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Randomised controlled trial of conservative management of postnatal urinary and faecal incontinence: Six year follow up

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To determine the long term effects of a conservative nurse-led intervention for postnatal urinary incontinence. Randomised controlled trial. Community based intervention in three centres in the United Kingdom and New Zealand. 747 women with urinary incontinence at three months after childbirth, of whom 516 were followed up again at 6 years (69%). Active conservative treatment (pelvic floor muscle training and bladder training) at five, seven, and nine months after delivery or standard care. Urinary and faecal incontinence, performance of pelvic floor muscle training. Of 2632 women with urinary incontinence, 747 participated in the original trial. The significant improvements relative to controls in urinary (60% v 69%) and faecal (4% v 11%) incontinence at one year were not found at six year follow up (76% v 79% (95% confidence interval for difference in means -10.2% to 4.1%) for urinary incontinence, 12% v 13% (-6.4% to 5.1%) for faecal incontinence) irrespective of subsequent obstetric events. In the short term the intervention had motivated more women to perform pelvic floor muscle training (83% v 55%) but this fell to 50% in both groups in the long term. Both urinary and faecal incontinence increased in prevalence in both groups during the study period. The moderate short term benefits of a brief nurse-led conservative treatment of postnatal urinary incontinence may not persist, even among women with no further deliveries. About three quarters of women with urinary incontinence three months after childbirth still have this six years later.
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doi:10.1136/bmj.38320.613461.82
2005;330;337-; originally published online 22 Dec 2004; BMJ
and P Don Wilson
Cathryn M A Glazener, G Peter Herbison, Christine MacArthur, Adrian Grant
incontinence: six year follow up
management of postnatal urinary and faecal
Randomised controlled trial of conservative
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Papers
Randomised controlled trial of conservative management of
postnatal urinary and faecal incontinence: six year follow up
CathrynMAGlazener, G Peter Herbison, Christine MacAr thur, Adrian Grant, P Don Wilson
Abstract
Objective To determine the long term effects of a conservative
nurse-led intervention for postnatal urinary incontinence.
Design Randomised controlled trial.
Setting Community based intervention in three centres in the
United Kingdom and New Zealand.
Participants 747 women with urinary incontinence at three
months after childbirth, of whom 516 were followed up again at
6 years (69%).
Intervention Active conservative treatment (pelvic floor muscle
training and bladder training) at five, seven, and nine months
after delivery or standard care.
Main outcome measures Urinary and faecal incontinence,
performance of pelvic floor muscle training.
Results Of 2632 women with urinary incontinence, 747
participated in the original trial. The significant improvements
relative to controls in urinary (60% v 69%) and faecal (4% v
11%) incontinence at one year were not found at six year follow
up (76% v 79% (95% confidence interval for difference in
means –10.2% to 4.1%) for urinary incontinence, 12% v 13%
( 6.4% to 5.1%) for faecal incontinence) ir respective of
subsequent obstetric events. In the short term the intervention
had motivated more women to perform pelvic floor muscle
training (83% v 55%) but this fell to 50% in both groups in the
long term. Both urinary and faecal incontinence increased in
prevalence in both groups during the study period.
Conclusions The moderate short term benefits of a brief
nurse-led conservative treatment of postnatal urinary
incontinence may not persist, even among women with no
further deliveries. About three quar ters of women with urinary
incontinence three months after childbirth still have this six
years later.
Introduction
About 20-30% of women have postpartum urinary inconti-
nence,
1
and 3-5% have faecal incontinence.
2
Controversy exists
about how to manage these problems. A Cochrane review
suggested that pelvic floor muscle training is better than no
treatment and that more intensive exercising is best.
3
The trials
included in the review were in general populations of older
women with stress incontinence with only two randomised trials
among postnatal women.
45
Pelvic floor muscle training is routinely taught in maternity
care, but its effectiveness in prevention of incontinence is
questionable.
6
A Cochrane review of prevention of incontinence
was inconclusive,
6
and trials targeting antenatal
78
and postpar-
tum
910
women had conflicting findings. Maximum follow up was
one year. These inconsistent findings, together with electrophysi-
ological evidence of postpartum nerve recovery,
11
suggested that
targeting women with persistent incontinence might be more
effective.
4
Our multi-centre, randomised controlled trial of nurse-led
enhanced conservative interventions in 747 women who
reported urinary incontinence three months after delivery
5
showed that at one year fewer women in the intervention group
had urinary incontinence (60% v 69%, P = 0.037) and fewer had
faecal incontinence (4% v 11%, P = 0.012). We examined the long
term outcomes to determine whether these differences persisted.
Methods
The women were recruited in 1993-4 in three centres (Aberdeen,
Birmingham, and Dunedin). All the women had urinary inconti-
nence three months after delivery and were randomised by
remote concealed computer allocation, stratified by method of
delivery, parity, and baseline frequency of incontinence, to
receive either enhanced conservative management or standard
care. Study methods, interventions, and one year outcomes have
been reported previously.
5
In the intervention group nurses
assessed urinary incontinence and gave advice on pelvic floor
muscle training exercises at five, seven, and nine months after the
index delivery, supplemented (for those with urge symptoms)
with bladder training at seven and nine months. Women in the
control group received standard postnatal management, which
usually included a brief description on pelvic floor exercises.
We contacted the women again by postal questionnaire at six
years. The primary outcome was the incidence of urinary incon-
tinence. Secondary outcomes included use of pelvic floor
exercises and faecal incontinence. We also collected data on
obstetric histories.
We compared data with
2
tests or Student’s t tests as appro-
priate and have expressed results as absolute or relative
differences with 95% confidence intervals. Analysis was by origi-
nal group assignment. We used pre-specified secondary stratified
analyses using logistic regression to explore possible differential
effects attributed to severity and type of urinary incontinence at
baseline, and whether or not women reported a fur ther delivery
by the six year follow up. We expected that any effect was more
likely to be sustained in the subgroups of women who had more
severe incontinence at baseline, had stress urinary incontinence,
and had no further deliveries.
