University of Central Florida University of Central Florida

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Honors Undergraduate Theses UCF Theses and Dissertations

2016

Pelvic Floor Muscle Training in Management of Postpartum Pelvic Pelvic Floor Muscle Training in Management of Postpartum Pelvic

Floor Dysfunctions: A Literature Review Floor Dysfunctions: A Literature Review

Rebecca S. Tanner University of Central Florida

Part of the Musculoskeletal, Neural, and Ocular Physiology Commons, Nursing Midwifery Commons,

Obstetrics and Gynecology Commons, Physical Therapy Commons, Preventive Medicine Commons, and

the Reproductive and Urinary Physiology Commons

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Recommended Citation Recommended Citation Tanner, Rebecca S., "Pelvic Floor Muscle Training in Management of Postpartum Pelvic Floor Dysfunctions: A Literature Review" (2016). Honors Undergraduate Theses. 110. https://stars.library.ucf.edu/honorstheses/110

PELVIC FLOOR MUSCLE TRAINING IN MANAGEMENT OF POSTPARTUM PELVIC

FLOOR DYSFUNCTIONS: A LITERATURE REVIEW

by

REBECCA S. TANNER

A thesis submitted in partial fulfillment of the requirements for the Honors in the Major Program in Health Sciences Pre-Clinical

in the College of Health and Public Affairs and in The Burnett Honors College at the University of Central Florida

Orlando, Florida

Fall Term 2016

Thesis Chair: Dr. Carey Rothschild

ii

Abstract

Women can face a wide range of pelvic floor dysfunctions following pregnancy, ranging

from urinary incontinence to pelvic pain. Unfortunately, these problems are not routinely

checked for in postpartum check-ups and women do not always bring it to the physician’s

attention. Strengthening of the pelvic floor muscles may be able to help women prevent these

disorders and improve these women’s lifestyles.

The purpose of this thesis was to review and analyze different trials to determine if

different pelvic floor dysfunctions (urinary incontinence, sexual dysfunction, and pelvic girdle

pain) can be treated using pelvic floor muscle training in the postpartum. After reviewing the

literature, it was determined that Pelvic floor muscle training may be effective in treating

Urinary incontinence, but there is a lack of research to state that it helps treat sexual

dysfunction and pelvic pain. Pelvic floor muscle training is a conservative non-invasive

treatment and very simple for women to do on their own, therefore more research should be

performed to see if this can be a simple fix to a plethora of problems women face in the

postpartum.

iii

Table of Contents

Background ............................................................................................................ 1

Anatomy and Function of the Pelvic Floor ......................................................... 1

Risk Factors for Pelvic Floor Dysfunction ............................................................ 2

The Pelvic Floor During Pregnancy ..................................................................... 4

The Pelvic Floor During Childbirth ...................................................................... 5

Background of Pelvic Floor Disorders ................................................................. 6

Urinary Incontinence ..................................................................................... 6

Pelvic Girdle Pain ........................................................................................... 8

Sexual Dysfunction ......................................................................................... 9

Screening of Pelvic Floor Disorders in the Postpartum Female .........................10

Pelvic Floor Muscle Training .............................................................................11

Methods ...............................................................................................................12

Data Sources .....................................................................................................12

Study Selection .................................................................................................12

Quality Assessment ...........................................................................................12

Results ..................................................................................................................14

Quality Assessment ...........................................................................................14

Discussion .............................................................................................................15

Urinary Incontinence ........................................................................................15

Sexual Dysfunction ............................................................................................16

Pain ...................................................................................................................17

Conclusion ............................................................................................................19

Appendix A: Summary of Studies ..........................................................................20

Appendix B: Scoring of Articles .............................................................................26

iv

Appendix C: Level of Evidence ..............................................................................29

References ............................................................................................................31

1

Background

The number of births in the United States have trended upward in recent years; in 2015,

4 million births were reported, and 37% of these women encountered some kind of pelvic floor

dysfunction following delivery.1,2 Of these dysfunctions urinary incontinence has a prevalence

rate of 33%, sexual dysfunction has a rate of 71%, and pelvic pain occurs between 16% and 25%

in the postpartum.3-5 A variety of treatments are available to treat these conditions including

pelvic floor muscle training (PFMT).

PFMT aims to restore the neuromuscular control and strength of the muscles in the

pelvic floor so that they can aid in supporting the organs and structures involved in the

common dysfunctions. PFMT consists of repetitions of contraction and relaxations of the

muscles in the pelvic region.6

Anatomy and Function of the Pelvic Floor

The pelvic floor is a complex integrated collection of innervated ligaments, muscles and

extracellular matrix found in both males and females. Its primary role is to provide support to

the pelvic organs and to protect the bladder, urethra, reproductive organs, and the rectum.7

Three orifices weaken the pelvic floor in females: the vagina, the urethra and the anus.

