Knowledge, self-perception and ability of pelvic floor muscle contraction among Nepalese women with urinary incontinence.

In terms of the effectiveness of PFME programs, the results of this review indicate that urinary incontinence following childbirth can be improved by performing PFME and that any form of a specific PFME program appears to improve exercising frequency. However, the value of individual components of PFME programs, such as take-home materials, reminder telephone calls and feedback of exercising effectiveness, is less clear.

Objectives The primary objective of this review was to determine, from the available evidence, the effectiveness of an antenatal and/or a post-natal program of pelvic floor muscle exercises (PFME) compared with usual care on preventing, reducing or resolving the incidence and severity of stress incontinence, urge incontinence or mixed stress and urge urinary incontinence following childbirth. Secondary objectives were included to examine the effectiveness of a PFME program on pelvic floor muscle strength and on encouraging adherence to an exercising program. Inclusion criteria Types of studies Randomised controlled trials and non-randomised controlled trials were included in the review if, in relation to urinary incontinence, and/or adherence to a PFME program, and/or pelvic floor muscle strength, the following had been explored: antenatal PFME compared with usual care; post-natal PFME compared with usual care; a PFME program compared with usual care. Usual care is commonly used to describe the care women normally receive from health professionals in the antenatal and/or post-natal period. In some cases usual care includes a standard information package given to all women attending the health service and in others it is advice about performing PFME. Types of participants Participants included women who experienced a spontaneous onset of labour and who subsequently delivered at more than 20 weeks gestation either vaginally, both spontaneous and assisted, or by non-elective caesarean section. Exclusions: women who delivered by elective caesarean section; women experiencing post-partum overflow urinary incontinence. Types of interventions 1 Pelvic floor muscle exercises. 2 PFME instruction and a PFME program's components, such as educational materials, feedback (including biofeedback, e.g. information about strength of pelvic floor muscle contractions by various means) and number of PFME. Exclusions: electrical stimulation of pelvic floor muscles; vaginal cones; or other adjunct therapies. In studies that included a subgroup treated with one of these interventions, the results of the subgroup were excluded from the review's analysis. Types of outcome measures Outcomes that were of interest: non-occurrence of urinary incontinence following childbirth; a change in the frequency, duration or severity (as appropriate) of urinary incontinence up to 12 months following childbirth. a change in the strength of pelvic floor muscle contractions; period of time PFME continued after initial instruction; frequency of PFME undertaken; women's awareness of the importance of PFME; satisfaction with PFME instruction. Search strategy All major electronic sources of information relevant to the topic (e.g. PubMed, CINAHL and the Cochrane Library) were searched to identify published and unpublished studies and previous work in the field. Printed journals were hand-searched and reference lists checked for potentially useful research. The review included any studies undertaken between 1981 and 2003. The search did not attempt to locate unpublished research before 1991. Assessment of quality An independent Review Panel carried out quality assessment of studies. Two members of the panel, using quality assessment checklists developed for the review, reviewed each study. Disagreements between reviewers were resolved through discussion or a third reviewer examining a study. Data extraction and analysis A data extraction tool was developed to extract data relating to participant characteristics, study methods, interventions and outcomes. Two reviewers independently extracted the required data. Randomised controlled trials included in the review were pooled in several meta-analyses using RevMan software program. Heterogeneity between studies was determined to ensure that they were sufficiently similar to allow for the pooling of their results. Non-randomised controlled trials were discussed in narrative comparisons. Results Six randomised controlled trials met the inclusion criteria for the primary objective of the systematic review. The results of this review indicate that antenatal PFME and post-natal PFME are effective in resolving or reducing urinary incontinence following childbirth. There was insufficient evidence to conclude that PFME can prevent urinary incontinence in post-partum women. In most of these studies women were selected randomly and therefore included women without urinary incontinence and women with urinary incontinence. Two randomised controlled trials selected their sample on the criteria of existing post-partum urinary incontinence. A subgroup analysis of these studies showed that post-natal PFME also have a significant effect on reducing or resolving urinary incontinence in women with existing post-partum urinary incontinence. Seven randomised controlled trials and three non-randomised controlled trials met the inclusion criteria for the secondary objectives of the review. Findings of the studies included in the review suggest a PFME program will improve the frequency with which women perform PFME. Two studies found that women receiving the intervention (a PFME program) and who were performing PFME regularly in the month before data collection were significantly less likely to have any incontinence. The review's results support previous findings showing there is little evidence that a high-intensity PFME program is more effective than a low-intensity PFME regimen of exercising. No conclusions about the effectiveness of feedback to a woman about pelvic floor muscle strength, for example, perineometer measures, as part of a PFME program can be reached. The mixed results of this review mean that no conclusions can be reached about the effectiveness of a PFME program, antenatal or post-natal, on improving pelvic floor muscle strength. A number of studies reported a high percentage of women lost to follow-up and the data collected in most of the studies relied on self-reports relating to urinary incontinence and/or frequency of exercising. These factors may have affected the overall results of the review. However, wherever possible, tests for heterogeneity were carried out to determine if studies should be combined in meta-analyses and in other cases the results' limitations are acknowledged. Implications for practice In terms of the effectiveness of PFME programs, the results of this review indicate that urinary incontinence following childbirth can be improved by performing PFME and that any form of a specific PFME program appears to improve exercising frequency. However, the value of individual components of PFME programs, such as take-home materials, reminder telephone calls and feedback of exercising effectiveness, is less clear. Encourage women to undertake both antenatal and post-natal PFME (E1). Pay particular attention to women with antenatal and post-natal urinary incontinence in providing advice and PFME instruction (E1). To encourage adherence and continuation, PFME education programs should be multifaceted with a number of components, rather than only supplying an information booklet (E4). Include PFME as a specific program in all antenatal and post-natal care, incorporating at least two individual instruction sessions into the program (E1). Provide post-partum contact, particularly for those discharged early, either by telephone, electronic or home visits (E4). Design pelvic floor muscle home exercise programs that are realistic given the demands on a mother and that can be incorporated into her daily routine in terms of number and frequency. Two or more training sessions per week are recommended (E4). Health professionals working with women in the post-partum period should ask about symptoms of incontinence to ensure assistance is offered to those experiencing urinary incontinence (E4).

