episodes in 24 hrs on bladder diary,
amount of leakage from a short or long pad-test, and gen-
eral QoL.
Search Methodology and Up-to-Dateness of the
Cochrane Review
The review authors searched for studies published up to
February 12, 2018.
What Were the Main Results of This Cochrane
Review?
The review included 31 trials (10 of which were new for
this update) involving 1817 women from 14 countries. The tri-
als included women with SUI, UUI, MUI, or UI all types. The
women were allocated randomly to either receive or not receive
PFMT, and the effects were compared.
Symptomatic Cure of UI
Women with SUI in the PFMT groups were, on aver-
age, eight times more likely to report being cured, whereas
women with UI all types were, on average, five times to re-
port being cured.
Symptomatic Cure or Improvement of UI
Women with SUI in PFMT groups were, on average, six
times more likely to report that they were cured or improved.
Women with UI all types were roughly twice as likely to report
that they were cured or improved.
Urinary Incontinence–Specific Symptoms and
Condition-Specific QoL
Women with SUI and UI all types in the PFMT groups
were more likely to report significant improvement in UI
symptoms and condition-specific QoL. One small trial for
women with MUI reported better QoL.
Leakage Episodes in 24 hrs
Pelvic floor muscle training reduced leakage episodes by
one in 24 hrs in women with SUI and UI all types. Pelvic floor
muscle training seemed to reduce urine loss in women with
UUI alone.
Leakage on Short (up to 1 hr) Clinic-Based Pad Test
Women with SUI and UI all types in the PFMT groups
lost significantly less urine in short pad tests than controls.
Other Outcomes
Women in the PFMT groups were also more satisfied with
treatment and their sexual outcomes were better. Women in
control groups were more likely to seek further treatments.
Adverse events were very rare and promptly resolved.
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Urinary Incontinence in Women
The evidence was generally downgraded to moderate
on methodological grounds with the exception of
“participant-perceived cure” in women with SUI, which
was rated as high quality.
What Were the Authors’ Conclusions?
Pelvic floor muscle training can cure or improve symp-
toms of SUI reducing the number of leakage episodes, the
quantity of leakage on the short pad tests, and symptoms on
UI-specific symptom questionnaires. A similar pattern is seen
in studies that recruit women with all types of UI (SUI, MUI,
and UUI) rather one specific type of UI.
The long-term effectiveness of PFMT needs to be fur-
ther researched.
What Are the Implications of the Cochrane
Evidence for Practice in Rehabilitation?
The Cochrane review indicates that PFMT should be
included in first-line conservative management for women
with UI.
Rehabilitation professionals should get involved in this
field because UI is a frequent and bothersome condition and
the efficacy of this rehabilitation intervention (PFMT) is sup-
ported by high level of evidence.
Remaining Issues
Although the PFMT is useful to reduce or cure UI, there
are some unresolved issues.
The proposed PFMT programs differed in terms of type
and number of voluntary PFM contractions, duration of hold-
ing and rest time, body positions, and treatment length. Thus,
optimal program has not yet been identified. However, it could
also be argued that this heterogeneity in exercise content adds
to the robust nature of the evidence; then, the finer detail of
program content may be less important.
As said before, there is no strong evidence of the long-
term effects of PFMT. Research is needed to identify strat-
egies, which may allow patients to maintain the positive
treatment outcomes.
ACKNOWLEDGMENTS
We thank the authors of Cochrane Review (Chantale
Dumoulin, Licia Cacciari, and Jean Hay-Smith), the Cochrane
Rehabilitation and Cochrane Incontinence Group for reviewing
the Contents of the Cochrane Corner.
REFERENCES
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inactive control treatments, for urinary incontinence in women (Review). Cochrane Database
Syst Rev 2018;10:CD005654
2. Abrams P, Cardozo L, Wagg A, et al: (eds): Incontinence, 6th ed 2017. Tokyo, 6th International
Consultation on Incontinence, 2016
3. Kegel AH: Progressive resistance exercise in the functional restoration of the perineal muscles.
Am J Obstet Gynecol 1948;56:238–48
4. Bø K: Pelvic floor muscle training for stress urinary incontinence. In: Bø K, Berghmans B,
Mørkved S, Van Kampen M (eds): Evidence-Based Physical Therapy for the Pelvic Floor.
Bridging Science and Clinical practice. Philadelphia, PA, Butterworth Heinemann Elsevier, 2007
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6. Godec C, Cass AS, Ayala GF: Bladder inhibition with functional electrical stimulation.
Urology 1975;6:663–6
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