Therefore, the musculature and ligamentous structures in this area must be strong and

supportive to prevent pelvic floor disorders. 7,8 This region is composed of six layers of tissue:

the pelvic peritoneum, the visceral layer of pelvic fascia, the deep muscles, the superficial

2

muscles, and the subcutaneous fat and skin.8 Both the superficial and deep layers of muscles

play an important role in providing hammock-like support to the pelvic organs.

The superficial layer consists of five structures: transverse perineal muscle,

bulbocavernosus muscle, ischoocavernosus muscle, external anal sphincter, and the

membranous sphincter of the urethra.9 The strength of these muscles maintain the pelvic floor

structure and directly support the urethral, vaginal and anal sphincters.8 The deep muscles of

the pelvic floor are commonly known as the levator ani muscles. Strength in these muscles

provides the primary support of the pelvic region. The levator ani consists of three different

muscles: the pubococcygeus, the iliococcygeus and the ishiococcygeus. The levator ani and

coccygeus muscles orginate on the inner surface of the side of the lesser pelvis and insert into

the inner surface of the coccyx bone. This cross sectioning of the muscles across the inner pelvis

allows for the hammock like support to the inner organs.10 A critical function of the muscles is

to provide stabilization when there is an increase in intra-abdominal pressure caused by

vomiting, coughing, urination, and defecation.8 The deep muscles indirectly support the uterus,

directly support the vagina, and play a vital role in childbirth.7

Risk Factors for Pelvic Floor Dysfunction

Decreased muscular strength in the pelvic floor muscles can lead to dysfunctions

including incontinence, pelvic pain and sexual dysfunction. Estimates suggest that 24% of the

female population in U.S may suffer from some form of pelvic floor dysfunction.11 Risk factors

for such conditions include age, increased body weight, smoking, pregnancy, and childbirth.

3

Age is a contributing factor for conditions of pelvic floor dysfunction. Thirty-nine

percent of women between the ages of 60-79 years have some type of pelvic floor dysfunction,

and this rate increases to 50% in women 80 years or older. 12 With normal aging the pelvic floor

muscles become weakened and overstretched, which may cause it to be insufficiently able to

support the structure and organs of the pelvis. Hence, rates of incontinence and pelvic organ

prolapse are likely to increase.7,13

An increase in body weight and obesity can have adverse effects on a women’s health.

The increase in intra-abdominal pressure can put strain on the connective tissue and muscles of

the pelvic floor causing pelvic floor dysfunctions.14 It has been found that morbidly obese

women have an increased risk for urinary incontinence and pelvic organ prolapse.15

Another contributing factor that raises the risk of pelvic floor dysfunction is smoking.

Coughing associated with inhaled tobacco use increases the intra-abdominal pressure and can

damage the pelvic floor by weakening the collagen of the pelvic floor tissues.15 Smoking also

causes irritation to the bladder endothelium by causing inflammation to the bladder wall.16

Hojberg et al found that women who smoked during pregnancy had a 6.8% greater chance of

urinary incontinence.17

Pregnancy and childbirth are also significant contributors to pelvic floor dysfunction as

they often lead to a considerable reduction in pelvic floor muscle strength.18 This reduction of

strength may be the cause of pelvic girdle pain, sexual dysfunction and urinary incontinence.

Studies have shown that pelvic floor muscle training (PFMT) during pregnancy and the

4

postpartum period can improve the strength of the pelvic floor musculature and possibly

prevent and manage such symptoms.19-22

The Pelvic Floor During Pregnancy

During pregnancy, a considerable amount of stress is placed on a woman’s pelvic floor

musculature and supportive structures. The pelvic region must support the weight of the baby

(or babies in the event of multiples) as well as the placenta and amniotic fluid.7 The increasing

weight further causes a rise in the intra-abdominal pressure, which, in turn leads to a

weakening and stretching of the pelvic floor muscles.3

Pregnancy hormones may also contribute to laxity of the pelvic floor muscles.

Progesterone and relaxin hormones cause a softening of the ligaments and muscles in the

pelvic region, by allowing remodeling and stretching of the area in preparation for the passage

of the baby through the birth canal.8 Excessive stretching of the muscles and ligaments in the

pelvic region can cause nerve injury. Consequently, muscles of the pelvic floor may be

affected. Injury to the pudendal nerve may result in partial denervation to the pelvic floor

musculature and subsequent muscular weakness ultimately leading to the development of

stress urinary incontinence and pelvic organ prolapse. 8,23

As pregnancy progresses the fetus starts to descend, which increases the amount of

pressure placed on other organs in the pelvic region. It is common for pregnant women to

report increased urinary urgency as a result of the bladder having less room to expand and

accumulate urine.24 Pregnancy can also potentially push the bladder forward causing an