Results
Of the 747 women recruited, 524 (70.1%) responded one year
later. At six years, we were unable to approach five women
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known to have moved or who had died (figure), giving a
corrected response rate of 516/742 (69.5%). In all, 394
responded at both follow ups (52.7%). There were no significant
baseline differences between the women recruited (n = 747) and
those who responded at one year (n = 524) or six years (n = 516)
in age, parity, method of index delivery, and severity of urinary or
faecal incontinence (table 1). The randomised groups were also
similar.
The mean length of follow up from the index birth was 5.9
years (range 5.0-7.1). The mean age at this time was 35.9 years
(range 23-50). Parity was unchanged in 275/512 (54%). Thus,
237 women had had at least one further delivery (46.9% and
45.6% in the randomised groups), of whom 27 and 7,
respectively, had had two and three more births.
Table 2 describes women’s reported use of pelvic floor mus-
cle exercises. At six years, the differences in the number
performing exercises and the number of contractions (which
had been present at one year) had disappeared (table 2). The dif-
ference in urinary incontinence between the groups seen at one
year had also disappeared by six years (table 3). There was no
evidence that the effect at one year was more likely to persist
among women with more severe incontinence at baseline or
according to type of incontinence or further deliveries. No
women reported any adverse effects related to the active
intervention. Three quarters of the incontinent women were still
incontinent six years later.
Faecal incontinence
Some women with urinary incontinence at baseline also had fae-
cal incontinence. The reduction in faecal incontinence in the
intervention group (4% v 11%, P = 0.012) at one year was not
sustained at six years (12% v 13%, P = 0.932, table 4). The pattern
was similar for women with more severe faecal incontinence
(table 4) and among subgroups characterised by whether or not
they had faecal incontinence at entry into the trial (table 4).
Notably, two fifths of those women had persistent faecal inconti-
nence.
Incontinent women entering trial at baseline (n=747)
Intervention group (n=371)
Did not receive
intervention*
(n=55)
1993-4
1994-5
(1 year follow up)
1999-2000
(6 year follow up)
Received
intervention
(n=316)
Received
intervention
(n=376)
Control group (n=376)
Responded
(n=279, 75%)
No response
(n=92)
Responded
(n=263, 71%
of original
total)
No
response
(n=39)
No
response
(n=66)
Responded
(n=253, 67%
of original
total)
No
response
(n=61)
No
response
(n=39)
Responded
(n=245, 65%)
No response
(n=131)
Lost to follow
up
(n=2)
Lost to follow
up
(n=1)
Lost to follow
up
(n=2)
Lost to follow
up
(n=0)
*New pregnancy, too busy, moved away, family problems, incontinence resolved, non-stress or non-urge incontinence.
Known to have moved or died.
Progress of women through phases of trial
Table 1 Baseline comparison of respondents at entry (three months after delivery) and at one year, and six years after index delivery
All respondents Intervention respondents Control respondents
Entry (n=747)
One year
(n=524)
Six years
(n=516) Entry (n=371)
One year
(n=279)
Six years
(n=263) Entry (n=376)
One year
(n=245)
Six years
(n=253)
Mean (SD) age at entry
(years)
29.6 (5.0) 30.0 (4.8) 30.0 (4.7) 29.8 (4.9) 30.2 (4.7) 30.1 (4.7) 29.4 (5.1) 29.7 (4.8) 29.8 (4.7)
Primiparity at entry* (%) 37.1 38.2 38.8 36.7 37.7 39.1 37.6 38.8 38.5
Method of index delivery† (%):
Standard vaginal 78.5 79.5 80.0 78.3 79.3 79.5 78.6 79.6 80.6
Assisted vaginal 13.8 13.0 13.5 13.7 13.4 13.6 13.8 12.5 13.4
Caesarean 7.8 7.6 6.5 8.0 7.2 7.0 7.6 7.9 6.1
Severe urinary incontinence
(at least once/week) (%)
56.1 52.1 54.3 57.7 53.8 57.8 54.5 46.8 50.6
Any faecal incontinence at
entry (%)‡
15.7 15.4 13.9 16.3 15.5 14.1 15.1 15.3 13.8
*Based on respondents’ totals of 735, 516, and 505 at entry, one year, and six years.
†Based on respondents’ totals of 734, 516, and 505 at entry, one year, and six years.
‡Based on respondents’ totals of 708, 500, and 488 at entry, one year, and six years.
Papers
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Discussion
Principal findings
Although at one year after delivery women who received active
pelvic floor muscle training (with bladder training if appropriate)
had lower rates of both urinary and faecal incontinence than
women who received standard care, these differences did not
persist to six years. There were no subgroups in which the inter-
vention was more successful long term, even among those who
had not had a further pregnancy.
Three quarters of those with urinary incontinence at baseline
still had urinary incontinence six years later. Two fifths of women
with faecal incontinence at baseline still reported it six years
later, and another one in 20 developed it as a new symptom.
Strengths and weaknesses
There was about a 30% non-response rate at both one and six
years. Those responding, however, were similar to non-
responders in terms of age, parity, delivery mode, and baseline
urinary or faecal incontinence. The results were the same when
we considered only those who responded at both times. The
study was powered to detect a 10% difference. Although it was
not possible to rule out a difference of this size (95% confidence
interval of the difference –10.2% to 4.1%), results for other out-
comes support the finding of no difference.
Women with faecal incontinence all had coexisting urinary
incontinence. A further 329/4818 (7%) were continent to urine
but incontinent to faeces at baseline but were not eligible for the
trial because our inclusion criterion was urinary incontinence.
Our findings regarding faecal incontinence cannot therefore be
generalised to women who do not also have urinary
incontinence.
Meaning of the findings
The moderate short term intervention effect (about 1 in 11 fewer
women having ur inary incontinence and 1 in 16 fewer having
faecal incontinence) was not present in the long term. Similarly,
the earlier difference in the performance of pelvic floor muscle
exercises had also disappeared, which could account for the lack
of difference in urinary and faecal outcomes. The effect might
have persisted for longer if there had been continual
reinforcement or if it had been carried out by physiotherapists
rather than nurses, but these suggestions would need to be tested
by controlled trial.
