Pelvic floor exercises are used as a first line treatment option once someone presents with the symptoms of SI (NICE 2003). A systematic review was carried out by Hay-Smith et al. (2001) on PFM training and its effectiveness for stress or mixed UI in women. They found that pelvic floor muscle training (PFMT) is more effective than no treatment or placebo in women with stress or mixed UI. The thorough search strategy and the statistical combination of studies strengthen the results of this review.
Although 43 randomised control trials (RCTs) were identified and included in the review, 15 of these were conference abstracts, which limited the reviewers’ ability to assess the quality of the trials and may have led to an exaggerated treatment effect. A large variation in the methods of teaching PFME’s, methods of assessing pelvic muscle strength, and measurement of clinical outcomes were identified and this should be rectified in future research.
Furthermore, most of the studies in this review were limited to young premenopausal women, so more research is needed to establish the effect in other sample groups. The validity of the questionnaires used can be questioned in some of the studies reviewed. In order to minimize recall and interpretation bias, the patients were asked (at 0, 5 and 10 years) simple and straightforward questions that referred to their ‘actual’ condition. Thus the degree of incontinence and the frequency of home practicing could be compared in a standard way throughout the follow-up.
A more recent systematic review by Haddow et al. (2005) looked at the effectiveness of a PFME program on UI following childbirth. The primary aim of this review was to determine, from the available evidence, the effectiveness of an antenatal and/or a post-natal program of PFME compared with usual care on preventing, reducing or resolving the incidence and severity of SI, urge incontinence or mixed stress and urge UI following childbirth.
The literature gathered underwent an assessment of quality and if there were any disagreements by the two assessors reviewing the literature, a third reviewer on the panel was used. Six RCT’s met the inclusion criteria and the results of this review indicated that antenatal PFME and post-natal PFME are effective in resolving or reducing UI following childbirth. There was insufficient evidence to conclude that PFME can prevent UI in post-partum women. In most of these studies women were selected randomly and therefore included women without UI and women with UI.
Two RCT’s selected their sample on the criteria of existing post-partum UI. The mixed results of this review mean that no conclusions can be reached about the effectiveness of a PFME program, antenatal or post-natal, on improving PFM strength. A number of studies reported a high percentage of women lost to follow-up and the data collected in most of the studies relied on self-reports relating to UI and/or frequency of exercising. These factors may have affected the overall results of the review.
Neumann et al.(2006) carried out a systematic review on pelvic floor muscle training and adjunctive therapies for the treatment of stress urinary incontinence in women. Both RCTs and non-RCTs were included in this review, cohort studies, case series were considered for this review in order to source all the available evidence relevant to clinical practice. Twenty four studies, including 17 RCTs and seven non-RCTs, met the inclusion criteria. The methodological quality of the studies varied but lower quality scores did not necessarily indicate studies from lower levels of evidence.
This review found consistent evidence from a number of high quality RCTs that PFMT alone and in combination with adjunctive therapies is effective treatment for women with SUI with rates of ‘cure’ and ‘cure/improvement’ up to 73% and 97% respectively. The methodological quality of the studies was variable, with some RCTs being of lower quality than the lower level studies. This provides a dilemma for systematic reviewers, as restriction of study inclusion to RCTs is considered to ensure identification of high quality studies.
However, the possibility of well-designed cohort studies providing less biased evidence than poorly designed RCTs has been documented. One of the aims of this review was to investigate outcomes relevant to clinical practice. To this end, level III and IV studies, not previously reported in systematic reviews of the literature on SUI, were included. The inclusion of these studies with lower levels of evidence provided information about aspects of physical therapy not obtainable from the RCTs reviewed, for example, about the different response rate and the effectiveness of treatment in the primary care setting.