5

increase in the angle between the bladder neck and the urethra which may lead to urinary

incontinence.24,25

The Pelvic Floor During Childbirth

The effects of childbirth on the pelvic floor depend on the type of delivery, either

vaginal or Cesarean (C-section). During vaginal delivery the baby must pass through the pelvic

floor which causes stretching of the nerves, blood vessels, muscles and ligaments in this area. 7

Sigurdardottir et al showed that in vaginal delivery, pelvic floor muscle strength was decreased

considerably compared to antepartum. During the second stage of labor the levator ani muscle

undergoes significant strain which leads to stretching and potential damage of the muscles.7

Estimates suggest that 13-36% of women who deliver vaginally may experience some type of

levator ani muscle injuries.26 The levator hiatus, the most prevalent hernia opening in the body,

also distends remarkably to enable an infant to pass through the birth canal.27 This expansion

can cause the surrounding levator ani muscles to reach their elastic limit, potentially causing

permanent injury.28

Muscle strength is greatly influenced by mode of delivery; while pelvic floor muscle

strength decreases more in women who deliver vaginally.18 Hiatal sizes are also seen to be

larger in women who deliver vaginally, this difference in hiatal dimensions between vaginal and

C-section deliveries may be caused by the increased occurrence of levator ani avulsions during

vaginal delivery. Studies have shown a correlation between the number of avulsions to the

increased hiatal dimensions post-vaginal delivery.29

6

Women with these avulsions are at risk for a reduction of pelvic floor muscle strength

which may be a leading cause of pelvic floor disorder.30 24 Instrument-assisted deliveries may

further increase the chances of some dysfunctions. The use of forceps during delivery can

increase the rate of levator ani muscle damage as much as 35-64%.6 The greater the levator ani

muscle trauma, the more likely of pelvic floor dysfunction. Other risk factors leading to pelvic

floor impairments during delivery include delayed childbearing, large head circumference,

prolonged second stage of labor, pushing during the second stage of labor and increased age of

the mother during pregnancy.13,24,31

Background of Pelvic Floor Disorders

Urinary Incontinence

Urinary incontinence (UI) is the most prevalent pelvic floor dysfunction seen in women.

Estimates suggest that urinary incontinence affects between 32% and 64% of all women and a

33% prevalence rate during the first three months of the postpartum period.3,25 UI is defined as

“any complaint of involuntary leakage of urine”.21 There are three main types of UI: Stress

urinary incontinence (SUI), urgency UI and mixed UI. SUI is defined as the “involuntary leakage

on effort or exertion or on sneezing or coughing.”32 Urgency UI is the “involuntary leakage

accompanied by or immediately proceeded by urgency”. Mixed UI is the “involuntary leakage

associated with urgency, as well as urgency with exertion, effort, sneezing and coughing”.25 SUI

is the most common type of UI in women, followed by urgency UI.32

7

SUI is likely caused by the lack of muscle strength in the sphincters and the supportive

structures in the pelvic floor muscles and tissue.21 Athletic participation in sports such as

gymnastics may place further demand on the pelvic support system; 80% of gymnasts may

suffer from SUI.25 Gymnast landing on a balancing beam or on the uneven bars can cause

increase in intra-abdominal pressure, causing direct trauma on the urethral sphincter and the

supporting pelvic floor.33 This can further cause Intrinsic urethral sphincter deficiency resulting

in UI.34 Stress and urge urinary incontinence are also more likely in women who are elite

athlete.35 Poswiata found that 50% of the elite athletes, such as cross country skiers and

runners, were losing urine, either urge UI or SUI associated with coughing and sneezing.35

UI may increase in women during pregnancy and childbirth. Bozkurt reported 65% of

women stated a first occurrence of UI either during pregnancy or in the postpartum period.24

There is also a higher rate of UI in women who have had levator ani muscle avulsions during

childbirth.30 Another risk factor contributing to UI is the mode of delivery. Women who deliver

via a C-section may have a lesser occurrence of incontinence.12,36 Risk factors during pregnancy

that contribute to UI are excessive weight gain, family history of UI and women of older age.37

There are several treatments available for UI. To treat stress urinary incontinence

women can perform PFMT, electric and magnetic stimulation or take medication such as topical

estrogen.38 To treat urgency UI, timed or scheduled voiding, often referred as bladder drills, are

recommended to increase bladder capacity. Doing percutaneous tibial nerve stimulation is

effective in improving UI and treating an overactive bladder by preventing bladder

8

contractions.39 Taking medications such as Tolterodine also helps prevent UI by blocking

acetylcholine in the muscles of the bladder. Blocking acetylcholine reduces the urge to urinate

and slows the pressure build up in the bladder. It is still unknown if Tolterodine is found in

breast milk and therefore women should contact their doctor before taking.40 38 In more

extreme cases surgical treatments are available.41

Pelvic Girdle Pain

Lumbopelvic pain is a common issue for women during pregnancy. Pelvic girdle pain

