Effectiveness of supervised Kegel exercises using bio-feedback versus unsupervised Kegel exercises on stress urinary incontinence: a quasi-experimental study

INTRODUCTION AND HYPOTHESIS

The objective was to investigate and compare the efficacy of supervised Kegel exercises with bio-feedback on stress urinary incontinence (SUI) and pelvic floor muscle strength (PFMS) compared with unsupervised Kegel exercises.

METHOD

Matched-group quasi-experimental study of 29 female participants divided into two groups (supervised and non-supervised) was conducted over 12 weeks. Baseline measurements of PFMS were undertaken by a women's health physiotherapist and a Kegel exercise regime bespoke designed for each participant. The supervised group visited the physiotherapist monthly for bio-feedback training (BT); the unsupervised group continued at home with their individualised Kegel exercises. Data were collected via a perineometer (Peritron™) and self-reporting responses to questionnaires. All participants received a final PFMS measurement on completion of the study.

RESULTS

Overall Incontinence Severity index (ISI) score was significantly lower in the supervised group post-intervention. Wilcoxon signed-rank tests indicated that supervised Kegel exercises significantly reduced frequency (p= 0.002) and severity (p= 0.020) of overall ISI. Analysis of PFMS were not significantly different, despite an increase in maximum voluntary contraction or pelvic floor muscle strength (PFMS) (p= 0.032) in the supervised group. Of the questionnaires, results of Wilcoxon signed-rank tests indicated that "total bother" was significantly reduced (p= 0.005) in the supervised group. The correlation analysis between PFMS and ISI did not reveal any significant results.

CONCLUSIONS

The study confirmed that supervised BT is more effective in reducing SUI than unsupervised Kegel exercises, and that this reduction in ISI score did not correlate with the improvement in PFMS.

Does a Kegel Exercise Program Prior to Resistance Training Reduce the Risk of Stress Urinary Incontinence?

This comparative pre-post intervention study investigated the feasibility and benefits of Kegel exercises amongst incontinent women, prior to commencing resistance training (RT), to reduce the risk of stress urinary incontinence (SUI) compared to a group of women without prior Kegel exercises (KE). Incontinence severity index (ISI) score, pelvic floor muscle strength (PFMS), and body composition (such as body mass index (BMI), fat, and muscle mass), were obtained pre and post intervention. Results demonstrated that RT reduced SUI to a significantly greater extent only if preceded by KE as was observed in the Kegel exercise plus RT group (KE + RT) over time. The improvements in total ISI in both the KE + RT and RT groups were large (d = 1.50 and d = 1.17 respectively). A two-way ANOVA indicated a statistically significant improvement in average PFMS within the KE + RT group over time and between the two groups. A positive correlation was found between the average strength of pelvic floor muscles and SUI. Participants in KE + RT group demonstrated a significant increase in muscle mass (p ≤ 0.001) and concomitant reduction in fat mass (p = 0.018). This study determined a dedicated program of KE preceding a RT program improved average pelvic floor muscle strength and was effective in reducing SUI among incontinent women.

Are hypopressive and other exercise programs effective for the treatment of pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS

Pelvic floor muscle training (PFMT) is effective for the treatment of pelvic organ prolapse (POP), but other exercise programs have also been promoted and used. The aim of this review was to evaluate the effect of hypopressive and other exercise programs besides PFMT for POP.

METHODS

A literature search was conducted on Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro, and Scopus databases from January 1996 to 30 December 2021. Only randomized controlled trials (RCTs) were included. The keywords were combinations of "pelvic organ prolapse" or "urogenital prolapse," and "exercise therapy," "hypopressive exercise," "Kegel," "pelvic floor muscle training," "pelvic floor muscle exercises," "Pilates," "treatment," "yoga," "Tai Chi." Methodological quality was assessed using the PEDro rating scale (0-10).

RESULTS

Seven RCTs containing hypopressive exercise, yoga or breathing and hip muscle exercises in an inverted position were retrieved and analyzed. PEDro score ranged from 4 to 7. There was no additional effect of adding hypopressive exercise to PFMT, and PFMT was more effective than hypopressive exercise alone. The studies that included the term "yoga" included regular PFMT and thus can be classified as PFMT. Hip exercises in an inverted position added to PFMT vs PFMT alone showed better improvement in some secondary outcomes but not in the primary outcome, POP stage.

CONCLUSIONS

There are few RCTs assessing the effects of other exercise programs besides PFMT in the treatment of POP. To date, there is no evidence that other exercise programs are more effective than PFMT for POP.

Mechanisms of pelvic floor muscle training for managing urinary incontinence in women: a scoping review

BACKGROUND

Pelvic floor muscle training is recommended as first line treatment for urinary incontinence in women based on three proposed theorized mechanisms: 'Enhanced Pelvic Floor Muscle Strength,' 'Maximized Awareness of Timing,' and 'Strengthened Core Muscles'. The purpose of this scoping review was to systematically map evidence for and against theorized mechanisms through which pelvic floor muscle training interventions work to reduce urinary incontinence in women.

