ArticlePDF AvailableLiterature Review

Abstract and Figures

Pelvic floor muscle exercises have been recommended for urinary incontinence since first described by obstetrician gynecologist Dr. Arnold Kegel more than six decades ago. These exercises are performed to strengthen pelvic floor muscles, provide urethral support to prevent urine leakage, and suppress urgency. In clinical urology practice, expert clinicians also teach patients how to relax the muscle to improve bladder emptying and relieve pelvic pain caused by muscle spasm. When treating lower urinary tract symptoms, an exercise training program combined with biofeedback therapy has been recommended as first-line treatment. This article provides clinical application of pelvic floor muscle rehabilitation using biofeedback as a technique to enhance pelvic floor muscle training.
Content may be subject to copyright.
UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4 193
The pelvic floor contains
a group of muscles –
pelvic floor muscles
(PFMs) – that extend
from the symphysis pubis (ante-
rior) to the back (posterior) of the
bony pelvis, forming a hammock
that supports the pelvic organs
(Newman & Wein, 2009). The
PFMs are composed of the leva-
tor ani group and includes the
pubococcygeus, puborectalis,
and ileococcygeus muscles (see
Table 1 and Figure 1). PFMs are
composed primarily of skeletal
muscle that differs from other
skeletal muscle because they not
only provide support for all the
organs of the pelvis, they have a
higher resting muscle tone so as
to support the external urinary
sphincter. PFMs are entirely
under voluntary control and play
an important role in maintaining
continence, and can become
weakened from pregnancy and
childbirth, lack of use, a decrease
in the hormone estrogen, aging,
surgery, and injury (Maserejian et
al., 2014).
Pelvic Floor Muscle Exercises
Weakness in PFMs can lead
to problems with both bladder
and rectal support because fecal
and urinary continence are diffi-
cult to maintain without ade-
Pelvic Floor Muscle Rehabilitation
Using Biofeedback
Diane K. Newman
Diane K. Newman, DNP, ANP-BC, FAAN,
BCB-PMD, is an Adjunct Professor of
Urology in Surgery and Research
Investigator Senior, Perelman School of
Medicine, University of Penn sylvania’ and
Co-Director, Penn Center for Continence and
Pelvic Health, Division of Urology, Penn
Medicine, Philadelphia, PA.
Advanced Clinical Practice
© 2014 Society of Urologic Nurses and Associates
Newman, D.K. (2014). Pelvic floor muscle rehabilitation using biofeedback.
Urologic Nursing, 34(4), 193-202. doi:10.7257/1053-816X.2014.34.4.193
Pelvic floor muscle exercises have been recommended for urinary incontinence
since first described by obstetrician gynecologist Dr. Arnold Kegel more than six
decades ago. These exercises are performed to strengthen pelvic floor muscles,
provide urethral support to prevent urine leakage, and suppress urgency. In clin-
ical urology practice, expert clinicians also teach patients how to relax the mus-
cle to improve bladder emptying and relieve pelvic pain caused by muscle spasm.
When treating lower urinary tract symptoms, an exercise training program com-
bined with biofeedback therapy has been recommended as first-line treatment.
This article provides clinical application of pelvic floor muscle rehabilitation using
biofeedback as a technique to enhance pelvic floor muscle training.
Key Words: Pelvic floor muscle training, biofeedback therapy, electro myo -
gram, vaginal and rectal sensors, pelvic floor muscle electrical
Figure 1.
Muscles of the Pelvic Floor
Source: © Diane K. Newman. Used with permission.
Ischiocavernous Muscle
Bulboocavernous Muscle
Deep Transverse
Perineal Muscle
Perineal Body
Superficial Transverse
Perineal Muscle
Ischial Tuberosity
External Anal Sphincter
Levator Ani Muscle
Anococcygeal Ligament
Pubis Pubic
Copyright 2014 Society of Urologic Nurses and Associates (SUNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the Society of Urologic Nurses and Associates. doi 10.7257/1053-816X.2014.34.4.193
194 UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4
quate strength and support. Cor -
recting PFM weakness through
muscle rehabilitation is helpful
in treating urinary incontinence
(UI) if lack of pelvic support is
the causative factor. Increasing
functionality of PFMs has also
been shown to help with alleviat-
ing urinary urgency and frequen-
cy, and has been linked to activa-
tion of the sacral micturition cen-
ter, which in turn results in uri-
nary urge inhibition (Moore et
al., 2013; Wyman, Burgio, &
Newman, 2009).
Pelvic floor muscle training
(PFMT) is based on the presump-
tion that exercising can both
increase the capacity of existing
muscle and hypertrophy the
muscle (aerobic and anaerobic
capacity); thus, strong repeated
exercise increases muscle bulk,
and prolonged muscle contrac-
tion at moderate intensity in -
creases endurance. Hypertrophy
of the muscle might take weeks
to months before it is apparent
(McLean et al, 2013). In addition
to PFMT with biofeedback, clini-
cians with expertise in behav-
ioral treatments for UI and relat-
ed lower urinary and pelvic
symptoms add other interven-
tions, including bladder training
with urgency inhibition or sup-
pression, and diet and fluid man-
agement to maximize outcomes
(Greer, Smith, & Arya, 2012;
Newman & Wein, 2013; Wyman
et al, 2009).
Biofeedback Therapy
Biofeedback (BF) therapy is a
technique in which physiologi-
cal activity (neuromuscular and
autonomic activity) is monitored,
amplified, and conveyed to the
patient (feedback) as visual or
acoustic signals (Newman &
Wein, 2009). As a result, BF gives
an individual immediate feed-
back about normal body process-
Table 1.
Muscles of the Pelvic Floor
Origin Insertion Action Relevance
Pelvic Floor Muscle
Coccygeus Pelvic surface of
the ischial spine
Side of the coccyx and
lower sacrum
Elevates the
pelvic floor
Cases of pain associated with
sitting, vaginal delivery, or chronic
constipation due to prolonged,
repetitive, or traumatic irritation
and compression.
Levator ani (LA) Posterior surface
of the body of the
pubis, arcus
tendineus levator
ani, ischial spine
Anococcygeal raphe
and coccyx
Elevates the
pelvic floor, mid-
urethral vaginal
vault, and anus
Serves as an inner-core muscle
to provide lumbopelvic stability,
and it protects the pelvic girdle
by resisting increases in intra-
abdominal pressure.
Contracts during orgasm.
Ability to relax volitionally to
assist normal urination and
Layers of the Levator Ani
Arcus tendineus
levator ani, and
the ischial spine
Anococcygeal raphe
and the coccyx
(clinically called the
levator plate)
Elevates the
pelvic floor
Creates a supportive diaphragm
posteriorly to resist elevated
intra-abdominal pressures.
Posterior aspect
of the superior
pubic ramis
Passes backward along
the puborectalis muscle
and inserts into the
anococcygeal and the
superior surface of the
Elevates the
pelvic floor
Fibers create a band (often
referred to as a hammock).
Provides essential support to the
proximal bladder neck and
Posterior aspect
of the body of the
Proceeds backward
along the edge of the
genital hiatus in contact
with the side of the
vagina and loops
around the rectum
(anorectal junction)
creating the anorectal
angle below the coccyx
Draws the distal
rectum forward
and superiorly
Pulls rectum forward during
contraction and assisting with
providing anal continence.
Source: Adapted from Corton, 2009.
Copyright 2014 Society of Urologic Nurses and Associates (SUNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the Society of Urologic Nurses and Associates. doi 10.7257/1053-816X.2014.34.4.193
UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4 195
es of which they may not be
aware. It provides instantaneous
information to the patient about
the status of the PFM. While
some consider BF part of comple-
mentary therapy, it is also
viewed as an adjunct to PFM
rehabilitation for persons with
lower urinary tract symptoms
(LUTS) (e.g., irritative and emp-
tying symptoms) and pelvic floor
dysfunction (e.g., pelvic pain).
Figure 2 outlines a Decision Tree
for instituting PFM rehabilitation
for LUTS, neurogenic bladder
dysfunction, and pelvic pain.
BF therapy that involves
neuromuscular training is an
instrument-based learning pro -
cess based on “operant condi-
tioning” techniques. The govern-
ing principal is that any behavior
(whether it is a complex maneu-
ver, such as eating, or a simple
task, such as muscle contrac-
tion), when reinforced, its likeli-
hood of being repeated and per-
fected increases.
One goal of BF-assisted
behavioral treatment of LUTS is
to alter physiologic responses of
the detrusor and PFM that medi-
ate urine loss and cause urinary
urgency, such as with individu-
als experiencing urgency UI
and/or overactive bladder (OAB).