These findings are also disappointing because pelvic floor
muscle training and bladder training have the merit of being
simple to teach and perform (although expensive in terms of
teaching time by health professionals) and have few if any
adverse effects. The findings, however, are in line with Cochrane
reviews of pelvic floor muscle training
3
and bladder training
12
for
urinary incontinence and conservative treatment for faecal
incontinence.
13
Our results represent the longest follow up of any
trial so far. There is a need to identify conservative strategies for
both urinary and faecal incontinence that have longer term
effects than those seen in this study and then to test them rigor-
ously by randomised controlled trials with long term follow up.
Table 2 Reported use of pelvic floor muscle training (PFMT) six years after
index delivery
Intervention Control
Difference (95% CI), P
value*
All participants 263 253
No (%) performing any
PFMT
131 (50) 126 (50) 0.0% (8.6 to 8.6),
1.00
No (%) performing
PFMT daily
17 (6) 29 (12) 5.2% (10.1 to –0.2),
0.060
Median (IQR) No of
contractions/day†
0.0 (0.0 to 15.0) 0.0 (0.0 to 15.0) 0 (0 to 0), 0.866
*For 2×2 tables P values are given with continuity correction.
†In 262 women in intervention group and 249 in control group. Medians are based on all
women—that is, counting those not doing PFMT as having frequency of contractions of 0.
Table 3 Urinary incontinence at six years after index delivery with subgroup
analyses. Figures are numbers (percentages) of women unless stated
otherwise
Intervention Control
Difference in % (95%
CI), P value*
No of women 263 253
Any urinary incontinence 201 (76) 201 (79) 3.0 (10.2 to 4.1),
0.471
At least once/week 100 (38) 99 (39) 1.1 (9.5 to 7.3), 0.867
Using pads 72 (28) 59 (24) 3.7 (3.9 to 11.3), 0.395
Mean (SD) overall rating
of severity†
35.3 (25.1) 31.4 (23.8) 3.9 (1.0 to 8.8), 0.120
Severity of incontinence at baseline:
At least once per week:
No of women 152 128
Any urinary
incontinence
122 (80) 102 (80) 0.6 (8.8 to 10.0), 1.0
Less than once a week:
No of women 111 125
Any urinary
incontinence
79 (71) 99 (79) 8.0 (19.1 to 3.0),
0.201
Type of incontinence at baseline:
Stress incontinence:
No of women 149 126
Any urinary
incontinence
111 (75) 97 (77) 2.5 (12.6 to 7.7),
0.736
Urge incontinence:
No of women 41 39
Any urinary
incontinence
31 (76) 32 (82) 6.4 (24.3 to 11.4),
0.667
Mixed incontinence:
No of women 71 80
Any urinary
incontinence
57 (80) 66 (83) 2.2 (14.7 to 10.2),
0.888
Delivery after index birth:
Women without further deliveries:
No of women 138 137
Any urinary
incontinence
108 (78) 109 (80) 1.3 (10.9 to 8.3),
0.907
Women with further deliveries:
No of women 122 115
Any urinary
incontinence
91 (75) 91 (79) 4.5 (15.2 to 6.2),
0.501
*For 2×2 tables P values are given with continuity correction.
†Visual analogue scale 0=“no problem at all” to 100=“Can’t think of anything worse” (n=195
in intervention group, n=190 in control group).
Table 4 Faecal incontinence six years after index delivery. Figures are
numbers (percentages) of women unless stated otherwise
Intervention Control
Difference (95% CI), P
value*
All women 261 248
Any faecal incontinence 32 (12) 32 (13) 0.6% (6.4 to 5.1), 0.932
Severe faecal incontinence† 15 (6) 8 (3) 2.5% (1.1 to 6.1), 0.248
Faecal incontinence at baseline:
No of women 35 33
Any faecal incontinence 15 (43) 13 (39) 3.4% (19.9 to 26.8),
0.965
No faecal incontinence at baseline:
No of women 213 203
Any faecal incontinence 12 (6) 15 (7) 1.8% (6.5 to 3.0), 0.598
*
For 2×2 tables P values are given with continuity correction.
†Severe defined as occurring sometimes, often, or always.
Paper s
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We are grateful to Anne-Marie Rennie, Alison McDonald, Jane Harvey, and
Jane Cook, who provided nursing and administrative support to the origi-
nal trial. Anne-Marie Rennie conducted the six year follow up in Aberdeen
and Birmingham, and Ros Herbison in Dunedin. Magnus McGee provided
extra statistical help.
Contributors: All authors contributed to the design, analysis, and writing up
of the study. CMAG is guarantor.
Funding: Birthright (now WellBeing), Royal College of Obstetricians and
Gynaecologists, London; New Zealand Lottery Grant Board; Health
Services Research Unit, University of Aberdeen. The health services
research unit is funded by the Chief Scientist Office of the Scottish Execu-
tive Health Department.
Competing interests: None declared.
Ethical approval: Ethical approval was obtained in each centre for the origi-
nal and follow up studies from each local ethics committee.
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2 MacArthur C, Bick DE, Keighley MR. Faecal incontinence after childbirth. Br J Obstet
Gynaecol 1997;104:46-50.
3 Hay-Smith EJC, Bo K, Berghmans LCM, Hendriks HJM, de Bie RA, van Waalwijk van
Doorn ESC. Pelvic floor muscle training for urinary incontinence in women. Cochrane
Database Syst Rev 2001;(1): CD001407.
4 Wilson PD, Herbison GP. A randomized controlled tr ial of pelvic floor muscle exercises
to treat postnatal urinary incontinence. Int Urogynecol J 1998;9:257-64.
5 Glazener CMA, Herbison GP, Wilson PD, MacArthur C, Lang GD, Gee H, et al.
Conservative management of persistent postnatal urinary and faecal incontinence: a
randomised controlled trial. BMJ 2001;323:593-6.
6 Hay-Smith EJC, Herbison P, Mørkved S. Physical therapies for prevention of urinary
and faecal incontinence in adults. Cochrane Database Syst Rev 2002;(2):CD003191.