METHODS

The scoping review is based upon a comprehensive search of relevant literature published from 1990 to 2020 in PubMed, CINAHL, PsycINFO, ClinialTrials.gov, reference lists from review articles, and hand searches of articles by known researchers in the field. We included English-language, peer-reviewed articles on pelvic floor muscle training as an intervention for adult women if they provided empirical evidence to testing the theorized intervention mechanisms. Two independent reviewers screened articles for inclusion and extracted data to describe details of each study (author, year, country, design, sampling), measures of pelvic floor muscle strength and urinary incontinence, statistical analysis of linkage between changes in the measures, and pelvic floor muscle training regimens. Data were summarized to facilitate the integration of diverse evidence to draw conclusions on supporting or refuting the three proposed theorized mechanisms for managing urinary incontinence in women.

RESULTS

Of the 278 articles identified with the search, 13 (4.7%) met inclusion criteria. There was weak to no evidence for the mechanism of enhanced pelvic floor muscle strength, equivocal support for maximized awareness of timing, and no evidence for strengthened core muscles.

CONCLUSIONS

This review revealed extremely limited data supporting the proposed theorized mechanisms underlying pelvic floor muscle training programs to manage urinary incontinence in women. Such evidence is needed to help women and clinicians understand how, why and when a woman benefits from pelvic floor muscle training. Future studies should specifically state and report statistical analysis that relates the theorized mechanisms to the training outcomes observed.

Association of pubovisceral muscle tear with functional capacity of urethral closure: evaluating maternal recovery from labor and delivery

BACKGROUND

Vaginal birth is a risk factor for pubovisceral muscle tear, decreased urethral closure pressure, and urinary incontinence. The relationship between these 3 factors is complicated. Urinary continence relies on maintaining urethral closure pressure, particularly when low urethral closure pressure can usefully be augmented by a volitional pelvic muscle (Kegel) contraction just before and during stress events like a cough. However, it is unknown whether a torn pubovisceral muscle decreases the ability to increase urethral closure during an attempted pelvic muscle contraction.

OBJECTIVE

We tested the null hypothesis that a pubovisceral muscle tear does not affect the ability to increase urethral closure pressure during a volitional pelvic muscle contraction in the Evaluating Maternal Recovery from Labor and Delivery (EMRLD) study.

STUDY DESIGN

We studied 56 women 8 months after their first vaginal birth. All had at least 1 risk factor for pubovisceral muscle tear (eg, forceps and long second stage). A tear was assessed bilaterally by magnetic resonance imaging. Urethral closure pressure was measured both at rest and during an attempted volitional pelvic muscle contraction. A Student t test was used to compare urethral closure pressures. Multiple linear regression was used to estimate the effect of a magnetic resonance imaging-confirmed pubovisceral muscle tear on volitionally contracted urethral closure pressure after adjusting for resting urethral closure pressure.

RESULTS

The mean age was just a little more than 30 years, with the majority being white. By magnetic resonance imaging measure, unadjusted for other factors, the 21 women with tear had significantly lower urethral closure pressure during an attempted contraction compared with the 35 women without tear (65.9 vs 86.8 cm H₂O, respectively, P = .004), leading us to reject the null hypothesis. No significant group difference was found in resting urethral closure pressure. After adjusting for resting urethral closure pressure, pubovisceral muscle tear was associated with lower urethral closure pressure (beta = -21.1, P = .001).

CONCLUSION

In the first postpartum year, the presence of a pubovisceral muscle tear did not influence resting urethral closure. However, women with a pubovisceral muscle tear achieved a 25% lower urethral closure pressure during an attempted pelvic muscle contraction than those without a pubovisceral muscle tear. These women with pubovisceral muscle tear may not respond to classic behavioral interventions, such as squeeze when you sneeze or strengthen through repetitive pelvic muscle exercises. When a rapid rise to maximum urethral pressure is used as a conscious volitional maneuver, it appears to be reliant on the ability to recruit the intact pubovisceral muscle to simultaneously contract the urethral striated muscle.