(PGP) is prevalent in 20% of all women but increases to 50% with pregnancy.36,42 Some studies

suggest that PGP is a form of lower back pain, but PGP can occur independently of lower back

pain.36 There are four categories of PGP depending on the location of the pain: pelvic girdle

syndromes (anterior and posterior of pelvic girdle), symphysiolsis (anterior pelvic girdle and

pubic symphysis), one-sided sacroiliac syndrome (posterior pelvic girdle and unilateral sacroiliac

joints), and double-sided sacroiliac syndrome (posterior girdle and bilateral sacroiliac joints).4,43

The location of PGP is commonly reported in the area between the gluteal fold and the

posterior iliac crest, and can promulgate to the posterior thigh.36

The exact cause of pelvic girdle pain is still unknown, but the location of the pain has a

correlation with how long the pain persists.44 Studies suggest that if PGP occurs in conjunction

with lower back pain during pregnancy, PGP can persist up to 3 months postpartum. Women

who have fewer pain locations during pregnancy are less likely to have PGP that persists in the

postpartum period.45 Mode of delivery also influences PGP, women who deliver vaginally may

9

have a lesser chance of pelvic girdle pain postpartum. 12,36 When pelvic pain persists after

pregnancy and is prolonged after childbirth a woman’s ability to function in daily activities may

be significantly reduced.42

Sexual Dysfunction

Sexual dysfunction can be defined as the “disordered desire, arousal, orgasm, or pain

and distress” experienced by women during intercourse, which has been found to increase in

women following childbirth.24,46 Dissatisfaction can be due to decreased arousal related to

sleep deprivation, anxiety, postpartum depression and even pain during intercourse.24

Dyspareunia and the loss of desire are typically short-term postpartum sexual changes and are

common in postpartum women, occurring at rates of 22% and 86% respectively.20 Studies have

reported that the pelvic floor muscles play a major role in a women’s sexual function and

orgasmic potential. The muscles have a role in the voluntary rhythmic contractions in

receptivity and motor responses during orgasm.20 Without the proper functioning of these

muscles women may develop these sexual dysfunctions.

Studies have shown a correlation between an increased occurrence of sexual

dysfunction and an increased rate of avulsion in the levator ani muscle.9 Levator ani muscle

avulsion may result in reduced vaginal sensation following childbirth. Women who have had

less severe avulsions during childbirth were able to resume sexual intercourse within 3 months

after delivery.30 Hence, the pelvic floor muscle plays a very important role when it comes to

female sexual function.

10

Risk factors associated with sexual dysfunction include the mode of delivery (vaginal

delivery has a greater risk), perineum tears, or maternal fatigue.47 Vaginal dryness related to

breastfeeding is due to decreased estrogen levels and can be treated with lubricants. Sexual

dysfunction can also be caused by the lack of desire leading to decreased arousal, and aberrant

sexual response cycle. Having a baby can be overwhelming and time-consuming causing women

to have a decreased sexual desire.48

There is a lack of research on treating sexual dysfunction in the postpartum period, but

treatments that are being used are pelvic muscle contractions, vaginal lubricants and

communication with one’s partner to make time for sexual activity. 49

Screening of Pelvic Floor Disorders in the Postpartum Female

Even though pelvic floor disorders are commonly seen in women after pregnancy,

screening and evaluation is not universal. Some providers may ask women in their postpartum

checkup how they are doing but not ask specifically of such disorders. Unless the patient brings

up the issues herself, the provider may be unaware of such problems.50

A routine postpartum examination includes a screen for mental and physical well-being,

assessment of breast feeding, evaluation of any surgical incisions, and a pelvic exam if indicated

to assess the perineum for healing.51 If women do report pelvic floor dysfunctions to their

provider, pelvic floor rehabilitation may be recommended. This therapy consists of stretches

and contractions of the pelvic floor muscles to regain pelvic floor strength.52

11

Pelvic Floor Muscle Training

PFMT is a program taught or supervised most commonly by a physical therapist and

consists of the relaxation and contraction of the muscles of the pelvic region.6 The objective of

PFMT is to strengthen the muscles of the pelvic region to help prevent/treat pelvic floor

dysfunctions. A common way to perform PFMT is to hold a contraction for 10 seconds followed

by the relaxation for another 10 seconds, repeated 10 times 3-5 times a day, also known as a

Kegel.53

PFMT is commonly used to increase the strength of the pelvic floor to help improve

symptoms such as UI. The purpose of this literature review is to determine if PFMT is effective

in treating UI, Pelvic girdle pain and sexual dysfunction in the postpartum period.

12

Methods

Data Sources

Searching specific databases, (MEDLINE-EBSCOhost, CINAHL Plus full text, and

SPORTDiscu) while implementing an inclusion and exclusion criteria was performed to examine

PMFT muscle training on postpartum women to manage pelvic floor disorders. This review and

analysis of literature completed between September of 2015 to November of 2015. The

keywords used were pelvic floor muscle training or PFMT in combination with urinary

incontinence, stress urinary incontinence, pelvic pain, pelvic girdle pain, and sexual dysfunction.