BF can also be used to teach per-
sons new skills for preventing UI,
assist them in relearning previ-
ous bladder control behaviors,
and how to relax a muscle that
may be in spasm. Therefore, BF
can be a vital component of a
behavioral program to treat stress
and urgency UI (Hay-Smith,
Henderschee, Dumoulin, &
Herbison, 2012; Herderschee,
hay-Smith, Herbison, Roovers, &
Heineman, 2011; Newman &
Wein, 2013).
Biofeedback is also used in
patients with bowel dysfunction,
such as fecal (anal) incontinence
(FI) (Heymen et al., 2009; Norton
& Cody, 2012). In these patients,
the goal is to strengthen the anal
sphincter to restore a normal pat-
tern of defecation. In patients
with dyssynergic defecation and
loss of stool, the goal of neuro-
muscular training is two-fold: 1)
to correct the dyssynergia or in -
coordination of the abdominal,
rectal, puborectalis, and anal
sphincter muscles to achieve a
normal and complete evacuation;
and 2) to enhance rectal sensory
perception in patients with im -
paired rectal sensation (Markland
et al., 2008).
Use of BF in Specialty
Clinical Practice
Applying BF in a specialty
clinical practice (e.g., urology,
urogynecology) is a dynamic
process because there is transfer-
ence of information to the
patient. This process begins with
a pelvic floor muscle assessment
(see Figure 3). The patient learns
to control bladder, sphincter,
PFMs, and intra-abdominal pres-
sure by responding to visual or
auditory signals generated
through the activity of an inter-
nal physiologic process. As pre-
viously noted, the advantage for
both the patient and the clinician
is that information is immediate
and can be in terpreted simulta-
neously, allow ing the patient to
control re sponses of which they
may have little or no knowledge
or awareness. For example, BF
can provide motivation to
patients who may be frustrated
over inability to isolate PFMs or
who lack sensation of muscle
A patient education handout
that provides information on BF
(see Figure 4) may be given to all
patients prior to treatment. BF
therapy is most useful when the
patient is motivated, wants to be
actively involved in their therapy,
can follow directions, and when
there is a readily identified and
measurable muscle re sponse. The
clinician, though, is integral to a
Figure 2.
Lower Urinary and Pelvic Floor Disorders Decision Tree
Urinary Incontinence
Stress, urgency, or mixed
Neurogenic Detrusor Overactivity
(NDO) Chronic Pelvic Pain/Spasm
Urgency, mixed,
or overactive
bladder (OAB)
Incomplete bladder
emptying (detrusor
sphincter dysynergia)
Pelvic floor
muscle relaxation
Pelvic floor muscle
training (PFMT) with
knack/stress strategies
Lifestyle modifications
Behavioral therapy (bladder training,
urge suppression techniques, PFMT with
biofeedback, knack/stress strategies)
based on PVR
Source: © 2013 Diane K. Newman. Used with permission.
Copyright 2014 Society of Urologic Nurses and Associates (SUNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the Society of Urologic Nurses and Associates. doi 10.7257/1053-816X.2014.34.4.193
196 UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4
Prior to examination, the patient should have voided.
Have the participant undress from the waist down and lie supine (women with
hips and knees flexed; men should lie on left side with knees drawn up). Use a
draw sheet to drape participant from waist to knees to maximize privacy but still
allow necessary observation of pelvic floor muscle (PFM) contractions. The use
of stirrups in women should be considered.
Before starting the internal examination, ask the patient to contract PFMs using
cues such as “squeeze your pelvic muscle and try to pull in and up,” “tighten up
like you are trying to not pass gas.
Observe externally the perineum (see illustration to the right) to assess if the
patient is bearing down, using accessory muscles, or performing a correct con-
traction (perineal body, including vaginal introitus in women, and anus move
inward [in men, the penis may lift]).
Muscle Assessment Vaginally: Insert one (or two) gloved, lubricated index fin-
gers into the vagina to the depth of the proximal inter-phalangeal joint (see illus-
tration to the right).
If vaginal stenosis or atrophy is present and/or patient expresses concern or dis-
comfort/pain about undergoing examination, only insert one finger into the vagina.
a. Muscle Location: Finger(s) are inserted into the vagina, finger pads down,
in a posterior direction; eventually, they will encounter the edge of the leva-
tor ani (LA) (if proceeding more posteriorly, fingers will drop off the edge).
Once at the edge, fingers should be retracted such that they rest on the
muscle belly of the LA. Palpate the LA muscle laterally, at the four and eight
o’clock position, just superior to the hymenal ring. Discomfort or tenderness
to palpation should be noted.
Muscle Assessment Rectally: Inspect outside of anus to determine presence
of hemorrhoids. Ask the patient to bear down or cough.
a. Muscle Location: As the sphincter relaxes, gently insert index finger into the anal canal in a direction pointing toward
the umbilicus. Note the resting sphincter tone of the anus. Normally, the muscles of the anal sphincter close snugly
around the entire circumference of the examiner’s finger. In the rectum, the distal external sphincter is felt just inside
the anal canal. The PR portion of the LA muscle can be palpated about 2.5 to 4 centimeters from the anal verge. To
assess the strength of the sphincter muscle, ask the patient to tighten his or her rectum around your finger. The exam-
iner should feel a griping pulling in around entire circumference of finger.
b. Insert the index finger farther into the rectum to examine as much of the rectal wall as possible. Palpate in sequence
the right lateral surfaces, noting any induration, nodules, or irregularities.
Assessing Muscle Isolation: Ask the patient to contract PFMs around examiners finger(s) with as much muscle force
as possible. Say to the patient:
“I am going to count to 3, and when I say 3, I want you to contract your pelvic floor muscle for as long and as hard as
you can.
a. The following qualities of the muscle contraction should be assessed and noted:
1. Ability to produce force in the PFMs.
2. Ability to coordinate a PFM contraction. The patient should be able to contract PFMs without contraction of
abdominal, hip adductors, and/or gluteal muscles. In addition, full muscle relaxation should follow a contraction.
3. Duration the participant can hold the contraction consistently.
b. If no PFM activity is palpated, encourage the patient to contract again focusing on the PFMs, avoiding thigh and
gluteal contractions. The examiner can palpate and gently (and if needed, repeatedly) press on the LA or rectal
muscle to help the patient identify and activate this muscle.
Figure 3.
Pelvic Floor Muscle Assessment
Source: © 2010 Diane K. Newman. Used with permission.
BF-assisted PFM rehabilitation
program because more intensive
supervised programs taught by
health professionals have been
shown to be better than self-
directed programs (Moore et al.,
2013). This service model is used
in many urology practices or
pelvic floor centers, which
employ trained health care spe-
cialists (usually registered nurses,
nurse practitioners, physical ther-
apists). In these types of specialty
practices, patients who receive BF
and other conservative treatment
have more contact with the health
care provider and receive more
intensive treatment. Contact and
interaction with a pelvic floor spe-
cialist can be an important com-
ponent of BF-assisted PFMT. A
Copyright 2014 Society of Urologic Nurses and Associates (SUNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the Society of Urologic Nurses and Associates. doi 10.7257/1053-816X.2014.34.4.193
UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4 197
Figure 4.
Patient Education Tool: Biofeedback Treatment
Biofeedback is a painless, effective treatment to help you identify and strengthen your pelvic floor muscles. Most men and
women do not exercise these muscles the right way. Biofeedback will help you learn about your muscles and how to use them
to prevent incontinence, bladder or bowel
urgency, and frequency. Using biofeedback to
retrain your pelvic muscles has been shown to
help 8 out of 10 people and is the recommend-
ed “first-line” treatment for bladder and pelvic
What Is Biofeedback?
Biofeedback uses a computer that records your
muscle activity, the muscle contraction, relax-
ation, and strength. It produces computer-gen-
erated graphs that are displayed on a monitor.
Biofeedback helps you find your pelvic muscles
by showing changes when you squeeze or
tighten the right muscle. Much like an athlete
uses special equipment to train, you can use
biofeedback equipment to reach a new level of
strength in your pelvic muscles. Biofeedback
can also use sound to help you identify the
muscles you are to train. It teaches you not to
tighten other muscle groups, such as your
stomach muscles.
How Is It Done?
There are two different ways to provide the
“feedback.” One is to place two “skin patches”
that have adhesive at your anus (the opening to
your rectum). A second way is to insert a small
sensor in your vagina (used in women) or your
rectum (used in men or women). Either way,
these pick up signals from your muscle and
measure the muscle contraction and the relax-
ation. The sensors are connected to a comput-
er that displays muscle changes on a monitor.
You will immediately see when you are con-
tracting the correct set of muscles and doing
the exercise the right way. You will be able to fol-
low your progress as your pelvic muscles gets
stronger with each biofeedback session.