Self-Perceived Improvement in Bladder Health After Viewing a Novel Tutorial on Knack Use: A Randomized Controlled Trial Pilot Study

Purpose: To test a novel bladder health tutorial on use of the Knack for overcoming bladder control challenges. The Knack-tutorial is a self-administered vignette-based instructional program on preempting bladder challenges in daily life (urgency, stress-leakage, or urge-leakage) through anticipatory, well-timed pelvic floor muscle contraction at the moment of challenge. Materials and Methods: This is a randomized controlled trial pilot test of 108 women with stress or mixed urinary incontinence. The Knack-tutorial group saw a 15-minute slide show with 10 vignettes portraying use of the Knack in daily life. The slide show format used inserted narrated videos, dubbed and animation enhanced pictures and cartoons, and automatic slide advancement. A control group saw a similarly constructed slide show on incorporating good diet/exercise habits. Outcomes were self-perceived improvement (yes/no, and as 0%-100%) 1 month after viewing the tutorial. Results: We enrolled 123 women, randomizing 64 to Knack-tutorial group and 59 to diet/exercise tutorial group. Eleven and one participant, respectively, did not return. Three did not fill out the self-perceived improvement report. Significant improvement was reported by 71% in the Knack-tutorial group compared to 25% in the diet/exercise group (p < 0.001). Self-perceived improvement was 21%-22% higher (Model I Est: 21.01, SE: 4.25, p < 0.001) in the Knack-tutorial group. Conclusions: An electronic tutorial viewed independent of a health care provider with vignettes showing Knack application to manage the everyday bladder challenges women face shows benefit of a magnitude that warrants more widespread use and rigorous testing. A professional remake of the intervention is now available (www.myconfidentbladder.com).

Characterizing pelvic floor muscles activities using magnetomyography

AIMS

To characterize levator ani muscle (LAM) activity in nulligravidas using magnetomyography (MMG) and define MMG characteristics associated with LAM activity with and without accessory muscle contributions.

METHODS

MMG data were collected from eight nulligravidas during rest and voluntary LAM contractions (Kegels) of varying intensity. We utilized simultaneous vaginal manometry and surface electromyography (sEMG) to evaluate for accessory muscle recruitment. Moderate Kegel (MK) MMG trials were sub-selected based on the presence or absence of accessory muscle interaction. Amplitude and spectral-related indicators were calculated across MK epochs: root-mean square (RMS) amplitude, percentage amplitude relative to rest, and relative power spectrum density (rPSD) in three frequency bands (low, middle, high). Ternary diagram characterized rPSD from selected Kegels and ROC analysis was performed to identify cut-points to differentiate MKs from interacting MKs.

RESULTS

Nineteen MMG recordings were obtained. Amplitude and spectral parameters were significantly different between isolated and interacting MK epochs. Mean RMS and power values of the isolated MK were, respectively, 120.66 ± 43.8 fT and 1.72 ± 1.44 (T² /Hz)*10^-28 . Amplitudes of MK were 64% and 117 higher than baseline activities for the isolated and interacting epochs, respectively. ROC curves reveled cut-off points on low and middle frequency bands that achieved perfect separation (ROC-AUC = 1.0) between isolated and interacting MK.

CONCLUSIONS

Our study demonstrates that MMG, a novel biomagnetic technique, allows precise detection and characterization of normal female pelvic floor function. Results show that isolated moderate voluntary contraction of the LAMs produces distinct MMG amplitude and spectral characteristics compared with Kegels involving co-activation of other muscle groups.

Variables affecting maximum urethral closure pressure (MUCP) and abdominal leak point pressure (ALPP) measurements

INTRODUCTION AND HYPOTHESIS

The relationship between pelvic floor muscles and measurements of urethral function is not well studied. It is not known whether adjusting for clinical, demographic and urodynamic parameters would improve the association between MUCP and ALPP. Our hypothesis was that pelvic floor muscle strength (PFMS) influences the relationship between MUCP and ALPP.

METHODS

This was a retrospective study of women who underwent a complex urodynamic study with evaluation of MUCP and ALPP using ICD-9 codes with documentation of PFMS.

RESULTS

Urodynamic stress incontinence was confirmed in 478 patients, of whom 323 had MUCP recorded and 263 had both MUCP and ALPP recorded. Women with higher PFMS had a higher MUCP. In regression analysis ALPP at 150 mL and MUCP were weakly associated (coefficient 0.43, 95% CI 0.08-0.78; p = 0.02), whereas ALPP at capacity and MUCP were moderately associated (coefficient 0.60, 95% CI 0.25-0.95; p < 0.001).

CONCLUSIONS

This study showed that MUCP and ALPP at 150 mL were weakly associated and that this improved to a moderate association for ALPP at capacity. MUCP increased with increasing PFMS among women with stress urinary incontinence and decreased with increasing age. There was no evidence that ALPP was associated with PFMS or age. The relationship between MUCP and ALPP was unchanged when accounting for covariates of PFMS (age, parity, BMI, prior procedure, urethral mobility, bladder capacity, stage of cystocele, or stage of uterine or apical prolapse).

Pelvic Floor Muscle Training to Manage Overactive Bladder and Urinary Incontinence

Overactive bladder (OAB) and urinary incontinence (UI) are common chronic conditions that can negatively affect women's quality of life. Pelvic floor muscle training is the first-line treatment. Two recent Cochrane Reviews examining pelvic floor muscle training for the treatment of UI and OAB are summarized here to provide women's health nurses with current recommendations for UI and OAB management. This column also identifies practice improvement education in the area of pelvic floor muscle training and treatment for OAB and UI.