Expert Commentary

Antepartum pelvic floor exercises and incontinence

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References

THE QUESTION:
Can antepartum pelvic-floor exercises prevent stress incontinence in at-risk primigravidas with bladder-neck mobility?

Past Studies

There is extensive evidence suggesting that immediate postpartum pelvic-floor exercises can reduce the incidence of incontinence. However, little research has been conducted to determine whether antepartum pelvic-floor exercises were effective in reducing postpartum stress incontinence in at-risk primigravidas.

This Study

Primigravidas at 20 weeks’ gestation with bladder-neck mobility were selected to participate in supervised pelvic-floor exercises with a physiotherapist until they delivered. The exercises included 3 repetitions of 8 contractions each held for 6 seconds, with 2-minute rests between repetitions. At 34 weeks’ gestation, the number of contractions per repetition was increased to 12.

Of the 230 women observed, 120 took part in the pelvic-floor exercises and 110 were observed in the control group. Participants in the control group performed pelvic-floor exercises as instructed by a physician, but did so unsupervised.

Those patients performing pelvic-floor exercises for 28 days or more were less likely to have postpartum stress incontinence compared with the control group (19.2% and 32.7%, respectively). There was no change in bladder-neck mobility and no difference in pelvic-floor strength between groups after exercise. However, gravidas who developed postpartum stress incontinence had poorer perineometry scores than those who were continent.

Based on these findings, the researchers support the view that supervised antepartum pelvic-floor exercises are effective in reducing the risk of postpartum stress incontinence.

Find this Study

January 2002 issue of the British Journal of Obstetrics and Gynaecology; abstract online at www.bjog-elsevier.com.

Who May be Affected by These Findings?

Primigravidas at risk for postpartum stress incontinence in particular, and all pregnant women in general.

Expert Commentary

It is difficult to estimate the number of women affected by stress incontinence and other pelvic-floor disorders such as pelvic-organ prolapse and fecal incontinence.1 Several markers indicate that a large segment of the adult female population is affected. Olsen and colleagues estimated the lifetime risk of undergoing surgery for pelvic-floor disorders in the United States was 11.1%.2 In addition, Korn et al noted that in the early 1990s, more than 100,000 operations were performed annually for stress incontinence in this country.3 These statistics indicate that preventive measures are in order.

The role that pregnancy and route of delivery play in the development of postpartum stress incontinence is not clear. Current evidence implicates pregnancy as a major risk factor and suggests that vaginal delivery may play a contributing role.4 Further, there is evidence to support the hypothesis that injuries associated with pregnancy may cause stress incontinence and that immediate rehabilitation of the pelvic-floor muscles may reduce this morbidity.5 In this study, the researchers have taken the next logical step to answer the following: If the muscles of the pelvic floor are optimally trained prior to delivery, will they be less likely to sustain injury? The results are encouraging.

Women who underwent coached pelvic-floor muscle exercises experienced postpartum stress incontinence in about 20% of cases, whereas those without coaching experienced incontinence in one-third of cases. This is even more impressive given the heterogeneity of compliance within the coached group: Approximately 39% of those supervised did not consistently perform the exercises. Further, the relative risk of stress incontinence was 0.59 favoring the control group.

However, objective outcome measures of pad test, pelvic-muscle strength, and bladder-neck mobility showed no difference in either group.

The Bottom Line

It is difficult to design trials for pelvic-floor exercise, particularly in conjunction with pregnancy and delivery. While the authors of this study did a commendable job, additional data is still needed. In the meantime—because of this research—it is appropriate to recommend antepartum pelvic-floor exercises for all women, and to consider coached exercises for gravidas who are at highest risk for postpartum stress incontinence. Unfortunately, surgical interventions for pelvic-floor disorders are imperfect, so we should undertake every effort to optimize preventive measures.

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