How Long Is Each Biofeedback Visit?
The biofeedback treatments are usually 20 to
30 minutes long, once or twice a month.
How Many Biofeedback Treatment Visits
Will I Need?
To get the best results, you should have
biofeedback visits over a six-month period and
then follow-up treatments periodically, depend-
ing on your symptom improvement. But the fre-
quency of biofeedback visits will depend on
your muscle assessment at your first visit. In
the beginning, you may need to come more fre-
quently, maybe twice a week or more. For
“homework” you will be given an “Exercise
Prescription” to follow for exercising at home.
You will also be asked to keep a Bladder Diary.
Your progress will be discussed during your
office visits, and the biofeedback will show you
how your muscle is progressing.
Source: © 2010 Diane K. Newman. Used with permission. This patient education tool may be photocopied.
Copyright 2014 Society of Urologic Nurses and Associates (SUNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the Society of Urologic Nurses and Associates. doi 10.7257/1053-816X.2014.34.4.193
198 UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4
2011 Cochrane review noted that
BF may add benefit to PFMT, but
the observed effect could well be
related to another variable, such
as the amount of clinician contact
rather than the actual BF
(Herderschee et al., 2011, 2013).
The International Consultation
on Incontinence (ICI) Committee
on Adult Conservative Treatment
(Moore et al., 2013) also noted
that it is not known if regular vis-
its with the clinician vs. the actu-
al treatment using BF is more
Biofeedback Equipment
And Parameters
Dr. Arnold Kegel developed
the first biofeedback device, the
perineometer, which was a pres-
sure manometric sensor inserted
into the vagina. One of its uses
was to assist female patients with
stress UI in identifying the PFM
muscle and to visualize the feed-
back when contracting (Kegel,
1948). Since then, there have
been no studies that have pro-
posed the best equipment and/or
technology to use when perform-
ing biofeedback for PFM dys-
function. In this author’s experi-
ence, the system needs to be ver-
satile because it should be opera-
tor- and patient-friendly. Optimal
BF therapy includes visualiza-
tion of both pelvic and abdomi-
nal muscle movement; thus, a
two-channel system is available
(Newman & Wein, 2013). A mul-
tichannel system allows for both
pressure manometry and elec-
tromyography (EMG) channels.
EMG is the measure of electrical
activity of skeletal muscle – the
PFM. Increased electrical activity
is a result of more muscle activi-
ty; however, it is not a measure of
force. Audio feedback can also be
an attractive component of BF
For information to be accu-
rate and helpful, instrumentation
must be accurate and dynamic.
In reference to PFM training, the
instrument must be both sensi-
tive and have little lag time in
both displaying and recording
information. Immediate, accurate
“feedback” is the goal of the
biofeedback instrument.
Cost and ease of use are also
important considerations in bio -
feedback instrumentation. High -
er cost does not always translate
into better equipment. To date,
there is no research, which has
compared cost, ease of use, and
accuracy of any BF system avail-
able for PFM dysfunction.
When looking into the
instrument for use in delivering
BF, careful consideration of the
patient population is paramount.
For example, if using this instru-
ment with older adult patients,
visual displays that can be seen
by the aging eye are needed, or
the instrument’s auditory compo-
nents should have a lower fre-
quency sound that the aging ear
can appreciate. Biofeedback dis-
plays that utilize games may be
appropriate in children and
younger adults.
Biofeedback parameters in -
clude measurement of resting
tone, muscle strength (maximal
and submaximal contractions),
contractility, power, and endur -
ance (ability to sustain a muscle
contraction) (see Table 2). At
least a five-second muscle relax-
ation period should be used
between each contraction be -
cause easily fatigable muscles
need a chance to recover, without
permitting excessive rest periods
for strong muscles. Measurement
of EMG muscle activity is usual-
ly in microvolts, and measure-
ment of manometric muscle
activity is a measurement of pres-
sure in millimeters of mercury.
EMG provides information on
the ability of the PFM to contract
and manometry quantifies PFM
strength. Electromyography, the
electrical activity of a muscle, is a
practical indicator of muscle
activity and is defined as:
The study of electrical poten-
tials generated by the depo-
larization of muscle.
A monitor of bioelectrical
activity correlating to motor
unit activity; it does not
measure the muscle contrac-
tility itself, but the electrical
correlate of the muscle con-
An indicator of the physio-
logical activity of the muscle.
The advantage of EMG over
manometric pressure is that pro-
vided the machinery is of suffi-
cient sophistication with ade-
quate filtering, the EMG appara-
tus can accommodate the newer
types of electrodes that are light-
weight and designed to stay in
place, hence allowing more func-
tional positions during assess-
ment and treatment.
Table 2.
Measurement Parameters by Electromyography
(EMG) or Manometry
• Rest
– The ability of the muscle to return to a resting state between each
• Strength
– Recorded as the peak maximum pressure (the maximal
contraction) and the ability to sustain or hold the contraction.
• Contractibility
– The rate of the original rise of the muscle contraction.
– The ability of the muscle to “contract–relax” as quickly and strongly
as possible, until the muscle fatigues; these are often called “quick flicks.
• Endurance
– The time that a sub-maximum muscle contraction can be
maintained or repeated before a 50% or more reduction in power is
detected (the muscle contraction is timed until the muscle fatigues).
• Repetitions
– The number of repetitions (up to 10) of the muscle contraction
of equal force that can be achieved which indicate muscle coordination and
• Fatigue
– Failure to maintain the required or expected force of the PFM
contraction for more than one or two times in succession.
Source: Adapted from Newman & Wein, 2009.
Copyright 2014 Society of Urologic Nurses and Associates (SUNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the Society of Urologic Nurses and Associates. doi 10.7257/1053-816X.2014.34.4.193
UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4 199
Frequency of Sessions
Biofeedback sessions may be
weekly, biweekly, and even
monthly. Frequency of sessions
should be individualized, and
patients may need frequent ses-
sions initially to aide in identifi-
cation and isolation of PFMs.
On the converse, less frequent
sessions are helpful because
changes in PFMs and lower uri-
nary tract symptoms occur slow-
ly. Improvement in pelvic sup-
port can be seen in one month,
but significant changes occur
after three to six months. Symp -
toms improve slowly, and track-
ing symptom improvement is
essential to PFMT. Establishing
realistic goals and expectations at
the beginning of treatment can
contribute to successful patient-
centered outcomes.
During BF sessions, patients
are taught quick muscle contrac-
tions (referred to as the “knack”
or stress strategies) for use prior
to the event that causes urine
leakage (Miller, Ashton-Miller, &
DeLancey, 1996, 1998). For
example, if urine leakage occurs
with a sneeze or cough, the
patient contacts the PFM prior to
or at the time of the event. For
practice, the clinician will have
the patient cough while viewing
the BF screen and contract the
PFM prior to and during the
cough. Quick pelvic floor muscle
contractions at the time of blad-
der urgency can suppress a
strong urge, delay voiding and
prevent an urge UI episode
(Wyman et al., 2009).
Measuring PFM Response
There are several approaches
for measuring PFM activity to
ensure effective BF. First, PFMs
as a group should be identified
during a vaginal and/or rectal dig-
ital examination (see Figure 3,
second illustration). It is helpful
to guide the patient toward isola-
tion of the PFM with minimal use
of accessory muscle groups. In
this author’s experience, it is
more effective that the clinician
assist to confer success and sup-
port the patient rather than to
focus solely on isolation of PFMs
at any cost.
In specialty clinical practice,
EMG measurement of gross neu-
romuscular function of the PFM
is often performed by using elec-
trodes that are placed on the skin
surface (see Figure 3, second
illustration) or sensors (probes)
inserted in the vagina or rectum
(see Figure 4, third illustration).
Because the deep PFMs lie adja-
cent to the vaginal walls, a vagi-
na sensor positioned against the
lateral vaginal walls is a conven-
Table 3.
ICI Grade of Recommendation
Treatment Recommendations Grade
PFMT Clinicians should provide the most intensive
program possible (in terms of exercise dose,
health professional teaching, and supervision).
Supervised programs taught by health
professionals are better than self-directed
programs; more health professional contact is
better than less.
Although studies are inconsistent, there does not
appear to be a clear benefit of adding clinic OR
Home-based biofeedback to a PFMT program.
PFMT Supervised PFMT should be offered as first-line
conservative therapy to women with stress, urge,
or mixed UI.
PFMT in women
with SUI
PFMT is better than electrical stimulation as first-
line conservative therapy, particularly if PFMT is
intensively supervised.
PFMT is better than BT as first line conservative
PFMT in men
Some pre-operative or immediate post-operative
instruction in PFMT for men undergoing radical
prostatectomy may be helpful.
