Impact of menopausal status on the outcome of pelvic floor
physiotherapy in women with urinary incontinence
Christiana Campani Nygaard & Cornelia Betschart &
Ahmed A. Hafez & Erica Lewis & Ilias Chasiotis &
Stergios K. Doumouchtsis
Received: 19 December 2012 /Accepted: 12 February 2013
#The International Urogynecological Association 2013
Introduction and hypothesis The purpose of this study was
to evaluate the effectiveness of pelvic floor muscle training
in pre- and postmenopausal women using a quality-of-life
Methods We retrospectively reviewed the medical recordsof
96 patients with urinary incontinence who participated in a
pelvic floor muscle-training (PFMT) program at the
Physiotherapy Department in a London University Hospital
between January 2010 and August 2011.
Results A period of supervised PFMT resulted in significant
improvement in symptoms of stress urinary incontinence,
urge urinary incontinence, urgency, frequency, and nocturia,
irrespective of menopausal status.
Conclusions Pre- and postmenopausal women experience
similar outcomes in relation to urinary symptoms following
a short-term supervised PFMT.
Pelvic floor muscle training
Pelvic floor muscle
Stress urinary incontinence
Urge urinary incontinence
International Consultation on Incontinence
Modular Questionnaire/Female Lower
Urinary Tract Symptoms
Hormonal replacement therapy
Body mass index
Urinary incontinence (UI) is a common condition, with ap-
proximately 10 % of women experiencing urine leakage at
least once a week, with a significant impact on quality of life
(QOL) . Current guidelines recommend conservative man-
agement, defined as interventions that do not involve treat-
of pelvic floor muscle training (PFMT) of at least 3 months
should be offered, with reasonably frequent appointments [3,
4]. It has been reported that women receiving regular super-
visionare morelikelytocomplyand reportimprovement than
women doing PFMTwith little or no supervision .
C. C. Nygaard (*)
Departament of Gynaecology, Pontifícia Universidade Católica do
Rio Grande do Sul, St George´s Healthcare NHS Trust,
Porto Alegre, Brazil
Department of Gynecology, University Hospital Zurich
A. A. Hafez
Faculty of Health and Social Care Sciences, Kingston University,
St. George’s University of London, London, UK
St George’s Healthcare NHS Trust, London, UK
Department of Obstetric and Gynecology, General Hospital of
Nikaia, Athens, Greece
S. K. Doumouchtsis
St George’s Healthcare NHS Trust / St George’s University of
London, London, UK
Int Urogynecol J
PFMTis based on principles of strengthening the muscular
components of the urethral closure mechanism. Intensive
strength training may build up structural support of the pelvis
by permanently elevating the levator plate to a higher position
inside the pelvis. It also enhances hypertrophy and stiffness of
connective tissues [5–7]. The bladder neck receives support
from a strong, toned PFM, which limits its downward move-
ment during effort and exertion, preventing stress urinary
incontinence (SUI) . PFM contraction stimulates sympa-
thetic nerve fibers of the internal urethral sphincter, decreases
detrusor muscle tone, and suppresses detrusor contraction ,
which prevents urinary urgency incontinence (UUI) .
Female genital and urinary tracts share a common em-
bryologic origin arising from the urogenital sinus. Both are
sensitive to the effect of female “sex” steroid hormones.
Estrogens play an important role in lower urinary tract func-
tion throughout the adult lifespan. Estrogen deficiency after
menopause causes atrophic changes to the urogenital tract
and is associated with urinary symptoms . Estrogens also
increase urethral closure pressure, urethral blood flow, α-
adrenergic receptor sensitivity, and improve cellular matura-
tion in both the urethra and vagina .
As the tissues involved in the female urinary continence
mechanism are estrogen sensitive, it is possible that estrogen
deficiency after menopause may be an etiological factor in the
development or progress of UI. The condition may improve
with the use of local estrogen treatment . However, a
systematic review of the literature reveals little evidence from
trials on the period after estrogen treatment had finished .
In addition, no evidence is available regarding long-term
effects of this therapy. Conversely, in the same review, sys-
temic hormone replacement therapy using conjugated estro-
gen showed it may even worsen incontinence . Thus,
evidence does not favor a beneficial effect on SUI with the
use of local estrogen therapy .
Our hypothesis isthat estrogen statusmaybe animportant
contributing factor to the effectiveness of pelvic floor physio-
therapy. Therefore, the aim of this study was to evaluate and
toms in pre- and postmenopausal woman.
