Ltd. Pelvic floor muscle training for urinary incontinence postpartum. Urinary incontinence can be defined as 'the complaint of any involuntary leakage of urine' ( ...
Pelvic floor muscle training for urinary incontinence postpartum Bethany Hall and Sue Woodward
The offering of pelvic floor muscle exercises to all women during their first pregnancy is recommended by National Institute for Health and Care Excellence (NICE) guidelines. Pelvic floor muscles suffer significant trauma throughout pregnancy and childbirth, which may sometimes lead to urinary incontinence postpartum. However, it is uncertain how effective pelvic floor muscle exercises are in treating this incontinence. Several trials have been analysed to try and understand this query. Issues such as when the exercises were undertaken, how often they were performed and in what circumstances they were carried out, have all been considered. While it is still uncertain whether they are effective in reducing urinary incontinence postpartum, as they are non-invasive and fairly simple to carry out, they are still the first-line management for urinary incontinence postpartum with other treatments being considered if this is ineffective. Key words: Pelvic floor muscles ■ Urinary incontinence ■ Postpartum ■ Regimen
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rinary incontinence can be defined as ‘the complaint of any involuntary leakage of urine’ (National Collaborating Centre for Women’s and Children’s Health (NCCWCH), 2013). Under this wider definition are many different manifestations. Included are: ■■ Stress urinary incontinence: the involuntary leakage of urine during sneezing, coughing or exertion and effort ■■ Urgency urinary incontinence: the involuntary leakage of urine, accompanied, or immediately preceded by the urgency to urinate ■■ Mixed urinary incontinence: the involuntary leakage of urine associated with both urgency and exertion. (NCCWCH, 2013) Postpartum urinary incontinence is sometimes an unavoidable complication of vaginal delivery, especially if it happens to be a woman’s first vaginal delivery (Farrell et al, 2001). However, Logan (2005) identified that direct trauma from forceps or head compression and stretching or traction from prolonged pushing in the second stage can also contribute. While this urinary incontinence Bethany Hall, Staff nurse, neonatal unit, St George’s University Hospitals NHS Foundation Trust, London; Sue Woodward, Lecturer, Florence Nightingale Faculty of Nursing and Midwifery, King’s College London. Accepted for publication: March 2015
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usually resolves within the first 3 months after delivery, if it continues after this point, long-term symptoms may persist (Viktrup, 2002). Morkved and Bo (1999) believed that this problem could affect up to 38% of women after childbirth. During pregnancy the weight of the developing baby and uterus cause anatomical changes to the bladder and urethra—for example widening the bladder neck—and these coupled with the hormonal influences on the pelvic floor can lead to an increased risk of urinary incontinence (Herbert, 2009). There is currently no clear evidence as to which type of birth, be it instrumental, prolonged or large baby size, causes the highest prevalence of urinary incontinence postpartum. However, it should be noted that caesarean birth is not now thought to be associated with postpartum urinary problems (Herbert, 2009; Barbosa et al, 2013). As a result, it must be assumed that the cause is the multifactorial physiological trauma to the body during labour and delivery (Brubaker, 2002). Although there is little to no evidence of how to prevent this during labour, there are techniques that have been suggested to help control the symptoms of urinary incontinence postpartum. This article aims to critically analyse the role of the pelvic floor in continence and the effectiveness of pelvic floor muscle training on urinary incontinence postpartum.
What are pelvic floor muscle exercises and what do they do? The pelvic floor muscles begin at the pubic bone and pass between the legs to the base of the spine (Herschorn, 2004) (Figure 1). Pelvic floor muscle exercises involve squeezing the muscles that would stop the flow of urine (NHS Choices, 2015). This can be repeated 10-15 times with each squeeze lasting a few seconds. However it is important to note not to do this often during urination as it can be harmful to the bladder—incomplete bladder emptying can increase the risk of urinary tract infection and cause damage to the normal urinary reflexes (NHS Choices, 2015). Pelvic floor muscle training (PMFT) is the first-line treatment for urinary incontinence (Hay-Smith et al, 2001) and can sometimes be used in conjunction with vaginal cones and electrical stimulation (Dumoulin, 2006). The aim of this is to stabilise the bladder neck during abdominal pressure such as sneezing or coughing, which will in turn prevent urinary leakage (Peschers et al, 2001). PFMT can also build up ongoing support by elevating the levator plate and enhancing hypertrophy of the pelvic floor muscles and surrounding connective tissue (Bo, 2004). Dumoulin (2006) suggested that, in order for PMFT to be effective, a dosage, regimen or plan must be followed as the type of exercise undertaken, along with duration and intensity can all affect the outcome of the training, as can adherence to the training programme. Bo (2004) suggested that three sets of eight to twelve contractions held for 6–8 seconds each, undertaken three times a week and continued for 15–20 weeks would be advisable for optimum outcomes. Verbal and written information is often given regarding PMFT antenatally; nevertheless, not all women receive encouragement and reinforcement of this education after childbirth (Day and Goad 2010). If a woman is suffering from stress urinary incontinence, it may also be recommended that she undertake these exercises with a women’s health physiotherapist (Britnell et al, 2005). A physiotherapist may also be able to offer additional advice on diet, lifestyle and fluid intake to consider while also
British Journal of Nursing, 2015 Vol 24, No 11
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Abstract
CLINICAL FOCUS carrying out PMFT in order to optimise results. This will enable them to monitor progress and modify the exercise regime accordingly (Chartered Society of Physiotherapists, 2014). The evidence suggests that the more intensive the PMFT programme, the better the outcome for the woman (Boyle et al, 2012).
