Evidence Based Physical Therapy for the Pelvic Floor Bridging Science and Clinical Practice

294 PELVIC FLOOR DYSFUNCTION AND EVIDENCE-BASED PHYSICAL THERAPY patients? Canadian Journal of Physiology and Pharmacology Methodological quality 64(6):781–783 Wagner T H, Patrick D L, McKenna S P et al 1996 Cross-cultural Methodological rigor was assessed by a PEDro quality development of a quality of life measure for men with erection score (Table 9.17). difficulties. Quality of Life Research 5:443–449 Waldinger M D, Hengeveld M W, Zwinderman A H et al 1998 An Evidence for the effect empirical operationalization study of DSM-IV diagnostic criteria for premature ejaculation. International Journal of Psychiatric Only two randomized controlled trials (RCTs) provided Practice 2:287 evidence that pelvic floor muscle exercises (PFME) World Health Organization 1992 International statistical cured or improved erectile function (Dorey et al 2004, classification of diseases and related health problems. 1989 Sommer et al 2002). The trial by Sommer et al (2002) Revision. World Health Organization, Geneva scored 7/10 using a PEDro quality score and the trial by Xin Z C, Choi Y D, Rha K H et al 1997 Somatosensory evoked Dorey et al (2004) scored 8/10 (see Table 9.17). potentials in patients with primary premature ejaculation. The Journal of Urology 158(2):451–455 Five trials that were either non-randomized or uncon- Xin Z C, Chung W S, Choi Y D et al 1996 Penile sensitivity in trolled provided weak evidence (Claes & Baert 1993, patients with primary premature ejaculation. The Journal of Claes et al 1995, Colpi et al, 1994, Mamberti-Dias & Urology 156(3):979–981 Bonierbale-Branchereau 1991, Van Kampen et al 2003). Two non-randomized uncontrolled trials solely used TREATMENT electrical stimulation and provided only weak evidence (Derouet et al 1998, Stief et al 1996). Grace Dorey The trial by Sommer et al (2002) used a large sample The treatment of male sexual dysfunction by physical size of 124 men with venogenic erectile dysfunction. therapists has been based on the evidence from a few Men were randomized into three groups with one group trials. These trials were limited to the treatment of erec- receiving PFME, one group receiving Viagra and one tile dysfunction and premature ejaculation. group receiving a placebo. At 3 months the PFME group improved more than the Viagra group and significantly ERECTILE DYSFUNCTION more than the placebo group. In the trial by Dorey et al (2004) 55 men were randomized into two groups with A literature review was undertaken to ascertain if physi- one group receiving PFME and one group receiving cal therapy had merit as a conservative treatment for lifestyle changes. At 3 months the PFME group improved erectile dysfunction. significantly compared to the control group. The control group were then given PFME and they improved sig- Literature search strategy nificantly when compared to their erectile function at baseline. Both groups continued home exercises for a A search of the following computerized databases from further 3 months. 1980 to 2005 was undertaken: Medline, AAMED (Allied and Alternative Medicine), CINAHL, EMBASE – Reha- Effect size bilitation and Physical Medicine and The Cochrane Library Database. The keywords chosen were erectile The two randomized controlled trials both showed sig- dysfunction, impotence, conservative treatment, physi- nificantly improved erectile function with PFME. cal therapy, physical therapy, pelvic floor exercises, bio- feedback, electrical stimulation and electrotherapy. A Dorey et al (2004) found at 3 months using the erec- manual search was undertaken of identified manu- tile function domain of the International Index of scripts reporting on research studies gained from the Erectile Function (IIEF) that the PFME group improved references of this literature. significantly (p = 0.001) compared with the control group (p = 0.658) (Fig. 9.31). At 3 months, when the Selection criteria control group were given PFME they improved erectile function significantly (p < 0.001). This trial also found A study was included if the trial reported the results of that anal pressure in the intervention group significantly physical therapy for men with erectile dysfunction and improved after 3 months PFME (p < 0.001) when com- the outcome measures were reliable and relevant to the pared to the control group. problem under investigation (Table 9.16). Sommer et al (2002) found that the group of men who performed PFME improved more than the group of men receiving oral phosphodiesterase type 5 (PDE5) inhibi-

Male sexual dysfunction 295 Table 9.16 Literature review of physical therapy for erectile dysfunction Study Mamberti-Dias & Bonierbale-Branchereau 1991 Design n Not random Diagnosis No control Training protocol Drop-out 210 men with erectile dysfunction Adherence Some with venous leakage Results Some psychological Study Some with venous leakage Design Some psychological erectile dysfunction n PFME & electrical stimulation sacral & penile or perineal electrode 5–25 Hz then 50–400 Hz Diagnosis intermittent Training protocol Visual stimulation and penile temperature 15 treatments Drop-out Adherence Drop-outs not given Adherence not given At 3 months 111 (53%) cured 44 (21%) improved 55 (26%) failed 67% attained 4/10 to 8/10 ISMR (index of subjective mean rigidity) Subjective outcome Claes & Baert 1993 Randomized No control 150 men with venogenic erectile dysfunction Age 23–64 Median age 48.7 Group 1 72 surgery Group 2 78 PFME Venogenic erectile dysfunction Group 1 Surgery deep dorsal vein Group 2 Patient education 5-weekly PFME Home exercises Digital anal assessment baseline, 4 and 12 months 40 mg papaverine + needle EMG ischiocavernosus muscle + maximum PFM contraction Drop-outs not given Adherence not given

296 PELVIC FLOOR DYSFUNCTION AND EVIDENCE-BASED PHYSICAL THERAPY Table 9.16 Literature review of physical therapy for erectile dysfunction—cont’d Results At 4 months Group 1 Study 44 (61%) cured Design 17 (23.6%) improved n 11 (15.2%) failed Group 2 Diagnosis 36 (46%) cured Training protocol 22 (28%) improved Drop-out 20 (25.6%) failed Adherence At 12 months Results Group 1 30 (42%) cured Study 23 (32%) improved Design Group 2 n 33 (42%) cured 24 (31%) improved 45 (58%) refused surgery Subjective and objective outcomes Colpi et al 1994 Not random Controlled 59 men Age 20–63 Mean age 39 Group 1 33 men: PFME and biofeedback Group 2 26 men: controls Venogenic erectile dysfunction 30 of 59 deep dorsal vein surgery 30 of 59 psychological therapy No information which? No information on type of biofeedback Drop-outs not given Adherence not given At 11 months Group 1 21 (63%) cured or improved Group 2 4 (15%) cured or improved 9 refused surgery Subjective outcome Claes et al 1995 Not random No control 122 men with venogenic erectile dysfunction

Male sexual dysfunction 297 Table 9.16 Literature review of physical therapy for erectile dysfunction—cont’d Diagnosis Venogenic erectile dysfunction Training protocol Patient education Drop-out PFME Adherence EMG or pressure biofeedback Results ES with anal or surface electrode, symmetrical biphasic low frequency 50 Hz pulse 100 μs 6 s Study stimulation 12 s rest maximum intensity Design n 14/122 drop-outs (11.5%) Diagnosis Training protocol 88.5% adhered Drop-out At 4 months Adherence 53 (43%) cured Results 37 (30%) improved 32 (26.2%) failed including 14 drop-outs Study At 12 months Design 44 (36%) cured n 41 (33.6%) improved Diagnosis 37 (30.3%) failed including 14 drop-outs Training protocol 65 (53.4%) refused surgery Drop-out Subjective outcome Stief et al 1996 Not random Controlled 22 men with erectile dysfunction who were vasoresponders Venogenic erectile dysfunction Transcutaneous ES to smooth muscle corpus cavernosum Low-frequency symmetrical trapezoidal 100–200 μs 12 mA alternating 10–20 Hz & 20–35 Hz 5 s stimulation 2–5 days for 20 min Drop-outs not given Adherence not given At 5 days 5 (23%) cured 3 (13.6%) responded to vasoactive drugs 14 (63%) failed Subjective outcome Derouet et al 1998 Not random No control 48 men with erectile dysfunction Erectile dysfunction Transcutaneous ES penile or perineal electrodes bipolar pulsed 85 μs 30 Hz 20–120 mA 3-s stimulation 6-s rest 20 min daily for 3 months 10/48 drop-outs (20.8%)

298 PELVIC FLOOR DYSFUNCTION AND EVIDENCE-BASED PHYSICAL THERAPY Table 9.16 Literature review of physical therapy for erectile dysfunction—cont’d Adherence 79.2% adhered Results At 3 months Study 5 (10.4%) cured Design 20 (41.6%) improved n 23 (47%) failed including 10 drop-outs Subjective improvement Diagnosis Training protocol Sommer et al 2002 Drop-out Randomized Adherence Controlled PEDro score 7/10 Results 124 men with venogenic erectile dysfunction Study Aged 21–72 Design Mean age 43.7 n Group 1: 40 men Diagnosis Group 2: 36 men Training protocol Group 3: 28 men Venogenic erectile dysfunction Group 1: 3 weekly PFME Group 2: oral PDE5 inhibitor Group 3: placebo At baseline, 4 weeks and 3 months: KEED erectile dysfunction questionnaire, IIEF Q 3 and 4, GAQ At baseline and 3 months: caversonography Drop-outs not given Adherence not given At 3 months Group 1 80% improved significantly 46% improved penile rigidity Group 2 74% improved Group 3 18% improved Subjective and objective Van Kampen et al 2003 Not random No control 51 men with erectile dysfunction with mixed aetiology Age 25–64 Mean age 46 Erectile dysfunction Patient education PFME in lying, sitting and standing Anal pressure biofeedback ES anal or surface electrode 50 Hz 200 μs 6 s stimulation 12 s rest once a week for 4 months Home exercise 90 contractions

Male sexual dysfunction 299 Table 9.16 Literature review of physical therapy for erectile dysfunction—cont’d Drop-out 9/51 drop-outs (18%) Adherence Results 82% adhered Study At 4 months Design 24 (46%) cured n 12 (24%) improved 15 (31%) failed including drop-outs Diagnosis Subjective outcome Training protocol Dorey et al 2004 Drop-out Adherence Randomized Controlled PEDro score 8/10 Results 55 men with erectile dysfunction with mixed aetiology Age 22–78 Mean age 59 Intervention group 28 men PFME + lifestyle changes Control group 27 men lifestyle changes Erectile dysfunction Intervention group Patient education 5 weekly PFME and anal pressure biofeedback + home exercises + lifestyle changes Control group 5× weekly lifestyle changes At 3 months control group given intervention Outcome measures at 3 and 6 months: IIEF, ED-EQOL, anal manometry, blind assessment At 3 months 5/55 drop-outs (9%) Adherence at 3 months (91%) At 3 months Erectile function domain of IIEF: intervention group significantly improved (p = 0.001) Control group (p = 0.658) Anal pressure: intervention group significantly improved (p < 0.001) At 6 months Blind assessment 22 (40%) normal function including drop-outs 19 (34.5%) improved including drop-outs 14 (25.5%) failed including drop-outs Subjective and objective outcomes ED-EQOL, Erectile Dysfunction Effect on Quality of Life; ES, electrical stimulation; IIEF, International Index of Erectile Function; KEED, Kölner Erfassungsbogen für Erektile Dysfunktion; PDE5 inhibitor, phosphodiesterase type 5 inhibitor; PFME, pelvic floor muscle exercises.

300 PELVIC FLOOR DYSFUNCTION AND EVIDENCE-BASED PHYSICAL THERAPY Table 9.17 PEDro quality score of RCTs in systematic review of physiotherapy for erectile dysfunction E – Eligibility criteria specified 1 – Subjects randomly allocated to groups 2 – Allocation concealed 3 – Groups similar at baseline 4 – Subjects blinded 5 – Therapist administering treatment blinded 6 – Assessors blinded 7 – Measures of key outcomes obtained from over 85% of subjects 8 – Data analysed by intention to treat 9 – Statistical comparison between groups conducted 10 – Point measures and measures of variability provided Study E 1 2 3 4 5 6 7 8 9 10 Total score Sommer et al 2002 + + + + − − − + + + + 7/10 Dorey et al 2004 ++++−−+++++ 8/10 +, criterion is clearly satisfied; −, criterion is not satisfied; ?, not clear if the criterion was satisfied. Total score is determined by counting the number of criteria that are satisfied, except that scale item one ‘eligibility criteria specified’ is not used to generate the total score. Total scores are out of 10. Mean erectile function domain of IIEF scale 40 Fig. 9.31 Mean erectile function domain of International Index of Erectile Function (IIEF) scores for both groups at 35 * * each assessment. (From Dorey et al 2004, with permission. 30 © British Journal of General Practice.) 25 16 16 16 16 Control 20 Erectile function baseline 15 Erectile function 3 months Erectile function 6 months 10 Erectile function 9 months 5 0 –5 –10 N = 17 17 17 17 Intervention Sample group Key: * Denotes significant difference (p = 0.001) Lifestyle changes Intervention Home exercises

Male sexual dysfunction 301 6 ** Type of intervention 5 Only one trial used PFME alone (Sommer et al 2002). This trial provided good results without biofeedback 4 and questions the need for biofeedback. Two trials included biofeedback as the only other modality (Colpi KEED scale 3 et al 1994, Dorey et al 2004), while two combined PFME with biofeedback and electrical stimulation (Claes et al 2 1995, Van Kampen et al 2003). It is impossible to deter- mine which modality has caused the effect when three 1 modalities are used. 0 Viagra Pelvic floor The amount of PFME varied. Colpi et al (1994) Placebo exercises expected men to perform daily home exercises for 30 minutes a day for 9 months as a realistic alternative to Fig. 9.32 Changes in Kölner Erfassungsbogen für Erektile surgery. Dorey et al (2004) instructed men to perform Dysfunktion (KEED) at 3 months compared to baseline. 18 strong contractions a day with an emphasis on func- (From Sommer et al 2002.) tional work. No trial mentioned a long-term follow-up or advised a maintenance programme for life, though tor (Viagra) and significantly more than the group Claes & Baert (1993), and Claes et al (1995) followed up receiving a placebo (Fig. 9.32). subjects for 12 months with encouraging results. Clinical significance Two trials used electrical stimulation alone. Derouet et al (1998) found electrical stimulation to the ischiocav- Both Sommer et al (2002) and Dorey et al (2004) found ernosus muscle produced a cure rate of only 10.4% that PFME improved erectile function clinically. Sommer while Stief et al (1996) in a controlled trial explored found that 46% of men had improved penile rigidity transcutaneous electrical stimulation to the smooth and Dorey found that 40% of men regained normal erec- muscle of the penile corpus cavernosum and effected a tile function, and a further 34.5% improved erectile 23% cure rate. Whatever effect was achieved, both cure function. rates were low compared to the PFME trials. Methodological quality Frequency and duration of training The methodological quality was good in the two ran- The amount of treatment varied from between five and domized controlled trials. The sample size was larger in 20 treatment sessions, though some papers did not the study by Sommer et al (2002). Sommer et al (2002) provide this information. Sommer et al (2002) treated studied men with proven venogenic erectile dysfunc- men in three weekly PFME sessions and monitored the tion. Dorey et al (2004) studied men with a wide range men at 4 weeks and 3 months. Dorey et al (2004) treated of aetiology. Both used validated subjective outcome men in five weekly PFME sessions and monitored the measures and unlike the other trials both used objective men at 3 months and at 6 months. In both studies men outcome measures. performed home exercises. The results from the uncontrolled or non- Short- and long-term effects randomized trials should be interpreted with caution due to poor methodology. Only one of these trials used From the available data, it appears that patients were randomization, five of the trials lacked controls, and assessed initially and then at between 3 and 12 months. seven provided only subjective outcomes. The lack of The exception to this was the trial by Stief et al (1996) control groups in these trials impinged on the validity where outcomes were assessed after 5 days. of evidence provided. The lack of randomization is an important methodological limitation that fundamen- Both Sommer et al (2002) and Dorey et al (2004) used tally limits any definitive interpretation and translation the subjective validated IIEF, which is used extensively of the findings from these trials. for trials using oral medication for erectile dysfunction. Sommer et al (2002) used the validated Kölner Erfas- sungsbogen für Erektile Dysfunktion (KEED). Dorey et al (2004) used an assessor who was blinded to the subject group to report trial outcomes. Mamberti- Dias & Bonierbale-Branchereau (1991) used an index of