7 Hughes P, Jackson S, Smith P, Abrams P. Can antenatal pelvic floor exercises prevent
postnatal incontinence [abstract]. Neurourol Urodyn 2001;20:447-8.
8 Salvesen KA,.Morkved S. Randomised controlled trial of pelvic floor muscle training
during pregnanc y. BMJ 2004;329:378-80.
9 Sleep J, Grant A. Pelvic floor exercises in postnatal care. Midwifery 1987;3:158-64.
10 Chiarelli P, Cockburn J. Promoting urinary continence in women after delivery:
randomised controlled trial. BMJ 2002;324:1241.
11 Snooks SJ, Badenoch DF, Tiptaft RC, Swash M. Perineal nerve damage in genuine
stress urinary incontinence. An electrophysiological study. Br J Urol 1985;57:422-6.
12 Wallace SA, Roe B, Williams K, Palmer M. Bladder training for urinary incontinence in
adults. Cochrane Database Syst Rev 2004;(4):CD001308.
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(Accepted 23 November 2004)
doi 10.1136/bmj.38320.613461.82
Health Services Research Unit, University of Aberdeen Medical School,
Foresterhill, Aberdeen AB25 2ZD
Cathryn M A Glazener senior clinical research fellow
Adrian Grant director
Department of Preventive and Social Medicine, Dunedin School of Medicine,
University of Otago, PO Box 913, Dunedin, New Zealand
G Peter Herbison associate professor
Department of Women’s and Children’s Health, Dunedin School of Medicine,
University of Otago
P Don Wilson professor of obstetrics and gynaecology
Department of Public Health and Epidemiology, University of Birmingham, PO
Box 363, Edgbaston, Birmingham B15 2TT
Christine MacArthur professor of maternal and child epidemiology
Correspondence to: CMAGlazenerc.glazener@abdn.ac.uk
What is already known on this topic
Childbirth is a major cause of urinary and faecal
incontinence in women
A one year follow up study showed that women who were
randomised to active pelvic floor muscle training (with
bladder training if appropriate) were more often continent
than women in a control group and were also more likely
to be performing pelvic floor exercises
What this study adds
At six years after the index delivery, three quarters of the
women still had urinary incontinence and over 10% had
faecal incontinence
The benefits seen at one year were no longer apparent
Only half the women were still performing any pelvic floor
exercises, irrespective of initial group assignment
Papers
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... Studies rarely pursue follow-up after 12 months postpartum, and attrition rate increases over time. Follow-up studies reporting 6-year and 12-year outcomes on PFMT and postpartum UI demonstrated limited efficacy of PFMT over time, 27,28 but these data are compromised by recall bias and high attrition rates in both study arms. More RCTs reporting follow-up beyond 12 months postpartum are needed to elucidate the efficacy of PFMTon pelvic floor disorders in the long term. ...
Article
Objectives: Pelvic floor muscle training (PFMT) is often recommended to treat postpartum urinary incontinence (UI). However, the role of postpartum PFMT in pelvic organ prolapse (POP), sexual function, and anal incontinence (AI) remains unclear. We therefore aim to assess the efficacy of postpartum PFMT on these pelvic floor disorders. Methods: This study is a meta-analysis consisting of randomized controlled trials (RCTs). We searched databases including CENTRAL, MEDLINE, EMBASE, CINAHL, and PEDro. We also sought after grey literature including conference proceedings. We included RCTs comparing PFMT versus watchful waiting in women with stage II or less POP within 1 year postpartum. Two authors independently performed study screening, risk of bias assessments, and data extraction. Results: Fifteen RCTs (3845 patients) were included. Women undergoing PFMT less likely report bothersome POP symptoms (risk ratio [RR], 0.48 [0.30-0.76]; very low-quality evidence). There is no significant difference in the number of women with stage II or greater POP (RR, 0.74 [0.45-1.24]; moderate-quality evidence). Fewer women receiving PFMT report the presence of sexual dysfunction (RR, 0.48 [0.30-0.77]; low-quality evidence). There is no significant difference in AI symptoms (RR, 1.11 [0.82-1.51]), but PFMT may be more beneficial for women with anal sphincter injuries (standardized mean differencein AI scores, -0.57 [-1.12 to -0.02]; low-quality evidence). Women receiving PFMT less likely report UI (RR, 0.44 [0.25-0.75]; moderate-quality evidence) with a more pronounced effect on stress UI (SUI). Conclusions: At present, it remains uncertain whether postpartum PFMT improves POP symptoms because of very low-quality evidence, and more high-quality RCTs are needed in this area. The POP staging will likely not change with postpartum PFMT. The PFMT may result in improved postpartum sexual function compared to watchful waiting, and may provide benefit for AI in women with anal sphincter injuries. Postpartum PFMT likely reduces the risk of UI, particularly stress urinary incontinence symptoms. There is currently little evidence about postpartum PFMT and long-term pelvic floor function.
... (15,16) 3 Treatment strategies for LUTS are often hindered by side effects and poor patient compliance. (17)(18)(19)(20) Current diagnostic tools are unable to provide evidence as to which women will either benefit from, or tolerate different treatments. The identification of novel, non-invasive biomarkers would provide substantial clinical benefit in helping to direct and tailor treatments. ...
Article
Lower urinary tract symptoms (LUTS), including urinary incontinence, urgency and nocturia, affect approximately half of women worldwide. Current diagnostic methods for LUTS are invasive and costly, while available treatments are limited by side effects leading to poor patient compliance. In this study, we aimed to identify urine metabolic signatures associated with LUTS using proton nuclear magnetic resonance (¹H-NMR) spectroscopy. A total of 214 urine samples were collected from women attending tertiary urogynaecology clinics (cases; n=176) and healthy control women attending general gynecology clinics (n=36). Despite high variation in the urine metabolome across the cohort, associations between urine metabolic profiles and BMI, parity, overactive bladder syndrome, frequency, straining and bladder storage were identified using KODAMA (knowledge discovery by accuracy maximization). Four distinct urinary metabotypes were identified, one of which was associated with increased urinary frequency and low BMI. Urine from these patients was characterized by increased levels of isoleucine and decreased levels of hippurate. Our study suggests that metabolic profiling of urine samples from LUTS patients offers the potential to identify differences in underlying aetiology, which may permit stratification of patient populations and the design of more personalized treatment strategies.
