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Pelvic floor health and solutions
This is an excerpt from Physiology of Exercise and Healthy Aging-2nd Edition by Albert W. Taylor & Michel J. Johnson.
By Linda McLean, BSc (PT), MSc, PhD, and Carolyn Vandyken, BHSc (PT)
Evidence-Based Strategies for the Maintenance of a Healthy Pelvic Floor With Aging
In a quarter of the population studied by Shaw et al. (2019), as discussed earlier, women assumed that urinary incontinence could not be cured. Informing women that urinary incontinence can be effectively treated is an important educational strategy. There is strong evidence that exercise and behavioral therapies are effective for many forms of UI, as well as for fecal incontinence and for pelvic organ prolapse, and that these therapies are as effective for older adults as they are for younger adults. Since therapies are designed to target the specific impairments associated with the different forms of incontinence, or different forms of pelvic floor dysfunction, we describe therapies and the strength of the evidence by the type of dysfunction.
Urinary Incontinence Therapies
Urinary incontinence can impact both men and women. Therapies address each urinary incontinence issue: stress urinary incontinence, urgency urinary incontinence, mixed urinary incontinence, and overflow incontinence.
Stress Urinary Incontinence in Women
The mainstay of conservative management for SUI is PFM exercise. Pelvic floor muscle training (PFMT) normally involves an exercise prescription tailored to findings on assessment of PFM strength, which is evaluated clinically through intravaginal palpation. A modified Oxford scale is typically used to grade PFM strength between 0 (no trace of a contraction) and 5 (a strong contraction) in which both a squeeze and lifting action is palpated and maintained against strong resistance (Laycock and Jerwood 2001). Additional measures of PFM function sometimes include combinations or static and dynamic endurance as well as motor control (Laycock and Jerwood 2001). In addition to strength (a.k.a. Kegel exercises), power or endurance training, a coordination exercise, termed “the knack,” is normally instructed at initial treatment sessions and reinforced throughout subsequent sessions. The knack maneuver involves voluntarily contracting the PFMs prior to activities that normally induce urine leakage, such as coughing, sneezing, or laughing. The performance of the knack has demonstrated immediate effectiveness at reducing the volume of urine leaked during a cough (Miller et al. 2001) when performed by women with SUI.
Indeed, the recommendation for PFMT as an intervention for SUI is supported by a high-quality systematic review (Dumoulin, Cacciari, and Hay-Smith 2018). Women with SUI who undergo physiotherapist-supervised PFMT are six times more likely to report cure or improvement than women in control groups. Consistent with this, after an intervention period, women who undergo PFMT leak less urine on brief or 24 h pad tests (in which the outcome is the weight increase of an incontinence pad during the tests) and have better outcomes in terms of quality of life and sexual function.
Structured PFMT in early pregnancy is recommended for continent women because it may prevent the onset of UI in late pregnancy and postpartum. More specifically, PFMT performed by continent women while pregnant reduces the risk by 62% that they will develop UI in late pregnancy or will have UI symptoms 3 to 6 months after delivery (Woodley et al. 2020). Yet if a woman has already developed UI during pregnancy, there is no evidence that PFMT will alleviate UI symptoms at this stage.
While additional modalities to PFMT have been proposed, including the use of weighted cones in the vagina to provide a loading stimulus (Herbison and Dean 2013), electrical stimulation of the PFMs to enhance neuromuscular activation (Stewart et al. 2017), and acupuncture (Wang et al. 2013), none have demonstrated effectiveness that is better than outcomes seen in women who perform PFMT alone. In a recent trial focused on postmenopausal women with SUI, electromyography biofeedback also offered no added benefit over PFMT alone (Bertotto et al. 2017).
Some trials have specifically looked at the impact of PFMT in older adults. Strength increases can be achieved with PFMT in women throughout perimenopause and into the postmenopausal period (Madill et al. 2013). Among postmenopausal women over the age of 60 years, PFM training has been shown to improve symptoms of SUI (Kim et al. 2007), with concurrent reduction in serum myostatin concentration (Radzimińska et al. 2018), a protein marker of physical inactivity and inhibitor of skeletal muscle growth. In another small trial, postmenopausal women with both UI and osteoporosis demonstrated a 75% reduction in their median number of leakage episodes per week when compared to a control group who received no intervention; further, these improvements were maintained after one year whereas leakage in the control group worsened (Sran et al. 2016).
While PFMT exercise is considered to be the first line treatment of choice for women with SUI, it is not always effective. An intravaginal support device called a pessary may also be effective for some women, yet the evidence is not clear (Lipp, Shaw, and Glavind 2014). Pessaries can be prescribed by physicians or by physiotherapists who have received appropriate post-graduate training in this specific area. However, discontinuation of pessary use appears to be quite high, attributed to the pessary being uncomfortable, rotating, or falling out during use or because it is coupled with a high burden of ongoing care to prevent infection or erosion of the vaginal wall (Robert et al. 2013). For both men and women, paraurethral bulking agents can be injected to enhance urethral sphincteric closure. However, the effects are not permanent, and thus the technique must be repeated (Maggiore et al. 2015). While surgery is recommended only after more conservative approaches have been unsuccessful, it is highly effective for the reduction of SUI symptoms (Kershaw et al. 2020). Risks have been identified with the use of some materials and procedures (Ford et al. 2015; Keltie et al. 2017) that have recently resulted in the restriction of certain procedures in some countries.
Stress Urinary Incontinence in Men
In a recent Cochrane review, PFM training was not recommended as a first line of defense for SUI experienced subsequent to radical prostatectomy, since UI improved over time irrespective of management (Anderson et al. 2015). Large variability of training regimes was likely responsible for this unequivocal conclusion (Anderson et al. 2015). However, a recent randomized controlled trial (RCT) of 97 men (Milios, Ackland, and Green 2019) demonstrated that a much higher training frequency than standardly prescribed (120 repetitions per day of 1 s and 10 s contractions combined, compared to 30 repetitions of 10 sec contractions once a day), commenced prior to RP, resulted in improvement in PFM strength, reduced postprostatectomy incontinence, and improved quality of life measures related to incontinence (Milios, Ackland, and Green 2019).
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