Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women.

backgroundPelvic floor muscle training (PFMT) is a recommended treatment for female stress, urgency, and mixed urinary incontinence. Training varies in exercise type (pelvic floor muscles contracting with and without other muscles), dose, and delivery (e.g. amount and type of supervision).

objectivesTo assess the effects of alternative approaches (exercise type, dose, and delivery) to pelvic floor muscle training (PFMT) in the management of urinary incontinence (stress, urgency, and mixed) in women. SEARCH

methodsWe searched the Cochrane Incontinence Specialised Register (searched 27 September 2023; which contains CENTRAL, MEDLINE, ClinicalTrials.gov, and World Health Organization ICTRP), handsearched journals and conference proceedings, and reviewed reference lists of relevant articles. SELECTION CRITERIA: Randomised, quasi-randomised, or cluster-randomised trials in female stress, urge, or mixed urinary incontinence where one trial arm included PFMT and another was an alternative approach to PFMT type, dose, or intervention delivery. We excluded studies with participants with neurological conditions or pregnant or recently postpartum. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for eligibility and methodological quality using the Cochrane RoB 1 tool. We extracted and cross-checked data and resolved disagreements by discussion. Data processing was as described in the Cochrane Handbook for Systematic Reviews of Interventions (Version 6). Synthesis was completed in intervention subgroups. MAIN

resultsThis is a review update. The analysis included 63 trials with 4920 women; the previous version included 21 trials with 1490 women. Samples sizes ranged from 11 to 362. Overall, study participants were mid-age (45 to 65 years) parous women with stress or stress-predominant mixed urinary incontinence (46 trials), who had no prior incontinence treatment or pelvic surgery, or appreciable pelvic floor dysfunction. Trials were conducted in countries around the world, mostly in middle- or high-income settings (53 trials). All trials had one or more arms using 'direct' PFMT, defined as repeated, isolated, voluntary pelvic floor muscle contractions. Trials were categorised as comparisons of exercise type (27 trials, 3 subgroups), dose (11 trials, 5 subgroups, 1 with no data), and delivery (25 trials, 5 subgroups). Incontinence quality of life data are reported here as the primary outcome. Adverse event data were summarised narratively. Comparison 1: exercise type Co-ordinated training (body movements with concurrent pelvic floor muscle contraction) versus direct PFMT Co-ordinated training may slightly improve quality of life (standardised mean difference (SMD) -0.22, 95% confidence interval (CI) -0.44 to -0.01; I AUTHORS'

conclusionsAlthough there is low- to moderate-certainty evidence that some approaches to PFMT are better than others, for some there was little or no difference. The 7th International Consultation on Incontinence recommends PFMT as first-line therapy for women with urinary incontinence. Direct PFMT (sets of repeated, isolated, voluntary pelvic floor muscle contractions) may result in a small improvement in incontinence quality of life compared to indirect training. In terms of improved quality of life, PFMT can be supervised individually or in a group because it probably makes little to no difference in achieving this outcome. Many comparisons had low- or very low-certainty evidence, often because there was only one trial or several small trials with methodological limitations. More, better designed and reported trials, directly comparing PFMT approaches are needed, especially trials investigating exercise dose.