... Glazener et al. 23 realizaron un seguimiento a varios grupos de mujeres 6 años después del parto, y no encontraron diferencias significativas entre ellos: presentaron incontinencia urinaria por lo menos una vez por semana 100/263 del grupo de EFSP (38%) y 99/253 (39%) del grupo control, e incontinencia fecal (con heces) 32/261 (12%) y 32/248 (13%), respectivamente. ...
Article
Full-text available
About a third of women have urinary incontinence and up to a tenth have fecal incontinence after child birth. Pelvic floor muscle training is commonly recommended during pregnancy and after birth, both for prevention and treatment of incontinence. This article reviews the current state based on the literature of the effect of pelvic floor muscle training during pregnancy. In view of the current review results on exercises tostreng then the pelvic during preg- nancy on urinary and fecal incontinence during pregnancy and postpartum. We can say that training is effective. However, this beneficial effect disappears in the long run if you stop training. No side effects were found in the exercises. Moreover, pelvic floor muscle training during pregnancy may facilitate the delivery.
Article
Full-text available
Background: Pelvic floor dysfunction (PFD) seriously affects the patients’ quality of life, and its incidence is closely related to pregnancy and delivery. Pelvic floor muscle training (PFMT) is a conservative treatment of PFD. For decades, different researchers have conducted PFMT research on different female groups. However, the efficacy of PFMT for pregnant and postpartum women is controversial. Therefore, this article aimed to systematic review the efficacy of PFMT for them. This article reviewed the relationship between the occurrence and development of PFD during pregnancy and delivery, and the effect of PFMT on PFD in pregnant and postpartum women.Method: We used the keywords of “pelvic floor dysfunction” and “pelvic floor muscles training”, and focused on the study of PFMT during pregnancy and postpartum. Finally, 54 related studies were selected, including randomized controlled trials, quasi experimental trials, observational studies, longitudinal cohort studies, cross-sectional studies, and systematic reviews.Result: During pregnancy, PFMT can prevent the occurrence of PFD in late pregnancy and early postpartum, and in the early postpartum period, PFMT can improve the symptoms of PFD. PFMT has a protective effect on the pelvic floor without obvious negative effects. However, PFMT has not been popularized in pregnant and postpartum women. And its beneficial effects cannot be maintained for a long time if women cannot insist on it for a long time. Conclusion: The popularization and standard guidance of PFMT during the pregnancy and postpartum period should be strengthened vigorously in hospital. The development of a personalized PFMT program according to the individual situation of pregnant and postpartum women can improve the pelvic floor symptoms and their quality of life of women.
Article
Background: About one-third of women have urinary incontinence (UI) and up to one-tenth have faecal incontinence (FI) after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both preventing and treating incontinence. This is an update of a Cochrane Review previously published in 2017. Objectives: To assess the effects of PFMT for preventing or treating urinary and faecal incontinence in pregnant or postnatal women, and summarise the principal findings of relevant economic evaluations. Search methods: We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearched journals and conference proceedings (searched 7 August 2019), and the reference lists of retrieved studies. Selection criteria: We included randomised or quasi-randomised trials in which one arm included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention. Populations included women who, at randomisation, were continent (PFMT for prevention) or incontinent (PFMT for treatment), and a mixed population of women who were one or the other (PFMT for prevention or treatment). Data collection and analysis: We independently assessed trials for inclusion and risk of bias. We extracted data and assessed the quality of evidence using GRADE. Main results: We included 46 trials involving 10,832 women from 21 countries. Overall, trials were small to moderately-sized. The PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Two participants in a study of 43 pregnant women performing PFMT for prevention of incontinence withdrew due to pelvic floor pain. No other trials reported any adverse effects of PFMT. Prevention of UI: compared with usual care, continent pregnant women performing antenatal PFMT probably have a lower risk of reporting UI in late pregnancy (62% less; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; moderate-quality evidence). Antenatal PFMT slightly decreased the risk of UI in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; high-quality evidence). There was insufficient information available for the late postnatal period (more than six to 12 months) to determine effects at this time point (RR 1.20, 95% CI 0.65 to 2.21; 1 trial, 44 women; low-quality evidence). Treatment of UI: compared with usual care, there is no evidence that antenatal PFMT in incontinent women decreases incontinence in late pregnancy (very low-quality evidence), or in the mid-(RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; low-quality evidence), or late postnatal periods (very low-quality evidence). Similarly, in postnatal women with persistent UI, there is no evidence that PFMT results in a difference in UI at more than six to 12 months postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; low-quality evidence). Mixed prevention and treatment approach to UI: antenatal PFMT in women with or without UI probably decreases UI risk in late pregnancy (22% less; RR 0.78, 95% CI 0.64 to 0.94; 11 trials, 3307 women; moderate-quality evidence), and may reduce the risk slightly in the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; low-quality evidence). There was no evidence that antenatal PFMT reduces the risk of UI at late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; moderate-quality evidence). For PFMT started after delivery, there was uncertainty about the effect on UI risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; moderate-quality evidence). Faecal incontinence: eight trials reported FI outcomes. In postnatal women with persistent FI, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (very low-quality evidence). In women with or without FI, there was no evidence that antenatal PFMT led to a difference in the prevalence of FI in late pregnancy (RR 0.64, 95% CI 0.36 to 1.14; 3 trials, 910 women; moderate-quality evidence). Similarly, for postnatal PFMT in a mixed population, there was no evidence that PFMT reduces the risk of FI in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, low-quality evidence). There was little evidence about effects on UI or FI beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it. Authors' conclusions: This review provides evidence that early, structured PFMT in early pregnancy for continent women may prevent the onset of UI in late pregnancy and postpartum. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on UI, although the reasons for this are unclear. A population-based approach for delivering postnatal PFMT is not likely to reduce UI. Uncertainty surrounds the effects of PFMT as a treatment for UI in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women. It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches, and in certain groups of women. Hypothetically, for instance, women with a high body mass index (BMI) are at risk of UI. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups, and how much PFMT women in both groups do, to increase understanding of what works and for whom. Few data exist on FI and it is important that this is included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence. In addition to further clinical studies, economic evaluations assessing the cost-effectiveness of different management strategies for FI and UI are needed.