302 PELVIC FLOOR DYSFUNCTION AND EVIDENCE-BASED PHYSICAL THERAPY subjective mean rigidity (ISMR) and reported an increase Diagnosis from 4 out of 10 to 8 out of 10 mean ISMR. Testosterone assay Most outcomes used patient reported ‘cure’, First-line treatment ‘improved’ or ‘failure’. ‘Cure’ was defined as an erection Pelvic floor muscle exercises suitable for satisfactory sexual performance with vaginal penetration in all studies. ‘Improvement’, however, was Second-line treatment defined in a number of ways from ‘a significant increase Oral therapy of erection quality and performance’ (Colpi et al 1994) to ‘partial response for those patients who reported some Vacuum devices increase in quality (duration or rigidity) of erections but Constriction bands not sufficient for sexual intercourse’ (Claes et al 1995). Counselling/sex therapy Intracavernous injections Three trials used objective outcome measurements. Intraurethral medication Claes & Baert (1993) injected 40 mg papaverine to achieve penile rigidity and tested with needle electro- Topical therapy myography (EMG) while contracting the ischiocaver- nosus muscle maximally. Sommer et al (2002) used Third-line treatment Rigiscan® as an objective measurement of penile rigid- Vascular surgery ity and Dorey et al (2004) used anal manometric bio- Prosthetic implant feedback readings. Fig. 9.33 Suggested algorithm for treatment of erectile Sommer et al (2002) used a quality of life instrument dysfunction. (From Dorey et al 2004, with permission. and Dorey et al (2004) used the validated Erectile Dysfunction – Effect on Quality of Life (ED-EQoL) © British Journal of General Practice.) (MacDonagh et al 2002). Dorey et al (2004) found there was poor correlation of the IIEF with the ED-EQoL in Conservative management for the prevention the intervention group, but significant correlation in the of erectile dysfunction control group. This finding showed that erectile dys- function may have impacted on men in different ways There were no publications using preventative conser- and demonstrated a clear reason for the clinical useful- vative treatment. However, if the pelvic floor muscula- ness of a quality of life questionnaire. ture is poor and PFME can relieve erectile dysfunction, then it seems reasonable to suppose that preventative The short-term effects were good in all trials of PFME muscle strengthening may help to prevent erectile for erectile dysfunction. The two randomized controlled dysfunction. trials have provided good results at 3 months (Dorey et al 2004, Sommer et al 2002) and 6 months (Dorey et al Conclusions 2004). The results were good at 12 months in the trial by Claes & Baert (1993). There is good-level evidence that PFME seem to have merit as a treatment for erectile dysfunction. For those Psychosexual issues patients who appear to have been cured or improved with PFME, it may be prudent to continue these simple All the trials used a sample of heterosexual men. No exercises for life and possibly avoid a return of erectile study mentioned any cultural factors. The perceptions dysfunction. However, long-term compliance may be a of sexual activity vary from one man to another and problem. Following initial pelvic floor training, it may impact on the expectations and the subjective measure- be possible to maintain muscle performance with a ment of sexual performance. Not all men wish to prac- minimal exercise programme. tise penetrative sex. There were no studies that identified and addressed the difficulties and needs of homosexual There was no strong evidence that electrical stimula- men who practise anal intercourse. tion was effective. Recommendations based on evidence No studies demonstrating preventative conservative treatment were found. PFME should be the first-line treatment for erectile dys- function (Fig. 9.33). They may be performed in conjunc- A multicentre randomized controlled trial with larger tion with other treatment for erectile dysfunction such sample numbers is needed to explore the use of PFME as oral therapy, vacuum devices, intracavernosus injec- as a first-line treatment for men with erectile dysfunc- tions, intraurethral medication, constriction bands and counselling.

Male sexual dysfunction 303 tion. Similar trials are also needed to ascertain the role Methodology of PFME as prophylaxis for erectile dysfunction. La Pera & Nicastro (1996) used PFME, pressure biofeed- PREMATURE EJACULATION back and electrical stimulation in a non-randomized and uncontrolled trial of 18 patients with a mean age of A literature review was undertaken to ascertain whether 34 years (range 20–52 years) to treat premature ejacula- PFME may have merit as a treatment for premature tion; 15 had experienced the problem for over 5 years. ejaculation. The results showed that 11 patients (61%) were cured and able to control the ejaculatory reflex associated with Literature search strategy improved PFM control and seven (39%) had no improve- ment. The biofeedback readings were not given. This A search of the following computerized databases from non-randomized, uncontrolled study has shown that 1980 to 2005 was undertaken: Medline, AAMED (Allied there may be merit in strengthening the PFM to control and Alternative Medicine), CINAHL, EMBASE – Reha- the ejaculatory reflex to prevent premature ejaculation. bilitation and Physical Medicine and The Cochrane Library Database. The keywords chosen were prema- In a non-randomized uncontrolled trial, Claes & van ture ejaculation, conservative treatment, physical Poppel (2005) investigated the action of PFME and elec- therapy, physical therapy, pelvic floor muscle exercise, trical stimulation on 29 men with premature ejaculation. biofeedback, electrical stimulation and electrotherapy. A After treatment, they found that 19 men (65.5%) showed manual search was also undertaken. improvement, which was verified by their partner. At 12 months, most of the men who had improved still Selection criteria showed a positive result. A study was included if it reported the results of physi- Methodological quality cal therapy for men with premature ejaculation. The methodology used in these two trials without ran- Methodological quality domization or the use of a control group and with a small sample size provided only weak evidence. No RCTs were identified. However, results from these trials indicated that this subject is worth further exploration. Results Recommendations Only two non-randomized uncontrolled trials was found providing weak evidence (Table 9.18). RCTs need to be undertaken to investigate PFME for premature ejaculation before any conclusions can be made. Table 9.18 Trials of physical therapy for premature ejaculation Study Design Subjects Method Outcomes La Pera & Non-randomized 18 men with PFME At 7 weeks Nicastro No control premature Pressure biofeedback 11 (61%) cured 1996 ejaculation ES 7 (39%) no improvement Anal probe 50 Hz Subjective and objective Aged 20–52 Mean age 34 3×/week for 20 sessions outcomes Claes & van Non-randomized 29 men with PFME After treatment premature ES 19 (65.5%) improved Poppel 2005 No control ejaculation Parameters not given 10 (34.5%) failed to improve Ejaculatory latency time At 12 months Age not disclosed Method of measurement Most of the 19 who improved not given still showed a positive response ES, electrical stimulation; PFME, pelvic floor muscle exercises.

304 PELVIC FLOOR DYSFUNCTION AND EVIDENCE-BASED PHYSIOTHERAPY REFERENCES Claes H, Baert L 1993 Pelvic floor exercise versus surgery in the MacDonagh R, Ewings P, Porter T 2002 The effect of erectile treatment of impotence. British Journal of Urology 71:52–57 dysfunction on quality of life: psychometric testing of a new quality of life measure for patients with erectile dysfunction. The Claes H, Van Kampen M, Lysens R et al 1995 Pelvic floor exercises Journal of Urology 167:212–217 in the treatment of impotence. European Journal of Physical Medicine Rehabilitation 5:135–140 Mamberti-Dias A, Bonierbale-Branchereau M 1991 Therapy for dysfunctioning erections: four years later, how do things stand? Claes HI, van Poppel H 2005 Pelvic floor exercise in the treatment of Sexologique 1:24–25 premature ejaculation. The Journal of Sexual Medicine 2(suppl 1):9 Sackett DL 1986 How are we to determine whether dietary interventions do more good than harm to hypertensive patients? Colpi GM, Negri L, Scroppo FI et al 1994 Perineal floor Canadian Journal of Physiology and Pharmacology 64(6):781–783 rehabilitation: a new treatment for venogenic impotence. Journal of Endocrinological Investigation 17:34 Sommer F, Raible A, Bondarenko B et al 2002 A conservative treatment option of curing venous leakage in impotent men. Derouet H, Nolden W, Jost W H et al 1998 Treatment of erectile European Urology 1(suppl 1):153 dysfunction by an external ischiocavernosus muscle stimulator. European Urology 34(4)355–359 Stief C G, Weller E, Noack T et al 1996 Functional electromyostimulation of the penile corpus cavernosum Dorey G, Speakman M, Feneley R et al 2004 Randomised controlled (FEMCC). Initial results of a new therapeutic option of erectile trial of pelvic floor muscle exercises and manometric dysfunction. Der Urologe Ausg A 35(4):321–325 biofeedback for erectile dysfunction. British Journal of General Practice 54(508):819–825 Van Kampen M, De Weerdt W, Claes H et al 2003 Treatment of erectile dysfunction by perineal exercises, electromyographic La Pera G, Nicastro A 1996 A new treatment for premature biofeedback and electrical stimulation. Physiotherapy 83(6):536– ejaculation: the rehabilitation of the pelvic floor. Journal of Sex 543 and Marital Therapy 22(1):22–26 Fecal incontinence INTRODUCTION DEFINITION AND CLASSIFICATION Ylva Sahlin and Espen Berner Fecal incontinence is described as the unintentional loss of rectal contents. There is no validated consensus defi- Fecal incontinence is defined as the involuntary passage nition for the condition. The main diversity in definition of gas or stool from the anal canal. The condition may is whether the loss of gas should be considered as an seriously affect quality of life (QoL) (Bravo Gutierrez aspect of fecal incontinence. It is therefore difficult to et al 2004). Patients have described their lack of bowel compare results from the studies done in this field. This control as the loss of adulthood (Rozmovits & Ziebland, is especially a problem when trying to estimate preva- 2004). When handling patients with fecal incontinence lence. How common is this condition? There is a need health care workers should be aware of the adverse for a standard definition of fecal incontinence based on psychological effects of the condition. Embarrassment, severity and frequency. social isolation, depression and reduced QoL character- ize patients with fecal incontinence. Examination for fecal incontinence should include a general physical examination and supplementary inves- There is a lack of knowledge about the problems of tigation procedures. Endoanal ultrasound, rectoanal fecal incontinence both among people in general and endoscopy, anal manometry and pudendal nerve termi- among health care workers. Physicians too often ignore nal motor latency (PNTML) show no correlation with symptoms, hence necessary treatment is not initiated. the quantity and quality of symptoms and no objective Patients often hesitate discussing the condition of fecal measures correlate with severity. Grading is therefore incontinence. Only one-third of patients affected seek best described using patient-reported symptoms. There medical advice (Johanson & Lafferty 1996, Kantalar et al is no official method for collecting data. One can either 2002). Many patients are unaware that the condition can use a retrospective questionnaire or an incontinence often be treated. Patients tend to suffer in silence because diary. fecal incontinence is a taboo subject.

Fecal incontinence 305 Table 9.19 St Marks Incontinence Score Type of Never Rarely Sometimes Weekly Daily incontinence No episodes 1 episode >1 episode 1 or more 1 or more past 4 weeks past 4 weeks past 4 weeks episodes a week episodes a day Solid stool Liquid stool 0 1 2 3 4 Gas Alterations in lifestyle 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 Need to wear pad or plug No Yes Taking constipating medicines 0 2 Lack of ability to defer defecations for 15 minutes 0 2 0 4 Add one score from each row: Minimum score = 0 = perfect continence, maximum score = 24 = totally incontinent. Fecal incontinence is in general graded from 1 to 4 Box 9.10: Categories of fecal incontinence using the Parks incontinence scoring system (Browning & Parks, 1983): PASSIVE INCONTINENCE • Passive incontinence is unconscious loss of stool • Grade 1 – normal: complete continence. • The patient feels nothing before leakage • Grade 2 – mild incontinence: the loss of gas and URGE INCONTINENCE minor staining. • Urge incontinence is the inability to control a • Grade 3 – moderate incontinence: the loss of gas and perceived impending bowel movement. liquid stool. • Grade 4 – severe incontinence: complete incontinence ICD-10, The International Classification of Diseases by the World Health Organization (2005) classifies fecal of gas, liquid and solid stool. incontinence as R15: ‘A symptom or sign associated with gastrointestinal disorders’. Fecal incontinence is in Several medical units use a modified edition of this this respect not a specific disease, but rather a symptom scoring system in their studies of fecal incontinence. resulting from one ore more disorders that impair con- Still, this system gives no information about the fre- tinence by various mechanisms. There is no further clas- quency of bowel accidents, which is important in evalu- sification of the condition in the ICD-10. This illustrates ating patients and treatment. Other frequently used the lack of acknowledgement of fecal incontinence as a grading systems of fecal incontinence have emerged in disorder of its own. Based on aetiology and patient- the absence of a uniform classification (Jorge & Wexner, reported symptoms, the condition should be placed 1993, Pescatori et al 1993, Rockwood et al 1999, Vaizey into two categories: passive and urge incontinence et al 1999). The Wexner Incontinence Grading Scale and (Box 9.10). St Marks Incontinence Score are most often used (Table 9.19). These grading scales give a fine description of the Fecal incontinence in children includes both encop- severity of symptoms and are easy to use in a clinical resis and soiling. Encopresis is the expulsion of a normal context. bowel movement in inappropriate places by a child aged 4 years or older. Soiling is the involuntary leakage The Fecal Incontinence Quality of Life Scale (FIQL) of small amounts of stool. developed by Rockwood et al (2000) is a specific QoL questionnaire for fecal incontinence and is a useful instrument in evaluating patients with fecal inconti- nence (Halverson & Hull, 2002).

306 PELVIC FLOOR DYSFUNCTION AND EVIDENCE-BASED PHYSIOTHERAPY Prevalence and risk factors often use a variety of drugs that may further impair their fecal continence. Age above 65 years seems to be The prevalence of fecal incontinence varies with age, an independent risk factor (Nelson et al 1995) and cogni- sex, general health status and physical debilities. Data tive dysfunction is associated with a high prevalence on prevalence are mostly based upon epidemiological (Porell et al 1998). Without the conscious desire to main- studies. The results are diverse due to the variety of tain continence the ability to maintain normal bowel populations studied and the diversity in definitions of habits declines. In the Wisconsin nursing homes’ study fecal incontinence. In broad community-based studies Nelson et al (1998) found that urinary incontinence was the prevalence of fecal incontinence is estimated to 2– the factor that most commonly correlated to fecal incon- 18% in the population studied (Macmillan et al 2004, tinence. In this study there was no difference in preva- Madoff et al 2004, Nelson et al 1995). lence of fecal incontinence between the sexes. The mean age of this population was 84 years. Several epidemio- Younger female patients dominate clinical manage- logical studies also show a high prevalence among ment studies of fecal incontinence. Nelson et al (1995) ageing men. High age seems to wipe out the difference have explained this by a higher incidence in young in prevalence between the sexes (Tariq et al 2003). females. Obstetric trauma causing an injury to the anal sphincter muscles and the pudendal nerves is described Diarrhoea is associated with fecal incontinence. This as the primary risk factor. Injury to the anal sphincter is mainly caused by volume and liquid overflow and muscles occurs in 0.5–2.5% of all vaginal deliveries rapid stool transport. Patients with Crohn’s disease, (Sultan et al 1999). Risk factors are primiparous women, ulcerative colitis and diseases of other intestinal disor- large birth weight and instrumental deliveries, espe- ders have a higher incidence of fecal incontinence (Leigh cially when forceps are used. Most sphincter injuries are & Turnberg 1982). Diabetes mellitus, multiple sclerosis, surgically reconstructed immediately after delivery. Parkinson’s disease, stroke and spinal cord injury may However, more than one-third of all patients with cause diarrhoea or constipation, which trigger inconti- sphincter disruption develop symptoms of fecal incon- nence (Wald 1995). Surgical procedures of the anal canal tinence despite primary repair (Gjessing et al 1998). The such as lateral internal sphincterotomy, anal dilatation physical postpartum examination underestimates the and fistulotomy may also result in fecal incontinence frequency of sphincter disruption. Many women live on (Lindsey et al 2004). In addition, certain congenital with occult defects causing fecal incontinence or predis- anomalies are associated with continued fecal inconti- posing to fecal incontinence later in life. nence despite surgical corrections. Irritable bowel syndrome is also a risk factor for As there are no high-quality data based on random- developing fecal incontinence. It tends to be more ized clinical trials (RCTs) for any risk factors for fecal common among women and is correlated to postpar- incontinence there is a need for prospective epidemio- tum fecal incontinence (Drossman 1989). In addition, logical studies to determine prevalence and aetiology. young adult women are probably more active in seeking medical treatment and more willing to report symptoms PATHOPHYSIOLOGY than men (Nelson et al 1995). There seems to be a re- ferral bias in the reporting of symptoms of fecal Passage of rectal contents occurs when the pressure in incontinence. the rectum overcomes the pressure in the anal canal. Incontinence results when the normal anatomy or phys- Studies have shown that the prevalence of fecal iology that maintains the structure and function of the incontinence among the elderly in institutions is extraor- anorectal unit is impaired. Fecal incontinence is rarely dinarily high. In populations of long-term hospitalized related to only one single factor. Rao & Patel (1997) patients and patients in nursing homes the prevalence found more than one pathogenic abnormality in over is close to 50% (Borrie & Davidson 1992, Nelson et al 80% of patients; there seems to be a cumulative multi- 1998). Fecal incontinence is in fact often the main reason factorial process leading to fecal incontinence. for nursing home admissions. Long-term hospitalized patients have in general poorer health status and often The development of fecal incontinence occurs by suffer from physical disabilities; both related to fecal three mechanisms: incontinence. Patients who are in need of physical help either to get to the toilet or evacuate stool must alter • mechanical weakening and disruption; their normal bowel habits. On occasions they have to • neuropathy; or postpone toilet visits due to lack of help at desired • intestinal disorders. moments of defecation. Being unable to follow their own toilet habits may contribute to fecal incontinence. The anal sphincter consists of two muscles: the inter- In addition they often have other medical problems and nal (IAS) and external anal sphincter (EAS). The smooth