The use of BF to assist PFMT is currently a
clinician/patient decision based on economics and
PFMT + BT in
women with UUI
or MUI
PFMT and BT are effective first line conservative
For women with SUI or MUI, a combination of
PFMT/BT may be better than BT alone in the
PFMT + BF Use of BF for the treatment of FI after other
behavioral and medical has been tried, if
adequate relief has not been obtained.
Notes: BF = biofeedback, BT = bladder training, PFMT = pelvic floor muscle train-
ing, SUI = stress urinary incontinence, MUI = mixed urinary incontinence, FI = fecal
incontinence, UI = urinary incontinence, UUI = urge urinary incontinence.
A = Recommendation usually depends on consistent evidence from meta-analyses
of RCTs or high quality individual RCTs.
B = Recommendation usually depends on majority of evidence from RCTs or
prospective cohort (case-controlled) studies.
C = Recommendation usually depends on retrospective cohort (case-control) stud-
ies, case series, or low quality RCTs.
Source: Adapted from Abrams, Khoury, & Grant, 2013; Moore et al., 2013.
Copyright 2014 Society of Urologic Nurses and Associates (SUNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the Society of Urologic Nurses and Associates. doi 10.7257/1053-816X.2014.34.4.193
200 UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4
ient means to record EMG activi-
ty in female patients (Keshwani
& McLean, 2013). The longitudi-
nal (lengthwise, not circular)
detection electrodes on the sen-
sor maintain the proper orienta-
tion to muscle fibers for highest
accuracy. Manometry or pressure
biofeedback can only be accom-
plished using intravaginal or
intrarectal sensors. Patients often
identify their PFMs with a sensor
simply because the resistive
device gives them something to
contract against. All electrodes
and sensors can be adapted for
use with most commercially
available instruments. Vaginal or
rectal sensors are single use, and
when in active therapy, patients
use the same internal sensor at
each session. An added benefit of
internal sensors is that they can
be used for both EMG and PFM
electrical stimulation.
Figure 5 is the smallest, most
comfortable female EMG sensor
available, and features gold
detection electrodes that provide
consistently superior measure-
ments and are also hypoaller-
genic. This sensor is inserted
similar to a tampon and posi-
tioned above the urogenital
diaphragm. It is able to measure
muscle activity even when the
patient is moving.
Evidence-Based Biofeedback
The ICI Committee on Adult
Conservative Treatment made evi-
dence-based recommendations
for PFMT and bladder training
(BT), alone or in combination,
(see Table 3), but the research is
inconclusive to the improved effi-
cacy of adding BF therapy as an
adjunct method for PFMT for any
dysfunction in the pelvic floor
(Ayeleke, Hay-Smith, & Omar,
2013; Moore et al., 2013). A 2011
Cochrane review (Herderschee et
al., 2011; Herderschee, Hay-
Smith, Herbison, Roovers, &
Heineman, 2013) on feedback or
biofeedback to augment PFMT
included 24 trials involving 1,583
women and concluded that
women who received PFMT with
BF were significantly more likely
to report their UI was cured or
improved compared to those
who received PFMT alone. How -
ever, as with other research in
this area, treatment groups dif-
fered on parameters other than
BF, such as preparation of the cli-
nician providing the therapy. A
recent Cochrane review (Ayeleke
et al., 2013) noted there was not
enough evidence to say whether
or not the addition of BF to
PFMT in women with UI results
in more benefits when compared
to the same active treatment
Since the 1980s, this author
has used BF as an adjunct to
PFMT in patients with PFM dys-
function. She conducted research
in a community health center and
home care setting (Baigis-Smith,
Smith, Rose, & Kaschak, 1989;
Newman, Lynch, Smith, & Cell,
1991; Rose, Baigis-Smith, Smith,
& Newman, 1990). In a study con-
ducted in a New Jersey public
health center (Baigis-Smith et al.,
1989), a portable EMG perineome-
ter that provided feedback via the
use of lights was used to provide
biofeedback-assisted PFMT to 54
subjects, men and women, ages 60
to 86 years, with UI (Baigis-Smith
et al., 1989). In addition to PFMT,
subjects were also taught BT. The
mean reduction in incontinence
episodes was 78% from baseline,
with 50% of subjects showing a
90% improvement. A second
study (Rose et al., 1990) reported
on 21 elderly homebound
patients who were visited in their
home and treated with PFM exer-
cises and BF. Improvement in
weekly incontinent episodes was
78% from baseline.
Use of Pelvic Floor Muscle
Electrical Stimulation
Pelvic floor muscle electrical
stimulation (PFMES) involves the
application of low-grade electrical
stimulation to the PFM. Electrical
stimulation can activate inhibito-
ry nerve fibers, causing reflex
inhibition of the detrusor muscle,
thereby preventing bladder over-
activity (Newman & Wein, 2009).
There is also an effect on the stri-
ated PFM, causing hypertrophy of
the muscles by recruiting the PFM
fast-twitch fibers. The delivery of
the electric current to the PFM is
via vaginal or rectal sensors, and
the technique is often used in con-
junction with biofeedback (Starr
et al., 2013). Clinicians who spe-
cialize in pelvic floor dysfunction
use PFMES as adjunct treatment
Assist with identification
and isolation of PFM.
Increase PFM strength.
Decrease unwanted or unin-
hibited detrusor muscle con-
Assist with normalizing PFM
This article is a short review
of clinical application of biofeed-
back therapy in a pelvic floor
muscle rehabilitation program.
Clinicians providing this treat-
ment should understand spe -
cifics about pelvic floor muscle
Figure 5.
IVS Vaginal Sensor
Source: T-Doc. Used with permission.
continued on page 202
Copyright 2014 Society of Urologic Nurses and Associates (SUNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the Society of Urologic Nurses and Associates. doi 10.7257/1053-816X.2014.34.4.193
UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4 201
Figure 6.
Case Studies
Case Study #1
J.O. is a 56-year-old female diagnosed with mul-
tiple sclerosis eight years ago. She was referred to
urology because of lower urinary tract symptoms,
including incomplete bladder emptying and urinary
tract infections. Patient’s most bothersome lower uri-
nary tract symptoms (LUTS) included urgency and
frequency with incontinence. She reported poor blad-
der emptying, decreased force of stream, and a diffi-
cult time initiating voiding. She strains to void.
Urodynamics studies indicated detrusor overactivity
with incontinence, EMG activity indicated poor
dyssynergia. Post-void residual was 450 mLs. Since
then, she has been performing self-catheterization at
least three times per day; catheterization volumes
average 350 mLs. Cathe terization has not changed
her LUTS of urgency and frequency. PFM assess-
ment indicated fair sensation, no discomfort, and lev-
ator ani palpation bilaterally, weak muscle contraction
with length of fingers lifted and drawn in. Contraction
duration was four seconds. Slight discomfort was
noted during digital examination; it appeared as
though muscle spasm was present. The patient pur-
chased the vaginal sensor for use at weekly biofeed-
back (BF) sessions. Initial EMG BF session noted ele-
vated muscle relaxation with generalized weakness.
At this visit, BF was used solely to allow the patient to
isolate muscle and to concentrate on relaxation. The
patient was primarily prescribed a stepped strength-
ening exercise program with emphasis on muscle
relaxation. Over a two-month period during the BF
session, the patient worked to increase muscle
strength and endurance. She continued on the pre-
scribed muscle strength training and used muscle
relaxation to aid voiding. By four months, the patient’s
urgency and voiding initiation improved. By five
months, the patient was only self-catheterizing once a
day because volumes had decreased to less than
200 mLs. She also stopped straining to void. EMG BF
indicated very little muscle spasm, and muscle
strength had increased by 40%.
Case Study #2
S.A. is a 64-year-old female with a history of
adenosquamous carcinoma of the uterus with inva-
sion. She underwent abdominal hysterectomy with
subsequent vaginal chemotherapy and pelvic radia-
tion. The patient presented with both urinary and anal
incontinence. The patient was told that cancer treat-
ments resulted in PFM weakness causing her bowel
and bladder symptoms. The patient also had urinary
and bowel urgency and frequency. Her most bother-
some symptoms were urgency; she lacked “control”
and feared being in a situation where she would not
be able to manage urinary and/or stool leakage. The
patient was on a prescribed bowel regimen to keep
stools soft, but she would have multiple daily bowel
movements over a very short period of time.
Endoscopy indicated that the patient had irritable
bowel symptoms with alternating constipation and
diarrhea, and the rectal scan revealed decreased
sphincter tone. She kept daily records of bladder and
bowel symptoms. The patient’s oncologist recom-
mended the patient undergo BF therapy, but she
delayed seeking treatment because of ongoing can-
cer treatments and a generalized sense of hopeless-
ness and embarrassment. Physical examination
reviewed normal post-void residual and significant
vaginal stenosis. Levator ani was palpated bilaterally
with poor contraction of only one-second duration.