Article
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Objectives : The present systematic review focused on the prevention or treatment of three main types of pelvic floor dysfunctions (PFDs) specifically pelvic organ prolapse (POP), urinary incontinence (UI), and fecal incontinence (FI) using physiotherapy and pelvic floor muscle exercises (PFMEs). With regard to the breadth of the problem, there is not much evidence grounded on the best management. The main purpose of this systematic review was to evaluate the effects of physiotherapy and PFMEs on the prevention and treatment of pregnancy-related PFDs; namely, POP, FI, and UI. Therefore, this review incorporated studies comparing the use of physiotherapy and PFMEs with every other existing interventions. Methods : This systematic review and meta-analysis was conducted on randomized-controlled-trial (RCT) articles and quasi-RCT designs through a search in the studies published with no time limits until December 2017 in the databases of PubMed (Medline), Web of Science, Scopus, Embase, Cochrane Library, and ProQuest. The meta-analysis was also applied for data synthesis. Moreover, heterogeneity was assessed using Cochran’s Q test and I2 index. Results : A total number of 26 RCTs were examined in this review in which the outcome variables were related to POP, UI, and FI prevalence; POP, UI, and FI severity, as well as pelvic floor muscle (PFM) strength and endurance. In most articles, UI prevalence or severity in intervention groups had significantly improved compared with those in controls. The number of studies examining POP and FI was also relatively low. In two studies, FI severity or prevalence in intervention groups had significantly enhanced in comparison with those in control groups; however, FI prevalence in two articles had been reported lower in intervention groups than that in control groups although no significant difference had been observed. There was also no significant improvement in intervention groups in two other studies in this respect. Besides, three articles had not reported traces of improvement in POP, as well as a significant difference between intervention and control groups. Nevertheless, two studies had found a significant improvement in POP in this regard. Based on meta-analysis results for the variable of PFM strength, Cochran’s Q test (P<0.001) and I2 index (90.02) indicated heterogeneity between studies; so, a random-effect meta-analysis was applied to estimate overall effect sizes. The overall mean differences following intervention between the study groups were also equal to 6.94, with a 95% CI (1.36 to 12.52). Conclusions : It was concluded that physiotherapy and PFMEs might have effects on pregnancy-related UI, but they had not consistently reduced FI severity or prevalence and failed to constantly improve POP.
Chapter
The puerperium is an extremely important time in the management of pregnancy as it involves physiological, psychological and social adaptation. While these processes happen in a normal fashion in the majority, a minority of patients will develop puerperal problems, both medical and psychiatric, that may be fatal. It is important to understand the risks of the medical complications of the puerperium, including the risk of deep venous thrombosis and pulmonary embolism, puerperal sepsis, postpartum haemorrhage and puerperal psychological disorders. Attention to the clinical symptoms and signs of these conditions may avoid a maternal death. Successful management of the puerperium by a multidisciplinary team of healthcare professionals should result in a highly successful and emotionally enjoyable experience.
Article
Background: About one-third of women have urinary incontinence and up to one-tenth have faecal incontinence after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both prevention and treatment of incontinence.This is an update of a review previously published in 2012. Objectives: To determine the effectiveness of pelvic floor muscle training (PFMT) in the prevention or treatment of urinary and faecal incontinence in pregnant or postnatal women. Search methods: We searched the Cochrane Incontinence Specialised Register (16 February 2017) and reference lists of retrieved studies. Selection criteria: Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trial included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention. Data collection and analysis: Review authors independently assessed trials for inclusion and risk of bias. We extracted data and checked them for accuracy. Populations included: women who were continent (PFMT for prevention), women who were incontinent (PFMT for treatment) at randomisation and a mixed population of women who were one or the other (PFMT for prevention or treatment). We assessed quality of evidence using the GRADE approach. Main results: The review included 38 trials (17 of which were new for this update) involving 9892 women from 20 countries. Overall, trials were small to moderate sized, and the PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Other than two reports of pelvic floor pain, trials reported no harmful effects of PFMT.Prevention of urinary incontinence: compared with usual care, continent pregnant women performing antenatal PFMT may have had a lower risk of reporting urinary incontinence in late pregnancy (62% less; risk ratio (RR) for incontinence 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; low-quality evidence). Similarly, antenatal PFMT decreased the risk of urinary incontinence in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; moderate-quality evidence). There was insufficient information available for the late (more than six to 12 months') postnatal period to determine effects at this time point.Treatment of urinary incontinence: it is uncertain whether antenatal PFMT in incontinent women decreases incontinence in late pregnancy compared to usual care (RR 0.70, 95% CI 0.44 to 1.13; 3 trials, 345 women; very low-quality evidence). This uncertainty extends into the mid- (RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; very low-quality evidence) and late (RR 0.50, 95% CI 0.13 to 1.93; 2 trials, 869 women; very low-quality evidence) postnatal periods. In postnatal women with persistent urinary incontinence, it was unclear whether PFMT reduced urinary incontinence at more than six to 12 months' postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; very low-quality evidence).Mixed prevention and treatment approach to urinary incontinence: antenatal PFMT in women with or without urinary incontinence (mixed population) may decrease urinary incontinence risk in late pregnancy (26% less; RR 0.74, 95% CI 0.61 to 0.90; 9 trials, 3164 women; low-quality evidence) and the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; very low-quality evidence). It is uncertain if antenatal PFMT reduces urinary incontinence risk late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; low-quality evidence). For PFMT begun after delivery, there was considerable uncertainty about the effect on urinary incontinence risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; very low-quality evidence).Faecal incontinence: six trials reported faecal incontinence outcomes. In postnatal women with persistent faecal incontinence, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (RR 0.68, 95% CI 0.24 to 1.94; 2 trials; 620 women; very low-quality evidence). In women with or without faecal incontinence (mixed population), antenatal PFMT led to little or no difference in the prevalence of faecal incontinence in late pregnancy (RR 0.61, 95% CI 0.30 to 1.25; 2 trials, 867 women; moderate-quality evidence). For postnatal PFMT in a mixed population, there was considerable uncertainty about the effect on faecal incontinence in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, very low-quality evidence).There was little evidence about effects on urinary or faecal incontinence beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it. We found no data on health economics outcomes. Authors' conclusions: Targeting continent antenatal women early in pregnancy and offering a structured PFMT programme may prevent the onset of urinary incontinence in late pregnancy and postpartum. However, the cost-effectiveness of this is unknown. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on urinary incontinence, although the reasons for this are unclear. It is uncertain whether a population-based approach for delivering postnatal PFMT is effective in reducing urinary incontinence. Uncertainty surrounds the effects of PFMT as a treatment for urinary incontinence in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women.It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches and in certain groups of women. Hypothetically, for instance, women with a high body mass index are at risk factor for urinary incontinence. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups and how much PFMT women in both groups do, to increase understanding of what works and for whom.Few data exist on faecal incontinence or costs and it is important that both are included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence.