Fecal incontinence 307 IAS muscle contributes to about 60–80% of anal pres- may develop fecal incontinence. This mechanism is seen sure at rest. The striated EAS also contributes to the in patients with colitis or radiation proctitis. Continence pressure at rest by a constant tonus, which is character- mechanisms are designed anatomically and physiologi- istic of the striated muscles of the pelvic floor. The EAS cally to eliminate formed stool. If these mechanisms are controls voluntary anal continence. impaired the anorectum and sphincter muscles become stressed. An overflow may produce urgency and In general, passive incontinence is associated with incontinence. IAS dysfunction whereas urge incontinence is associ- ated with EAS dysfunction. Often there is a combined Constipation may also lead to fecal incontinence, in injury and the symptoms overlap. Obstetric trauma is particular an urge incontinence of the overflow type. the most common cause of anal sphincter disruption The mechanism is decreased anorectal sensation (Kamm 1994). Many patients with sphincter injury may and reduced sphincter pressure (Wrenn 1989). Consti- be asymptomatic for a long period of time after delivery pation is associated with repeated straining to discharge and first become incontinent at menopause. This dem- rectal contents. Lasting many years, constipation may onstrates that the cause is multifactorial. An age-related lead to descent of the pelvic floor, damage to the EAS change and weakening of the pelvic floor may predis- due to repeated stretch injury, and progressive denerva- pose to fecal incontinence (Nygaard et al 1997). It is a tion of the muscles (Lubowsky et al 1988). Whether this common opinion that ageing causes a physiological causes fecal incontinence depends on the general state decrease in sphincter pressure. of the pelvic floor and strength of the sphincter muscles. The structural condition of the pelvic floor muscles is important in maintaining continence. The EAS is on The pathophysiology of fecal incontinence is complex the posterior side of the rectum followed proximally by and multifactorial. Clinicians should consider a full ano- the medial fibres of the pubococcygeus muscle. This rectal investigation of adult patients before treating it. posterior muscle sling is called puborectalis. The This is especially important before surgical treatment. puborectalis muscle is crucial in maintaining the ano- Physical investigation often reveals the aetiology. Ano- rectal angle. The axis of the anus is at rest about 90º to rectal ultrasound and endoscopy are the most vital the axis of the rectum. An injury to or weakening of the complementary tools in the physical examination. muscles of the pelvic floor may open the anorectal angle PNTML and anal manometry should be considered but and an obtuse anorectal angle may impair continence. give less clinical information. The significance of the anorectal angle in fecal conti- nence is not entirely known (Womack et al 1988). CONSERVATIVE TREATMENT The pudendal nerves are the main nerves of the ano- Numerous medical conditions may cause fecal inconti- rectum and the EAS. They arise from the sacral nerves nence. Muscle injuries to the anal sphincter complex S2–S4 and serve both sensory and motor functions. An caused by childbirth, anorectal surgery, anorectal injury to the pudendal nerve impairs innervation of trauma, inflammatory processes or tumours are typical the anorectum and perineum, causes weakening of the causes of disruption of the muscles of the anal canal. sphincter muscle, and may result in passive inconti- Neurological conditions causing degeneration of the nence. An injured pudendal nerve causes a block in the pelvic floor muscles and the sphincter complex may be rectoanal contractile reflex. This reflex is vital in inhibit- caused by childbirth, spinal cord injuries or congenital ing discharge of rectal contents during bowel move- abnormalities such as spina bifida or myelomeningo- ment. Rectal distension and a decrease in rectoanal cele. Neurological conditions such as dementia, multiple pressure initiate a contractile response of the EAS medi- sclerosis and brain tumours may lead to general dys- ated by the pudendal nerve. Neuropathy following function of the pelvic floor, consequently affecting fecal neurological diseases, spinal cord injury, surgery or continence. Diarrhoea and constipation occasionally excessive straining results in altered bowel control for cause fecal incontinence; in such cases it is obvious that the same reason. Intact sensation provides warning of the goal of the treatment must be treating the diarrhoea imminent defecation and discriminates between flatus, or constipation and not the pelvic floor. liquid and solid stool. The primary treatment for fecal incontinence is Consistency and volume of stool are important in the conservative. The treatment has to be multifactorial. pathophysiology of fecal incontinence. In healthy indi- Strengthening of the pelvic floor muscles, increasing viduals the colon absorbs liquid and passes only one- sensibility of the rectal ampulla, keeping the rectal tenth of its contents further to the rectum. The rectum ampulla empty and finally changing the consistence of functions as a reservoir of stool. It can obtain large quan- the stool are factors that may lead to improved fecal tities without increasing its pressure. Impaired compli- ance of the rectum reduces this capacity and patients

308 PELVIC FLOOR DYSFUNCTION AND EVIDENCE-BASED PHYSIOTHERAPY continence. The aim of the treatment should be to dimin- Rothelbarth et al 2000). Whether biofeedback and pelvic ish the frequency of incontinence episodes and to change floor exercises are profitable additional therapies for the quality of the stool; gas incontinence and soiling is improving the long-term results is still uncertain. not as distressing as incontinence of loose or solid Unpublished data show promising results. stool. Severe incontinence due to spinal cord injuries or A systematic review of RCTs assessing the effect of other neurological disorders may be helped with a biofeedback and physical therapy modalities in general colostomy, which has been shown to improve quality of to treat fecal incontinence is given on p. 310. life for patients (Kelly et al 1999, Rosito et al 2002). MEDICAL TREATMENT Sacral nerve stimulation is an option for patients with functional but not anatomical deficits of the anal Mild incontinence is often cured by dietary changes, sphincter muscle. An electrode is placed through the avoiding food that may cause diarrhoea. This is often sacral foramen to stimulate the sacral nerve segment S3. combined with bowel habit training. Bulking agents The results so far are promising with a high success rate increase the volume of the stool and improve stool evac- and little morbidity. The long-term results for this treat- uation, resulting in an empty rectal ampulla, conse- ment are still unknown (Jarret et al 2004). quently improving continence. This can also be achieved using routine enemas. Loperamide is an antidiarrhoeal CLINICAL RECOMMENDATIONS drug and a useful measure for reducing incontinence (Madoff et al 2004). Fecal incontinence is an embarrassing and often debili- tating disorder. Its prevalence increases with age and it SURGERY is more frequent among women. Obstetric sphincter rupture is the most common cause in the young female Surgical treatment is the treatment of choice for severe adult population. Knowledge of the treatment measures fecal incontinence. An established injury to the anal available is not widely known among health care takers sphincter is treated with an overlapping sphinctero- or by patients. Therefore many patients remain untreated plasty. The success rates for this type of surgery vary though most conditions are treatable. Conservative between 60 and 80% (Wexner & Marchetti 1991). treatment including dietary restrictions and medical However, several studies have shown that the results treatment are often successful for mild incontinence. after sphincteroplasty deteriorate substantially over The role of biofeedback treatment and pelvic floor exer- time (Halverson & Hull, 2002, Malouf et al 2000, cises remains unclear. Surgery is the treatment of choice for severe incontinence. REFERENCES Borrie M J, Davidson H A 1992 Incontinence in institutions: cost and Johanson J F, Lafferty J 1996 Epidemiology of fecal incontinence: the contributing factors. CMAJ 147:322–328 silent affliction. The American Journal of Gastroenterology 91:33–36 Bravo Gutierrez A, Madoff R D, Lowry A C et al 2004 Long-term results of anterior sphincteroplasty. Diseases of the Colon and Jorge J M, Wexner S D 1993 Etiology and management of Rectum 47(5):727–732 fecal incontinence. Diseases of the Colon and Rectum 36: 77–97 Browning G, Parks A 1983 Postnatal repair for the neurological faecal incontinence: correlation of clinical results and anal canal Kamm M A 1994 Obstetric damage and faecal incontinence. Lancet pressure. The British Journal of Surgery 70:101–104 344:730–733 Drossman D A 1989 What can be done to control incontinence Kantalar J S, Howell S, Talley N J 2002 Prevalence of faecal associated with the irritable bowel syndrome? The American incontinence and associated risk factors; an underdiagnosed Journal of Gastroenterology 84:355–357 problem in the Australian community? The Medical Journal of Australia 176:54–57 Gjessing H, Backe B, Sahlin Y 1998 Third degree obstetric tears; outcome after primary delivery. Acta Obstetricia et Gynecologica Kelly S R, Shashidharan M, Borwell B et al 1999 The role of Scandinavica 77(7):736–740 intestinal stoma in patients with spinal cord injury. Spinal Cord 37:211–214 Halverson A L, Hull T L 2002 Long-term outcome of overlapping anal sphincter repair. Diseases of the Colon and Rectum 45:345– Leigh R J, Turnberg L A 1982 Faecal incontinence: the unvoiced 348 symptom. Lancet 1:1349–1351 Jarrett M E, Mowatt G, Glazener C M et al 2004 Systemic review of Lindsey, I, Jones O M, Smilgin-Humphreys M M et al 2004 Patterns sacral nerve stimulation for faecal incontinence and constipation. of fecal incontinence after anal surgery. Diseases of the Colon The British Journal of Surgery 91:1559–1569 and Rectum 47(10):1643–1649

Fecal incontinence 309 Lubowsky D Z, Swash M, Nicholls R J et al 1988 Increase in PHYSICAL THERAPY FOR pudendal nerve terminal motor latency with defaecation FECAL INCONTINENCE straining. The British Journal of Surgery 75(11):1095–1097 Siv Mørkved Macmillan A K, Merrie A E, Marshall R J et al 2004 The prevalence of fecal incontinence in community-dwelling adults: a systematic The treatment of fecal incontinence by physical thera- review of the literature. Diseases of the Colon and Rectum pists has mainly focused on activation and strengthen- 47(8):1341–1349 ing of the pelvic floor muscles (PFM). Different interventions have been used; PFM training (PFMT) Madoff R D, Parker S C, Varma M G et al 2004 Faecal incontinence with and without the use of biofeedback, and electrical in adults. Lancet 364:621–632 stimulation (ES). Similar treatment modalities have been conducted by nurses, and it is therefore difficult to dis- Malouf, A J, Norton C S, Engel A F et al 2000 Long term results of tinguish between studies including treatment by nurses overlapping anterior anal-sphincter repair for obstetric trauma. and by physical therapists. Two Cochrane reviews Lancet 355:260–265 addressing conservative treatment of fecal incontinence (Hosker et al 2000, Norton et al 2000), and one address- Nelson R, Furner S, Jesudason V et al 1998 Fecal incontinence in ing physical therapies for prevention of urinary and Wisconsin nursing homes: prevalence and associations. Diseases fecal incontinence in adults (Hay-Smith et al 2002) have of the Colon and Rectum 41(10):1226–2129 been published. All three reviews conclude that the limited numbers of trials do not allow a reliable assess- Nelson R, Norton N, Cautley E et al 1995 Community-based ment of the possible role of the different interventions prevalence of anal incontinence. JAMA 274(7):559–561 in the prevention and treatment of fecal incontinence. However, several new studies have been published. Nygaard I E, Rao S S, Dawson J D 1997 Anal incontinence after anal Therefore a literature review was undertaken to ascer- sphincter disruption: a 30-year retrospective cohort study. tain whether PFMT with and without the use of biofeed- Obstetrics and Gynecology 89(6):896–901 back or ES have merit as conservative treatments for fecal incontinence. Pescatori M, Anastasio G, Bottini C et al 1993 New grading system and scoring for anal incontinence. Evaluation of 335 patients. LITERATURE SEARCH STRATEGY Diseases of the Colon and Rectum 36:482–487 A search of the following computerized databases from Porell F, Caro F G, Silva A et al 1998 A longitudinal analysis of 1999 to 2005 was undertaken: Medline, CINAHL, nursing home outcomes. Health Services Research 33(4 pt EMBASE, The Cochrane Library Database. The search 1):835–865 strategy recommended by the International Continence Society was used. A manual search was undertaken of Rao S S C, Patel R S 1997 How useful are manometric tests of identified manuscripts reporting on research studies anorectal function in the management of defecation disorders? gained from the references of this literature. Only ran- The American Journal of Gastroenterology 92:469–475 domized or quasi-randomized trials with sufficient data to allow statistical analyses were included. A study was Rockwood T H, Church J M, Fleshman J W et al 2000 Fecal included if the trial reported the results of physical incontinence quality of life scale. Diseases of the Colon and therapy (PFMT with or without the use of additional Rectum 43:9–17 biofeedback and/or ES) for adults with fecal inconti- nence and where symptoms of fecal incontinence was a Rockwood T H, Church J M, Fleshman J W et al 1999 Patient and predefined outcome measure. We found eight studies surgeon ranking of the severity of symptoms associated with meeting the inclusion criteria (Table 9.20). In addition, fecal incontinence. Diseases of the Colon and Rectum 42:1525– two studies with different clinically relevant interven- 1532 tions, but not totally meeting the inclusion criteria are discussed below (Miner et al 1990, Schnelle et al 2002). Rosito O, Nino-Murcia M, Wolfe V A et al 2002 The effects of colostomy on the quality of life in patients with spinal cord METHODOLOGICAL QUALITY injury: a retrospective analysis. The Journal of Spinal Cord Medicine 25(3):174–183 Methodological rigor was assessed from a hierarchy of evidence following the PEDro method score. The Rothelbarth J, Bemelman W A, Meijerink W J et al 2000 Long-term results of anterior anal sphincter repair for fecal incontinence due to obstetric injury. Digestive Surgery 17(4):390–394 Rozmovits L, Ziebland S 2004 Expressions of loss of the narratives of people with colocectal cancer. Qualitative Health Research 14:187–203 Sultan A H, Monga A K, Kumar D et al 1999 Primary repair of obstetric anal sphincter rupture using the overlap technique. British Journal of Obstetrics and Gynaecology 106:318–323 Tariq S H, Morley J E, Prather C M 2003 Fecal incontinence in the elderly patient. The American Journal of Medicine 115:217–227 Vaizey C J, Carapeti E, Cahill J A et al 1999 Prospective comparison of faecal incontinence grading systems. Gut 44:77–80 Wald A 1995 Systemic diseases causing disorders of defecation and continence. Seminars in Gastrointestinal Disease 6:194–202 Wexner S D, Marchetti G 1991 The role of sphincteroplasty for fecal incontinence reevaluated: a prospective physiologic and functional review. Diseases of the Colon and Rectum 34:22–30 Whitehead W E, Burgio KL, Engel BT 1985 Biofeedback treatment of fecal incontinence in geriatric patients. Journal of the American Geriatrics Society 33:320–324 Womack N R, Morrison J F, Williams N S 1988 Prospective study of effects of postnatal repair in neurogenic faecal incontinence. The British Journal of Surgery 75:48–52 World Health Organization 2005 The international classification of diseases. World Health Organization, Geneva Wrenn K 1989 Fecal impaction. The New England Journal of Medicine 321:658–662

