Pelvic floor exercises & incontinence

You can’t visit your midwife, GP or obstetrician without them reminding you to ‘do your pelvic floor exercises’… and basically that’s about all the advice you get…

Why this advice? Because ‘do your pelvic floor exercises’ sounds so much nicer than ‘do them or you won’t be able to control your pee and poo and adult diapers really suck’.  There. Said it.  No one wants to discuss pee and poo (except Mike Patton – those of you who know his group Mr Bungle will know what I mean)…

But we should, because incontinence is really shitty.

Pun totally intended.

Following are some snippets from journal articles on the topic… to save my poor fingers from repetitive strain injury, some abbreviations and definitions:

PF = pelvic floor
PFD = pelvic floor dysfunction
PFMT = pelvic floor muscle training
UI = urinary incontinence
AI = anal incontinence (aka faecal incontinence)
SI = stress incontinence
VD = vaginal delivery
CSD = Caesarean section delivery
ID = instrumental delivery (eg. vacuum/ suction, forceps)

pelvic floor ms

netdoctor.co.uk

“Is it worth doing the PF exercises as recommended at the antenatal classes?”

  • When comparing PFMT to usual antenatal and postnatal care on incontinence, it was found that PFMT may prevent urinary incontinence up to 6 months after delivery; unfortunately there is little evidence about long-term effects of PFMT on incontinence (both urinary and faecal);
  • PFMT taught in a general exercise class three times per week during pregnancy helped to prevent UI in primiparous pregnant women;
  • Supervised PFMT training during pregnancy was found to be effective in preventing and treating UI, especially when it followed strength-training principles, emphasised close to maximal contractions, and training lasted at least 8 weeks;
  • PFMT in pregnancy can increase PF muscle contractility and decreases UI;
  • PFMT is effective to prevent SI during pregnancy and in the postpartum period;
  • Pelvic floor exercises during pregnancy were found to decrease urinary stress incontinence in post-natal women, but again, there was no evidence of long-term effectiveness;
  • Many women do not exercise their PF muscles according to instructions.

“Are there any factors that may predispose me to incontinence?”

  • Factors that may increase your chances of incontinence include new onset of UI or AI during pregnancy, positive family history, excessive weight gain during pregnancy, and vaginal delivery.

“Is there any difference between vaginal delivery and C-section delivery with respect to pelvic floor dysfunction? My friend had an elective C-section because that prevents urinary incontinence – right?”

  • Instrumental deliveries have been found to result in PFD and decreased sexual satisfaction 1 year post delivery;
  • Elective CSD does not prevent urinary incontinence;
  • SI is more common with increasing parity (number of babies you birthed), there is no reduction in  incontinence after CSD;
  • VD can result in reduced vaginal resting pressure and PF muscle strength and endurance compared with CSD;
  • Pregnancy itself increases PFD, and PFMT should be offered to all pregnant women.  Elective CSD should not be offered for the prevention of urinary or anal incontinence;
  • Spontaneous vaginal delivery has been found to be significantly associated with stress incontinence and prolapse (compared with Caesarean section), however the most dramatic risk of incontinence is associated with operative vaginal birth.

“What if I go on to have more than one child?”

  • After delivery (even your first), there is an increased risk of SI and AI. The good news is that there no further increase in PFD with subsequent pregnancies.

Bottom line

  • Pelvic floor muscle training can help with urinary incontinence in the early period after delivery, but the exercises must be done regularly and properly;
  • Pregnancy itself can increase incontinence, and while it’s clear that there is an increased risk of incontinence with instrumental delivery, the jury is still out on whether vaginal delivery increases incontinence more than C-section delivery. Nevertheless, elective C-section is NOT recommended simply in an attempt to reduce incontinence – it is major surgery after all.