Article
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Objective: To investigate the influence of a protocol of Pilates exercises on the functionality and contractility of the pelvic floor muscles (PFM) of older women living in the city of Campo Grande, Mato Grosso, Brazil. Method: Ten women (median age of 63.4±4.5 years) with little or no pelvic floor dysfunction were subjected to 24 sessions of Pilates exercises lasting one hour each, for 12 weeks. The pressure of the pelvic floor muscles (PFM) was assessed using a perineometer (cmH20) and contractility was assessed with the PERFECT scheme. Data were described as median ± interquartile range and inferential analysis was performed using the Wilcoxon paired test, with a significance level of 5%. Results: In view of the proposed treatment, the degree of voluntary contraction of the PFM of the participants increased from 79.0±83.5 to 90.0±82.0 cmH20, with a statistically significant difference in paired comparison (p=0.012). According to the PERFECT scheme, there was an increase in contraction time (from 5.0±0.1 to 7.0±4.7 seconds) and in the number of fast repetitions (from 7.0±4.5 to 8.0±4.7), with a statistically significant difference for both variables (p=0.017 and p=0.008, respectively). Conclusion: The results indicate that the Pilates method increased the contractility and pressure of the PFM of elderly women with little or no PFM impairment. Further studies are required to determine whether the Pilates method is an effective method for the treatment of women with severe pelvic floor dysfunction.
Article
IntroductionBackground Overview of the ReviewIssues that Arose from Carrying Out the ReviewConclusion References
Article
Objective: To examine the relation between obstetric factors and the prevalence of urinary incontinence three months after delivery. Design: 2134 postal questionnaires sent between August 1989 and June 1991. Setting: Teaching hospital in Dunedin, New Zealand. Subjects: All women three months postpartum who were resident in the Dunedin area. Main outcome measure: Prevalence of urinary incontinence. Results: 1505 questionnaires were returned (70.5% response rate). At three months postpartum 34.3% of women admitted to some degree of urinary incontinence with 3.3% having daily or more frequent leakage. There was a significant reduction in the prevalence of incontinence for women having a caesarean section, in particular in primiparous women with a history of no previous incontinence (prevalence of incontinence following a vaginal delivery 24.5%, following a caesarean section 5.2% P = 0.002). There was little difference between elective caesarean sections and those carried out in the first and second stages of labour. The odds ratios for women having a caesarean section were 0.4 (95% confidence interval (CI) 0.2.-0.7) (all women and all primiparae) and 0.2 (95% CI 0.0-0.6) (primipara with no previous incontinence) in comparison with those having a normal vaginal delivery. The prevalence of incontinence was also significantly lower in women having had two caesarean sections (23.3%; P = 0.05) but similar in those women having three or more caesarean sections (38.9%) in comparison with those women who delivered vaginally (37.7%). Other significant independent odds rations were found for daily antenatal pelvic floor exercises (PFE) (0.6, 95% CI 0.4-0.9), parity > or = 5 (2.2, 95% CI 1.0-4.9) and pre-pregnancy body mass index (1.07, 95% CI 1.04-1.10). Conclusions: Adverse risk factors for urinary incontinence at three months postpartum are vaginal delivery, obesity and multiparity (> or = 5). Caesarean section and daily antenatal PFE appear to be protective, although not completely so.
Article
Objective To measure the prevalence and severity of postpartum faecal incontinence, especially new incontinence, and to identify obstetric risk factors. Design A cohort study with information on symptoms collected in home-based interviews and obstetric data from hospital casenotes. Setting Deliveries from a maternity hospital in Birmingham. Participants Nine hundred and six women interviewed a mean of 10 months after delivery. Main outcome measures New faecal incontinence starting after the birth, including frank incontinence, soiling and urgency. Results Thirty-six women (4%) developed new faecal incontinence after the index birth, 22 of whom had unresolved symptoms. Twenty-seven had symptoms several times a week, yet only five consulted a doctor. Among vaginal deliveries, forceps and vacuum extraction were the only independent risk factors: 12 (33%) of those with new incontinence had an instrumental delivery compared with 114 (14%) of the 847 women who had never had faecal incontinence. Six of those with incontinence had an emergency caesarean section but none became incontinent after elective sections. Conclusions Faecal incontinence as an immediate consequence of childbirth is more common than previously realised, and medical attention is rarely sought. Forceps and vacuum extraction deliveries are risk factors, with no protection demonstrated from emergency caesarean section. Identification and treatment is a priority.