310 PELVIC FLOOR DYSFUNCTION AND EVIDENCE-BASED PHYSIOTHERAPY Table 9.20 Randomized controlled trials on conservative treatment (PFMT with or without biofeedback, ES) in the treatment of fecal incontinence Study Fynes et al 1999 Design 2-arm RCT: vaginal BF + home PFMT, anal BF + ES + home PFMT n 40 women, mean age 32 (range 18–48) Diagnosis FI caused by obstetric anal sphincter injury Training protocol 1. Vaginal BF: 12 weeks with one weekly 30-min session (20 short max contractions of 6–8 s,10 s rest between + long contractions 30 s) + home training (standard Kegel PFMT–instructions not reported). 2. Anal BF: 12 weeks with one weekly session of audiovisual EMG feedback and ES + home training (standard Kegel PFMT–instructions not reported) Drop-out Adherence 1/40 No ITT analysis Adherence not reported Results After the 12-week intervention: sign. difference in favour of the group training with anal BF + ES in the number of people who became asymptomatic (OR 4.54 95% CI 1.30 to 1.83) or improved in their continence status (OR 12.38 95% 2.67 to 57.46) Study Glazener et al 2001 and 2005 Design 2-arm RCT: advice on PFMT + visits by nurse (n = 371), standard care (n = 376) n 747 women with urinary incontinence 3 months postnatally, at three centres Diagnosis Self-reported symptoms of FI 3 months postnatally Training protocol Advice on PFMT at 5, 7, and 9 months after delivery (8–10 sessions each day of 80–100 fast and slow contractions + bladder training if appropriate Drop-out Adherence Lost to follow-up 12 months: 25% in TG, 35% in CG 6 years: 29% in TG, 33% in CG Adherence reported ITT analysis Results FI at baseline: TG 57/371 (16%), CG 54/376 (15%) FI at 12 months postnatally: TG 12/273 (4%) CG 25/237 (10%) p = 0.012 (sign) FI at 6-year follow-up: TG 32/261 (12%), CG 32/248 (13%) NS Study Norton et al 2003 Design 4-arm RCT: standard care (advice) (n = 29), advice + instruction on sphincter exercises + home training (n = 32), hospital-based computer-assisted sphincter pressure BF (n = 44), hospital biofeedback + use of a home EMG BF (n = 35) n 171 patients (male/female) with FI at a specialized colorectal hospital, mean age 56 years (range 26–85), 1-year follow-up 106/160 Diagnosis Any self-reported symptom of FI Training protocol 1. Standard care (advice) 2. Advice + instruction on sphincter exercises + home training: 50 maximal voluntary sustained sphincter contractions and 50 fast-twitch contractions per day 3. Hospital-based computer-assisted sphincter pressure BF to improve rectal sensitivity and muscle strength and endurance 4. Hospital BF + use of a home intra-anal EMG BF device. Median five sessions (1–9) over a period of 3–6 months

Fecal incontinence 311 Table 9.20 Randomized controlled trials on conservative treatment (PFMT with or without biofeedback, ES) in the treatment of fecal incontinence—cont’d Drop-out Adherence 9.4% drop-out 5 withdrawal, 10 did not return questionnaires Adherence not reported 34% did not attend 1-year follow-up Results Immediately after the intervention period: NS difference between groups in symptom change or QoL (SF-36 and unpublished disease specific) Combination of groups: 60% reduction in FI (sign) 4.6% cured QoL sign improved in all domains 1-year follow-up: NS difference between groups Combination of groups: virtually all parameters remained sign. improved from pre-treatment values Study Solomon et al 2003 Design 3-arm RCT: BF with anal manometry (n = 39), BF with transanal ultrasound (n = 40), PFMT with feedback from digital examination (n =41) n 120 patients (male/female) with mild to moderate FI Diagnosis Self-reported symptoms of mild to moderate FI with at least mild neuropathy and no anatomical defect in the external sphincter Training protocol Sessions of 30 min once a month in 5 months Home exercises twice daily: 10 sessions of 10 × 5 s sphincter contractions Drop-out Adherence 15% drop-out Adherence reported ITT analysis Results NS difference between groups in any outcome measure Combination of groups: 70% improvement in symptom severity (sign.), 69% improvement in QoL (direct questioning of objectives) (sign.) Study Davis et al 2004 Design 2-arm RCT: sphincter repair (n = 17), sphincter repair + BF (n = 14) n 43 women with FI referred to a colorectal unit undergoing sphincter repair operation, mean age 60.48 (11.92) Diagnosis Persistent leakage of liquid or solid stool over at least the previous 12 months Training protocol Sphincter repair + anal BF starting 3 months after surgery. 1 h/week for 6 weeks (5 series of maximal long contractions 10 s, submaximal contractions 5 s and series of fast contractions) + daily home training twice daily and in functional situations Drop-out Adherence 5 withdrawals 2 excluded from analyses Adherence not reported Results At 6 and 12 months after surgery: NS difference in improved FI between groups (93% in BF group, 65% in CG) At 6 months one patient in each group achieved complete continence Lower embarrassment QoL (disease-specific) score in BF group Improvement in mean resting and squeeze pressures in BF group at 6 months and still above preoperative levels at 12 months, NS In CG mean pressures reduced sign. between 6 and 12 months

312 PELVIC FLOOR DYSFUNCTION AND EVIDENCE-BASED PHYSIOTHERAPY Table 9.20 Randomized controlled trials on conservative treatment (PFMT with or without biofeedback, ES) in the treatment of fecal incontinence—cont’d Study Mahony et al 2004 Design 2-arm RCT: intra-anal BF + home exercises daily (n = 26), intra-anal BF + ES + home exercises daily (n = 28) n 60 women with symptoms of FI at 12 weeks after vaginal delivery, mean age 1. 35 (23–39) 2. 32 (22–42) Diagnosis Symptoms of impaired fecal continence Training protocol 12 week intervention: 1. Intra-anal BF. 10 min: 3 rapid maximal contractions in 5 s and rest 8 s alternating with slow contractions of 5 s and 8 s rest 2. Intra-anal BF + intra-anal neuromuscular electrical stimulation. Standard frequency of 35 Hz with 20% ramp modulation time. 20 min with 5 s stimulation and 8 s rest. Intensity that elicited external anal sphincter contractions Drop-out Adherence 10% drop-out Adherence reported Results Immediately after the intervention period: NS difference between groups in symptoms of FI and other outcome measures Combination of groups (sign. change): improvement in FI 85%, cure FI 26%, improvement in anal squeeze pressure improvement QoL (disease-specific FIQL) Study Österberg et al 2004 Design 2-arm RCT: anterior levatorplasty, anal plug ES of the pelvic floor n 59/70 male and female, median age 68 (range 52–80), median age 64 (range 43–81) Diagnosis Incontinence of idiopatic (neurogenic) origin, persisting after dietary advice Training protocol Levatorplasty, median hospital stay 3 (range 2–7) days Anal plug ES median 4 (range 2–7) weeks (12 sessions of 20 min). MS210, frequency was 25 Hz, duration 1.5 s, with pulse-train interval of 3 s Drop-out Adherence 11 drop-outs Adherence not reported No ITT analysis Results At 3 months: sign. higher proportion of patients with improved Miller’s incontinence score, and physical and social handicap in the levatorplasty group At 12 months: NS difference in incontinence score, sign. difference in physical and social handicap At 24 months: NS difference in incontinence score, sign. difference in physical and social handicap NS improvement in objective indices of sphincter function (manometric evaluation) BF, biofeedback; CG, control group; CI, confidence interval, ES, electrical stimulation; FI, fecal incontinence; ITT, intention to treat; NS, not statistically significant; OR, odds ratio; PFMT, pelvic floor muscle training; QoL, quality of life; RCT, randomized clinical trial; TG, training group; Sign, statistically significant.

Fecal incontinence 313 methodological quality based on PEDro method score reducing fecal incontinence (Fynes et al 1999). However, varies between 5/10 and 8/10. This reflects a fairly the PFMT protocols in the two groups were not similar. good quality, accepting that the two criteria related to It is therefore questionable if the difference in outcome blinding of therapist and patient are almost impossible is attributable to ES and the placement of the biofeed- to meet in this kind of trial (Table 9.21). back advice. The other study showed that fecal inconti- nence was less common in postpartum women following EFFECT SIZE a PFMT programme than in women randomized to standard care (Glazener et al 2001). Only women with It is difficult to compare effect size due to different study postnatal urinary incontinence were included, and fecal populations and different outcome measures in all incontinence was a secondary outcome measure. included studies. All interventions used in the presented studies have an effect on reduction of symptoms of fecal CLINICAL SIGNIFICANCE incontinence. Most studies measure self-reported symp- toms (see Table 9.20), and distinctions between incon- All studies reported clinically significant effects of the tinence of gas, fluid or solid stool are not made. interventions, addressing a significant reduction in Nevertheless, no statistically significant differences symptoms or episodes of fecal incontinence after inter- between interventions have been found, except for two vention. No adverse effects of the interventions were studies. In one study a combination of anal biofeedback reported. However, no specific intervention can yet be and ES was more effective than vaginal biofeedback in recommended as preferable. Table 9.21 PEDro quality score of RCTs in systematic review E – Eligibility criteria specified 1 – Subjects randomly allocated to groups 2 – Allocation concealed 3 – Groups similar at baseline 4 – Subjects blinded 5 – Therapist administering treatment blinded 6 – Assessors blinded 7 – Measures of key outcomes obtained from over 85% of subjects 8 – Data analysed by intention to treat 9 – Comparison between groups conducted 10 – Point measures and measures of variability provided Study E 1 2 3 4 5 6 7 8 9 10 Total score Fynes et al 1999 ++−+−−++−++ 6/10 Glazener et al 2001 & 2005 + + + + − − − − + + + 6/10 Norton et al 2003 ++++−−−++++ 7/10 Solomon et al 2003 ++++−−+++++ 8/10 Davis et al 2004 ++++−−+++++ 8/10 Mahony et al 2004 ++++−−++−++ 7/10 Österberg et al 2004 ++? +−−−+−++ 5/10 +, criterion is clearly satisfied; −, criterion is not satisfied; ?, not clear if the criterion was satisfied. Total score is determined by counting the number of criteria that are satisfied, except that E (eligibility criteria specified) is not used to generate the total score. Total scores are out of 10.

314 PELVIC FLOOR DYSFUNCTION AND EVIDENCE-BASED PHYSICAL THERAPY TYPE OF INTERVENTION a 6-year follow-up (Glazener et al 2005). The effects of the intervention seem to be still present at the 1 year In all studies the interventions included PFMT, but fol- follow-up studies, but not in the 6-year follow-up lowing several different training protocols. The studies study. compared PFMT with (Davis et al 2004, Fynes et al 1999, Mahony et al 2004, Norton et al 2003) or without RECOMMENDATIONS BASED (Glazener et al 2001, Mahony et al 2004, Norton et al ON EVIDENCE 2003) the use of biofeedback or ES (Fynes et al 1999, Mahony et al 2004). In two studies (Glazener et al 2001, According to the results of the present review PFMT Norton et al 2003) a control group received standard with and without biofeedback and also ES seem to be care (advise), and in another study (Österberg et al 2004) effective in reducing fecal incontinence in different the effect of ES was compared to levatorplasty. All bio- study populations. However, the results of one trial feedback studies, except one, included anal biofeedback. showed that exercises and biofeedback did not enhance Anal ES was also used. the effect of standard nursing support and advice (diet, fluids, techniques to improve evacuation, a bowel train- In a controlled study by Miner et al (1990) (not ing programme, titration of dose of anti-diarrhoeal meeting the inclusion criteria and not included in the medication if previously prescribed, and practical man- table) active sensory retraining reduced the sensory agement). These results indicate that the reported ben- threshold, corrected any sensory delay, and reduced the eficial effects of other interventions may be associated frequency of incontinence. In another study by Schnelle with the relationship with the therapist and advice et al (2002) (not meeting the inclusion criteria and not given. It is open to discussion whether these results may included in the table) an intervention including inconti- be generalized to other study populations with different nence care and general exercises resulted in reduced underlying pathophysiology. frequency of fecal incontinence in patients in a nursing home. Another aspect is that the training protocols used in several studies do not follow recommendations FREQUENCY AND DURATION from exercise science (American College of Sports OF TRAINING Medicine 1990), highlighting intensity and frequency of training. Nevertheless, PFMT with and without In the studies including PFMT the frequency and dura- the use of biofeedback has been shown to be effective tion varied from weekly sessions for 6 weeks (Davis et in several studies. Anal biofeedback may be more al 2004) to 1–9 sessions over a period of 3–6 months effective than vaginal biofeedback. There is still a (Norton et al 2003). Additional daily home training was question whether biofeedback has an additional effect emphasized in most studies. Both short and long con- compared to PFMT without biofeedback. Based on the tractions of the PFM were parts of the training protocols. current knowledge no first-choice treatment can be However, the duration of the contractions classified as determined. fast- and slow-twitch contractions differed between studies. The rationale behind the training protocols was Both in clinical practice and in research, distinctions poorly described in most studies. In addition, there was should be made between incontinence of gas, fluid or a lack of assessment of adherence to the training proto- solid stool. col in several publications. This fact makes it difficult to discuss the real effect of the intervention. Clinicians have to take into account that the pathophysiology of fecal incontinence is complex and SHORT- AND LONG-TERM EFFECTS multifactorial. Thus, interventions should most likely be multifactorial, aiming at reducing the frequency of Three studies reported short-term effects (effect imme- incontinence episodes, improving rectal sensibility diately after cessation of the training protocol) (Fynes and changing the quality of the stool. To enhance the et al 1999, Glazener et al 2001, Mahony et al 2004), and quality of the PFMT protocols recommendations for two studies reported longer term effects (9–12 months strength training from exercise science should be after cessation of the training protocol) (Davis et al 2004, applied. Norton et al 2003), while one study reported effects from There is a need for further long-term follow-up studies with improved experimental design and an adequate sample size that allow meaningful analysis. In addition, the intervention used to treat fecal inconti- nence should be of the highest quality related to the aims of the intervention.