The studies were also restricted to have the requirements of being written in English.

Study Selection

Originally the studies that were chosen had pelvic floor muscle training/PFMT in

combination with the keywords stated in the title or abstract. A meeting between two

reviewers was held to further include or exclude articles. During this time articles were

excluded if PMFT was not done in the postpartum period. Exclusion keywords included

antepartum, antenatal and prenatal. The two reviewers agreed on the articles to be used for

the quality assessment (APPENDIX A).

Quality Assessment

The Downs and Black checklist was used to check the methodological quality of the

articles. The checklist provides an overall score value in assessing the quality of the article

based on four categories of assessment: reporting, external validity, internal validity-bias, and

13

internal validity-confounding. The maximum score a study can receive is 26; the higher the

score an article received the better the quality of the study. The Downs and Black checklist has

been found to have a high internal consistency (KR-20: .89) for both randomized and non-

randomized studies, a high test-retest reliability (r=.88), a good inter-rater reliability (r= .75)

and a high quality index score (.90)(APPENDIX B).54 Using the overall score of each article they

were further categorized from conflicting evidence to strong evidence using Van Tulder’s level

of evidence table (APPENDIX C).55

14

Results

Fifteen articles were obtained using the exclusion and inclusion criteria. The dispersion

of articles by condition were as follows: ten urinary incontinence, three pelvic girdle pain, and

two sexual dysfunction.

Quality Assessment

After analyzing each article with the Downs and Black checklist there was an average

score of 17.26 with a range from 14 points to 20 points. The average score for the urinary

incontinence articles was 17.60 points, while the pelvic girdle pain articles averaged 16.67

points and the two sexual dysfunction articles averaged 16.50 points.

15

Discussion

Urinary Incontinence

There is strong evidence that PFMT improves UI in postpartum women. Based on the

ten articles that were reviewed, 8 found that PFMT resulted in improved UI symptoms. Meyer’s

study, which had a follow up period of 10 months, saw a 19% improvement in the PFMT group

compared to a 2% improvement in the control group. 56 Sut’s study investigated PFMT in

improving pelvic floor muscle strength and UI symptoms. The results indicated a correlation

between an increase in pelvic floor strength and an increase in the quality of the women’s life.57

A seven year follow up was performed in Dumoulin’s study which also saw improvement in UI,

but it was not as pronounced immediately after the training.58 Thus, PFMT may be considered

useful in managing UI symptoms in both the short and long-term periods following childbirth.

Based on the 8 articles that support PFMT, specific pelvic floor muscle contraction

routines help reduce UI in postpartum women. Multiple studies performed a maximum

contraction and held this contraction for 6-8 seconds followed by 10 fast contractions. The

women would than repeat this 10 times daily. 19,57,59,60 However, in Kim’s study the subjects did

the exact same exercise but in various positions (supine, prone, sitting and standing).61 Kim and

Marques paired the use of contractions with the inclusion of other exercises to try to improve

pelvic floor muscle strength. The exercises included abdominal strengthening and trunk

stabilizing exercises.19,61 While each of these methods improved UI, alternating pelvic floor

contractions seems to be necessary to prevent UI.

16

Two studies did not find improvement in UI with the use of PFMT. Hilde et al had a

follow up period of 6 months and subjects performed weekly supervised sessions for 16 weeks

but did not see any significant improvements.62 This article had the lowest score on the Downs

and Black checklist compared to the other UI studies; the internal validity of the selection bias

was scored low. The lack of choosing an appropriate assessment for this study could have

contributed to the different results from the other studies. Glazener performed two studies

investigating PFMT on UI, one in 2001 and the other in 2013. The first assessed participants at

one year post-delivery, while the second used the same participants but at a 12 year follow up.

After one year there were significant improvement in UI symptoms compared to the control

(60% vs 69%), however, after 12 years there was little to no improvement (80% vs 83%).60,63

This may be due to 92% of the women had at least one more child following the initial study

and if the women did not continue PFMT, the pelvic floor muscles would not regain its

strength.63

Sexual Dysfunction

Limited evidence supports the use of PFMT in treating sexual dysfunction in postpartum

women. Citak’s study scored a total of 18 points on the Downs and Black checklist, indicating

moderate quality; the lowest section being external validity. This study did an inadequate job of

representing an entire population by taking a low number of 75 volunteers from one hospital

instead of randomly choosing women from different areas. If more volunteers were chosen it

may have been a more adequate depiction of the population. The result of this study showed

17

that PFMT had a positive effect on improving female sexual function by the seventh month

postpartum. Arousal, lubrication and orgasm scores all seemed to improve compared to the

control group, who did not receive PFMT treatment.20 However, due to the poor quality of the

study, these positive findings must be interpreted cautiously.