Uterus
Bladder
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Effect of labour on pelvic floor muscles Guidance commissioned by the National Institute for Health and Care Excellence (NICE) (NCCWCH, 2013) suggests that all women should be taught pelvic floor muscle exercises during their first pregnancy. Pelvic floor muscles support the internal organs, prevent prolapse, control the bladder and bowel and also have a role in childbirth. During pregnancy a hormone called relaxin is produced that softens muscles and ligaments to prepare for child bearing. As the uterus enlarges, the core muscles weaken, especially the pelvic floor muscles which are supporting the weight of the foetus (Day and Goad, 2010). Constipation, which is frequently experienced during pregnancy, can also impose extra pressure on the pelvic floor muscles (Marshall et al, 1998). Throughout labour the pelvic floor muscles undergo significant strain as the levator ani muscle, which makes up part of the pelvic floor muscle, has to distend to at least five times the original size. In addition to this, in order to birth a full-term foetal head, the levator hiaitus has to enlarge from 15–25 cm2 to 60–80 cm2 (Svabik et al, 2009).
were all searched to find appropriate literature on the topic; Table 1 documents the results. EMBASE yielded no further appropriate articles as all appropriate articles found were duplicates of those already identified through CINAHL or MEDLINE. Exclusion criteria were articles that were not available in English and those published before 2000, to ensure the review was up to date.
PFMT for urinary incontinence
During pregnancy or postpartum
PMFT is the most common intervention used for women with urinary incontinence (HaySmith and Dumoulin, 2006) and has three main components. The first is to ensure that the participant can contract and relax their pelvic floor muscle on demand. Once this has been established the second component, PMFT, can commence. The third involves neuromuscular re-education (Konstantinos et al, 2006). In addition to this, PMFT can focus on timing a pelvic floor muscle contraction with a secondary event that usually leads to urinary incontinence, such as coughing. This contraction will increase urethral closure pressure, which will in turn prevent urine loss. By establishing this, a woman may be able to reduce instances of urinary incontinence (Dilek and Khorshid, 2009).
Typically pelvic floor muscle exercises are recommended during pregnancy. However, trials on the effectiveness of PFMT in reducing
Literature search
The Cumulative Index to Nursing and Allied Health (CINAHL), MEDLINE and EMBASE
British Journal of Nursing, 2015, Vol 24, No 11
Urethra Rectum
© Peter Lamb
Vagina
Levator ani muscle (pelvic floor) Figure 1. Location of pelvic floor muscles
incontinence assess the success both before and after delivery. Bo and Haakstad (2011) conducted a randomised control trial to assess whether attending a fitness class that taught (PMFT would effectively prevent and treat urinary incontinence postpartum. This is a well-chosen method as randomised control trials are often considered the most reliable methods of experimental research (Churchill and Pringle, 1995). This trial consisted of a fairly small sample of 105 pregnant women split between two groups, with the first group receiving PMFT at a fitness class (n=52) and the second being a control
Table 1. Search results Database searched
Search terms
Results found
Appropriate results
CINAHL
■■ Pelvic
floor muscle exercise* OR exercise* OR ■■ Pelvic floor muscle training ■■ Urinary Incontinence ■■ Postpartum
23
5
■■ Pelvic
floor muscle exercise* OR exercise* ■■ Urinary incontinence ■■ Postpartum
20
3
■■ Pelvic
63
0
■■ Kegel
MEDLINE
■■ Kegel
EMBASE
floor muscle exercise* OR exercise* ■■ Urinary incontinence ■■ Postpartum ■■ Kegel
Note: wildcard symbol (*) allows simultaneous search for ‘exercise’ and ‘exercises’
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together to form a more precise and accurate result (Ko et al, 2010). In contrast to the aforementioned trials, Morkved and Bo (2000) conducted a trial on postpartum women rather than women during pregnancy and reported a significant reduction in the prevalence of postpartum urinary incontinence in their PFMT group both 16 weeks after delivery and 1 year postpartum compared with the matched control group.This trial followed up the participants, which could lead to a higher reliability in the results. The trial originally comprised 99 pairs of mothers who were paired considering age, parity and delivery method. Many different factors were taken into account when matching mothers, which strengthens the conclusions reached by the trial. However, the weight of the baby was not considered. This factor could have affected the outcome in some form. Each pair split into the intervention group and the control group, however, this does mean while the group are evenly matched, randomisation cannot occur. While the control group once again received the normal care, the PFMT group received training with a physiotherapist for 45 minutes once a week between the eighth and sixteenth week after delivery. Participants were asked to perform two sets of 8–12 contractions held for 6–8 seconds and perform 3–4 fast contractions at the end of each long one. Similarly to the Mason et al (2010) PFMT group, the PFMT group in this trial also followed a hometraining programme, but in this case it was for 6 months after delivery. At the 1-year follow up, more women from the control group than the PFMT group reported urinary incontinence (p