Rectal sphincter tone was weak, and there was dis-
comfort with the digital rectal examination. Because of
the vaginal stenosis and rectal discomfort, the URway
Intravaginal EMG Sensor®was used to provide BF. At
the first session, the patient exhibited a very weak
muscle with little sensation of contraction; the biofeed-
back EMG graph indicated a weak contraction of 2.0
to 2.5 microvolts. PFMES was attempted but was
uncomfortable for the patient, so it was abandoned.
For two months, the patient was seen weekly and
received a 30-minute BF session. At the end of the
two months, muscle sensation had improved, and
strength had increased. At eight months, EMG testing
indicated increased muscle strength (averaged 8.5
microvolts), normal relaxation (< 1 microvolt), and
ability to sustain contract for eight to 10 seconds with-
out accessory muscle contraction. The first symptoms
to improve were urinary frequency and UI. The patient
felt her rectal muscle becoming stronger, allowing her
to use the muscle to suppress fecal urgency and pre-
vent fecal leakage. There were ongoing instances
where the patient reported being able to retain stool,
such as when bending over, a cause of incontinence
prior to starting the BF program. Stools also became
more formed, aiding in control. The patient continues
to use the intravaginal sensor as a training or resistive
device for exercising at home.
Copyright 2014 Society of Urologic Nurses and Associates (SUNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the Society of Urologic Nurses and Associates. doi 10.7257/1053-816X.2014.34.4.193
202 UROLOGIC NURSING / July-August 2014 / Volume 34 Number 4
anatomy, examination, measure-
ment through EMG or manome-
try, and understand the parame-
ters for providing appropriate
feedback. Two case studies
where biofeedback was integral
to successful pelvic floor muscle
rehabilitation are included (see
Figure 6).
Abrams, P., Khoury, S., & Grant, A. (2013).
Evidence-based medicine –
Overview of the main steps for
developing and grading guideline
recommendation. In P. Abrams, L.
Cardozo, S. Knoury, & J. Wein (Eds.),
Incontinence (5th ed., pp. 8-9).
Arnhelm, The Netherlands: Euro -
pean Association of Urology
Ayeleke, R.O., Hay-Smith,E.J., & Omar,
M.I. (2013). Pelvic floor muscle
training added to another active
treatment versus the same active
treatment alone for urinary inconti-
nence in women. Cochrane Data -
base of Systematic Reviews, 11,
Baigis-Smith, J., Smith, D., Rose, M., &
Kaschak, D. (1989). Managing uri-
nary Incontinence in community-
residing elderly persons. The
Gerontologist, 29(2), 229-233.
Corton, M.M. (2009) Anatomy of pelvic
floor dysfunction. Obstetrics &
Gynecology Clinics of North
America, 36(3), 401-419.
Greer, J.A., Smith, A.L., & Arya, L.A.
(2012). Pelvic floor muscle training
for urgency urinary incontinence in
women: A systematic review. Inter -
national Urogynecology Journal,
23(6), 687-697.
Hay-Smith, J., Henderschee, R.,
Dumoulin, C., & Herbison, P. (2012).
Comparisons of approaches to
pelvic floor muscle training for uri-
nary incontinence in women: An
abridged Cochrane systematic re -
view. European Journal of Physical
and Rehabilitation Medicine, 48(4),
Herderschee, R., Hay-Smith, E.J.,
Herbison, G.P., Roovers, J.P., &
Heineman, M.J. (2011). Feedback or
biofeedback to augment pelvic floor
muscle training for urinary inconti-
nence in women. Cochrane Data base
Systematic Reviews, 7, CD009252.
doi: 10. 1002/ 14 65 18 58. CD 009252
Herderschee, R., Hay-Smith, E.C.,
Herbison, G.P., Roovers, J.P., &
Heineman, M.J. (2013). Feedback or
biofeedback to augment pelvic floor
muscle training for urinary inconti-
nence in women: Shortened version
of a Cochrane systematic review.
Neurourology Urodynamics, 2(4),
325-329. doi:10.1002/nau.22329.
Heymen, S., Scarlett, Y., Jones, K., Ringel,
Y., Drossman, D., & Whitehead, W.E.
(2009). Randomized controlled trial
shows biofeedback to be superior to
pelvic floor exercises for fecal incon-
tinence. Diseases of the Colon &
Rectum, 52, 1730-1737.
Kegel, A. (1948). Progressive resistance
exercise in the functional restoration
of the perineal muscles. American
Journal of Obstetrics and Gyne -
cology, 56, 238-248.
Keshwani, N. & McLean, L. (2013). State
of the art review: Intravaginal probes
for recording electromyography
from the pelvic floor muscles [Epub
ahead of print]. Neurourology Uro -
dynamics. doi: 10. 1002/ nau. 22 5 29
Markland, A.D., Richter, H.E., Burgio,
K.L., Wheeler, T.L. 2nd, Redden,
D.T., & Goode, P.S. (2008). Outcomes
of combination treatment of fecal
incontinence in women. American
Journal of Obstetrics and Gyne -
cology, 199(6), 699.e1-7.
Maserejian, N.N., Minassian, V.A., Chen,
S., Hall, S.A., McKinlay, J.B., &
Tennstedt, S.L. (2014). Treatment
status and risk factors for incidence
and persistence of urinary inconti-
nence in women. International Uro -
gynecology Journal, 25, 775-782.
McLean, L., Varette, K., Gentilcore-
Saulnier, E., Harvey, M.A., Baker, K.,
& Sauerbrei, E. (2013). Pelvic floor
muscle training in women with
stress urinary incontinence causes
hypertrophy of the urethral sphinc-
ters and reduces bladder neck
mobility during coughing. Neuro -
urology Urodynamics, 32(8),1096-
Miller, J., Ashton-Miller, J.A., &
DeLancey, J.O.L. (1996). The knack:
Use of precisely timed pelvic muscle
exercise contraction can reduce
leakage in SUI. Neurourology and
Urodynamics, 15, 302-393.
Miller, J.M., Ashton-Miller, J.A., &
DeLancey, J.O.L. (1998). A pelvic
muscle contraction can reduce
cough-related urine loss in selected
women with mild stress urinary
incontinence. Journal of the
American Geriatrics Society, 46,
Moore, K., Bradley, C., Burgio, B.,
Chambers, T., Hagen, S., Hunter, H.,
… Williams, K. (2013). Adult conser-
vative treatment. In P. Abrams, L.
Cardozo, S. Khoury, & A. Wein
(Eds.): Incontinence: Proceedings
from the 5th International Con sul ta -
tion on Incontinence (pp. 1101-
1228.). Plymouth, United Kingdom:
Health Publications.
Newman, D.K., Lynch, K., Smith, D.A., &
Cell, P. (1991). Restoring urinary
continence. American Journal of
Nursing, 91(1), 28-36.
Newman, D.K, & Wein, A.J. (2009).
Managing and treating urinary
incontinence (2nd ed., pp. 245-306).
Baltimore: Health Professions Press.
Newman, D.K., & Wein, A.J. (2013).
Office-based behavioral therapy for
management of incontinence and
other pelvic disorders. Urologic
Clinics of North America, 40(4), 613-
Norton C., & Cody JD. (2012). Biofeedback
and/or sphincter exercises for the
treatment of faecal incontinence in
adults. Cochrane Database System -
atic Reviews, 7, CD002111. doi: 10. 10
02/ 14 65 1858.CD002111.pub3
Rose, M.A., Baigis-Smith, J., Smith, D., &
Newman, D. (1990). Behavioral
management of urinary inconti-
nence in homebound older adults.
Home Healthcare Nurse, 8(5), 10-15.
Starr, J.A., Drobnis, E.Z., Lenger, S.,
Parrot, J., Barrier, B., & Foster, R.
(2013) Outcomes of a comprehen-
sive nonsurgical approach to pelvic
floor rehabilitation for urinary
symptoms, defecatory dysfunction,
and pelvic pain. Female Pelvic
Medicine and Reconstructive
Surgery, 19(5), 260-265.
Wyman, J.F., Burgio, K.L., & Newman,
D.K. (2009). Practical aspects of
lifestyle modifications and behav-
ioural interventions in the treatment
of overactive bladder and urgency
urinary incontinence. International
Journal of Clinical Practice, 63(8),
Copyright 2014 Society of Urologic Nurses and Associates (SUNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the Society of Urologic Nurses and Associates. doi 10.7257/1053-816X.2014.34.4.193
... Correct contraction of pelvic floor muscles in exercise training is described as contracting and inward lifting of the muscles around pelvic openings while keeping outer abdominal, gluteal and hip adductor muscles relaxed (116)(117)(118)(119). In recent studies the proportion of women who were unable to correctly activate the pelvic floor on initial exam varied from 14 to 53% (119-122). ...