Gagnon found that using PFMT during the postpartum resulted in an increase in pelvic

floor function but sexual function was found to be inconclusive. This may be attributed to the

fact that many women had not yet resumed sexual activity since childbirth.64 Hence, the three-

month follow up was an insufficient time period to deduce whether or not PFMT is effective in

treating sexual dysfunction.

Pain

There is limited evidence on the treatment of pelvic girdle pain with PFMT in

postpartum women. Sleep et al and Stuge et al both found an improvement in pelvic girdle

pain with the use of PFMT, while Gutke et al found no difference between the PFMT treatment

group and control group.

Sleep’s randomized control study received a fairly low score of a 14 on the Downs and

Black checklist, scoring the least amount of points in the reporting section. Sleep did not clearly

describe the characteristics of the patient and did not describe the intervention being used. The

study also did not describe the characteristics of the patients whom were lost to follow up, and

failed to measure the consequence of adverse events that may have changed the results. This

lead to a score of 0 for questions 3, 4, 8, and 9 in the reporting section. This study had women

18

perform specific stabilizing exercises as often as they can remember while doing daily tasks

such as chores, showering and using the bathroom. Because this study was subjective to

whether or not these women remembered to perform the exercises it was hard to record

actual compliance to the treatment.22 Stuge’s study received a high score of 20 on the Downs

and Black checklist and saw improvement in the exercise group in regards to pain in

postpartum women. Compared to Sleep’s study there was a higher compliance with the

exercise program by having supervised therapy sessions 3 days a week.43 Thus, supervised

PFMT may lead to better outcomes in improving pelvic girdle pain.

Gutke et al did not find a difference in the treatment and control group in regards of

improvement in pain. This may have been due to the fact that it was the responsibility of the

subjects to perform the exercises. The subjects did have to record a daily journal to help with

compliance to the program but the women can easily say they performed the treatment when

they actually did not, also known as recall bias.

19

Conclusion

It is evident that women can undergo substantial damage to their pelvic floor muscles

during pregnancy and childbirth, which can cause multiple dysfunctions in the postpartum

period. PFMT seems to be effective in treating UI, but there is a lack of research to state that

PFMT helps treat sexual dysfunction and pelvic pain. These studies have shown that the most

effective way to treat UI with PFMT is to have women perform daily contractions of their pelvic

floor muscles. She should first hold the contraction followed by a repetition of 10 fast

contractions.

Overall, PFMT is a conservative and non-invasive treatment to help women treat certain

dysfunctions. It is not only easy to teach, but is inexpensive compared to more invasive

treatments such as surgery. Although research shows PFMT to be an effective treatment for UI

further research investigating the use of PFMT for managing sexual dysfunction and/or pelvic

pain is warranted.

20

Appendix A: Summary of Studies

21

Study (year) Subjects Dysfunctio

n Category

PFMT Exercise

Protocol

Outcome measures

used

Pertinent

findings

Quality

(Was the

study a

Randomize

d Control

trial?)

Ahlund, Susanne, 2013

82 women

UI PFM exercises performed 7 days a week for 6 months, midwife would visit every 6 weeks to encourage intervention

Bristol female lower urinary tract symptoms questionnaire to measure strength of pelvic floor and UI symptoms. Contraction measured with perionometer

PFMT is effective for UI. Written training and home-based training had same effect.

Yes

Citak, Nevin, 2010

75 women

Sexual Function

Instructed PFMT by nurse, booklet description of PFMT, told to do 10secound duration of contraction 10xs for 15 days

PFM strength with oxford grading system with an inflatable intravaginal device attached to a manometer, Intravaginal pressures measured

Scores of sexual desire and pain improved at the 7th month. Arousal, lubrication, orgasm and total scores of FSFI were higher in the PFMT group

Yes

Dumoulin, Chantale, 2013

57 women

UI 15 min of electrical stimulation than 25 min of PFMT, 10 min of deep abdominal muscle exercises, once a day, 5 days a week for 8 weeks

Pad test for urinary incontinence, 3 questionnaires assessment on the symptoms associated with UI

Deep abdominal training does not appear to further improve the outcome of PMFT, but PFMT does

Yes

22

improve UI

Gagnon, Louise-Helene, 2015

50 women

Sexual Function

4 sessions, performed PFMT with direct feedback

PF function measured by PFIQ-7 and PISQ-12, PF strength by the MOS, satisfaction with 10-point Likert scale

Improvement in pelvic floor function , unable to assess impact on sexual function

No

Glazener, Catheryn, 2001

747 women

UI Assessment by nurses of UI with advice on PFM exercises at 5, 7 and 9 months postpartum.

