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Am Fam Physician. 2021;104(2):234-235

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

Clinical Question

Does pelvic floor muscle training (PFMT) help prevent or treat urinary or fecal incontinence during pregnancy or after delivery?

Evidence-Based Answer

Structured PFMT beginning early in pregnancy prevents the onset of urge incontinence later in pregnancy and in the postpartum period compared with no intervention (number needed to treat = 4; 95% CI, 3 to 9). (Strength of Recommendation [SOR]: B, based on inconsistent or limited-quality patient-oriented evidence.) There is no evidence that PFMT improves urinary incontinence later in pregnancy or in the postpartum period in pregnant patients who already have urinary incontinence. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) There is no clear evidence that PFMT effectively prevents or treats fecal incontinence later in pregnancy or after delivery.1 (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

More than one-third of pregnant patients experience urinary incontinence at some point in their second and third trimesters. Approximately one-fourth of pregnant patients experience fecal incontinence—the involuntary loss of flatus or feces—late in pregnancy, and about one-fifth of patients leak flatus or feces one year after delivery.1 Other factors that may increase incontinence include elevated prepregnancy body mass index, method of delivery (vaginal vs. cesarean), forceps- or vacuum-assisted delivery, multiple gestations, or history of multiple pregnancies. PFMT is the repeated voluntary contraction of the pelvic floor muscles (also known as Kegel exercises), and health care professionals commonly advise pregnant patients to do PFMT one or more times per day for at least eight weeks during and after pregnancy to prevent and treat urinary incontinence.

This Cochrane review included 46 trials involving 10,832 patients from 21 countries.1 Overall, the studies were small, and the PFMT programs varied in training methods as well as the strength, endurance, and coordination of exercises. Given the nature of the intervention, it was not possible to blind the participants or clinicians; thus, there is the risk of performance and detection bias. Outcomes were generally self-reported using urinary or fecal incontinence questionnaires.

The review included 10 randomized controlled trials of pregnant patients without urinary incontinence to see if PFMT could prevent the development of urinary incontinence later in pregnancy or after delivery. Trials included 1,384 participants from nine countries. Patients who were randomized to treatment received instruction in PFMT, although the instructions differed in each trial. The control groups received no instruction, were provided “usual care,” or treatment was not specified. All trials used the patient's self-report of urinary incontinence and some used the International Consultation on Incontinence Questionnaire–Urinary Incontinence Short Form, a validated questionnaire to report urinary frequency or incontinence, amount of urinary leakage, and overall impact of urinary incontinence. Others used self-report diaries or pad count. Patients randomized to PFMT were less likely to report urinary incontinence later in pregnancy compared with patients in the control group (relative risk = 0.38; 95% CI, 0.20 to 0.72).

Treatment trials included 1,140 primigravida and multigravida patients with symptoms of urinary or fecal incontinence; participants were from four countries. These randomized controlled trials showed no evidence that PFMT initiated early in pregnancy improved urinary or fecal incontinence, either later in pregnancy or after delivery.

The 2015 American College of Obstetricians and Gynecologists practice bulletin on urinary incontinence in women recommends PFMT as an effective first-line treatment for stress, urge, or mixed urinary incontinence.2 (SOR: A, based on consistent, good-quality patient-oriented evidence.) The bulletin does not specifically address the use of PFMT in pregnancy or the postpartum period. Other than occasional pelvic pain, there are few adverse effects of PFMT. Family physicians caring for pregnant patients should engage them early in pregnancy in a shared decision-making discussion on the use of PFMT to prevent urinary incontinence later in pregnancy and after delivery.

The practice recommendations in this activity are available at http://www.cochrane.org/CD007471.

Editor's Note: The NNT and related CI reported in this Cochrane for Clinicians were calculated by the author based on raw data provided in the original Cochrane review.

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