... 3. A complex training for pelvic-floor muscles should be focused both on their contractionand relaxation(116). Contractions are to improve, among others, supporting functions for pelvic organs and continence. ...
There are several guidelines supporting the benefits of exercising during pregnancy. Those documents contain very general recommendations on physical activity and exercise during pregnancy, such as general guidelines for health screening and prescription of aerobic exercise and strength training. They also include examples of safe physical activities during pregnancy, such as walking, running, swimming, stationary cycling, aerobics, modified yoga, and Pilates. However, those guidelines contain little information that exercise professionals could use when programming the contents of targeted exercise classes for pregnant women. This chapter addresses the steps for planning, conducting, and monitoring prenatal exercise classes, and explains how to select and adapt the exercises making them safe physical activities during pregnancy.KeywordsPregnancyExercisePhysical activityAerobicsResistanceFlexibilityFunctionalNeuromotorBalancePosturePelvic floor muscle trainingBreathingFitnessExercise planning
... Another method that can be used in the treatment of stress urinary incontinence is sonofeedback. This method uses biological feedback and, as shown in the studies presented in the available literature, can be used to strengthen the pelvic oor muscles [31][32][33]. ...
Full-text available
The number of people suffering from urinary incontinence increases every year. Along with it, the knowledge of the society increases that there are various methods of eliminating this ailment.. Both patients and researchers are constantly looking for new treatments for urinary incontinence. One of the new solutions is sonofeedback of the pelvic floor muscles, which may help to strengthen them and thus reduce the problem. The aim of this study was to evaluate the effectiveness of sonofeedback and transvaginal electrostimulation in increasing the bioelectrical activity of pelvic floor muscles in postmenopausal women with stress urinary incontinence. Sixty women with stress urinary incontinence were enrolled in the study. The patients were divided into two groups: A - where sonofeedback was used and B - where electrostimulation of the pelvic floor muscles was performed with biofeedback training. In patients, the resting bioelectrical activity of the pelvic floor muscles was assessed using an electromyograph. The assessment of the resting bioelectrical activity of the pelvic floor muscles was performed before the therapy, after the 5th training and after the therapy. It was observed that after the end of the therapy, the average bioeltrical potential increased by 1.1 µV compared with baseline in group A. It can be suggested that the sonofeedback method is comparatively effective in reducing symptoms that are associated with urinary incontinence as a electrostimulation method with biofeedback training.
... In 1948, Arnold Kegel first reported successful use of pelvic floor muscle training (PMFT) as a behavioral therapy for treating SUI symptoms in female patients. The therapy was designed to enhance muscle volume and contraction strength under increased intra-abdominal pressure [11]. Since then, it has been found to be able to improve UI symptoms in all types of incontinence without side effects [12]. ...
Full-text available
Objectives: To verify the safety and effectiveness of a novel micro-implantable wireless nerve stimulation device in healthy adult beagles and evaluate the feasibility of using the device in clinical practice. Methods: The stimulator was experimentally implanted into the quadriceps femoris of three adult beagles. The animals were subjected to training on daily basis for 14 days, and the threshold test was administered once a week. At the end, we analyzed the images of light microscopy and electron microscopy. Results: The implantation was easy to perform and the whole stimulation system worked stably and reliably. The stimulation threshold was stable. During the process, the stimulator did not move or cause damage to adjacent tissues. The whole system showed a good biocompatibility with recipient animals. The stimulator could induce muscular contraction and enhance the motor function of muscles. Conclusions: The preliminary results showed that the stimulator could be safely implanted into animal body, with good tissue compatibility, stability and reliability. In addition, it also worked well in eliciting muscle contraction. It promises to be used for the treatment of stress urinary incontinence in future.
Full-text available
Background: Living with urinary incontinence leads to changes in the lifestyle and habits of the person and his/her relatives, who may need to modify behaviors. Objective: To examine and to map the approach of the Rehabilitation Specialist Nurse in adults with changes of urinary elimination in every intervention context. Methodology: A scoping review was conducted according to the methodology recommended by the Joanna Briggs Institute, using CINAHL and MEDLINE databases. Results: According to the included articles, patient evaluation must include the description of the usual urinary habits, voiding characteristics, in which situations urinary incontinence occurs and devices used for urinary incontinence. Patients should also be assessed with a voiding diary and with the International Consultation on Incontinence Questionnaire. The included articles refer that the main rehabilitation interventions are kegel exercises, habit training, bladder training and fluid intake management. Conclusion: Urinary incontinence can be classified in different types, and so it is essential to carry out a specific and detailed evaluation that allows its correct characterization and the selection of the most adequate interventions. Keywords: nursing; nursing care; rehabilitation; urinary incontinence; promoting urinary continence
This study was designed to determine the effects of bladder training and Kegel exercises on urinary symptoms and the quality of life in female patients with multiple sclerosis. A pretest‐posttest quasi‐experimental study was conducted. The study was composed of 37 participants from two different hospitals in Turkey. The data collection tools included a Patient Information Form, Expanded Disability Status Scale, Multiple Sclerosis Quality of Life Scale‐54, King's Health Questionnaire, and a bladder diary. Participants were followed through phone consultation seven times during a 3 month period. The participants showed a significant improvement in both the physical and mental health of their quality of life scores compared to the baseline regarding the King's Health Questionnaire Scale, there was an increase in patients' general health perception compared to the baseline. There was reduction in the frequency, nocturia, urgency, and urinary incontinence compared to the baseline at much level of symptoms odds. In this sample, bladder training and Kegel exercises improved quality of life in female patients with MS. These techniques increased the patients'general health perception of their urinary symptoms.
Prostate cancer is one of the commonest types of cancer in men worldwide. The primary treatment option for localized prostate cancer is radical prostatectomy. Unfortunately, a considerable proportion of men may experience long‐term post‐surgical sequelae is to determine the effect of nursing interventions on urinary, bowel, and sexual dysfunction among post‐radical prostatectomy patients. A quasi‐experimental (one group, pre‐test–post‐test) research design. We included 30 post‐radical prostatectomy patients in this study. Each patient was interviewed in five sessions. During these sessions, the information about the complications of RP, pelvic floor exercise training and sexual rehabilitation was given. International Consultation on Incontinence Questionnaire‐Urinary Incontinence‐Short Form (ICIQ‐UI‐SF), The Revised Faecal Incontinence Scale (RFIS) and Sexual Health Inventory for Men (SHIM) were used to evaluate the effect of nursing interventions. The study results demonstrate that the incidence of urinary and sexual dysfunction is high among patients post‐radical prostatectomy patients. Fortunately, urinary and sexual dysfunctions were improved post‐implementation of nursing intervention with statistically significant differences (p‐value <0.05). The incidence of faecal incontinence was 16.7% while it was 13.3% post‐nursing implementation with no statistically significant differences. Nursing intervention is effective in the management of urinary incontinence after radical prostatectomy within a short period time while the improvement in sexual dysfunction may need more time.
