Pelvic floor dysfunction and incontinence are common after pregnancy and childbirth. In the first 3 months after childbirth about one-third of women have urinary incontinence and up to one-tenth have faecal incontinence. Pelvic floor muscle training is recommended to prevent and treat incontinence. A recent systematic review aimed to assess the effects of pelvic floor muscle training (antenatal or postnatal) for preventing or treating urinary and faecal incontinence in late pregnancy and after childbirth.
The Cochrane Incontinence Specialised Register was searched to identify randomised or quasi-randomised trials which compared pelvic floor muscle training to no training, usual care, another treatment, or an alternative form of pelvic floor muscle training in pregnant women (could be either continent or incontinent at the time of randomisation). The primary outcome was the self-reported presence of urinary or faecal incontinence. Where possible, risk ratios and 95% CIs were calculated at five time points using meta-analysis: late in pregnancy, in the early (0-3 months), mid (3-6 months) and late (6-12 months) postnatal periods and in the long term (> 5 years). Two reviewers independently selected trials for inclusion, extracted data, and evaluated trial quality. Any disagreements were resolved by discussion. Risk of bias was evaluated using the Cochrane tool and certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Separate analyses were performed for trials recruiting women who were continent (ie, prevention), women who were incontinent (ie, treatment), mixed prevention and treatment samples, and whether the pelvic floor muscle training occurred before or after delivery. 46 trials (10,832 participants) were included in the analyses.
Prevention of urinary incontinence
Compared with usual care, urinary continent pregnant women performing antenatal pelvic floor muscle training reduced the risk of becoming incontinent in late pregnancy (risk ratio 0.38, 95% CI 0.20 to 0.72, 6 trials, 624 participants, moderate-quality evidence) and in the early (risk ratio 0.38, 95% CI 0.17 to 0.83, 5 trials, 439 participants, GRADE not provided) and mid (risk ratio 0.71, 95% CI 0.54 to 0.95, 5 trials, 673 participants; high-quality evidence) postnatal periods. This effect was not evident in the small number of trials reporting data for the late postnatal period (risk ratio 1.20, 95% CI 0.65 to 2.21, 1 trial, 44 participants, low-quality evidence) and in the long term (risk ratio 1.07, 95% CI 0.77 to 1.48, 2 trials, 352 participants, GRADE not provided).
Treatment of urinary incontinence
Antenatal pelvic floor muscle training in incontinent women did not decrease urinary incontinence in late pregnancy (risk ratio 0.70, 95% CI 0.44 to 1.13, 3 trials, 345 participants, very low-quality evidence) and in the early (risk ratio 0.75, 95% CI 0.37 to 1.53, 2 trials, 292 participants, GRADE not provided), mid (risk ratio 0.94, 95% CI 0.70 to 1.24, 1 trial, 187 participants, low-quality evidence) or late (risk ratio 0.50, 95% CI 0.13 to 1.93, 2 trials, 869 participants, very low-quality evidence) postnatal periods. Pelvic floor muscle training started after delivery for women with urinary incontinence did not reduce the risk of incontinence in the late postnatal period (risk ratio 0.55, 95% CI 0.29 to 1.07, 3 trials, 696 participants, low-quality evidence).
Mixed prevention or treatment of urinary incontinence
Antenatal pelvic floor muscle training in women with or without urinary incontinence (ie, in mixed prevention and treatment samples) probably decreases urinary incontinence in late pregnancy (risk ratio 0.78, 95% CI 0.64 to 0.94, 11 trials, 3,307 participants, moderate-quality evidence) and in the early (risk ratio 0.83, 95% CI 0.71 to 0.99, 6 trials, 806 participants, GRADE not provided) and mid (risk ratio 0.73, 95% CI 0.55 to 0.97, 5 trials, 1,921 participants, low-quality evidence) postnatal periods. This effect was not evident in the late postnatal period (risk ratio 0.85, 95% CI 0.63 to 1.14, 2 trials, 244 women, moderate-quality evidence) or in the long term (risk ratio 1.38, 95% CI 0.77 to 2.45, 1 trial, 188 participants, GRADE not provided). Pelvic floor muscle training started after delivery for mixed prevention and treatment samples did not reduce the risk of incontinence in the late postnatal period (risk ratio 0.88, 95% CI 0.71 to 1.09, 3 trials, 826 participants, moderate-quality evidence).
Faecal incontinence
Only eight trials reported faecal incontinence outcomes. No trials evaluated antenatal pelvic floor muscle training to prevent or treat faecal incontinence. In women in mixed prevention and treatment samples, there was no evidence that antenatal pelvic floor muscle training reduced the risk of faecal incontinence in late pregnancy (risk ratio 0.64, 95% CI 0.36 to 1.14, 3 trials, 910 participants, moderate-quality evidence) or in the early postnatal period (risk ratio 0.76, 95% CI 0.34 to 1.70, 2 trials, 130 participants, GRADE not provided). Pelvic floor muscle training started after delivery for women with incontinence (risk ratio 0.68, 95% CI 0.24 to 1.94, 2 trials, 620 participants, very low-quality evidence) or in mixed prevention and treatment samples (risk ratio 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 participants, low-quality evidence) did not reduce the risk of incontinence in the late postnatal period.
Structured antenatal pelvic floor muscle training for continent women can prevent the onset of urinary incontinence in late pregnancy and in the early and mid postnatal periods. Uncertainty surrounds the effects of pelvic floor muscle training as a treatment for urinary incontinence in antenatal and postnatal women and for the treatment of faecal incontinence.
Woodley SJ, et al. Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev 2020;Issue 5