Fecal incontinence 315 REFERENCES American College of Sports Medicine 1990 Position stand. The with intra-anal electrical stimulation of the anal sphincter in the recommended quantity and quality of exercise for developing early treatment of postpartum fecal incontinence. American and maintaining cardiorespiratory and muscular fitness in Journal of Obstetrics and Gynecology 191:885–890 healthy adults. Medical Science in Sports and Exercise 22:265– Miner P B, Donnelly T C, Read N W 1990 Investigation of mode of 274 action of biofeedback in treatment of fecal ioncontinence. Digestive Diseases and Sciences 35:1291–1298 Davis K J, Kumar D, Poloniecki 2004 Adjuvant biofeedback Norton C, Hosker G, Brazzelli M 2000 Effectiveness of biofeedback following anal sphincter repair: a randomized study. Alimentary and/or sphincter exercises for the treatment of faecal Pharmacology & Therapeutics 20:539–549 incontinence in adults. Cochrane Database of Systematic Reviews 2:CD002111 Fynes M M, Marshall K, Cassidy M et al 1999 A prospective, Norton C, Chelvanayagam S, Wilson-Barnett J et al 2003 randomized study comparing the effect of augmented Randomized controlled trial of biofeedback for fecal biofeedback with sensory biofeedback alone on fecal incontinence. Gastroenterology 125:1320–1329 incontinence after obstetric trauma. Diseases of the Colon & Solomon M J, Pager C K, Rex J et al 2003 Randomized controlled Rectum 42:753–761 trial of biofeedback with anal manometry, transanal ultrasound, or pelvic floor retraining with digital guidance alone in the Glazener C M A, Herbison G P, Wilson P D et al 2001 Conservative treatment of mild to moderate fecal incontinence. Diseases of the management of persistent postnatal urinary and faecal Colon and Rectum 46:703–710 incontinence: randomised controlled trial. BMJ 323:1–5 Schnelle J F, Alessi C A, Simmons S F et al 2002 Translating clinical research into practice: a randomized controlled trial of exercise Glazener C M A, Herbison G P, MacArthur C et al 2005 and incontinence care with nursing home residents. The Journal Randomised controlled trial of conservative management of of the American Geriatric Society 50:1476–1483 postnatal urinary and faecal incontinence; six year follow up. Österberg A, Edebol Eeg-Olofsson K, Hållden M et al 2004 BMJ 330:337–339 Randomized clinical trial comparing conservative and surgical treatment of neurogenic faecal incontinence. British Journal of Hay-Smith J, Herbison P, Mørkved S 2002 Physical therapies for Surgery 91:1131–1137 prevention of urinary and faecal incontinence in adults. Cochrane Database of Systematic Reviews 2:CD003191 Hosker G, Norton C, Brazzelli M 2000 Electrical stimulation for faecal incontinence in adults. Cochrane Database of Systematic Reviews 2:CD001310 Mahony R T, Malone P A, Nalty J et al 2004 Randomized clinical trial of intra-anal electromyographic biofeedback physiotherapy

317 Chapter 10 Evidence for pelvic floor physical therapy for urinary incontinence during pregnancy and after childbirth Siv Mørkved CHAPTER CONTENTS Recommendations based on evidence 326 Clinical recommendations 326 Urinary incontinence during pregnancy and after childbirth 318 Evidence for pelvic floor physical therapy for urinary incontinence after delivery 327 Definitions, classifications and prevalence 318 Aetiology 318 Literature search strategy 327 Pathophysiology 319 Methodological quality 327 Effect size 327 Evidence for pelvic floor physical therapy Clinical significance 327 for urinary incontinence during Type of intervention 327 pregnancy 323 Frequency and duration of training 327 Short- and long-term effects 327 Literature search strategy 323 Recommendations based on evidence 333 Methodological quality 323 Clinical recommendations 333 Effect size 325 References 334 Clinical significance 325 Type of intervention 326 Frequency and duration of training 326 Short- and long-term effects 326

318 EVIDENCE FOR PELVIC FLOOR PHYSICAL THERAPY FOR URINARY INCONTINENCE Urinary incontinence during pregnancy and after childbirth Pregnancy and delivery have been considered main shown that the prevalence of SUI increases during preg- aetiological factors in the development of urinary incon- nancy and declines after delivery (Allen et al 1990, tinence. There has been considerable debate as to Mason et al 1999, Stanton et al 1980, Thorp et al 1999, whether this is due to pregnancy itself or to the act of Viktrup et al 1992,). This indicates that the increased childbirth (MacLennan et al 2000), and the evidence is pressure from the growing uterus on the bladder may contradictory (Hunskaar et al 2002, King & Freeman cause temporary leakage during pregnancy. Conflicting 1998, Koelbl et al 2002). hypotheses have been proposed recently suggesting that pregnancy urinary incontinence is not provoked by DEFINITIONS, CLASSIFICATIONS the mere onset of pregnancy, but by increasing hormo- AND PREVALENCE nal concentrations or local tissue changes caused by hormones (Hvidman et al 2002). The pregnancy itself Definitions and classifications are given in Chapter 9. and hereditary factors might predispose more than par- Prevalence estimates of any stress urinary inconti- turition trauma in some women (Demirci et al 2001, Foldspang et al 1999, Iosif 1981a, 1982), but the exact nence (SUI) during pregnancy and after childbirth mechanisms remain uncertain. Nevertheless, the preva- varies between 6 (Stanton et al 1980) and 67% (Francis lence is higher after delivery than before gestation 1960), and 2–3 months after delivery between 3 (Viktrup (Foldspang et al 1999, Mason et al 1999, Stanton et al et al 1993) and 38% (Mørkved & Bø 1999). The variation 1980, Thorp et al 1999, Viktrup & Lose 2000). may be explained by the different populations investi- gated (nulliparous, parous), the use of different defi- Different characteristics related to the pregnant nitions of incontinence (self-report, urodynamically women have been analysed to determine risk factors of proven, according to new or old definitions from the urinary incontinence. Obesity has been mentioned as a International Continence Society), and the registration possible risk factor for postpartum SUI (Rasmussen of incontinence at different stages of pregnancy or et al 1997, Wilson et al 1996). However, results from postpartum. other studies showed no relationship between increase in body mass index during pregnancy and experience AETIOLOGY of urinary incontinence (Chiarelli & Campell 1997, Højberg et al 1999). Coughing and sneezing on a regular Most data regarding risk factors for the development basis during pregnancy increased the risk of experienc- of urinary incontinence have been derived from cross- ing incontinence (Chiarelli & Campell 1997). Initial sectional studies of volunteer and clinical subjects strength of the pelvic floor muscles (PFM) is another (Hunskaar et al 2002). Risk factors such as smoking, factor that may influence continence status during preg- obesity, menopause, restricted mobility, chronic cough, nancy (Mørkved et al 2004) and after delivery (Sampselle chronic straining for constipation and urogenital surgery et al 1998). Previous urinary incontinence is a significant have not been as rigorously studied as parity and age risk factor (Beck & Hsu 1965, Eason et al 2004, Farrell et (Hunskaar et al 2002). However, there are problems al 2001, Hvidman et al 2002), and the results of a 15-year related to reports of risk factors and causal relationships follow-up study support the view that SUI arising because on many occasions the study designs used are during pregnancy increases the risk of SUI developing not appropriate to answer such questions. in the future (Dolan et al 2003). Urinary incontinence and SUI are strongly associated The association between urinary incontinence and with vaginal childbirth in many epidemiological studies. obstetric factors as parity, mode of delivery and weight Several studies, both epidemiological and clinical, have of the baby have been addressed in several studies. Sta- tistically significant associations between any inconti- nence and a birth weight of 4000 g or greater has been

Urinary incontinence during pregnancy and after childbirth 319 observed (Højberg et al 1999, Rortveit et al 2003b), but 1990). Rupture of muscle fibres and connective tissue others have reported conflicting results (Farrell et al and over stretching of supporting ligaments and fascias 2001, Viktrup et al 1992). during pregnancy and delivery are other risk factors (Landon et al 1990, Sayer et al 1990). The first vaginal delivery seems to be a major risk for developing urinary incontinence (Burgio et al 1996, The mechanisms behind pelvic floor damage leading Højberg et al 1999, Iosif 1981a). Increased prevalence of to SUI are often divided into two broad categories: urinary incontinence has been associated with increased denervation injury and support/anatomic injury. Both parity (Mason et al 1999), and with women having more types of injury may have consequences for the role of than four children (Groutz et al 1999, Thomas et al 1980, the PFM as continence mechanisms (DeLancey 1988, Wilson et al 1996). A linear correlation has been found Sultan et al 1994a). In addition, pathological processes between increased parity and increased frequency of in the intrinsic continence mechanisms causing detrusor incontinence (Jolleys 1988, Marshall et al 1998, Nygaard instability or low urethral pressure during pregnancy 1990). In contrast, no correlation between parity and may cause the symptom of urinary incontinence urinary incontinence has also been reported, and a (Cardozo & Cutner 1997). Possible mechanisms causing higher prevalence of urinary incontinence among white perinatal urinary incontinence will be presented in more compared to black women (Burgio et al 1996). detail in the following sections. Vaginal delivery has been found to be an adverse risk Denervation injury. In several studies, manometric factor for postpartum urinary incontinence (Mason et al and neurophysiological assessments have given evi- 1999, Wilson et al 1996). No multivariate association for dence of weakness in the pelvic floor, and this weakness forceps delivery or vacuum extraction delivery, episiot- is due to partial denervation of the pelvic floor striated omy, or perineal suturing was found in a large cross- muscles (Allen et al 1990, Snooks et al 1984, 1990). In sectional study (Foldspang et al 1999), but epidural many women, pudendal neuropathy due to vaginal anesthesia has been associated with SUI (Rørtveit et al delivery persists and may become worse with time 2003b). Elective caesarean section appears to be protec- (Snooks et al 1990). However, the results of a 15 year tive, though not completely (Eason et al 2004, Farrell follow up study showed that although pelvic floor et al 2001, Mason et al 1999, Rørtveit et al 2003a, Wilson reinnervation progressed after the postnatal period, et al 1996), but confounding factors may exist. Anatomi- the absence of an adequate marker for pelvic floor cal structures (the size of the mother’s pelvis, muscles, denervation makes it of uncertain clinical significance connective tissue) may be one reason for offering some (Dolan et al 2003). It has been found that during the women caesarean section. The same anatomical charac- first year postpartum, vaginal surface electromyogra- teristics may also protect against urinary incontinence phy, pressure and palpation measurements were after delivery. reduced in primiparous women with traumatic delivery (Gunnarson & Mattiasson 2002). The difference between According to Brubaker (1998) no method of obstetric women with traumatic and non-traumatic deliveries perineal management has been demonstrated to reduce was significant at 4 and 8 months postpartum for elec- the risk for incontinence. There is therefore still a need tromyography and pressure measurements and at 8 for strategies to treat and rehabilitate pelvic floor damage months for palpation. In addition, the risk of developing related to pregnancy and delivery. symptoms from the lower urinary tract during the first year postpartum was increased in women with trau- PATHOPHYSIOLOGY matic delivery (41%) compared to women with non- traumatic delivery (25%) (Gunnarson & Mattiasson 2002). The underlying causes of lower urinary tract symptoms Women older than 30 years and with a traumatic deliv- during pregnancy remain uncertain (Cardozo & Cutner ery had more than double the risk for lower urinary 1997). Two different pathological processes may cause tract dysfunction than those under the age of 30 did the symptom of SUI in pregnancy and during the post- (Gunnarson & Mattiasson 2002). partum period (Cardozo & Cutner 1997). Vaginal deliv- ery may initiate damage to the continence mechanism Comparison of antepartum and postpartum puden- by direct injury to the PFM, damage to their motor dal nerve conduction has shown that the causative innervations, or both (Koelbl et al 2002). Additional factor of denervation acts during the period of delivery, denervations may occur with ageing, resulting in a func- and specifically during the second stage of labour, tional disability many years after the initial trauma. whereas throughout pregnancy the nerve conduction is Stress urinary incontinence after childbirth has been minimally affected (Sultan et al 1994b, Tetzschner et al explained as a consequence of peripheral nerve damage 1997). There is a relationship between denervation and (Allen & Warell 1987, Allen et al 1990, Snooks et al 1984, the period of maximal distension of the soft tissues of the birth canal, including the muscles of the pelvic floor

320 EVIDENCE FOR PELVIC FLOOR PHYSICAL THERAPY FOR URINARY INCONTINENCE (Józwik & Józwik 2001). The injury seems to be neuro- Support/anatomical injury genic rather than muscular; this may be due to the dif- (PFM/ligaments/fascias) ferences in the vulnerability of nerves and skeletal muscles to withstand distension. Nerves of the PFM can The hormonal (oestrogen, progesterone, endocrine corti- be elongated by 6–22% of their initial length before coids, relaxin) changes during pregnancy influence the damage occurs (Jünemann & Thüroff 1994). In contrast, ligaments and smooth muscles, and may lead to increased human skeletal muscles are known to sustain distension joint mobility and increased mobility in pelvic organs up to 200% of their initial length (Åstrand & Rodahl that are stabilized by ligaments (Calguneri et al 1982). 1986). AB C Fig. 10.1A–C Examples of positions for pelvic floor muscle training.

Urinary incontinence during pregnancy and after childbirth 321 Joint hypermobility has been proposed as a marker for nificantly relevant during pregnancy where connective connective tissue weakness and subsequent develop- tissue is weaker than in a non-pregnant situation (Landon ment of prolapse and genuine SUI (GSUI) (Norton et al et al 1990). Reduced tensile strength in pregnant fascia 1995). However, descriptive data from studies on preg- has been found, which may account for the development nant women do not support this proposal (Chaliha et al of SUI in pregnancy (Landon et al 1990). Normally, the 1999, Farrell et al 2001, Reilly et al 2002). Nevertheless, fascia regain their previous strength after delivery, but in weak pelvic floor collagen may be important in the cases of permanent SUI the occurrence of overstretching genesis of GSUI (Keane et al 1997) and this may be sig- may cause irreversible damage. AB Fig. 10.2A–C Examples of positions for pelvic floor muscle C training.

322 EVIDENCE FOR PELVIC FLOOR PHYSICAL THERAPY FOR URINARY INCONTINENCE Histomorphological studies of the PFM in female Reduced PFM strength in the first week after deliv- cadavers have shown changes in the PFM related to ery was found in women after they gave birth vaginally, vaginal childbirth and age (Dimpfl et al 1998). Rupture but not in women after caesarean delivery (Peschers of muscle fibres and connective tissue because of over- et al 1997); 6–10 weeks later, palpation and vesical neck stretching during vaginal delivery has been extensively elevation measured by perineal ultrasound did not studied (Landon et al 1990, Sayer et al 1990, Sultan et al show any significant differences to antepartum values. 1993), and SUI may be due to a combination of muscular However, perineometric intravaginal pressure meas- and fascial damage (Sayer et al 1990). urements remained significantly lower in primiparous women, but not in multiparous women regardless of Stretching of supporting structures as a result of mode of delivery. Mørkved et al (2003) found that PFM pregnancy and delivery may lead to changes in the posi- strength (vaginal squeeze pressure) was lower after tion of the bladder neck, and damage and weakening of delivery than during pregnancy. The reduction in the urethral sphincter mechanisms. Increased bladder muscle strength was greater in a control group than in neck mobility might indicate loss of urethral support a group following an intensive pelvic floor training pro- (Cutner et al 1990). Meyer et al (1998a) studied bladder gramme during pregnancy (Mørkved et al 2003). In neck mobility and urinary sphincter function in preg- women with onset of incontinence after delivery, trans- nant and non-pregnant women. Although they found vaginal ultrasound images showed a more pronounced no significant changes in bladder neck mobility, preg- loss of volume in the striated rhabdosphincter muscle nancy resulted in decreased maximal urethral closure after delivery than in continent women (Toozs-Hobson pressure, decreased pressure transmission ratio values, et al 1997). and a backward displacement of the bladder neck. Com- pared with continent pregnant women, pregnant women Magnetic resonance imaging was used to study the with SUI also had a diminished urinary sphincter levator ani muscle recovery following vaginal delivery, function. and displacement of the perineum toward the sacrum was shown to persist for up to 6 months after vaginal Several studies have reported altered urethral support delivery (Tunn et al 1999). However, there were remark- in some women after vaginal delivery. The effects of able variations in levator ani structure changes among delivery on urinary continence mechanisms have been different individuals (Tunn et al 1999). studied by comparing nulliparous continent women to women who had normal and instrumented deliveries Other considerations (Meyer et al 1996, 1998b). Delivery induced no modifica- tions of bladder neck position at rest, but was responsi- Pregnancy and delivery introduce major anatomical ble for a lower bladder neck position during the Valsalva and physiological changes to the urinary tract that may manoeuvre in the standing position (Meyer et al 1996, result in alterations in urinary tract function, most com- 1998b). Women with previous forceps deliveries and monly manifested by development of urinary symp- women with SUI had a significantly lower bladder neck toms (Chaliha & Stanton 2002). Urodynamic studies than nulliparous continent women (Meyer et al 1996, during pregnancy and after delivery have been carried 1998b). It has been found that vesical neck mobility out to study potential causes of urinary incontinence. during Valsalva manoeuvre was increased after childbirth, and that the bladder neck was positioned A high prevalence of detrusor instability has been lower in women who had a vaginal delivery than those found during pregnancy, and the detrusor instability who had elective caesareans or were nulligravid has been shown to be significantly higher during preg- (Peschers et al 1996). In one study, women with post- nancy than after delivery (Cardozo & Cutner 1997, Nel partum SUI had significantly greater antenatal bladder et al 2001). However, in another study neither preg- neck mobility than continent women (King & Freeman nancy nor delivery resulted in any consistent effects on 1998). Results from another study reported quantifiable objective bladder function, and postpartum urodynamic differences in vesical neck mobility during a cough and measurements were not related to either obstetric or Valsalva manoeuvre in continent women, but not in neonatal variables, but were dependent on antenatal primiparous stress incontinent women (Howard et al values (Chaliha et al 1999a, b). 2000). In another study, vaginal delivery was found to affect bladder neck mobility and its position more nega- Urethral pressure changes during pregnancy and tively than caesarean section, and bladder neck mobility postpartum were reported by Iosif et al (1981b). In con- was associated with GSUI. However, the GSUI rate was tinent women there were progressive increases in not significantly different between the groups of women bladder pressure, maximum urethral closure pressure, delivered vaginally or by caesarean section (Demirci urethral pressure, functional urethral length and ure- et al 2001). thral length with increasing gestation. After delivery, the