Full-text available
ภาวะกลั้นปัสสาวะไม่อยู่ หมายถึง ภาวะที่มีปัสสาวะเล็ดราดออกมาโดยไม่สามารถควบคุมได้ ภาวะนี้ถือเป็นปัญหาสุขภาพในผู้สูงอายุเป็นอย่างมาก สาเหตุหลักมาจากความเสื่อมทางด้านร่างกาย จนทำให้การขับถ่ายปัสสาวะผิดปกติและเป็นภาวะเรื้อรังที่มีผลกระทบต่อร่างกาย จิตใจ สังคม เศรษฐกิจ ซึ่งสิ่งเหล่านี้ล้วนส่งผลต่อคุณภาพชีวิตที่ลดต่ำลง เช่น ผิวหนังเกิดการระคายเคืองจากปัสสาวะที่เล็ดราด ทำให้ผิวหนังเกิดการอับชื้นจนนำมาสู่การเกิดผื่นหรือแผลตามมาได้ อีกทั้งส่งผลต่อการนอนหลับพักผ่อนทำให้พักผ่อนไม่เพียงพอ และผลกระทบต่อทางด้านจิตใจ เช่น การขาดความมั่นใจในตนเอง ความเขินอาย ภาวะซึมเศร้า ซึ่งสิ่งเหล่านี้ส่งผลต่อการหลีกเลี่ยงการเข้าสังคมตามมา หากมีการเก็บรวบรวมข้อมูลของผู้สูงอายุที่ครบถ้วนจะช่วยให้สามารถนำข้อมูลไปใช้ในการแก้ปัญหา รักษา รวมทั้งป้องกันการเกิดภาวะแทรกซ้อนได้ บทความนี้มุ่งเน้นให้พยาบาลเกิดความรู้ ความเข้าใจ สามารถดูแลและให้คำแนะนำแก่ผู้ป่วยและญาติที่มีภาวะกลั้นปัสสาวะไม่อยู่ได้ มีการนำระบบการสร้างเสริมสุขภาพมาใช้กับผู้ป่วย เพื่อป้องกันและส่งเสริมสุขภาพ ตลอดจนจัดการกับสิ่งแวดล้อมและปัจจัยที่ส่งผลต่อคุณภาพชีวิตของผู้สูงอายุ เพื่อให้ผู้สูงอายุเกิดคุณภาพชีวิตที่ดี สามารถเข้าสังคม และเกิดการปรับตัวจนสามารถใช้ชีวิตได้อย่างมีความสุข
Objective To evaluate quality of life (QoL) in female veterans by comparing responses of the Pelvic Floor Impact Questionnaire (PFIQ-7) before and after a chosen treatment for urinary incontinence (UI), determine whether a QoL assessment was being completed for each woman seeking care for UI, and review the PFIQ-7 questionnaire scores to ensure the veterans were offered the appropriate levels of treatment. Design Quality improvement project using the plan–do–study–act cycle for evaluating change. Setting /Local Problem: A Veterans Affairs Medical Center in the midwestern United States. No standardized education or QoL questionnaire was being used for female veterans diagnosed with UI before implementation of the project. Participants Twenty female veterans diagnosed with stress or mixed UI who had completed Kegel exercises or pelvic floor rehabilitation (PFR) and a pre- and posttreatment PFIQ-7. Interventions/Measurements The Veterans Affairs Medical Center incorporated the PFIQ-7 into routine practice for pre- and posttreatment assessment of UI. Data were collected through a retrospective chart review. Results The mean initial PFIQ-7 score for participants (n = 4) who chose PFR was 71.77 (SD = 82.79). The mean final PFIQ-7 score for participants in the PFR group was 43.99 (SD = 63.34). The mean initial PFIQ-7 score for participants who chose Kegel exercises was 71.72 (SD = 34.92), and the final score was 60.71 (SD = 44.98). When comparing pre- and posttreatment scores, a lower score means there was a positive effect from the treatment and reflects an improved QoL. Conclusion The addition of the QoL assessment tool assisted staff in developing an individualized plan of care for female veterans. Regardless of treatment option chosen, participants who did not show an overall improvement in the pre- and posttreatment QoL scores were referred to a more advanced level of care.
Objective Pelvic floor muscle training (PFMT) is considered a behavioral task that requires the interaction of physical, social, and cognitive processes. Enablers and barriers to participation in PFMT has been explored primarily in women. This review aimed to identify the barriers and enablers that influence participation in PFMT in all adult populations. Methods A systematic review and meta-synthesis of qualitative literature was conducted. The inclusion criteria comprised qualitative studies with populations of people aged 18 years and older who have been recommended for PFMT. Line-by-line coding and an inductive thematic analysis identified themes that were applied to the Theoretical Domains Framework and Capabilities, Opportunities and Motivation Behavioural Model to determine behavioral influences on PFMT. Results Twenty full text articles met inclusion criteria. PFMT was mostly influenced by individual opportunities that were impacted by social determinants and competing demands. Capability of carrying out PFMT was impacted by knowledge, understanding, and appropriate skill acquisition that was linked to self-efficacy. Conclusion Increasing opportunities and capabilities for engagement in PFMT are the most important factors in optimizing positive behavior changes. Ways to address these factors include clear patient communication to boost confidence in skill acquisition and using technology to encourage autonomy and improve convenience. Future research should address the impact of health professionals’ beliefs about patient participation, assessing the role of social values and gender roles, and explore the timing of the implementation of behavioral change strategies to improve PFMT. Impact This is believed to be the first systematic review and qualitative meta-synthesis to consider the enablers and barriers to participation in PFMT for all adult populations, purposes, and symptom complexes. Patient opportunities and capabilities are the greatest influencers on participation and self-efficacy. Individualized treatment approaches that acknowledge and address social influencers and competing demands will optimize self-efficacy and participation. Lay Summary If you have pelvic floor muscle dysfunction, your opportunities and capabilities are the greatest influencers on participation and self-efficacy in PFMT. Your physical therapist can design individualized treatment approaches that acknowledge and address social influencers and competing demands to help you optimize participation.
Full-text available
This is the protocol for a review and there is no abstract. The objectives are as follows: To compare the effects of pelvic floor muscle training (PFMT) combined with another active treatment versus the same active treatment alone in the management of adult women with urinary incontinence. The comparisons will be: A Physical PFMT added to life-style intervention (e.g. weight reduction) versus life-style intervention alone (life-style intervention must be structured or supervised) PFMT added to vaginal cones versus vaginal cones alone PFMT added to bladder training versus bladder training alone (bladder training must include scheduled voiding regimen) B Electrical / magnetic PFMT added to electrical versus electrical stimulation alone (excluding implanted electrodes) PFMT added to magnetic stimulation versus magnetic stimulation alone C Mechanical PFMT added to pessaries versus pessaries alone D Drugs PFMT added to drug therapy (e.g. tolterodine) versus drug therapy alone E Surgery PFMT prior to surgical intervention (e.g. TVT) versus surgical intervention alone F Other PFMT added to any other stand-alone active treatment versus the same stand-alone active treatment.
Full-text available
The authors' intent was to determine the clinical efficacy of comprehensive pelvic floor rehabilitation among women with symptoms of pelvic floor dysfunction (PFD). We performed a retrospective analysis of women referred to an academic female pelvic medicine and reconstructive surgery practice for PFD. Data were gathered from the records of 778 women referred for pelvic floor therapy for urinary, bowel, pelvic pain, and sexual symptoms over the course of 4 years. Patients who completed at least 5 therapy sessions reported a mean symptom improvement of 80% in each of the 3 main categories analyzed, namely, urinary incontinence, defecatory dysfunction, and pelvic pain. Comprehensive, nonoperative management of PFD including pelvic floor muscle training, biofeedback, electrogalvanic stimulation, constipation management, behavioral modification, incontinence devices, and pharmacotherapy including vaginal estrogen is effective in the treatment of women with PFD.
Full-text available
The purpose of this study was to determine the effect of a 12-week pelvic floor muscle (PFM) training program on urethral morphology and mobility in women with stress urinary incontinence (SUI). Forty women with SUI were randomly assigned to one of two groups: the treatment group received 12 weekly physiotherapy sessions during which they learned how to properly contract their pelvic floor muscles (PFMs) and a home exercise program was prescribed, reviewed, and progressed; the control group received no treatment. Before and after the 12-week study period, ultrasound imaging was used to evaluate bladder neck position and mobility during coughing and Valsalva maneuver in supine and in standing, as well as urethral morphology. Secondary outcome measures included a 3-day bladder diary, 30-min pad test, the Incontinence Impact Questionnaire (IIQ-7) and the Urogenital Distress Inventory (UDI-6). The women in the treatment group demonstrated reduced bladder neck mobility during coughing and increased cross-sectional area of their urethra after as compared to before the training. These changes were not evident in the control group. No differences in the resting position of the bladder neck or in bladder neck excursion during Valsalva maneuver were noted in either group. Concomitantly the women in the treatment group demonstrated significant improvements in the 3-day bladder diary and IIQ-7 after the PFM training and improved significantly more than the control group. Physiotherapist-supervised PFM training reduces bladder neck motion during coughing, and results in hypertrophy of the urethral sphincter in women who present with SUI. Neurourol. Urodynam. © 2012 Wiley Periodicals, Inc.
