Can postpartum pelvic floor muscle training reduce urinary and anal incontinence?: An assessor-blinded randomized controlled trial

doi:10.1016/j.ajog.2019.09.011

American Journal of Obstetrics and Gynecology

Volume 222, Issue 3, March 2020, Pages 247.e1-247.e8

https://doi.org/10.1016/j.ajog.2019.09.011 Get rights and content

Background

Pelvic floor dysfunction, including urinary and anal incontinence, is a common postpartum complaint and likely to reduce quality of life.

Objective

To study the effects of individualized physical therapist–guided pelvic floor muscle training in the early postpartum period on urinary and anal incontinence and related bother, as well as pelvic floor muscle strength and endurance.

Materials and Methods

This was an assessor-blinded, parallel-group, randomized controlled trial evaluating effects of pelvic floor muscle training by a physical therapist on the rate of urinary and/or anal leakage (primary outcomes); related bother and muscle strength and endurance in the pelvic floor were secondary outcomes. Between 2016 and 2017, primiparous women giving birth at Landspitali University Hospital in Reykjavik, Iceland, were screened for eligibilty 6–10 weeks after childbirth. Of those identified as urinary incontinent, 95 were invited to participate, of whom 84 agreed. The intervention, starting at ∼9 weeks postpartum consisted of 12 weekly sessions with a physical therapist, after which the main outcomes were assessed (endpoint, ∼6 months postpartum). Additional follow-up was conducted at ∼12 months postpartum. The control group received no instructions after the initial assessment. The Fisher exact test was used to test differences in the proportion of women with urinary and anal incontinence between the intervention and control groups, and independent-sample t tests were used for mean differences in muscle strength and endurance. Significance levels were set as α = 0.05.

Results

A total of 41 and 43 women were randomized to the intervention and control groups, respectively. Three participants and 1 participant withdrew from these respective groups. Measurement variables and main delivery outcomes were not different at recruitment. At the endpoint, urinary incontinence was less frequent in the intervention group, with 21 participants (57%) still symptomatic, compared to 31 controls (82%) (P = .03), as was bladder-related bother with 10 participants (27%) in the intervention vs 23 (60%) in the control group (P = .005). Anal incontinence was not influenced by pelvic floor muscle training (P = .33), nor was bowel-related bother (P = .82). The mean differences between groups in measured pelvic floor muscle strength changes at endpoint was 5 hPa (95% confidence interval, 2–8; P = .003), and for pelvic floor muscle endurance changes, 50 hPa/s (95% confidence interval, 23–77; P = .001), both in favor of the intervention group. The mean between-group differences for anal sphincter strength changes was 10 hPa (95% confidence interval, 2–18; P = .01) and for anal sphincter endurance changes 95 hPa/s (95% confidence interval, 16–173; P = .02), both in favor of the intervention. At the follow-up visit 12 months postpartum, no differences were observed between the groups regarding rates of urinary and anal incontinence and related bother. Pelvic floor- and anal muscle strength and endurance favoring the intervention group were maintained.

Conclusion

Postpartum pelvic floor mucle training decreased the rate of urinary incontinence and related bother 6 months postpartum and increased muscle strength and endurance.

Section snippets

Study design

This was an assessor-blinded, parallel-group RCT with the allocation ratio 1:1 examining the effects of postpartum PFMT on the rate of UI and AI in primiparous women. The trial was carried out at Tap, Physical Therapy Clinic, Kopavogur, Iceland, from March 2016 to January 2018. Information and baseline assessment of participants were obtained at recruitment 9 weeks postpartum (range, 6–13 weeks), after completed treatment 6 months postpartum (endpoint, range, 5–7 months), and finally 12 months

Results

In all, 84 women, all of white ethnicity, were included, 41 in the intervention group and 43 in the control group. The initial appointment was on average 9 weeks postpartum (range, 6–13 weeks). Participant characteristics at recruitment/baseline are shown in Table 1. At baseline, 16 participants (19%) had difficulties activating their PFMs, but all were able to do this after verbal instruction and facilitation through vaginal palpation. Four women (3 from the intervention group) withdrew

Principal findings

Among women with urinary incontinence after childbirth, we showed that regular pelvic floor muscle training substantially reduced the rate of UI and related bother. Pelvic floor muscle strength and endurance were also improved. However, no differences were observed for anal incontinence and bowel-related bother between groups. At the 1-year follow-up, similar prevalences of urinary and anal incontinence were observed, whereas improvements in PFM and anal sphincter strength and endurance

Acknowledgments

The authors thank secretary Hulda Magnusdottir for her work in registering and administering all clinical appointments for the participants of the study, and physical therapists Fanney Magnusdottir and Gudrun Magnusdottir for carrying out the intervention. We express our gratitude for the permission given by Dr Kaven Baessler and coauthors to translate and use the Australian Pelvic Floor Questionnaire.

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: The authors report no conflict of interest.

: This study has received grants from the University of Iceland Research Fund; Public Health Fund, Icelandic Directorate of Health; Icelandic Physiotherapy Association Science Fund; and Landspitali Science Fund.

: Cite this article as: Sigurdardottir T, Steingrimsdottir T, Geirsson RT, et al. Can postpartum pelvic floor muscle training reduce urinary and anal incontinence? An assessor-blinded randomized controlled trial. Am J Obstet Gynecol 2020;222:247.e1-8.

: This trial was registered March 30, 2015, at https://register.clinicaltrials.gov (NCT02682212). Initial participant enrollment was March 16, 2016, and reported following CONSORT guidelines for RCTs.

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Original ResearchGynecologyCan postpartum pelvic floor muscle training reduce urinary and anal incontinence?: An assessor-blinded randomized controlled trial

Background

Objective

Materials and Methods

Results

Conclusion

Section snippets

Study design

Results

Principal findings

Acknowledgments

Eur J Obstet Gynecol Reprod Biol

Midwifery

Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women

Cochrane Database Syst Rev

Psychological consequences of pelvic floor trauma following vaginal birth: a qualitative study from two Australian tertiary maternity units

Arch Womens Ment Health

6th International Consultation on Incontinence. Recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse and faecal incontinence

Neurourol Urodyn

The effect of postpartum pelvic floor muscle exercise in the prevention and treatment of urinary incontinence

Int Urogynecol J Pelvic Floor Dysfunct

Postpartum pelvic floor muscle training and urinary incontinence: a randomized controlled trial

Obstet Gynecol

Vaginal palpation of pelvic floor muscle strength: inter-test reproducibility and comparison between palpation and vaginal squeeze pressure

Acta Obstet Gynecol Scand

Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: I. Reliability of vaginal pressure measurements of pelvic floor muscle strength

Neurourol Urodyn

Stress incontinence and genital relaxation

Ciba Clin Symp

Test-retest intra-rater reliability of vaginal measurement of pelvic floor muscle strength using Myomed 932

Acta Obstet Gynecol Scand

Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: II. Validity of vaginal pressure measurements of pelvic floor muscle strength and necessity of supplementary methods for control of correct contraction

Neurourol Urodyn

Are pelvic floor muscle thickness and size of levator hiatus associated with pelvic floor muscle strength, endurance and vaginal resting pressure in women with pelvic organ prolapse stages I-III? A cross sectional 3D ultrasound study

Neurourol Urodyn

Original Research
Gynecology
Can postpartum pelvic floor muscle training reduce urinary and anal incontinence?: An assessor-blinded randomized controlled trial