Evidence for pelvic floor physical therapy for urinary incontinence during pregnancy 323 measurement of these variables returned to early preg- douches and salves’ to restore the PFM after birth and nancy values. A group of incontinent women had the that Saranus attempted support with the hand to exercise same increase in bladder pressure, but no similar the PFM. In addition, information was given concerning increases in maximum urethral closure pressure and observations of unusually firm perinea in South African functional urethral length (Iosif et al 1981b). Cardozo & tribes due to the practice of the midwives who made Cutner (1997) and van Geelen et al (1982) report similar women contract the PFM around their distended fingers results. In addition, differences between continent after birth (Kegel 1948). As a consequence of Kegel’s and incontinent women in the transmission of intra- (1951) studies, women in most industrialized countries abdominal pressure to the urethra during early preg- have been encouraged to engage in PFM exercise during nancy have been reported (Cardozo & Cutner 1997). pregnancy and after delivery to strengthen the pelvic These findings indicate that because of the raised bladder floor and to prevent and treat urinary incontinence. pressures that occur during pregnancy, increases in ure- Despite the lapse of some 50 years since this practice was thral variables are necessary to maintain continence. introduced, the effects of such exercises have until However, according to Homma et al (2002) urodynamic recently been only sparsely documented (Hay-Smith et measurements are prone to artefacts, and the limitations al 2002). on the accuracy and the interchangeability of study results should be kept in mind during interpretation. One Cochrane review addressing physical therapies for prevention of urinary and fecal incontinence in The PFM comprise one factor that may be a target adults (Hay-Smith et al 2002) has been published. The for intervention that aims at preventing symptoms review concluded that the limited number of trials does following injury to the pelvic floor. As early as in 1948, not allow a reliable assessment of the possible role of the American gynaecologist Arthur Kegel emphasized the different interventions in the prevention of urinary the value of PFM exercise in restoring function after incontinence. However, several new studies have childbirth. He claimed that genital relaxation after now been published. Therefore literature reviews were delivery is due to nerve injury, overstretching of muscles undertaken to ascertain if PFM training (PFMT) with and tearing of fascias and that the method of restoring and without the use of biofeedback or electrical stimula- the condition is ‘tightening’ of the PFM. Kegel (1948) tion have merit as prevention and/or treatment for reported that Hippocrates tried ‘oil injections, hot urinary incontinence. Evidence for pelvic floor physical therapy for urinary incontinence during pregnancy LITERATURE SEARCH STRATEGY additional biofeedback and/or electrical stimulation). We found three studies meeting the inclusion criteria A search of the following computerized databases (Table 10.1). from 1985 to 2005 was undertaken: Medline, CINAHL, EMBASE, The Cochrane Library Database. The search METHODOLOGICAL QUALITY strategy recommended by the International Continence Society was used. A manual search was undertaken of Methodological rigor was assessed from a hierarchy of identified manuscripts reporting on research studies evidence following the Pedro method score. The meth- gained from the references of this literature. Only con- odological quality based on Pedro method score varies trolled trials with sufficient data to allow statistical between 7 and 8 out of 10 (Table 10.2). This reflects a analyses were included; abstracts were excluded. A high quality, accepting that the two criteria related to study was included if the trial reported the results blinding of the therapist and patient are almost impos- of physical therapy (PFMT with or without the use of sible to meet in this kind of trial.

324 EVIDENCE FOR PELVIC FLOOR PHYSICAL THERAPY FOR URINARY INCONTINENCE Table 10.1 Studies assessing the effect of pelvic floor muscle exercises during pregnancy to prevent/treat urinary incontinence Study Mørkved et al 2003 Design 2-arm RCT: control (n = 144), customary information from general practitioner/midwife; intervention (n = 145), 12 weeks of intensive PFMT n n = 289 primigravid women recruited at 20 weeks gestation; some women had existing UI; three outpatient physiotherapy clinics in Trondheim, Norway Diagnosis Self-report of stress incontinence Symptom questionnaire Training protocol Control: customary information from general practitioner/midwife. Not discouraged from PFMT. Correct VPFMC checked at enrolment. Intervention: 12 weeks of intensive PFMT (in a group) led by physiotherapist, with additional daily home exercises between 20 and 36 weeks gestation. Correct VPFMC checked before training Drop-outs/adherence 10 withdrawals (6 PFMT and 4 controls) Adverse events not stated ITT analysis Results [numbers Self-reported UI at 36 weeks pregnancy and percentage Control: 74/153 (48%) (%)] Intervention: 48/148 (32%) RR (95% CI): 0.67 (0.50–0.89) p = 0.007 PFM strength (cmH2O) (mean, SD): Control: 34.4 (32.6, 37.1) Intervention: 39.9 (37.1, 42.7) p = 0.008 UI at 3 months postpartum Control: 49/153 (32%) Intervention: 29/148 (19.6%) RR (95% CI): 0.61 (0.40–0.90) p = 0.018 PFM strength (mean, SD) Control: 25.6 (23.2, 27.9) Intervention: 29.5 (26.8, 32.2) p = 0.048 Study Reilly et al 2002 Design 2-arm RCT: control (n = 129), routine antenatal care (verbal advice); intervention (n = 139), individual PFMT with physiotherapist n n = 268 primigravid women with bladder neck mobility (on ultrasound) recruited at 20 weeks gestation Single centre, England Diagnosis Self-report of stress incontinence – Symptom questionnaire Bladder neck mobility measured by ultrasound Training protocol Control: routine antenatal care (verbal advice) Intervention: individual PFMT with physiotherapist at monthly intervals from 20 weeks until delivery; three sets of 8 contractions (each held for 6 s) repeated twice daily; instructed to contract the PFM when coughing or sneezing Drop-outs/adherence Data reported for 230/268 women, 38 withdrawals or losses to follow-up 51% of the women in the control group did unsupervised PFMT Adverse events not stated ITT analysis

Evidence for pelvic floor physical therapy for urinary incontinence during pregnancy 325 Table 10.1 Studies assessing the effect of pelvic floor muscle exercises during pregnancy to prevent/treat urinary incontinence—cont’d Results [numbers SUI at 3 months’ postpartum and percentage Control: 36/110 (32.7%) (%)] Intervention: 23/120 (19.2%) RR (95% CI): 0.59 (0.37–0.92) p = 0.023 Quality of life: higher score in the exercise group p = 0.004 Pad test: no significant difference Bladder neck mobility: no significant difference PFM strength: no significant difference Study Sampselle et al 1998 Design 2-arm RCT: control (n = 38), routine care; intervention (n = 34): a tailored PFMT programme n n = 72 primigravid women recruited at 20 weeks’ gestation, mean age 27.2 (SD 5.5) Groups comparable at baseline (including incontinence severity and maximum VPFMC strength) Single centre, USA Diagnosis Self-report of stress incontinence Standing stress test Training protocol Control: routine care with no systematic review Tailored PFMT programme: beginning with muscle identification progressing to strengthening. 30 contractions per day at max or near max intensity from 20 weeks of pregnancy. Correct voluntary PFM contraction checked Drop-outs/adherence 26/72 (36%) withdrawals Unsupervised PFMT reported by 20% of control group Adverse events not stated Self-reported adherence. Partial ITT analysis Results [numbers Change in mean UI symptom score and percentage 35-week pregnancy: control 0.20, intervention −0.02, p = 0.07 (%)] 6 weeks’ postpartum: control 0.25, intervention −0.06, p = 0.03 6 months’ postpartum: control 0.15, intervention −0.11, p = 0.05 12 months’ postpartum: control 0.06, intervention −0.00, p = 0.74 PFM strength: no significant difference (low numbers) PFMT, pelvic floor muscle training; VPFMC, voluntary pelvic floor muscle contraction; UI, urinary incontinence. EFFECT SIZE CLINICAL SIGNIFICANCE Studies by Reilly et al (2002) and Mørkved et al (2003) All studies included primigravid women recruited at 20 used similar interventions and partly also similar weeks of pregnancy. One study was a pure prevention outcome measures. These two studies showed the study, including only women at risk of developing largest effect size. However, the study by Sampselle et urinary incontinence (with bladder neck mobility) and al (1998) concluded that the group performing PFMT no previous urinary incontinence. All studies reported had less urinary incontinence at 35 weeks of pregnancy clinically significant effects of the interventions, address- and 6 weeks and 6 months after delivery, but found no ing a significant reduction in symptoms or episodes of difference between groups at 12 months after delivery. urinary incontinence after intervention.

326 EVIDENCE FOR PELVIC FLOOR PHYSICAL THERAPY FOR URINARY INCONTINENCE Table 10.2 Studies assessing the effect of pelvic floor muscle exercises during pregnancy to prevent/treat urinary incontinence: PEDro quality score of RCTs in systematic review E – Eligibility criteria specified 1 – Subjects randomly allocated to groups 2 – Allocation concealed 3 – Groups similar at baseline 4 – Subjects blinded 5 – Therapist administering treatment blinded 6 – Assessors blinded 7 – Measures of key outcomes obtained from over 85% of subjects 8 – Data analysed by intention to treat 9 – Comparison between groups conducted 10 – Point measures and measures of variability provided Study E 1 2 3 4 5 6 7 8 9 0 Total score Mørkved et al + + + + − − + + + + + 8/10 2003 Reilly et al 2002 + +++− −+ + + + + 8/10 Sampselle et al + +++− − + − + + + 7/10 1998 +, criterion is clearly satisfied; −, criterion is not satisfied; ?, not clear if the criterion was satisfied. Total score is determined by counting the number of criteria that are satisfied, except that scale item one (eligibility criteria specified) is not used to generate the total score. Total scores are out of 10. TYPE OF INTERVENTION Sampselle et al (1998) reported long-term effects (12 months after cessation of the training protocol), and No adverse effects of the interventions were reported. found that the effects of the intervention were not In all three studies the interventions included PFM present at the 1 year follow-up study. strength training, with some differences regarding the RECOMMENDATIONS BASED number of contractions suggested per day. The training ON EVIDENCE protocols in the studies by Reilly et al (2002) and Mørkved et al (2003) addressed close follow-up (monthly According to the results of the present review PFMT and weekly) by a physiotherapist. during pregnancy is effective in reducing urinary incontinence during pregnancy and in the immediate FREQUENCY AND DURATION postpartum period. However, the longer term effect is OF TRAINING questionable. No adverse effect of the PFMT has been reported. A study by Salvesen & Mørkved (2004) sug- The frequency and duration of PFMT are comparable gests that PFMT during pregnancy can facilitate rather in the studies, starting at 20 weeks of gestation, with than obstruct labour. 20–30 near-maximal contractions per day during pregnancy. CLINICAL RECOMMENDATIONS SHORT- AND LONG-TERM EFFECTS • The same PFMT protocol can be used in pregnant women as recommended for SUI in Chapter 9, p. All studies reported significant short-term effects (effect 184. immediately after cessation of the training protocol).

Evidence for pelvic floor physical therapy for urinary incontinence after delivery 327 Evidence for pelvic floor physical therapy for urinary incontinence after delivery LITERATURE SEARCH STRATEGY CLINICAL SIGNIFICANCE A search of the following computerized databases from All studies, except one (Sleep & Grant 1987), reported 1985 to 2005 was undertaken: Medline, CINAHL, clinically significant effects of the interventions address- EMBASE, The Cochrane Library Database. The search ing a significant reduction in symptoms or frequency of strategy recommended by the International Continence urinary incontinence after the intervention period. No Society was used. A manual search was undertaken of adverse effects of the interventions were reported. identified manuscripts reporting on research studies gained from the references of this literature. Only con- TYPE OF INTERVENTION trolled trials with sufficient data to allow statistical analyses were included, abstracts were excluded. A In all studies the interventions included PFMT, though study was included if the trial reported the results following several different training protocols. Most of physical therapy (PFMT with or without the use of studiescomparedPFMTwithcurrent standard care, allow- additional biofeedback and/or electrical stimulation). ing self-managed PFMT but not introducing a control We found ten studies meeting the inclusion criteria intervention. Only Dumoulin et al (2004) introduced an (Table 10.3). intervention in the control group (massage), and com- pared the control intervention with two different METHODOLOGICAL QUALITY combined PFM rehabilitation interventions. The train- ing protocols in the controlled studies by Mørkved & Six studies were RCTs: two of these trials have reported Bø (1997, 2000), Meyer et al (2001), and the RCT by results from follow-up studies. One study with an addi- Dumoulin et al (2004) addressed close follow-up tional 1-year follow-up, had a matched controlled (monthly and weekly) by a physiotherapist. No adverse design, while another study had a controlled design. effects of the interventions were reported. Methodological rigour was assessed from a hierarchy of evidence following the Pedro method score. The meth- FREQUENCY AND DURATION OF TRAINING odological quality based on Pedro method score varies between 4 and 8 out of 10 (Table 10.4). This reflects a All studies involved PFMT 5 days a week or more. The variability concerning quality. However, it is important duration of the PFMT programmes varied between 4 to notice that the studies also vary concerning the inter- and 8 weeks. ventions used, and this issue is in general seldom addressed in reviews. SHORT- AND LONG-TERM EFFECTS EFFECT SIZE All studies, except one (Sleep & Grant 1987), reported significant short-term effects (effect immediately after It is difficult to compare effect size due to different study cessation of the training protocol). Mørkved & Bø (2000) populations and different outcome measures in most found that the effect of PFMT was still present 1 year included studies. All interventions, except for one (Sleep after cessation of the training programme, while & Grant 1987) used in the presented studies have Chiarelli et al (2004) and Glazener et al (2005) found no an effect on reduction in symptoms of urinary inconti- difference in urinary incontinence between groups at 1 nence immediately after cessation of the intervention. and 6 years’ follow-up, respectively. Chiarelli et al (2004) However, it seems likely that the interventions includ- reported that continued adherence to PFMT at 12 months ing close follow-up (monthly and weekly) by a physio- was predictive of urinary incontinence at that time. therapist have the best effect.