Article
1800 women recruited within 24 hours of vaginal delivery, were randomly allocated to one of two pelvic floor exercise policies aimed at preventing urinary incontinence. Nine hundred women received instruction currently available to all postnatal women in the West Berkshire Health District and 900 were encouraged to follow a more intensive regime endorsed by the use of a 4-week exercise diary. When assessed 10 days and 3 months after delivery, women allocated to the intensive policy were more likely to be persevering with their exercises. There were no differences between the two groups in terms of the prevalence or severity of urinary or faecal incontinence, but women in the intensive exercise group were less likely to report perineal pain and feelings of depression 3 months after delivery. These findings raise questions about the content of current postnatal exercise programmes. The components of these should now be formally evaluated in further randomised trials.
Article
Twelve patients with genuine stress incontinence of urine were investigated using manometric and electrophysiological techniques. All were shown to have slowed conduction in the perineal branch of the pudendal nerve which innervates the periurethral striated sphincter muscle. The mean perineal nerve terminal motor latency in these patients was 3.9 +/- 0.8 (ms) and in 20 age and parity matched control subjects was 2.0 +/- 0.2 (ms) (P less than 0.001). These results are consistent with a neurogenic factor in patients with genuine stress incontinence of urine which may have implications regarding selection of patients for surgery to restore urethral competence.
Article
To measure the prevalence and severity of postpartum faecal incontinence, especially new incontinence, and to identify obstetric risk factors. A cohort study with information on symptoms collected in home-based interviews and obstetric data from hospital casenotes. Deliveries from a maternity hospital in Birmingham. Nine hundred and six women interviewed a mean of 10 months after delivery. New faecal incontinence starting after the birth, including frank incontinence, soiling and urgency. Thirty-six women (4%) developed new faecal incontinence after the index birth, 22 of whom had unresolved symptoms. Twenty-seven had symptoms several times a week, yet only five consulted a doctor. Among vaginal deliveries, forceps and vacuum extraction were the only independent risk factors: 12 (33%) of those with new incontinence had an instrumental delivery compared with 114 (14%) of the 847 women who had never had faecal incontinence. Six of those with incontinence had an emergency caesarean section but none became incontinent after elective sections. Faecal incontinence as an immediate consequence of childbirth is more common than previously realised, and medical attention is rarely sought. Forceps and vacuum extraction deliveries are risk factors, with no protection demonstrated from emergency caesarean section. Identification and treatment is a priority.
Article
A randomized controlled trial was carried out to evaluate the extent to which a program of reinforced pelvic floor muscle exercises (PFME) reduces urinary incontinence 1 year after delivery. Two hundred and thirty women who were incontinent 3 months postpartum were randomized to either a control group doing standard postnatal pelvic floor muscle exercises (n = 117) or to an intervention group (n = 113) who saw a physiotherapist for instruction at approximately 3, 4, 6 and 9 months postpartum. Results collected 12 months after delivery included prevalence and frequency of incontinence and PFME, sexual satisfaction, perineometry measurements and pad tests. Twenty-six (22%) of the control group and 59 (52%) of the intervention group withdrew before the final assessment. The prevalence of incontinence was significantly less in the intervention group than in the control group (50% versus 76%, P=0.0003), and this group also did significantly more PFME. There were no significant differences between the groups as regards sexual satisfaction, perineometry measurements or pad test results.
Article
Faecal incontinence is a particularly embarrassing and distressing condition with significant medical, social and economic implications. Sphincter exercises 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. To determine the effects of biofeedback and/or anal sphincter exercises/pelvic floor muscle training for the treatment of faecal incontinence in adults. We searched the Cochrane Incontinence Group trials register, the Cochrane Controlled Trials Register, Medline, Embase and all reference lists of relevant articles up to November 1999. Date of the most recent searches: November 1999. All randomised or quasi-randomised trials evaluating biofeedback and/or anal sphincter exercises in adults with faecal incontinence. Three reviewers assessed the methodological quality of eligible trials and two reviewers independently extracted data from included trials. A wide range of outcome measures were considered. Only five eligible studies were identified with a total of 109 participants. In the majority of trials methodological quality was poor or uncertain. All trials were small and employed a limited range of outcome measures. Follow-up information was not consistently reported amongst trials. Only two trials provided data in a form suitable for statistical analyses. There are suggestions that rectal volume discrimination training improves continence more than sham training and that anal biofeedback combined with exercises and electrical stimulation provides more short-term benefits than vaginal biofeedback and exercises for women with obstetric-related faecal incontinence. Further conclusions are not warranted from the available data. The limited number of identified trials together with their methodological weaknesses do not allow a reliable assessment of the possible role of sphincter exercises and biofeedback therapy in the management of people with faecal incontinence. There is a suggestions that some elements of biofeedback therapy and sphincter exercises may have a therapeutic effect, but this is not certain. Larger well-designed trials are needed to enable safe conclusions.
Article
Bladder training is widely used for the treatment of urinary incontinence. It is generally used for the treatment of people with urge incontinence or detrusor instability, although it is also thought that it might be of use for people with mixed incontinence or stress incontinence. To assess the effects of bladder training for the treatment of urinary incontinence. We searched the Cochrane Incontinence Group trials register up to July 1999. Date of the most recent search: July 1999. Randomised or quasi-randomised trials of bladder training for the treatment of incontinence. Two reviewers independently extracted data that were then cross-checked by the third reviewer. All three reviewers assessed trial quality. We found seven eligible trials with a total of 259 predominantly female patients with urinary urge incontinence. The quality of trials was variable. Three trials involving 92 women compared bladder training with no bladder training. These tended to favour bladder training but data were available for only a limited number of pre-specified outcomes that varied across the three trials. No data describing long term follow up are available. One trial compared bladder training with drug therapy, but was inconclusive. Another trial compared bladder training with an electronic prompt device. The trial was small and included only 20 women. Data were not presented in a form suitable for quantitative analysis. Two further trials compared bladder training supplemented by drug therapy with bladder training alone. Again, the limited data provided insufficient evidence on which to draw conclusions. Bladder training may be helpful for the treatment of urinary urge incontinence, but this conclusion can only be tentative, based on the evidence available. There was not enough evidence to show whether drug therapy was better than bladder training or useful as a supplement to it.