Urinary incontinence affects one in three women worldwide. Pelvic floor muscle training is an effective treatment. Electromyography biofeedback (providing visual or auditory feedback of internal muscle movement) is an adjunct that may improve outcomes. To determine the clinical effectiveness and cost-effectiveness of biofeedback-mediated intensive pelvic floor muscle training (biofeedback pelvic floor muscle training) compared with basic pelvic floor muscle training for treating female stress urinary incontinence or mixed urinary incontinence. A multicentre, parallel-group randomised controlled trial of the clinical effectiveness and cost-effectiveness of biofeedback pelvic floor muscle training compared with basic pelvic floor muscle training, with a mixed-methods process evaluation and a longitudinal qualitative case study. Group allocation was by web-based application, with minimisation by urinary incontinence type, centre, age and baseline urinary incontinence severity. Participants, therapy providers and researchers were not blinded to group allocation. Six-month pelvic floor muscle assessments were conducted by a blinded assessor. This trial was set in UK community and outpatient care settings. Women aged ≥ 18 years, with new stress urinary incontinence or mixed urinary incontinence. The following women were excluded: those with urgency urinary incontinence alone, those who had received formal instruction in pelvic floor muscle training in the previous year, those unable to contract their pelvic floor muscles, those pregnant or < 6 months postnatal, those with prolapse greater than stage II, those currently having treatment for pelvic cancer, those with cognitive impairment affecting capacity to give informed consent, those with neurological disease, those with a known nickel allergy or sensitivity and those currently participating in other research relating to their urinary incontinence. Both groups were offered six appointments over 16 weeks to receive biofeedback pelvic floor muscle training or basic pelvic floor muscle training. Home biofeedback units were provided to the biofeedback pelvic floor muscle training group. Behaviour change techniques were built in to both interventions. The primary outcome was urinary incontinence severity at 24 months (measured using the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form score, range 0-21, with a higher score indicating greater severity). The secondary outcomes were urinary incontinence cure/improvement, other urinary and pelvic floor symptoms, urinary incontinence-specific quality of life, self-efficacy for pelvic floor muscle training, global impression of improvement in urinary incontinence, adherence to the exercise, uptake of other urinary incontinence treatment and pelvic floor muscle function. The primary health economic outcome was incremental cost per quality-adjusted-life-year gained at 24 months. A total of 300 participants were randomised per group. The primary analysis included 225 and 235 participants (biofeedback and basic pelvic floor muscle training, respectively). The mean 24-month International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form score was 8.2 (standard deviation 5.1) for biofeedback pelvic floor muscle training and 8.5 (standard deviation 4.9) for basic pelvic floor muscle training (adjusted mean difference -0.09, 95% confidence interval -0.92 to 0.75; p = 0.84). A total of 48 participants had a non-serious adverse event (34 in the biofeedback pelvic floor muscle training group and 14 in the basic pelvic floor muscle training group), of whom 23 (21 in the biofeedback pelvic floor muscle training group and 2 in the basic pelvic floor muscle training group) had an event related/possibly related to the interventions. In addition, there were eight serious adverse events (six in the biofeedback pelvic floor muscle training group and two in the basic pelvic floor muscle training group), all unrelated to the interventions. At 24 months, biofeedback pelvic floor muscle training was not significantly more expensive than basic pelvic floor muscle training, but neither was it associated with significantly more quality-adjusted life-years. The probability that biofeedback pelvic floor muscle training would be cost-effective was 48% at a £20,000 willingness to pay for a quality-adjusted life-year threshold. The process evaluation confirmed that the biofeedback pelvic floor muscle training group received an intensified intervention and both groups received basic pelvic floor muscle training core components. Women were positive about both interventions, adherence to both interventions was similar and both interventions were facilitated by desire to improve their urinary incontinence and hindered by lack of time. Women unable to contract their muscles were excluded, as biofeedback is recommended for these women. There was no evidence of a difference between biofeedback pelvic floor muscle training and basic pelvic floor muscle training. Research should investigate other ways to intensify pelvic floor muscle training to improve continence outcomes. Current Controlled Trial ISRCTN57746448. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 70. See the NIHR Journals Library website for further project information.