Materials and methods
This was a retrospective study designed to evaluate the effec-
The primary outcome measure was the assessment of bladder
symptoms before and after a period of supervised and stan-
dardized PFMT. All women who attended the Physiotherapy
Department in a London University Hospital with UI between
January 2010 and August 2011, who participated in a specific
PFMT program, and who completed the questionnaire were
included (n=47 pre- and n=35 postmenopausal women). The
one-to-one PFMT sessions were conducted in ambulato-
ry hospital settings and supplemented by an individually
instructed and progressively adapted home exercise program.
patients. In addition, patients were instructed about the correct
PFM activation assessed by digital vaginal palpation in order to
empower their ability to incorporate PFMTin routine daily life.
Women with overactive bladder (OAB) symptoms were
ing and voiding behavior, as recommended. Patients who had
difficulties contracting PFM were supported by electromyogra-
phy biofeedback during office sessions to help them recognize
the right technique for muscle contraction .
Symptoms were assessed based on results of the val-
idated International Consultation on Incontinence Modular
Questionnaire/Female Lower Urinary Tract Symptoms (ICIQ-
FLUTS) questionnaire . Each answer in the questionnaire
the intensity of each symptom, where the greater the number,
the more severe and troubling the symptom. Changes in symp-
scores. The questionnaire is composed of 12 items, but we
particularly focused on OAB symptoms, such as frequency of
micturition, nocturia, urgency, urinary urgency incontinence
(UUI), and SUI.
To control for varying age of menopause onset and the
possibility of gradual changes over that critical period, 14
women between the ages of 45 and 55 years were excluded.
This would remove perimenopausal women from our cohort.
Menopause occurs at a median age of 51.4 years. The meno-
before the final menstrual period and occurs on average at
47 years. It includes a number of physiological changes and
marked hormonal fluctuations [14, 15]. We decided to avoid
using data for any patient in this age category. Patients >55
years were accepted as postmenopausal, and patients <45
al status was confirmed for all women in this study according
to the self-reported menopausal status in their charts. Patients
on hormone replacement therapy (HRT) were studied as a
separate subgroup to control for the possible impact of HRT.
Statistical analyses were performed using SPSS v21.
Descriptive statistics (mean, median, standard deviation, and
range) were used to present numerical variables values.
Numbers and absolute and relative percentage frequencies
were used to present categorical variables. Mann–Whitney
U test was used to assess statistical significance of differences
between median values. Continuous data were analyzed with
related-sample Student’s t test. To compare changes in symp-
toms between patients in the pre- and postmenopausal groups,
we further categorized the results into two subgroups: patients
who reported improved symptoms and patients who reported
no changes or worsening symptoms. The chi-square test was
Int Urogynecol J
changes in symptom severity after treatment. Significant dif-
ferences between groups were placed in a multiple logistic
regression analysis. This study was registered to our hospital
audit’s committee (audit registration number 3255).
Eighty-two women were included in the study and were di-
vided into two groups: those <45 years (n=47) were all pre-
menopausal, and those >55 years (n=35) were all postmeno-
and 55 years were excluded from the study for reasons
explained above. Patient characteristics are shown in Table 1.
The median baseline rate of reported UI symptoms was
similar in the pre- and postmenopausal groups regarding fre-
quency (p=0.432), urgency (p=0.090), UUI (p=0.415), SUI
(p=0.324), and leakage frequency (p=0.234). Symptoms were
significantly higher in the postmenopausal group in relation to
nocturia (p=0.040). A period of supervised PFMT resulted in
significant improvement in symptoms of SUI, UUI, urgency,
frequency, and nocturia in both groups (Table 2).
All relevant symptoms tended to improve to similar extent
episodes of nocturia increased in eight patients in the postmen-
opausal group. We examined any associations of changes with
menopausal status using the chi-square test and found no
statistically significant associations.
When changes of symptoms within the postmenopausal
group were compared in patients who had been on oral HRT
(n=10) and those who had never taken HRT, no significant
associations were observed in relation to all studied symptoms.
group (mean = 28.0) compared with the premenopausal group
(mean= 25.5, p=0.033), but whenwe examinedthe association
HRT failed to reach statistical significance as confounding fac-
tors for improvement in menopausal women (Table 4).
We aimed to assess the impact of PFMT and compare it
between in pre- and postmenopausal women. Symptoms of
frequency, urgency, nocturia, UUI, and SUI were studied in
the two groups before and after PFMT to assess a possible
impact for the change of estrogen levels due to menopause.
