What is the role of pelvic floor rehabilitation in urinary incontinence treatment?

Updated: Sep 23, 2019
  • Author: Sandip P Vasavada, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Answer

A level A guideline from the American Congress of Obstetricians and Gynecologists (ACOG) recommends pelvic floor training as an apparently effective noninvasive treatment for adult women with stress and mixed incontinence. [86] In women with mild stress urinary incontinence without vaginal prolapse, a success (ie, cure, improvement) rate of 75-80% may be attained by properly performed pelvic floor exercises.

A systematic review and meta-analysis of 31 studies concluded that pelvic floor muscle exercises can cure, or relieve symptoms, of stress urinary incontinence, mixed urinary incontinence, and urgency urinary incontinence in women. The authors recommended that although further research into long-term effectiveness and cost-effectiveness is needed, pelvic floor exercise therapy could be included in first-line conservative management programs for women with urinary incontinence. [87]

Pelvic floor exercises (ie, Kegel exercises) work best in mild cases of stress incontinence associated with urethral hypermobility but not intrinsic sphincter deficiency. They also benefit men who develop urinary incontinence following prostate surgery. [88]

Kegel exercises have been shown to improve the strength and tone of the muscles of the pelvic floor (ie, the levator ani, and particularly the pubococcygeus). During times of increased intra-abdominal pressure, tensing of these muscles tightens the connective tissue that supports the urethra. Thus, pressure transmission to the urethra may increase, and the urethra compresses shut during times of increased stress.

The exercises consist of voluntary contractions of the muscles of the pelvic floor. Because both fast-twitch and slow-twitch muscle fibers are found in the levator ani complex, both rapid contractions and slow contractions held for maximal duration should be performed to achieve the best possible results.

Patients can perform pelvic floor muscle exercises by drawing in or lifting up the levator ani muscles, as if to control urination or defecation with minimal contraction of abdominal, buttock, or inner-thigh muscles. The patient can confirm that she is using the correct muscles at home by periodically performing the contractions during voiding with the goal of interrupting the urinary stream.

If instructions for Kegel exercises are provided verbally or in written form alone, a significant percentage of individuals perform repetitive Valsalva maneuvers or gluteal contractions rather than pelvic muscle contractions. Therefore, instructing the patient in the examining room by having her squeeze the examiner's intravaginal or intrarectal finger is important.

Initially, patients are instructed to perform the squeezing exercise 5 times, holding each contraction for a count of 5. Five contractions equal 1 set. Patients should do 1 set every hour while they are awake, during such activities as driving, reading, or watching television. An alternate program requires 1 set of exercises every time the patient uses a bathroom. Soon after starting the exercises, the patient may be able to hold each contraction for at least 10 seconds, followed by an equal period of relaxation.

Another regimen is to perform the exercises for 10 minutes twice a day using an audiocassette tape. The audiocassette coaches the patient to contract the levator ani muscles for a count of 10 seconds and then to relax for a count of 10 seconds, performing 25 repetitions in a row. Twenty-five contractions equal 1 set. Perform the first set slowly, followed by a second set performed rapidly.

Approximately 6-12 weeks of exercises are required before improvement is noted, and 3-6 months are needed before maximal benefit is reached. The key to success with pelvic floor exercises is a commitment on the patient’s part to performing them for a long period of time. Patients who do not tend to revert back to pretherapy levels of incontinence.


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