REFERENCES
Barbosa AM, Marini G, Piculo F, Rudge CV, Calderon IM, Rudge MV. Prevalence of urinary incontinence and pelvic floor muscle dysfunction in primiparae two years after cesarean section: cross-sectional study. Sao Paulo Med J. 2013;131(2):95-9.  
Boyle R, Hay-Smith EJ, Cody JD, Mørkved S. Pelvic Floor Muscle Training for Prevention and Treatment of Urinary and Fecal Incontinence in Antenatal and Postnatal Women: A Short Version Cochrane Review. Neurourol Urodyn. 2013 Apr 24. doi: 10.1002/nau.22402. [Epub ahead of print]  
Pelaez M, Gonzalez-Cerron S, Montejo R, Barakat R. Pelvic floor muscle training included in a pregnancy exercise program is effective in primary prevention of urinary incontinence: A randomized controlled trial. Neurourol Urodyn. 2013 Feb 6. doi: 10.1002/nau.22381. [Epub ahead of print]  
Mørkved S, Bø K. Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review. Br J Sports Med. 2013 Jan 30. [Epub ahead of print]  
Crane AK, Geller EJ, Bane H, Ju R, Myers E, Matthews CA. Evaluation of pelvic floor symptoms and sexual function in primiparous women who underwent operative vaginal delivery versus cesarean delivery for second-stage arrest. Female Pelvic Med Reconstr Surg. 2013 Jan-Feb;19(1):13-6. doi: 10.1097/SPV.0b013e31827bfd7b.  
Chitra TV, Panicker S. Child birth, pregnancy and pelvic floor dysfunction. J Obstet Gynaecol India. 2011 Dec;61(6):635-7. doi: 10.1007/s13224-011-0095-7. Epub 2012 Jan 17. Study: Indian, determine the prevalence of incontinence and its relation to various factors like age, parity, mode of delivery and birth weight  
Marques J, Botelho S, Pereira LC, Lanza AH, Amorim CF, Palma P, Riccetto C. Pelvic floor muscle training program increases muscular contractility during first pregnancy and postpartum: Electromyographic study. Neurourol Urodyn. 2013 Sep;32(7):998-1003. doi: 10.1002/nau.22346. Epub 2012 Nov 5.  
Sahakian J. Stress incontinence and pelvic floor exercises in pregnancy. Br J Nurs. 2012 Oct 11-24;21(18):S10, S12-5.  
Kocaöz S, Eroğlu K, Sivaslıoğlu AA. Role of pelvic floor muscle exercises in the prevention of stress urinary incontinence during pregnancy and the postpartum period. Gynecol Obstet Invest. 2013;75(1):34-40. doi: 10.1159/000343038. Epub 2012 Oct 27.  
Hilde G, Stær-Jensen J, Siafarikas F, Engh ME, Brækken IH, Bø K. Impact of childbirth and mode of delivery on vaginal resting pressure and on pelvic floor muscle strength and endurance. Am J Obstet Gynecol. 2013 Jan;208(1):50.e1-7. doi: 10.1016/j.ajog.2012.10.878. Epub 2012 Oct 24.  
Koc O, Duran B. Role of elective cesarean section in prevention of pelvic floor disorders. Curr Opin Obstet Gynecol. 2012 Oct;24(5):318-23. doi: 10.1097/GCO.0b013e3283573fcb.  
Stafne SN, Salvesen KÅ, Romundstad PR, Torjusen IH, Mørkved S. Does regular exercise including pelvic floor muscle training prevent urinary and anal incontinence during pregnancy? A randomised controlled trial. BJOG. 2012 Sep;119(10):1270-80. doi: 10.1111/j.1471-0528.2012.03426.x. Epub 2012 Jul 17.  
Torrisi G, Minini G, Bernasconi F, Perrone A, Trezza G, Guardabasso V, Ettore G. A prospective study of pelvic floor dysfunctions related to delivery. Eur J Obstet Gynecol Reprod Biol. 2012 Jan;160(1):110-5. doi: 10.1016/j.ejogrb.2011.10.010. Epub 2011 Nov 16.  
Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott KC, Muñoz A. Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth. Obstet Gynecol. 2011 Oct;118(4):777-84. doi: 10.1097/AOG.0b013e3182267f2f.  
Jundt K, Scheer I, von Bodungen V, Krumbachner F, Friese K, Peschers UM. What harm does a second delivery to the pelvic floor? Eur J Med Res. 2010 Aug 20;15(8):362-6.  
Mason L, Roe B, Wong H, Davies J, Bamber J. The role of antenatal pelvic floor muscle exercises in prevention of postpartum stress incontinence: a randomised controlled trial. J Clin Nurs. 2010 Oct;19(19-20):2777-86. doi: 10.1111/j.1365-2702.2010.03297.x.

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