To determine the effectiveness of pelvic floor muscle training (PFMT) with or without biofeedback or electrostimulation in reducing urinary incontinence and pelvic floor muscle con-traction in non-pregnant women with urinary incontinence. Methods: The following electronic databases were searched: PubMed, Cochrane Central, ClinicalTrials.gov, EU Clinical Trials Register, and sources from NICE, FDA, EMA, and SMC (articles only in English, 2000–2021). Search terms were: urinary incontinence, pelvic floor muscle training or exercises, biofeedback, electrostimulation. We used the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) for this systematic review. Relevant articles were selected, data were extracted, and quality was assessed. Data were extracted in predesigned form, followed by narrative synthesis. Results: Following the search, 15 RCTs were retrieved using the strict inclusion and exclusion criteria, assessing 2441 non-pregnant women with urinary incontinence. Of the 15 studies, 7 were low risk, 5 were medium risk, and 3 were high-risk studies. Of the 2441 patients, 970 were in PFMT, 69 were in extracorporeal magnetic innervation (ExMi) or with PFMT + BF, 30 were in electrostimulation (ES), 21 were in whole body vibration training (WBVT), 23 were in pelvic floor muscle + abdominal muscle therapy (PFM + AMT), 326 were in PFMT + biofeedback, 93 were in vaginal cones (VC), 362 were in PFMT + education, 318 were in education, and 229 were in control groups. The most often measures employed were pad tests, bladder diary, and questionnaire on the quality of life. Stress, urge and mixed urinary incontinence were studied. In all RCT, PFMT significantly reduced urinary incontinence, essentially SIU and MUI, when compared with the control group before and after treatment. Overall, out of 997 PFMT or PFMT + education patients, 504 patients (50.5%) showed improvement in urinary incontinence, and 218 became continent (21.8%) (negative pad test). In total, 62% of patients significantly reduced their urinary incontinence or cured it and improved their pelvic floor muscle contraction. All other physiotherapist techniques also significantly reduced urinary leakages, e.g., vaginal cones, biofeedback, ExMI, and WBVT when compared with the control group. There were no significant differences between these methods in reducing the severity of urinary incontinence. Conclusion: PFMT alone or with bio-feedback or electrostimulation was effective in reducing urinary incontinence and improving pelvic floor muscle contraction. PFMT when compared with other interventions such as bio-feedback, VC, and WBVT did not show significant differences but was superior to the control group. RCT studies with similar parameters used for measuring the outcomes need to be included.