Full-text available
Pelvic floor muscle training (PFMT) is a first-line therapy for women with stress, urgency or mixed urinary incontinence (UI). Supervision and content of PFMT programmes is highly variable. The most effective approach to training is not known. The aim of the review was to compare the effects of different approaches to PFMT for women with UI. This was a systematic review with meta-analysis of randomized or quasi-randomized trials in women with stress, urgency or mixed UI that compared one approach to PFMT with another. The Cochrane Incontinence Group Specialised Trials Register (17 May 2011) was searched. Two reviewers independently assessed trials for eligibility and risk of bias, and extracted data. Data were analyzed as described in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.2.2). From 574 records we included 21 trials (1490 women randomized) that addressed 11 comparisons. Comparisons made included: differences in training supervision (amount, individual versus group), in approach (one versus another, the effect of an additional component) and the exercise training (type of contraction, frequency of training). There were few trials or data in any comparison. In women with stress UI, 10% who received more health professional contact (weekly or twice-weekly group supervision plus individual appointments) did not report improvement compared to 43% who had individual appointments only (risk ratio for no improvement 0.29, 95% confidence interval 0.15 to 0.55, four trials). While women receiving more contact were more likely to report improvement, the confidence interval was wide, and more than half of "controls" reported improvement. This finding, of subjective improvement in both active treatment groups, with more improvement reported by those receiving more health professional contact, was consistent throughout the review. Considerable caution is needed in interpreting the results of the review. Existing evidence is insufficient to make any strong recommendations about the best approach to PFMT. A consistent pattern of more self-reported improvement with more health professional contact was observed; the few data consistently showed that women receiving regular (e.g. weekly) supervision were more likely to report improvement than women doing PFMT with little or no supervision. The clinical rehabilitation impact is to offer women reasonably frequent health professional contact during supervised PFMT.
The objective of this analysis was to describe urinary incontinence (UI) incidence and persistence over 5 years in association with treatment status, sociodemographic, medical, and lifestyle factors, in a racially/ethnically diverse population-based female sample. The Boston Area Community Health Survey enrolled 3,201 women aged 30-79 years of black, Hispanic, and white race/ethnicity. Five-year follow-up was completed by 2,534 women (conditional response rate 83.4 %), allowing population-weighted estimates of UI incidence and persistence rates. Predictors of UI were determined using multivariate logistic regression models. Incidence of UI at least monthly was 14.1 % and weekly 8.9 %. Waist circumference at baseline and increasing waist circumference over 5-year follow-up were the most robust predictors of UI incidence in multivariate models (P ≤ 0.01). Among 475 women with UI at baseline, persistence was associated with depression symptoms [monthly UI, odds ratio (OR) = 2.39, 95 % confidence interval (CI) 1.14-5.02] and alcohol consumption (weekly UI, OR = 3.51, 95 % CI 1.11-11.1). Among women with weekly UI at baseline, 41.7 % continued to report weekly UI at follow-up, 14.1 % reported monthly UI, and 44.2 % had complete remission. Persistence of UI was not significantly higher (58.2 % vs. 48.0 %, chi-square P = 0.3) among untreated women. Surgical or drug treatment for UI had little impact on estimates for other risk factors or for overall population rates of persistence or remission. Women with higher gains in waist circumference over time were more likely to develop UI, but waist circumference was not predictive of UI persistence. UI treatments did not affect associations for other risk factors. Additional research on the role of alcohol intake in UI persistence is warranted.
To survey commercially available intravaginal probes designed to record electromyography (EMG) from the pelvic floor muscles (PFMs), and to discuss the strengths and limitations of current technology. The MEDLINE EMBASE, CINAHL, PEDRO, and Cochrane databases were searched for articles in which intravaginal probes were described as having been used to record EMG from the PFMs. The World Wide Web was also searched using the Google search engine to find devices used to record EMG from the PFMs. Finally, a Canadian distributer of intravaginal probes was contacted to identify intravaginal EMG probes not identified through other methods. The specifications of each probe were determined through the manufacturer or their website, and each device was acquired by the investigators to verify the specifications and electrode configuration. The devices were evaluated against international standards for recording EMG data. Sixteen different models of commercially available intravaginal probes were identified: seven from published research papers, seven using the World Wide Web, and two through communication with a distributer. The probes vary in shape, dimensions, electrode positioning, and electrode configuration, with many designs prone to recording motion artifact, crosstalk, and/or inappropriate EMG signals. All commercially available intravaginal probes had deficiencies in their design such as problems with probe geometry, electrode size, location, and/or configuration. Improved intravaginal EMG probes should be developed for use in research and clinical practice. Neurourol. Urodynam. © 2013 Wiley Periodicals, Inc.
BACKGROUND: Feedback and biofeedback (BF) are common adjuncts to pelvic floor muscle training (PFMT) for women with stress, urgency, and mixed urinary incontinence (UI). An up to date systematic review of adjunctive feedback or BF was needed to guide practice and further research. OBJECTIVES: To determine whether feedback or BF add benefit to PFMT for women with UI. METHODS: The Cochrane Incontinence Group Specialised Trials Register was searched (May 2010) for randomised or quasi-randomized trials in women with stress, urgency or mixed UI regardless of cause, which compared PFMT versus PFMT augmented with feedback or BF. Two reviewers independently undertook eligibility screening, risk of bias assessment and data extraction. Analysis was in accordance with the Cochrane Handbook for Systematic Reviews of Intervention (version 5.0.2). RESULTS: Twenty-four trials were included, and many were at moderate to high risk of bias. Women who received BF were less likely to report they were not improved (RR 0.75, 95% CI: 0.66-0.86), although there was no statistically significant difference for cure (RR 0.92, 95% CI: 0.81-1.05) and marginal statistical significance for leakage episodes (mean difference: -0.12 leaks/day, 95% CI: -0.22 to -0.01). It is possible the results are confounded because women in the BF group commonly had more contact with the health professional than those in the PFMT only arm. CONCLUSION: BF may add benefit to PFMT but the observed effect could well be related to another variable, such as the amount of health professional contact rather than the BF per se. Neurourol. Urodynam. © 2012 Wiley Periodicals, Inc.
Background: Faecal incontinence is a particularly embarrassing and distressing condition with significant medical, social and economic implications. Anal sphincter exercises (pelvic floor muscle training) and biofeedback therapy have been used to treat the symptoms of people with faecal incontinence. However, standards of treatment are still lacking and the magnitude of alleged benefits has yet to be established. Objectives: To determine the effects of biofeedback and/or anal sphincter exercises/pelvic floor muscle training for the treatment of faecal incontinence in adults. Search methods: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 24 January 2012) which contains trials from searching CENTRAL, MEDLINE and handsearching of conference proceedings; and the reference lists of relevant articles. Selection criteria: All randomised or quasi-randomised trials evaluating biofeedback and/or anal sphincter exercises in adults with faecal incontinence. Data collection and analysis: Two review authors assessed the risk of bias of eligible trials and two review authors independently extracted data from the included trials. A wide range of outcome measures were considered. Main results: Twenty one eligible studies were identified with a total of 1525 participants. About half of the trials had low risk of bias for randomisation and allocation concealment.One small trial showed that biofeedback plus exercises was better than exercises alone (RR for failing to achieve full continence 0.70, 95% CI 0.52 to 0.94).One small trial showed that adding biofeedback to electrical stimulation was better than electrical stimulation alone (RR for failing to achieve full continence 0.47, 95% CI 0.33 to 0.65).The combined data of two trials showed that the number of people failing to achieve full continence was significantly lower when electrical stimulation was added to biofeedback compared against biofeedback alone (RR 0.60, 95% CI 0.46 to 0.78).Sacral nerve stimulation was better than conservative management which included biofeedback and PFMT (at 12 months the incontinence episodes were significantly fewer with sacral nerve stimulation (MD 6.30, 95% CI 2.26 to 10.34).There was not enough evidence as to whether there was a difference in outcome between any method of biofeedback or exercises. There are suggestions that rectal volume discrimination training improves continence more than sham training. Further conclusions are not warranted from the available data. Authors' conclusions: The limited number of identified trials together with methodological weaknesses of many do not allow a definitive assessment of the role of anal sphincter exercises and biofeedback therapy in the management of people with faecal incontinence. We found some evidence that biofeedback and electrical stimulation may enhance the outcome of treatment compared to electrical stimulation alone or exercises alone. Exercises appear to be less effective than an implanted sacral nerve stimulator. While there is a suggestion that some elements of biofeedback therapy and sphincter exercises may have a therapeutic effect, this is not certain. Larger well-designed trials are needed to enable safe conclusions.
The objective of this study is to evaluate the effectiveness of existing physiotherapy modalities for the treatment of urge urinary incontinence (UUI). A systematic review was performed for primary studies of physiotherapy techniques for UUI published in English between 1996 and August 2010 in major electronic databases. Only randomized clinical trials that reported outcomes separately for women with UUI were included. Outcomes assessed were reduction in UUI, urinary frequency, and nocturia. Data from 13 full-text trials including the modalities of pelvic floor muscles exercises with or without biofeedback, vaginal electrical stimulation, magnetic stimulation, and vaginal cones were analyzed. The methodologic quality of these trials was fair. Significant improvement in UUI was reported for all physiotherapy techniques except vaginal cone therapy. There are insufficient data to determine if pelvic physiotherapy improves urinary frequency or nocturia. Evidence suggests that physiotherapy techniques may be beneficial for the treatment of UUI.