Stephanie Knight
Airedale General Hospital
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PFMT in treatment of incontinence
Abdominal muscles and continence
The role of exercise
Does general exercise improve continence
status?
What should we tell patients?
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I leak when I run or jump
I have stopped going to the gym because of
leakage
I can’t play in the park with my children
I daren’t jump on the trampoline
I don’t go to social functions/dancing
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Prevention and therapy for many chronic
diseases
Exercise increases muscle strength &
improves cardiovascular fitness
Is exercise a risk factor for incontinence?
Can general exercise improve continence?
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28% nulliparous female athletes reported
incontinence (Nygaard et al.1994)
Most common with high impact, jumping,
running, trampolining
Possible “continence threshold”
High incidence of UI in high impact sports
(Jang et al. 2004)
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3 Supportive Layers
Endopelvic fascia
Muscle layer (Levator Ani & Coccygeus)
Superficial perineal muscles
Additional urethral closure from striated
urethral muscle, smooth muscle and vascular
system
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Grade A evidence for improvement of stress
and mixed urinary incontinence (NICE CG40
2006)
NICE recommend vaginal assessment
Need to be performed correctly
Incorrect technique may promote
incontinence (straining/Valsalva/using other
muscles)
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Increase urethral pressure
Elevate bladder neck
Narrow the levator hiatus in AP & transverse
direction
Prevent descent of pelvic organs
Increase “stiffness” of PFM
Improve timing and coordination (the
“Knack”)
Improve endurance/reduce fatigue
Bo K. 2004
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Three layers
Deepest layer
Transversus
Abdominis (TrA)
TrA is part of core
stability complex
Synergist of PFM
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Indirect training of PFM via abdominal muscle
training
(Sapsford 2001)
Abdominals co-contract with PFM
No additional benefit of PFM + TrA training
(Dumoulin et al. 2003)
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No RCT’s to show PFM can be trained
indirectly
(Hay Smith et al. 2009)
“Paula” method also not effective
(Bo et al. 2011)
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Unable to provide pelvic organ support
Unable to increase urethral closure pressure
Unable to prevent bladder neck/urethral
descent
Potential to increase incontinence
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Pilates Method is an exercise system focused
on improving flexibility and strength for the
total body
The Pilates method relies on strengthening
core postural muscles and developing body
alignment
Exercise instruction should always start with
pelvic floor contraction
No claims to treat incontinence
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In normal activity PFM & TrA show synergistic
activity to stabilise the spine
Intra-abdominal pressure also increases
Lee & Lee 2004
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If continent urethral closure pressure
increases simultaneously with IAP
If PFM weak stress leak occurs
Muscle imbalance
“Timing” is important
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Instructors focus on Abd, back,adductors,
PFM
Hypothesis: Pilates strengthens PFM if taught
in conjunction
62 women little or no pelvic floor dysfunction
2 groups: PFMT/Pilates
Strength measured with perineometer in both
groups
PFM symptoms/QoL improved in both-no
significant difference
Culligan et al. 2010
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Grade A evidence that obesity increases risk
for incontinence (Subak et al. 2009)
Weight loss can improve continence
status(Subak et al. 2002)
Exercise promotes weight loss!
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Supervised
Maximal contractions?
Train for function
Encourage long term adherence
Make it FUN!
Combine with other exercises
Vaginal examination to ensure correct
contraction
NICE CG40 2006
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PFMT is long term
commitment
Need fun ways to
maintain motivation
Using other muscle
groups can improve
concordance
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No evidence that abdominal or physical
exercise alone improves continence status
PFMT does improve continence
Teach correct PFM contraction to combine
with general exercises
Weight loss important
Any fun activity to improve long term
adherence
Patients need motivation