Urinary incontinence is a common health problem that carries with it a significant burden. Nearly twice as many men suffer from this problem than women, and studies have demonstrated that help-seeking behavior is more challenging for men. This information sheet is based on a systematic review and focuses on the best-available evidence regarding educational interventions to raise men's awareness of bladder and bowel health. It also provides recommendations for practice.

Targeting continent antenatal women early in pregnancy and offering a structured PFMT programme may prevent the onset of urinary incontinence in late pregnancy and postpartum. However, the cost-effectiveness of this is unknown. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on urinary incontinence, although the reasons for this are unclear. It is uncertain whether a population-based approach for delivering postnatal PFMT is effective in reducing urinary incontinence. Uncertainty surrounds the effects of PFMT as a treatment for urinary incontinence in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women.It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches and in certain groups of women. Hypothetically, for instance, women with a high body mass index are at risk factor for urinary incontinence. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups and how much PFMT women in both groups do, to increase understanding of what works and for whom.Few data exist on faecal incontinence or costs and it is important that both are included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence.

This review provides evidence that early, structured PFMT in early pregnancy for continent women may prevent the onset of UI in late pregnancy and postpartum. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on UI, although the reasons for this are unclear. A population-based approach for delivering postnatal PFMT is not likely to reduce UI. Uncertainty surrounds the effects of PFMT as a treatment for UI in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women. It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches, and in certain groups of women. Hypothetically, for instance, women with a high body mass index (BMI) are at risk of UI. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups, and how much PFMT women in both groups do, to increase understanding of what works and for whom. Few data exist on FI and it is important that this is included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence. In addition to further clinical studies, economic evaluations assessing the cost-effectiveness of different management strategies for FI and UI are needed.

Getting Ready for Continence Certification: Assessing and Managing Stress Incontinence.