328 EVIDENCE FOR PELVIC FLOOR PHYSICAL THERAPY FOR URINARY INCONTINENCE Table 10.3 Studies assessing the effect of pelvic floor muscle exercises after delivery to prevent/treat urinary incontinence Study Chiarelli & Cockburn 2002 Design 2-arm RCT: control (n = 350), usual care; intervention (n = 370), continence promotion n 720 postnatal women following forceps or ventouse delivery, or delivered a baby ≥ 4000 g, age 15–44 Multicentre (3), Australia Diagnosis Self-report (continent or incontinent) Validated survey instrument Urinary diary (3 days) Training protocol Control: usual care Intervention: continence promotion: one contact with physiotherapist on postnatal ward and another at 8 weeks postpartum (correct VPFMC checked at second visit). Intervention included individually tailored PFMT, use of transversus abdominus contraction, the ‘knack’, techniques to minimize perineal descent, postpartum wound management. Written and verbal information Drop-outs/adherence Drop-out 6% in each group Adherence to PFMT: control 57.6%, intervention: 83.9% Adverse events not stated ITT analysis Results (numbers UI 3 months postpartum and percentage Control: 126/328 (38.4%) [%]) Intervention: 108/348 (31.0%) (95% CI 0.22–14.6%) p = 0.044 OR of incontinence for the women in the intervention group compared with control group 0.65 (0.46–0.91), p = 0.01 Study Chiarelli et al 2004 Design Control (n = 294), usual care Intervention (n = 275), continence promotion Diagnosis Telephone interview: Self-report (continent or incontinent) Drop-outs/adherence Drop-outs: 30% ITT analysis Results UI 12 months postpartum NS difference between groups Practice of PFMT at 12 months promotes continence at this time Study Dumoulin et al 2004 Design 3-arm RCT: control (n = 20), PFM rehabilitation (n = 21), PFM rehabilitation + training of deep abdominal muscles (n = 23) n 64 parous women under 45 years, still presenting symptoms of SUI at least once per week 3 months or more after last delivery; recruited during annual gynaecological visit at an obstetric clinic, Canada Diagnosis Self-reported urinary incontinence at least once per week Training protocol Control: 8 weekly sessions of massage

Evidence for pelvic floor physiotherapy for urinary incontinence after delivery 329 Table 10.3 Studies assessing the effect of pelvic floor muscle exercises after delivery to prevent/treat urinary incontinence—cont’d Training protocol PFM rehabilitation: weekly sessions supervised by physiotherapist for 8 weeks: 15-min electrical —cont’d stimulation (biphasic rectangular form; frequency 50 Hz; pulse with 250 μs; duty cycle, 6 s on and 18 s off for the first 4 weeks and 8 s on and 24 s off for the last 4 weeks; maximal tolerated current intensity) + 25 min PFMT with biofeedback + home training 5 days per week PFM rehabilitation as group 2 + 30 min of deep abdominal muscle training Drop-outs/adherence Drop-out rate 6% High adherence ITT analysis No adverse effect reported Results After the intervention period Objective cure (less than 2 g urine on pad test): Control: 0/19 PFM rehabilitation: 14/20 PFM rehabilitation + training of deep abdominal muscles: 17/23 Significant difference in favour of the PFM rehabilitation groups (p = 0.001) No significant difference between the two PFM rehabilitation groups PFM strength: no significant difference Study Glazener et al 2001 Design 2-arm RCT: control (n = 376), no visit; intervention (n = 371), assessment of UI by nurses, with conservative advice on PFM exercises Three centres (Aberdeen, Birmingham, Dunedin) n 747 women with UI 3 months postnatal, mean age at entry 29.6 (SD 5.0) Diagnosis Self-reported persistence of UI Training protocol Control: no visit Intervention: assessment of UI by nurses, with conservative advice on PFM exercises (80–100 fast/ slow contractions daily) 5, 7, and 9 months after delivery supplemented by bladder training if appropriate at 7 and 9 months Drop-outs/adherence Lost to follow-up at 12 months: control 35%, intervention: 25% ITT analysis Results (numbers Any UI and percentage Control: 169/245 (69%) [%]) Intervention: 167/279 (59.9%) p = 0.037 Severe UI Control: 78/245 (31.8%) Intervention: 55/279 (19.7%) p = 0.002 Study Glazener et al 2005 6-year follow-up Design Control: n = 253 Intervention: n = 263 n 516, mean age at entry 30.0 (SD 4.7) Drop-outs/adherence Lost to follow-up at 6 years: 30% Performing any PFMT: Control: 50% Intervention: 50%

330 EVIDENCE FOR PELVIC FLOOR PHYSICAL THERAPY FOR URINARY INCONTINENCE Table 10.3 Studies assessing the effect of pelvic floor muscle exercises after delivery to prevent/treat urinary incontinence—cont’d Results (numbers Severe UI and percentage Control: 99/253 (39%) [%]) Intervention: 100/263 (38%) p = 0.867 Study Meyer et al 2001 Design Allocated to 2 groups: control (n = 56), no education; intervention (n = 51), 12 sessions over 6 weeks with physiotherapist n 107 women after vaginal delivery (previously nulliparous), recruited during pregnancy, mean age 29 years (SD 4) At treatment allocation (2 months’ postpartum) 9/56 controls and 16/51 in the pelvic floor re-education group had self-reported SUI Single centre, Switzerland Diagnosis Self-reported urinary incontinence Bladder neck position and mobility Urodynamics Training protocol Control (n = 56): no pelvic floor re-education offered from 2–10 months’ postpartum Intervention (n = 51): 12 sessions over 6 weeks with physiotherapist. PFMT followed by 20 min of biofeedback and 15 min of electrostimulation. Electrostimulation (vaginal electrode, biphasic rectangular waveform, pulse width 200–400 μs, frequency 50 Hz, intensity 5–15 mA, contraction time 6 s, rest time 12 s) Drop-outs/adherence No withdrawals or loses to follow-up Adherence not reported Adverse events not stated Results (numbers SUI 10 months postpartum and percentage Control: 8/56 (32%) [%]) Intervention: 6/51 (12%) RR (95% CI): 0.82 (0.31, 2.21) Subjects cured: contro1 1/51(2%) p = 1.0 Intervention: 10/56 (19%) p = 0.02 PFM strength: NS difference Bladder neck position and mobility: NS difference Urodynamic parameters: NS differences Study Mørkved & Bø 1997 Design Prospective matched controlled: control (n = 99), customary written postpartum instructions from the hospital; intervention (n = 99), 8 weeks of intensive PFMT n 198 postpartum women Criteria for matching: age (±2 years), parity (1, 2, 3, 4 ≥ deliveries) and type of delivery Mean age 28 years (range19–40) Single centre, Norway Diagnosis Self-report of SUI Symptom questionnaire Standardized pad test (1 hour) Urodynamics

Evidence for pelvic floor physical therapy for urinary incontinence after delivery 331 Table 10.3 Studies assessing the effect of pelvic floor muscle exercises after delivery to prevent/treat urinary incontinence—cont’d Training protocol Control: customary written postpartum instructions from the hospital; not discouraged from performing PFM exercises on their own; correct VPFMC checked at enrolment Intervention: 8 weeks of intensive PFMT (in a group) led by physiotherapist with additional daily home exercises between 8 and 16 weeks postpartum; correct VPFMC checked Drop-outs/adherence Seven withdrawals in the intervention group 100% in the training group and 65% in the control group reported that they were doing PFMT between 8 and 16 weeks after delivery Adverse events not stated Results (numbers Self-reported UI at 16 weeks postpartum and percentage Control: 28/99 (28.3%) [%]) Intervention: 14/99 (14.1%) p = 0.015 Standardized pad test Control: 13/99 (13.1%) Intervention: 3/99 (3.0%) p = 0.009 PFM strength (cmH2O) improvement Control: 0.8 (95% CI: 0.3–1.7) Intervention: 5.3 (95% CI: 4.5–6.6) p < 0.01 Study Mørkved & Bø 2000 1-year follow-up Design Control (n = 81), intervention (n = 81) n 180 women 1-year postpartum. All women, who had participated in a matched controlled trial were contacted per telephone one year after delivery Single centre, Norway Training protocol Control: customary written postpartum instructions from the hospital; not discouraged from performing PFM exercises on their own; correct VPFMC checked at enrolment Intervention: 8 weeks of intensive PFMT (in a group) led by physiotherapist with additional home exercises between 8 and 16 weeks postpartum; correct VPFMC checked Drop-outs/adherence All longitudinal changes were conducted using a constant sample, including the 81 matched pairs who attended all tests (162/180) 53% in the training group and 24% in the control group reported that they were doing PFMT between 16th week and 1 year postpartum Adverse events not stated Results (numbers Self-reported UI at 12 months postpartum and percentage Control: 31/81 (38%) [%]) Intervention: 14/81 (17%) p = 0.003 Standardized pad test Control: 14/81 (13%) Intervention: 5/81 (3%) p < 0.03 PFM strength improvement Control: 1.7 (95% CI: 0.8–2.7) Intervention: 4.4 (95% CI: 3.2–5.6) p < 0.001 Change in PFM strength in women performing PFMT < 3¥ per week and 3¥ per week or more PFMT <3: 1.8 (95% CI: 0.8–2.7) PFMT ≥3: 4.9 (95% CI: 3.7–6.2)

332 EVIDENCE FOR PELVIC FLOOR PHYSICAL THERAPY FOR URINARY INCONTINENCE Table 10.3 Studies assessing the effect of pelvic floor muscle exercises after delivery to prevent/treat urinary incontinence—cont’d Study Sleep & Grant 1987 Design 2-arm RCT: control (n = 900), current standard care; intervention (n = 900), current standard care + individual sessions PFMT n 1800 postpartum women recruited within 24 h of vaginal delivery, mean age in control group 26.2 years (SD 5.3) and intervention group 27.1 years (SD 5.3) More women in intervention group had antenatal urinary incontinence (32 vs 29) Single centre, England Diagnosis Self-report (continent or incontinent at 3 months) Training protocol Controls: current standard antenatal and postnatal care, recommended to do VPFMC as often as remember and mid-stream urine stop 4-week health diary Intervention: as above plus one individual session daily while in hospital with midwifery coordinator, 4-week health diary including additional section recommending a specific PFMT task each week (all tasks related to integrating VPFMC with usual daily activity) Drop-outs/adherence Withdrawals at 3 months were 84/900 in control and 107/900 in PFMT group At 3 months’ postpartum 58% in the exercise group and 42% in control group reported that they were doing PFMT Adverse events not stated Not ITT analysis Results (numbers UI 3 months postpartum and percentage Control: 175/793 (22%) [%]) Intervention: 180/816 (22%) RR (95% CI): 1(0.83, 1.20) Study Wilson & Herbison 1998 Design 2-arm RCT: control (n = 117), customary information from general practitioner/midwife; intervention (n = 113), 12 weeks of intensive PFMT n 230 women with UI 3 months postpartum, mean age 27.8 (95% CI 27–28.7) Diagnosis Self-reported UI Home pad test Training protocol Control: standard postnatal PFM exercises Intervention: Instructions by physiotherapist (80–100 fast/slow contractions daily) 3, 4, 6 and 9 months postpartum; use of perineometer to teach awareness of pelvic floor contraction; three groups: 39 women performed only PFM exercises; 36 women trained only with vaginal cones 15 min/day; 38 women used both Drop-outs/adherence Women responding on 1-year outcome assessment: Controls: 91/117 Intervention: 54/113 Results (numbers Self-reported UI at 12 months postpartum and percentage Control: 69/91 (76%) [%]) Intervention: 27/54 (50%) p = 0.003 ITT, intention to treat analysis; mo, month; NS, non-significant; OR, odds ratio; PC, power calculation; PFM, pelvic floor muscles; PFMT, pelvic floor muscle training; RCT, randomized controlled trial; RR, relative risk; SD, standard deviation; SUI, stress urinary incontinence; UI, urinary incontinence; VPFMC, voluntary pelvic floor muscle contraction; vs, versus; wk, week.

Evidence for pelvic floor physiotherapy for urinary incontinence after delivery 333 Table 10.4 Studies assessing the effect of pelvic floor muscle exercises after delivery to prevent/treat urinary incontinence: PEDro quality score of RCTs in systematic review E – Eligibility criteria specified 1 – Subjects randomly allocated to groups 2 – Allocation concealed 3 – Groups similar at baseline 4 – Subjects blinded 5 – Therapist administering treatment blinded 6 – Assessors blinded 7 – Measures of key outcomes obtained from over 85% of subjects 8 – Data analysed by intention to treat 9 – Comparison between groups conducted 10 – Point measures and measures of variability provided Study E 1 23 4 5 6 7 8 9 0 Total score Chiarelli & + + ++ − − ? ++ ++ 7/10 Cockburn 2002 −+ ++ 6/10 Chiarelli et al + + ++ − − ? 2004 8/10 Dumoulin et al + + ++ − −+ ++ ++ 7/10 2004 6/10 3/10 Glazener et al + + ++ − −+ −+ ++ 4/10 2001 4/10 2005 + + ++ − −+ −− + + 4/10 Meyer et al 2001 + ? ?? − − ? +? ++ 5/10 Mørkved & Bø + − −+ − − − + − + + 1997 2000 + − −+ − −− +− ++ Sleep & Grant ? + ?? − − − + − + + 1987 Wilson & + + ++ − −− −− ++ Herbison 1998 +, criterion is clearly satisfied; −, criterion is not satisfied; ?, not clear if the criterion was satisfied. Total score is determined by counting the number of criteria that are satisfied, except that scale item one (eligibility criteria specified) is not used to generate the total score. Total scores are out of 10. RECOMMENDATIONS BASED CLINICAL RECOMMENDATIONS ON EVIDENCE The same PFMT protocol can be used in pregnant According to the results of the present review PFMT women as recommended for SUI in Chapter 9, p. 189. after delivery is effective in reducing urinary inconti- nence in the immediate postpartum period. However, the longer term effect is questionable. No adverse effect of the PFMT has been reported.

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337 Chapter 11 Evidence for pelvic floor physical therapy for neurological diseases Marijke Van D Kampen CHAPTER CONTENTS INTRODUCTION Introduction 337 Stroke 338 Several neurological disease processes can cause changes Definition 338 in bladder and bowel function and bladder and bowel Incidence and prevalence 338 problems cause much anxiety and may reduce quality Pathophysiology 338 of life (Chancellor & Blaivas 1995). Treatment: evidence for effect (prevention and Treatment procedures of neurological patients with treatment) 338 genitourinary and bowel problems are largely based Clinical recommendations 341 on empirical evidence with a limited research base Multiple sclerosis 341 (Chancellor & Blaivas 1995, Harari et al 2004, Leboeuf & Introduction 341 Gousse 2004). An assessment of a patient’s physical, Incidence and prevalence 341 psychological, cognitive and emotional limitations may Urological and bowel symptoms 341 influence the treatment strategy. Although many thera- Pathophysiology 341 peutic options exist, a stepwise approach with initially Treatment: evidence for effect (prevention and non-invasive treatment is important considering the course of the disease (Chancellor & Blaivas 1995, Leboeuf treatment) 341 & Gousse 2004). The role of pelvic floor physical therapy Clinical recommendations 342 for bladder and bowel problems in specific neurological Conclusion 342 diseases has been minimally investigated. Only three References 342 randomized controlled studies of pelvic floor physical therapy for patients with stroke and multiple sclerosis (MS) who have urinary incontinence have been pub- lished (Tibaek et al 2004, 2005, Vahtera et al 1997). Other neurological pathologies such as spina bifida, syringo- myelia, peripheral neuropathies, Parkinson’s and Huntington’s disease, multiple system atrophy, demen- tia, spinal cord injuries, disc prolapse and tumours of the spinal cord might be responsible for the development of a neurogenic bladder and bowel dysfunctions. As no studies on evidence for pelvic floor physical therapy in these neurological diseases can be found, this chapter is limited to the treatment of patients with stroke and MS who have genitourinary and/or bowel problems.

338 EVIDENCE FOR PELVIC FLOOR PHYSIOTHERAPY FOR NEUROLOGICAL DISEASES Stroke DEFINITION Initial incontinence is associated with age older than 75 years, visual field defect, dysphagia, motor weak- Stroke or cerebrovascular accident (CVA) is the clinical ness, severity of stroke, diabetes mellitus, hypertension manifestation of ischaemia or infarction of brain tissue and comorbidity with other diseases (Gross 2000, caused by arterial occlusion, intracerebral and subarach- Nakayama et al 1997, Patel et al 2001a, Sze et al 2000). noid haemorrhage or congenital malformation (Flisser Furthermore, urinary incontinence in the acute stage is & Blaivas 2004). a predictor of survival and closely associated with sever- ity of disability (Patel et al 2001a). Urinary incontinence INCIDENCE AND PREVALENCE emerged as a risk factor for nursing home replacement (Patel et al 2001a, Pettersen et al 2002). Each year a typical health authority can expect two new cases of stroke, four recurrent stroke patients and PATHOPHYSIOLOGY approximately six survivors of stroke living in the com- munity per 1000 men and women (Chancellor & Blaivas Not all incontinence after stroke is directly related to 1995). neurological injury of the micturition pathways. Other mechanisms are general impairment, cognitive deficits Urologic and bowel symptoms and and overflow incontinence unrelated to stroke (Flisser urodynamic investigation & Blaivas 2004). The neurophysiological explanation for detrusor areflexia in the initial phase after stroke is Urinary incontinence was reported in 32 to 83% of unknown. Detrusor hyperreflexia was noted in lesions patients in the early period after stroke. A review of of the frontal lobe as well as the basal ganglia. Uninhib- prevalence of incontinence is given by Brittain et al ited sphincter relaxation is typical for frontal lobe lesions (1998). The natural history of urinary incontinence and detrusor sphincter dyssynnergia is common in the following stroke is a gradual, spontaneous improve- basal ganglia lesions (Sakakibara et al 1996). The loca- ment from 19% at 3 months, 15% at 1 year to 10% at tion of the injury, the extent of the damage and the role 2 years (Patel et al 2001b). Jorgensen et al (2005) found of the affected area determine the precise urological a prevalence of 17% urinary incontinence among long- impact (Flisser & Blaivas 2004). term survivors and 7% of control subjects without stroke. Physical therapy to strengthen the pelvic floor muscles (PFM) after stroke is aimed at alleviating the Sakakibara (1996) analysed micturitional histories problems of urgency, stress and urgency incontinence. and urodynamic investigation in 72 stroke patients. A total of 53% of the patients had one or more urinary TREATMENT: EVIDENCE FOR EFFECT symptoms within 3 months after stroke: 36% had noctur- (PREVENTION AND TREATMENT) nal urinary frequency, 29% had urgency incontinence, and 25% difficulty of voiding. Urodynamic investigation There has been little research into the treatment of shows that initially after stroke, the bladder is often are- urinary and fecal incontinence and constipation in flexic (Flisser & Blaivas 2004). Detrusor hyperreflexia people who have had a stroke. Wikander et al (1998) and urgency incontinence generally follow. Sphincteric concluded that incontinence was significantly reduced incontinence in the recovery phase is normally not a after a special multidisciplinary programme in compari- consequence of the stroke, but is almost always a pre- son with a control group treated with a conventional morbid condition (Flisser & Blaivas 2004). rehabilitation programme. The special multidisciplinary programme contains physical training (dressing, trans- Fecal incontinence in patients with stroke has been fer in hospital and at home with attention to bladder reported in between 23 and 40% of patients on admis- and bowel management), social and cognitive inter- sion and between 7 and 9% 6 months after stroke (Brittain et al 1998, Brocklehurst et al 1985, Nakayama et al 1997).