Questionnaires regarding UI

Intervention group had less UI 12 months postpartum

Yes

Glazener, CMA, 2013

471 women

UI One-to-one instruction in PFMT with bladder training on 3 occasions

Questionnaire on fecal and urinary incontinence symptoms

Significant improvement relative to controls found in UI after 1 year follow up, but difference did not persist 6-12 year follow ups

Yes

Gutke, Annelie, 2010

88 women

Pain Specific stabilizing exercises, 2Xs a day with 10 repetitions

Disability measured with Oswestry Disability index, questionnaires looked at pain, quality of life, satisfaction and muscle function

PFMT was no more effective in improving pelvic girdle pain at 6 months post-delivery, although 3 months postpartum

Yes

23

did favor the treatment group

Hilde, Gunvor, 2013

175 women

UI Supervised exercise class, once a week for 16 weeks

Questionnaire, ultrasonography manometer 6 months postpartum

PFMT did not decrease UI 6 months after delivery

Yes

Kim, Eun-Young, 2011

18 women

UI Supervised sessions (23 sessions) 1 hour each , 3Xs a week for 8 weeks

Bristol female lower urinary tract symptom questionnaire, vaginal function test using a perineometer

Urinary symptoms, quality of life, vaginal squeeze pressure and holding time improved for the supervised sessions

Yes

Marques J et al, 2012

33 women

UI 10 sessions; 3/wk x 60min each; supervised by PT at home visits; pictures included

PF muscle contractility (digital palpation & sEMG); ICIQ-UI SF & ICIQ-OAB

Improvement in urinary loss based on ICIQ-UL SF scores. Frequency, urgency, nocturia, and urge decreased.

No

Morkved, Siv, 2000

81 women

UI 45 min exercise sessions once a week for 8 weeks, also including home based exercises

Questionnaire was given out 1 year postpartum to evaluate UI

After one year PFMT was effective in reducing UI

No

S. Meyer, 2001

107 women

UI 12 sessions that included 20 minutes of biofeedback and

Used questionnaire, clinical examinations,

UI decreased in the PFMT group

No

24

15 minutes of electrostimulation in conjunction with PFMT

perineosonograp-hy, urethral pressure recordings during pelvic floor contractions

Sleep, Jennifer, 1987

1800 women

Pain Instructed by midwife coordinator for exercise sessions, complete a health diary (described specific exercise, with pictures) over a 4 week period

Used a questionnaire, chi-square test to see statistical significance

Significant reduction in pain for the PFMT group

Yes

Stuge, Britt, 2004

81 women

Pain 40-60 min Physical therapy sessions 3 days a week for 20 weeks with specific stabilizing exercises

Questionnaires measured pain and functional status

Specific stabilizing exercises appears to be more effective to treat pelvic girdle pain after 20 weeks and 1-2 years after pregnancy

Yes

Sut, Hatice, 2015

60 women

UI Instructed on how to perform kegals, 10 contractions 3Xs a day

PFM strength measured with perineometry, urinary symptoms measured with OAB-q, voiding functions measured with

PFM exercises increased PFM strength and improves urinary symptoms and quality

Yes

25

uroflowmetry of life.

26

Appendix B: Scoring of Articles

27

A B C D

1)

Ob

jecti

ve i

s cl

earl

y d

esc

rib

ed

2)M

ain

ou

tcom

es

clea

rly

desc

rib

ed

3)C

ha

racte

ris

tics

of

pa

tien

ts c

lea

rly

desc

rib

ed

4

)In

terv

en

tio

ns

cle

arly

des

crib

ed

5)D

istr

ibu

tio

n o

f co

nfo

un

ders

in e

ach

gro

up

cle

arl

y d

esc

rib

ed

6

) F

ind

ing

s cl

earl

y d

esc

rib

ed

?

7)P

rovid

es

est

ima

tes

of

the v

ari

ab

ilit

y

8)A

dv

erse

ev

en

ts t

ha

t m

ay c

au

se

inte

rven

tio

ns

been

rep

orte

d

9)P

ati

en

ts l

ost

cle

arly

desc

rib

ed

10

)Actu

al

pro

ba

bil

ity

va

lues

bee

n

rep

orte

d

11

)su

bje

cts

rep

rese

nta

tive o

f en

tire

po

pu

lati

on

1

2)S

ub

jects

pre

pa

red

to

parti

cip

ate

rep

rese

nta

tive o

f p

op

ula

tio

n f

rom

wh

ich

th

ey w

ere r

ecru

ited

1

3)S

taff

,pla

ces,

an

d f

aci

liti

es

wh

ere

pa

tien

ts w

ere

trea

ted

rep

rese

nta

tive o

f

the m

ajo

rity

of

the t

rea

tmen

t fo

r

pa

tien

ts

14

)att

em

pt

to b

lin

d t

he

stu

dy

15

)Bli

nd

th

ose

measu

rin

g t

he

ou

tcom

es

16

)wa

s d

ata

dred

gin

g m

ad

e c

lea

r

17

)Tim

e p

eri

od

fo

r in

terven

tio

n a

nd

ou

tcom

e th

e s

am

e f

or c

ase

s/co

ntr

ols

1

8)

