Hypothesis / aims of study
To date there is Level 1 evidence/ recommendation A that pelvic floor muscle training (PFMT) should be first-line treatment for women with urinary incontinence (UI) and pelvic organ prolapse (POP) grade II-III (1,2). Hence, before considering surgery or other treatments all women should be offered PFMT. However, effective PFMT implies that the women’s ability to contract their PFM has been assessed, the training has been conducted with sufficient dosage and that the training has been supervised (1,3). So far, there are no published studies addressing whether women have received evidence based PFMT before opting for further treatments. The aim of the present study was to retrieve detailed information regarding quality of former PFMT practices and other conservative treatments from women with symptoms of UI and POP scheduled for investigation at a tertiary hospital. Furthermore, to compare background variables in women who had or had not received conservative treatment and the underlying reasons for not doing PFMT.
Study design, materials and methods
This was a descriptive, cross- sectional study conducted between October and December 2023. After attending a gynecological outpatient clinic in a tertiary university hospital, consecutive women with pelvic floor dysfunction (PFD) were asked to fill in a questionnaire focusing on previous PFMT.
Inclusion criteria: women aged ≥ 18 years with predominantly complaint of UI and/or POP considered for further treatment and able to understand written information in the native language.
The questionnaire contained 32 closed questions covering demographic and background variables such as age, weight and height and obstetric factors. In addition, the women were asked in depth questions on previous treatment and experiences with PFMT including frequency, intensity and duration of training, whether they had been assessed for ability to contract, how they were assessed, whether they used “the knack”, whether using “the knack” was effective in reducing symptoms, and whether they were able to stop the urine stream. Estimated time to fill in the questionnaire was 15 minutes.
Experienced nurses and gynecologists administered and provided the participants with the questionnaire within the 3 months data collection period.
SPSS version 28 was used for data analyses. Background data is reported as numbers with percentages (%) and means with standard deviation (SD). Responses to the questions are reported as numbers with %. Shapiro-Wilk test was used to test normality of distribution for continuous data. Comparison between women who had or not had previous conservative treatment was done with Chi-Square and t-tests. P-value was set to <0.05.
Results
One-hundred and two women, mean age 52.5 (SD 13.4) years, BMI 26.7 (SD 4.7), parity 2 (range 0-4) responded to the questionnaire. Fifty percent had college or university education. Eighty- eight of the participating women (86.3%) and 30 (29.4%) visited the hospital because of primary UI or POP complaints or a combination of these symptoms, respectively.
Thirty-eight (37.3%) had never been treated for their condition before the present visit to the hospital and 11 (10.8%) had undergone surgery. There was no statistically significant difference in age, BMI, level of education, parity, time since last birth, type of PDF between women who had been or not been treated conservatively before the present investigation. Seventy-four percent reported to have trained the PFM regularly over time, but only 33 % had trained with a physical therapist. Of the 11 operated women, six had trained the PFM with a physical therapist. Eighty percent responded correctly that a PFM contraction is a lift & squeeze around the urethra, vagina and rectum. However, 31.4% and 14.7%, respectively, also ticked that contracting the gluteal muscles and doing a crook-lying back lift were correct PFM contractions. More than 35% reported that their ability to contract was not assessed or they were unsure whether a health personnel had assessed it. Thirty-seven percent were not able to stop the urine stream while 10.8% did not know. Even though 52 % reported that they performed “the knack” often or every time before and during maneuvers triggering symptoms, only 15.7% reported it to be effective often or every time.
Reasons for not having trained the PFM before visiting the hospital included: not being motivated (14.7%), not knowing how to do PFMT (10.8%), not being told/advised to do it (6.7%) and/or not believing it would help (6.7%). Of those who had done PFMT there was a variation regarding training dosage: frequency of visits with health personnel: once (7.8%) - ≥ 8-12 times (15.6%), duration of the PFMT period: one week (5.9%) - > 6 months (7.8%), PFM contractions per set: 1-2 (4.9%) and > 20 (7.8%), number of sets per day: one set (44.1%) - ≥ 3 sets per day (15.6%). Mean holding time of each PFM contraction was 8.8 seconds (SD 6.7).
Interpretation of results
Although a large proportion of the women claimed to have trained the PFM over a period of time only one third had trained with a physical therapist and only one third had been clinically assessed by health personnel. Given that more than a third of women may not be able to contract the PFM correctly (3), absence of clinical assessment of ability to contract may negatively affect the success of PFMT. Also, a substantial number of women believed that contracting the gluteal muscles and performing a crook-lying back lift was a correct PFM contraction. Many women were not able to stop the urine stream, and this combined with the report that doing “the knack” did not reduce symptoms may indicate that they had not been able to perform an effective a PFMT program. Notably, the training dosage varied largely, and most women had not followed general strength training recommendations previously shown to be effective (1-3). Hence, when asking patients whether they have previously done PFMT, it is essential to ask about the details of their training protocol. Some general limitations of survey data should be acknowledged including recall bias and response bias (the wish to respond according to current known desirable practice of PFMT).