Stroke 339 action (memory training, problem solving, social inter- control group followed the normal standard programme action, expression and comprehension). Harari et al of rehabilitation without specific treatment of urinary (2004) concluded that a single clinical/educational nurse incontinence. intervention for stroke patients effectively improves bowel dysfunctions up to 6 months later and bowel- In the first study, the Qol measured with the Short modifying lifestyle behaviours up to 12 months later. Form 36 Health Survey Questionnaire (SF-36) and Incontinence Impact Questionnaire (IIQ7) did not show The effect of PFM training on incontinence in patients significant difference between the two groups after 12 with stroke was evaluated in two randomized control- weeks. led studies (RCTs): in fact, it is one RCT study of 26 incontinent women reported in two publications because In the second study, a significant improvement of two different assessment tools were used (Table 11.1). frequency of voiding (p = 0.028), 24-hour home pad test The effect of pelvic floor exercises in women with (p = 0.013) and endurance of PFM (p = 0.028) was dem- urinary incontinence after stroke was measured by onstrated in the treatment group compared with the Quality of life (Qol) parameters (Tibaek et al 2004) and control group. by diary for the frequency of voiding, incontinence epi- sodes and number of pads, 24-hour home pad test and The methodological quality has a score of 6 and 7 out vaginal palpation of PFM (Tibaek et al 2005). The inter- of 10 on the Pedro scale; neither the patients nor the vention included group treatment over 12 weeks com- therapist or assessor were blind to the study (Table 11.2). prising 12–24 standardized pelvic floor exercises. The Other limitations of the study are a small sample size (12/14 women in each group). In the first study (Tibaek et al 2004), the instruments to document the effect are Table 11.1 Randomized controlled studies of physiotherapy for bladder and bowel dysfunctions in neurological patients Study Tibaek et al 2004 Design n 2-arm RCT: experimental group (E), PFMT; control group(C), no treatment for incontinence Diagnosis Training protocol 26 women (E = 14, C = 12), mean age 60 years (range 56–74) with stroke Drop-out Short Form 36 Health Survey Questionnaire (SF-36) and Incontinence Impact Questionnaire (IIQ7) Results Study E: PFMT: 6-s contraction, 6-s rest, 3-s contraction, 3-s rest, 30-s contraction, 30-s rest; every Design contraction 4–8× in different positions, group treatment (6–8 patients) 1 h/week during n 12 weeks outpatient, vaginal palpation 2–3× over 12 weeks, home exercises 1–2× daily Diagnosis Training protocol C: no treatment for UI but normal standard programme for rehabilitation Drop-out 8% Results No significant difference between E and C group in SF-36 and IIQ Tibaek et al 2005 2-arm RCT: experimental group (E) PFMT; control group (C), no treatment for incontinence 26 women (E = 14, C = 12), mean age 60 years (range: 56–74) with stroke Voiding diary, UI 24-hour pad test, number of pads, digital palpation of pelvic floor muscles E: PFMT: 6-s contraction, 6-s rest, 3-s contraction, 3-s rest, 30-s contraction, 30-s rest, every contraction 4–8× in different positions, group treatment (6–8 patients) 1 h/week during 12 weeks outpatient, vaginal palpation 2–3× over 12 weeks, home exercises 1–2×/day 8% Significant difference between E and C group in frequency of voiding (p = 0.028), 24-h home pad test (p = 0.013) and endurance of pelvic floor muscles (p = 0.028)

340 EVIDENCE FOR PELVIC FLOOR PHYSIOTHERAPY FOR NEUROLOGICAL DISEASES Table 11.1 Randomized controlled studies of physiotherapy for bladder and bowel dysfunctions in neurological patients—cont’d Study Vahtera et al 1997 Design n 2-arm RCT: experimental group (E) PFMT and ES; control group (C), no treatment for lower urinary Diagnosis tract dysfunction (LUTS) Training protocol 50 women and 30 men with MS (E = 40, C = 40), mean age 43 years (range: 25–68) Drop-out Results LUTS by self administered questionnaire, muscle activity by surface EMG BF E: PFMT – 3-s contraction, 3-s rest (10×) 5-s contraction, 3-s rest (5×) 15-s contraction, 30-s rest (5×), others: 5× in different positions; ES – interferential currents carrier frequency of 2000 Hz treatment frequency of 5–10 Hz, 10–50 Hz and 50 HZ, 10 min of each frequency, 3 min rest; six sessions during 21 days’ outpatient; BF, same PFMT after ES during two sessions; home exercises, 20 contractions 3–5×/week during 6 months in sitting and standing position C: no treatment At 2 months 2/40, at 6 months 3/40 in the E group Not mentioned in control group Significant difference between E and C group in LUTS (incontinence, nocturia, urge) p < 0.001, Qol (travelling, social shame and need of diapers, muscle activity) p < 0.01 BF, biofeedback; ES, electrical stimulation; LUTS, lower urinary tract symptoms; MS, multiple sclerosis; PFMT, pelvic floor muscle training. Table 11.2 PEDro quality score of RCTs in systematic review of pelvic floor physiotherapy for neurological diseases E – Eligibility criteria specified 1 – Subjects randomly allocated to groups 2 – Allocation concealed 3 – Groups similar at baseline 4 – Subjects blinded 5 – Therapist administering treatment blinded 6 – Assessors blinded 7 – Measures of key outcomes obtained from over 85% of subjects 8 – Data analysed by intention to treat 9 – Comparison between groups conducted 10 – Point measures and measures of variability provided Study E 12 34 5 67 8 9 0 Total score Tibaek 2004 + ++ +− −−+ −+ + 6/10 +− −++ −+ + 7/10 Tibaek 2005 + ++ +− −−− −+ + 4/10 Vahtera 1997 + + − +, criterion is clearly satisfied; −, criterion is not satisfied; ?, not clear if the criterion was satisfied. Total score is determined by counting the number of criteria that are satisfied, except that E (eligibility criteria specified) is not used to generate the total score. Total scores are out of 10.

Multiple sclerosis 341 not the optimal choice because the SF-36 gives an indica- CLINICAL RECOMMENDATIONS tion of general health and the IIQ turned out to be rather insensitive towards women with urgency urinary incon- Clinical recommendations based on current evidence tinence. Remarkable is the fact that only 8% of the 339 promote pelvic floor exercises to reduce incontinence stroke patients were potential candidates for pelvic floor with special attention to education and improvement of physical therapy, mostly because of their neurological physical functions and social interaction (Tibaek et al status (Tibaek et al 2004, 2005). 2004, 2005, Wikander et al 1998). Multiple sclerosis INTRODUCTION tion has been found between subjective symptoms and objective urodynamic evaluations (Chancellor & Blaivas Definition 1995). MS is caused by inflammatory and demyelinating PATHOPHYSIOLOGY lesions in the white matter of the brain and spinal cord, leading to a wide variety of neurological deficits Damage to the innervation of the lower urinary tract (Chancellor & Blaivas 1995). mostly affects the sphincter and the detrusor. Three main types of pattern of urodynamic dysfunction are INCIDENCE AND PREVALENCE described: MS has an incidence of approximately 1 new case/10 000 • detrusor hyperreflexia without bladder outlet people every year, mostly manifesting between the ages obstruction in 26–99% of patients; of 20 and 50 years. It is more common in women than men by a ratio of 2 to 1. The prevalence is about 1/1000 • detrusor hyperreflexia with detrusor–external sphinc- in the USA and 2/1000 in North Europe. It is less ter dyssynergia (DESD) in 23–52%; common in Orientals (Leboeuf & Gousse 2004). • detrusor hypo or areflexia in 6–40% (Chancellor & Blaivas 1995, Gallien et al 1998, Leboeuf & Gousse 2004). UROLOGICAL AND BOWEL SYMPTOMS TREATMENT: EVIDENCE FOR EFFECT (PREVENTION AND TREATMENT) Urological symptoms in MS patients vary greatly from one study to another. Urgency, reported in 24–86% of A few authors have investigated physical therapy as a cases and frequency in 17–82% are the most frequent treatment modality in patients with MS but without a (Leboeuf & Gousse 2004, Mayo & Chetner 1992). Urgency control group (De Ridder et al 1999, Klarskov et al 1994, incontinence is reported in 19–72% while hesitancy and Primus 1992, Skeill & Thorpe 2001, Van Poppel et al retention occurs in 2–49% (Leboeuf & Gousse 2004, Mayo 1985) and noted a good subjective improvement in & Chetner 1992). Constipation occurs in 54% and 29% incontinent episodes and pad use after electrical stimu- experience fecal incontinence (Hennessey et al 1999). All lation or biofeedback training. Primus 1992 gave these symptoms are rated as the third most important maximal vaginal electrical stimulation to 27 patients problem in MS after spasticity and incoordination, limit- with MS and found an initial efficacy of 85%, but a ing ability to work (Jawad et al 1999). In men and women decrease during follow-up to 18% after 3 months. They with MS not all urological dysfunctions can be presumed concluded that long-term treatment is necessary to min- to be secondary to MS (Jawad et al 1999). A poor correla- imize symptoms in MS. De Ridder et al (1999) offered a

342 EVIDENCE FOR PELVIC FLOOR PHYSIOTHERAPY FOR NEUROLOGICAL DISEASES practical tool in the selection of patients to predict a were relatively easy to reduce in women. The methodo- good prognosis: pelvic floor physical therapy should be logical quality of the study was weak. Neither the thera- restricted to patients with mild MS, without pelvic floor pist nor the assessor were blind to the patient and no spasticity or DESD. They designed a digital scoring intention to treat analysis was done (see Table 11.2). system for pelvic floor spasticity based on experience: CLINICAL RECOMMENDATIONS 1. spastic muscle unable to relax even after passive elongation; Based on current evidence based on one study ES and PFM exercises in patients with MS decrease urgency, 2. hypertonic muscle with temporary relaxation after frequency, incontinence, nocturia and improve bladder elongation; emptying and PFM activity. Further research will estab- lish the efficacy of these interventions. 3. active relaxation after active contraction. CONCLUSION This digital test has shown inter-examiner reliability (r = 0.90). Conclusions and clinical recommendations on the role of pelvic floor physical therapy for genitourinary and Bowel management in patients with MS is empirical bowel problems in specific neurological diseases such with a lack of evidence. Only one study investigated as stroke and MS have to be considered with care the effect of physical therapy, but without control group. because of the lack of good RCTs with a sufficient Wiesel et al (2000) offered biofeedback training as treat- number of patients. ment to 13 patients with MS complaining of constipa- tion or fecal incontinence. Treatment is more likely to be A significant improvement of incontinence in patients successful in patients with limited disability and a non- with stroke was demonstrated with a 12-week PFM progressive disease course. exercise group treatment while quality of life was the same for both the experimental and control group. Evidence based medicine For patients with MS, there was a significant dif- Evidence based medicine on MS and pelvic floor physi- ference in lower urinary tract symptoms and pelvic cal therapy was limited to one study (see Table 11.1). muscle activity after 3 weeks of ES followed by PFM Vahtera et al (1997) investigated the effect of electrical exercises compared with a control group without spe- stimulation (ES) and PFM exercises on lower urinary cific treatment. tract symptoms in patients with MS with near-normal postvoid residual volumes (<100 mL) and mild MS. The The methodological quality of these three studies is control group was not treated or even tested for activity weak to good. of the pelvic floor. ES with interferential currents in combination with regular PFM exercises significantly For patients with other neurological disorders, the improved urgency, frequency, incontinence, nocturia efficacy of physical therapy has not yet been and bladder emptying in comparison with a control investigated. group without treatment. ES also significantly improved the maximal strength and endurance of the PFM. Research on the efficacy and selection criteria for Compliance with the PFM exercises was 62.5% after pelvic floor physical therapy is necessary to help prevent 6 months; others trained irregularly. Three patients urological and bowel complications in neurological relapsed because of bladder symptoms or severe patients and improve their quality of life. Future research relapses in MS. Men may respond more rapidly to the is being undertaken and studies on patients with stroke, therapy for incontinence. The symptoms of urgency MS and Parkinson’s disease are being presented at meetings, but have not yet been published. REFERENCES Brittain K, Peet SM, Castleden C M et al 1998 Stroke and De Ridder D, Vermeulen C, Ketelaer P et al 1999 Pelvic floor rehabilitation incontinence. Stroke 29:524–528 in multiple sclerosis. Acta Neurologica Belgica 99:61–64 Brocklehurst J C, Andrews K, Richards B et al 1985 Incidence and Flisser J A, Blaivas J G 2004 Cerebrovascular accidents, intracranial correlates of incontinence in stroke patients. Journal of the tumors and urologic consequences. In: Corcos J, Schick E American Geriatrics Society 33:540–542 Textbook of the neurogenic bladder. Adults and children. Martin Dunitz, London, p 305–313 Chancellor M B, Blaivas J G 1995 Practical neuro-urology. Genitourinary complications in neurologic disease. Butterworth– Gallien P, Robineau S, Nicolas B et al 1998 Vesicourethral Heinemann, p 119–137 dysfunction and urodynamic findings in multiple sclerosis:

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345 Chapter 12 Evidence for pelvic floor physical therapy in the elderly Margaret Sherburn CHAPTER CONTENTS INTRODUCTION Introduction 345 Classification of incontinence 346 Population ageing has a great impact on health and Prevalence of incontinence in the elderly 347 societal needs, health systems and disease patterns. In Aetiology and pathophysiology 348 most developed countries of the world populations Evidence for effect of PFMT in prevention of are ageing, and research into, and the development of age appropriate interventions, is required to meet the urinary incontinence in the elderly 351 growing needs and challenges brought about by popu- Evidence for effect of PFMT 353 lation ageing. The major focus of health care for an Specific treatments 354 ageing population must be to ensure an integrated and Clinical recommendations 360 comprehensive approach to the special needs of older References 365 people and their families. This quest for adequate and cost-effective health care for the growing number of older persons has received increased attention from national governments and international organizations. The World Health Organization (WHO) through its Centre for Health Development, Ageing and Health Programme, has initiated studies for the development of community health care models for older and ageing populations. The International Continence Society, in conjunction with the WHO, has also taken an active role in reporting and collating research into the causes and management of incontinence in the elderly through the International Consultation on Incontinence (Abrams et al 2002). The prevalence of urinary incontinence increases with increasing age, affects women more than men, and is associated with significant personal stress, shame and social stigma (Bogner 2004), with considerable morbid- ity (Grimby et al 1993) and cost (Fonda 1992). Around one-third of women over 60 years of age are affected (Chiarelli et al 1999). The social and psychological con- sequences of this problem are such that sufferers reduce their social activity and participation in physical activ- ity, which in turn leads to social isolation and poor