The primary objective of this review was to determine, from the available evidence, the effectiveness of an antenatal and/or a post-natal program of pelvic floor muscle exercises (PFME) compared with usual care on preventing, reducing or resolving the incidence and severity of stress incontinence, urge incontinence or mixed stress and urge urinary incontinence following childbirth. Secondary objectives were included to examine the effectiveness of a PFME program on pelvic floor muscle strength and on encouraging adherence to an exercising program.Randomised controlled trials and non-randomised controlled trials were included in the review if, in relation to urinary incontinence, and/or adherence to a PFME program, and/or pelvic floor muscle strength, the following had been explored:Usual care is commonly used to describe the care women normally receive from health professionals in the antenatal and/or post-natal period. In some cases usual care includes a standard information package given to all women attending the health service and in others it is advice about performing PFME.Participants included women who experienced a spontaneous onset of labour and who subsequently delivered at more than 20 weeks gestation either vaginally, both spontaneous and assisted, or by non-elective caesarean section.1 Pelvic floor muscle exercises.2 PFME instruction and a PFME program's components, such as educational materials, feedback (including biofeedback, e.g. information about strength of pelvic floor muscle contractions by various means) and number of PFME.In studies that included a subgroup treated with one of these interventions, the results of the subgroup were excluded from the review's analysis.Outcomes that were of interest: SEARCH STRATEGY: All major electronic sources of information relevant to the topic (e.g. PubMed, CINAHL and the Cochrane Library) were searched to identify published and unpublished studies and previous work in the field. Printed journals were hand-searched and reference lists checked for potentially useful research. The review included any studies undertaken between 1981 and 2003. The search did not attempt to locate unpublished research before 1991.An independent Review Panel carried out quality assessment of studies. Two members of the panel, using quality assessment checklists developed for the review, reviewed each study. Disagreements between reviewers were resolved through discussion or a third reviewer examining a study.A data extraction tool was developed to extract data relating to participant characteristics, study methods, interventions and outcomes. Two reviewers independently extracted the required data.Randomised controlled trials included in the review were pooled in several meta-analyses using RevMan software program. Heterogeneity between studies was determined to ensure that they were sufficiently similar to allow for the pooling of their results. Non-randomised controlled trials were discussed in narrative comparisons.Six randomised controlled trials met the inclusion criteria for the primary objective of the systematic review. The results of this review indicate that antenatal PFME and post-natal PFME are effective in resolving or reducing urinary incontinence following childbirth. There was insufficient evidence to conclude that PFME can prevent urinary incontinence in post-partum women. In most of these studies women were selected randomly and therefore included women without urinary incontinence and women with urinary incontinence. Two randomised controlled trials selected their sample on the criteria of existing post-partum urinary incontinence. A subgroup analysis of these studies showed that post-natal PFME also have a significant effect on reducing or resolving urinary incontinence in women with existing post-partum urinary incontinence.Seven randomised controlled trials and three non-randomised controlled trials met the inclusion criteria for the secondary objectives of the review. Findings of the studies included in the review suggest a PFME program will improve the frequency with which women perform PFME. Two studies found that women receiving the intervention (a PFME program) and who were performing PFME regularly in the month before data collection were significantly less likely to have any incontinence. The review's results support previous findings showing there is little evidence that a high-intensity PFME program is more effective than a low-intensity PFME regimen of exercising. No conclusions about the effectiveness of feedback to a woman about pelvic floor muscle strength, for example, perineometer measures, as part of a PFME program can be reached.The mixed results of this review mean that no conclusions can be reached about the effectiveness of a PFME program, antenatal or post-natal, on improving pelvic floor muscle strength.A number of studies reported a high percentage of women lost to follow-up and the data collected in most of the studies relied on self-reports relating to urinary incontinence and/or frequency of exercising. These factors may have affected the overall results of the review. However, wherever possible, tests for heterogeneity were carried out to determine if studies should be combined in meta-analyses and in other cases the results' limitations are acknowledged.In terms of the effectiveness of PFME programs, the results of this review indicate that urinary incontinence following childbirth can be improved by performing PFME and that any form of a specific PFME program appears to improve exercising frequency. However, the value of individual components of PFME programs, such as take-home materials, reminder telephone calls and feedback of exercising effectiveness, is less clear.

Pelvic floor muscle (PFM) exercises are essential for managing stress urinary incontinence (SUI), and various approaches, including differing lower limb positions and the use of assistive devices, have been proposed to enhance their effectiveness. This study aimed to evaluate how different lower limb positions and co-contraction of peri-hip muscles affect the efficiency of voluntary PFM contractions. Nineteen healthy female participants performed four types of PFM exercises: supine (Exercise A, Ex-A), supine kneeling (Exercise B,Ex-B), supine kneeling with hip abduction (Exercise C,Ex-C), and supine kneeling with hip adduction (Exercise D,Ex-D). Bladder base elevation, as an indicator of PFM contraction efficiency, was assessed using ultrasound. The results showed that the supine kneeling position (Ex-B) produced significantly greater bladder base elevation compared to the standard supine position (Ex-A) (p < 0.01). However, adding hip abduction or adduction (Ex-C and Ex-D) led to significantly lower elevations than Ex-B (p < 0.01), suggesting that co-contraction of the peri-hip muscles may reduce the efficiency of voluntary PFM contractions. This study indicates that the supine kneeling position is the most effective posture for PFM exercises, emphasizing the importance of avoiding unnecessary peri-hip muscle engagement to maximize contraction efficiency. These findings may help improve exercise protocols for preventing and managing SUI. However, a limitation of the study is the exclusive inclusion of young, healthy women; further research is needed in SUI patients or at-risk populations to confirm these results and develop more targeted exercise strategies.