PFMT is an intensive exercise that demands a great deal of
motivation and time from patients. Our hypothesis was that
premenopausal women would benefit more due to favorable
effects of estrogens on the pelvic floor. However, we found
that both pre- and postmenopausal women experience similar
short-term supervised PFMT. In both groups, patients im-
proved significantly in various domains of the ICIQ-FLUTS
nocturia, a notoriously complex symptom that is difficult to
treat, especially in comorbid postmenopausal women with
long-term conditions that might progressively contribute to
The similar outcomes point out that both groups were
able to apply and benefit from motor learning strategies
and adopt functional training to improve their urinary
symptoms in similar ways, irrespective of hormonal status
or HRT and BMI category. To the best of our knowledge,
this is the first study to address these issues and reach
Table 1 Patient characteristics
incontinence, SUI stress urinary
incontinence, MUI mixed uri-
nary incontinence, UUI urge
Mean (standard deviation)
Number of appointments
Positive family history of UI
Use of pads
Int Urogynecol J
these conclusions.Our findings pave the way for using PFMT
to support patients with urinary symptoms, regardless of their
hormonal status or BMI.
The literature diverges in regard to the effect of the age on
outcomes of PFMT for UI. Clinical trials report that older
women have worse outcomes [16, 17], whereas other trials
Table 2 Pre-and posttreatment reported symptoms severity of frequency, urgency, and nocturia
Int Urogynecol J
show no relationship [18–21]. In a study of community-
dwelling women who underwent nonsurgical incontinence
treatment, elderly patients reported less improvement than
the younger ones . Furthermore, a trial evaluating the
effectiveness of home biofeedback revealed a significant
difference between the youngest and the oldest age group
. However, a multicentre cohort found no association
with age and poor outcome of physiotherapy intervention in
women with SUI . A trial investigating baseline factors
that may predict treatment success and patient satisfaction in
women undergoing nonsurgical therapy for SUI revealed
that postmenopausal women were more likely to report a
greaterglobal impression of improved continence status than
were premenopausal women .
Clinical muscle strength measurement studies found no
direct correlation of improvement in continence with the
degree of increase in PFM strength . This emphasizes
the important role of neuromuscular adaptation or the
guarding reflex and neuronal control that can be trained at
different ages [23, 24]. It remains unclear, however, whether
older patients are more easily satisfied with their goal attain-
ment, especially for SUI, as they might be physically less
active. On the other hand, this debate may not hold true for
is more prevalent in postmenopausal patients. Therefore, it
may be more challenging to achieve successful treatment in
postmenopausal women with UUI and MUI . Baseline
incontinence is likely to be more severe in older patients, as
reported in previous studies, and this could affect the
expected outcome of PFMT . Despite these unfavorable
predictors in the elderly group, our study demonstrated that
postmenopausal women could benefit of PFMT in a similar
way to younger, premenopausal women, regardless of the
apparent hormonal disadvantage.
Obesity is a well-known risk factor for UI , and in our
sample, we found it was more prevalent in the postmenopausal
group. In order to explore the possible effect of high BMI, we
examined the association of changes in symptoms in
obese/overweight and nonobese patients from the two groups
and found no statistically significant association.
Table 4 Binary logistic regression analyses in postmenopausal women
Confounding factorScore Significance
Often leak leak
SUI stress urinary incontinence, UUI urgency urinary incontinence,
HRT hormone replacement therapy
Table 3 Changes in symptoms
Often leak Premenopausal
Int Urogynecol J
Our study has several limitations, the most important
being its retrospective design. In addition, data were avail-
able only for patients who were compliant with the treat-
ment, and a positive biased outcome could not be excluded.
This is an inherent weakness with most retrospective studies.
One could only speculate whether the extent of this bias is
valuable contribution to current knowledge and provide a
guide to future prospective studies.
In conclusion, our study showed no association between
menopausal status and improvement in UI symptoms with
PFMT. This study contributes to the knowledge that this effect
appears to be independent of menopausal status. Further re-
search is needed to explore the underlying pathophysiological
mechanisms and further elucidate any association between es-
trogen status, neuromuscular response, and clinical outcomes.
Conflicts of interest
Erica Lewis and Ilias Chasiotis declares no conflicts of interest.
Cornelia Betschart, Sponsorship by Astellas, Allergan and Pfizer for
participation in meetings.
Stergios K. Doumouchtsis, Sponsorship by Astellas and Pfizer for
participation in meetings.