Sta

tist

ica

l te

sts

use

d t

o a

sses

s th

e

main

ou

tcom

es

ap

pro

pri

ate

1

9)

Co

mp

lia

nce

wit

h t

he i

nte

rven

tion

s

reli

ab

le

20

) A

ccu

rate

ma

in o

utc

om

e m

easu

res

21

) S

ub

jects

recr

uit

ed

from

th

e sa

me

po

pu

lati

on

2

2)

Su

bje

cts

recr

uit

ed

wit

hin

th

e sa

me

tim

e 2

3)

Stu

dy

su

bje

cts

ra

nd

om

ized

to

inte

rven

tio

n g

rou

ps

24

) R

an

dom

ized

in

terv

en

tio

n

ass

ign

men

t co

nce

ale

d f

rom

pa

tien

ts

an

d h

ealt

h c

are

sta

ff

25

) A

deq

ua

te a

dju

stm

en

ts f

or

co

nfo

un

din

g v

ari

ab

les

26

) L

oss

es o

f p

ati

en

ts t

o f

oll

ow

-up

tak

en

in

to a

cco

un

t T

ota

l (o

ut

of

26

)

Ahlund,

Susanne,20

13

1 1 1 1 0 1 1 0 1 0 0 0 1 0 1 1 1 1 0 1 1 1 1 0 0 1 1

7 Citak,Nevi

n, 2010 1 1 1 1 0 1 1 0 1 1 0 0 1 0 1 1 1 1 0 1 1 1 1 0 0 1 1

8 Dumoulin,

Chantale,

2013

1 1 1 0 1 1 1 0 1 0 0 0 1 0 1 1 1 1 1 1 1 1 1 1 0 1 1

9 Gagnon,Lo

uise-

Helene,

2015

1 1 1 0 1 1 1 0 0 1 0 0 1 0 0 1 1 1 0 1 1 1 0 0 0 1 1

5

Glazener,C

atheryn,

2001

1 1 0 0 0 1 1 0 1 1 1 1 1 0 1 1 1 1 0 1 1 1 1 0 0 1 1

8 Glazner,

CMA, 2013 1 1 0 0 0 1 1 0 1 1 1 0 1 0 0 1 1 1 1 1 1 1 1 0 0 1 1

7 Gutke,

Annelie,

2010

1 1 1 0 1 1 1 0 1 1 0 0 1 0 1 1 1 1 0 1 0 0 1 0 0 1 1

6 Hilde,

Gunvor,

2013

1 1 1 0 1 1 1 0 0 1 0 0 1 0 1 1 0 1 0 1 1 1 1 0 0 1 1

6 Kim, Eun-

Young,

2011

1 1 1 0 0 1 1 0 1 1 0 0 1 0 1 1 1 1 1 1 1 1 1 0 0 1 1

8 Marques J

et al, 2012 1 1 1 1 0 1 1 0 1 1 0 0 1 0 1 1 1 1 1 1 1 1 0 0 0 1 1

8 Morkved,

Siv, 2000 1 1 0 1 2 1 1 0 1 1 1 1 1 0 0 1 1 1 0 1 1 1 1 0 0 1 2

0

28

Key: A: Reporting, B: External Validity, C: Internal Validity – Bias, D: Internal

Validity – Selection Bias

S. Meyer,

2001 1 1 1 0 2 1 1 0 0 0 0 0 1 0 1 1 1 1 1 1 1 1 0 0 0 0 1

6 Sleep,

Jennifer,

1987

1 1 0 0 1 1 1 0 0 0 1 1 1 0 0 1 1 1 0 0 1 1 1 0 0 0 1

4 Stuge,

Britt, 2004 1 1 1 1 1 1 1 0 1 0 0 0 1 0 1 1 1 1 1 1 1 1 1 1 0 1 2

0 Sut, Hatice,

2015 1 1 1 1 0 1 1 0 1 1 0 0 1 0 0 1 1 1 0 1 1 1 1 0 0 1 1

7

29

Appendix C: Level of Evidence

30

Level of Evidence Description

Strong evidence Pooled results derived from three or

more studies, including a minimum

of two high-quality studies which

are statistically homogenous (p >

0.05) - may be associated with

statistically significant or non-

significant pooled result

Moderate evidence Statistically significant pooled

results derived from multiple

studies, including at least one high-

quality study, which are statistically

heterogeneous (p < 0.05); or from

multiple low-quality studies which

are statistically homogenous (p >

0.05)

Limited evidence Results from multiple low-quality

studies which are statistically

heterogeneous (p < 0.05); or from

one high-quality study

Very limited evidence Results from one low-quality study

Conflicting evidence Pooled results insignificant and

derived from multiple studies,

regardless of quality, which are

statistically heterogeneous (p < 0.05,

i.e. inconsistent)

31

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