Does intensive postpartum pelvic floor muscle training reduce the prevalence of incontinence at six months?
This intervention, which included primiparous women with and without urinary incontinence at six weeks post-partum, demonstrated that intensive supervised pelvic floor muscle training did not reduce the prevalence of urinary incontinence at six months. These results are noteworthy because the trial was well designed and the results were unexpected. (Level of Evidence = 1b–)
These investigators conducted a well-designed randomized controlled trial including 175 primiparous women at a single institution in Norway. Women were enrolled at approximately six weeks postpartum, with and without urinary incontinence (mixed population), if they had a vaginal birth of at least 32 weeks' gestation and spoke a Scandinavian language. The authors excluded women with a perineal tear graded as 3b, 3c, or 4 (all of whom were referred to a physical therapist), and mothers or newborns with a serious illness. All of the women had received a leaflet at discharge after delivery describing and encouraging pelvic floor muscle exercises. The allocation was stratified by the presence (or not) of major defects of the levator ani muscle as assessed by transperineal ultrasonography. The intervention consisted of weekly classes for 16 weeks, supervised by an experienced physical therapist, and instruction to perform daily home exercises and to document adherence with a home diary.
Masked outcome assessment was at six months postpartum using a questionnaire (International Consultation on Incontinence Questionnaire—Urinary Incontinence Short Form), ultrasonography, and manometry, as compared with baseline. Analysis was by intention to treat; loss to follow-up was 14% in the intervention group and 9% in the control group. Adherence in the intervention group was greater than 80% for class attendance and reported daily home exercise. Urinary incontinence was not statistically different between groups at baseline (39% in the intervention group vs. 50% in the control group), although the intervention group tended to have more women with major levator ani defects (65% vs. 50%; P = .10). At six weeks postpartum, there were no differences between the groups in incontinence at any frequency (relative risk = 0.89; 95% confidence interval, 0.60 to 1.32). There were also no differences between groups on per protocol analysis or on subgroup analysis based on the presence of levator ani defect.
Study design: Randomized controlled trial (nonblinded)
Funding source: Government
Setting: Outpatient (any)
Reference: HildeGStær-JensenJSiafarikasFEllström EnghMBøKPostpartum pelvic floor muscle training and urinary incontinence: a randomized controlled trial. Obstet Gynecol.2013; 122( 6): 1231– 1238.