Christiana Campani Nygaard, Ahmed A. Hafez,
1. Vandoninck Vet al (2004) The prevalence of urinary incontinence
in community-dwelling married women: a matter of definition.
BJU Int 94(9):1291–1295
2. Thuroff JW et al (2011) EAU guidelines on urinary incontinence.
Eur Urol 59(3):387–400
3. National Institute for Health and Care Excellence (2006) Urinary
incontinence: the management of urinary incontinence in women.
Clinical Guideline. 40.
4. Hay-Smith EJ et al (2011) Comparisons of approaches to pelvic
floor muscle training for urinary incontinence in women. Cochrane
Database Syst Rev 12, CD009508
5. (1998) Terminologia anatomica: international anatomical terminol-
ogy. Thieme, Stuttgart. http://www.unifr.ch/ifaa/
6. Dumoulin C, Hay-Smith J (2010) Pelvic floor muscle training
versus no treatment, or inactive control treatments, for urinary
incontinence in women.CochraneDatabase SystRev1, CD005654
7. Bo K (2004) Pelvic floor muscle training is effective in treatment of
female stress urinary incontinence, but how does it work? Int
Urogynecol J 15(2):76–84
8. Ashton-Miller JA, Howard D, DeLancey JO (2001) The functional
anatomy of the female pelvic floor and stress continence control
system. Scand J Urol Nephrol Suppl 207:1–7, discussion 106–25
9. Robinson D,CardozoL(2003)Theroleofstrogens in femalelower
urinary tract dysfunction. Urology 62(4):45–51
10. Cardozo L, Bachmann G, McClish D, Fonda D, Birgerson L
(1998) Meta-analysis of estrogen therapy in the management of
urogenital atrophy in postmenopausal women: second report of
the Hormones and Urogenital Therapy Committee. Obstet Gynecol
11. Cody JD, Jacobs ML, Richardson K, Moehrer B, Hextall A (2012)
Oestrogen therapy for urinary incontinence in post-menopausal wom-
en. Cochrane Database Syst Rev (Issue 10. Art. No.):CD001405.
12. Nappi RE, Davis SR (2012) The use of hormone therapy for the
maintenance of urogynecological and sexual health post WHI.
consultation on Incontinence Modular Questionnaire: www.iciq.net.
J Urol 175(3):1063–1066
14. McKinlay SM, Brambilla DJ, Posner JG (1992) The normal men-
opause transition. Maturitas 14:103
15. Soules MR, Sherman S, Parrott E et al (2001) Executive summary:
Stages of Reproductive Aging Workshop (STRAW). Fertil Steril
16. Weinberger MW, Goodman BM, Carnes M (1999) Long-term effi-
J Gerontol A Biol Sci Med Sci 54(3):117–121
17. Smith DB, Boileau MA, Buan LD (2000) A self-directed
home biofeedback system for women with symptoms of stress, urge,
and mixed incontience. J Wound Ostomy Continence Nurs 27:240–
18. Theofrastous JP,WymanJF,BumpRC etal (2002)Effectsofpelvic
floor muscle training on strength and predictors of response in
the treatment of urinary incontinence. Neurourol Urodyn 21:486–
19. Burgio KL, Goode PS, Locher JL et al (2003) Predictors of out-
come in the behavioural treatment of urinary incontinence in wom-
en. Obstet Gynecol 102(5 Pt 1):940–947
20. Wyman JF, Fantl JA, McClish DK et al (1998) Comparative effi-
cacy of behavioral interventions in the management of female
urinary incontinence. Continence program for women research
group. Am J Obstet Gynecol 179(4):999–1007
21. Hendriks EJM, Kessels AGH, de Vet HCWet al (2010) Prognostic
indicators of poor short-term outcome of physiotherapy interven-
tion in women with stress urinary incontinence. Neurourol Urodyn
22. Schaffer J et al (2012) Predictors of success and satisfaction of
nonsurgical therapy for stress urinary incontinence. Obstet Gynecol
23. Quartly E, Hallam T, Kilbreath S et al (2010) Strength and endur-
ance of the pelvic floor muscles in continent women: an observa-
tional study. Physiotherapy 96(4):311–316
24. Park JM, Bloom DA, McGuire EJ (1997) The guarding reflex
revisited. Br J Urol 80:940–945
25. Kim JS, Kim SY, Oh DW et al (2010) Correlation between the
severity of female urinary incontinence and concomitant morbid-
ities: a multi-center cross-sectional clinical study. Int Neurourol J
Int Urogynecol J