Stress urinary incontinence (SUI) is managed with pelvic floor muscle training (PFMT), but the mechanism of treatment action is unclear. Resting maximal urethral closure pressure (MUCP) is lower in women with SUI, but it is unknown whether PFMT can alter resting MUCP. This systematic review evaluated whether voluntary pelvic floor muscle (PFM) contraction increases MUCP above its resting value (augmented MUCP) and the effect of PFMT on resting and augmented MUCP. Experimental and effect studies were identified using PubMed and PEDro. The PEDro scale was used to assess internal validity of interventional studies. We identified 21 studies investigating the influence of voluntary PFM contraction in women. Comparison was hindered by varying demographics, antecedent history, reporting of confirmed correct PFM contraction, and urethral pressure profilometry (UPP) techniques. Mean incremental increase in MUCP during PFM contraction in healthy women was 8-47.3cm H2O; in women with urinary incontinence (UI), it was 6-24cm H2O. Nine trials reporting MUCP as an outcome of PFMT were found. Wide variation in PFMT regimes affected the findings. Two studies found significant improvement in MUCP of 5-18cmH20. Seven studies assessed augmentation of MUCP with PFM contraction; mean increase was -0.1 to 25cmH20. There is no definitive evidence that PFMT increases resting MUCP as its mechanism of action in managing SUI. The degree to which a voluntary PFM contraction augments MUCP varies widely. There was evidence to suggest PFMT increases augmented MUCP. Drawing firm conclusions was hampered by study methodologies.

Pelvic floor muscle training after prostate surgery

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) share common pathological mechanisms,[1] and both manifest as a tape of pelvic floor dysfunction, often co-occurring and developing concomitantly. Although POP develops concomitantly with evident SUI in some cases, there have been instances wherein POP occurs without prior urine leakage before repositioning the prolapsed organs, but urinary incontinence develops after the prolapsed organs are repositioned. The condition in such cases is termed as occult SUI (OSUI), with an incidence of approximately 23.5% among patients with POP.[2] 1. Epidemiology and pathological mechanisms Despite sharing several epidemiological risk factors such as pregnancy, increased gravidity and parity, obesity, advanced age, persistently elevated intra-abdominal pressures (IAP) (eg, persistent cough or constipation), menopause, and family history, POP and SUI have complex and multifactorial etiologies. Furthermore, advanced age and Green type III cystocele (bladder prolapses to the level of the urinary meatus, the posterior urethrovesical angle <140°, urethral rotation angle ≥45°) are risk factors for concomitant OSUI in patients with POP.[3] Although POP and SUI represent distinct clinical manifestations with a shared cause, which is currently believed to be a class of disorders linked to an imbalance of pelvic floor dynamics, the majority of POP cases involve the anterior vaginal wall or the bladder. This type of prolapse is highly likely to result in laxity and protrusion of the bladder's neck and posterior wall, causing impaired support from the middle posterior urethra. This, in turn, leads to a reduced functional length of the urethra and the development of SUI symptoms.[4] Although current surgical procedures for POP repositioning can correct the anatomical positions of the involved organs, they cannot address problems involving the mechanisms of urinary control, such as sphincter dysfunction, thinning of the urethral mucosa, and autonomic dysfunction of the involved organs. Consequently, SUI becomes particularly prominent in the postoperative period.[5,6] Biomechanical finite element analyses of the pathological mechanisms of pelvic floor stress dysfunction reveal that SUI and POP are disorders of mechanical imbalance inexorably linked to each other. Moreover, they serve as pelvic manifestations of the overall systemic deterioration of the body's mechanical properties. Achieving optimal therapeutic efficacy requires more than just correcting SUI or POP in isolation. It necessitates restoring the overall health of the body and its mechanics through a comprehensive understanding of the body's overall condition and mechanical imbalance post–pelvic floor stress dysfunction.[7,8] 2. Diagnosis and evaluation The diagnosis of POP accompanied by SUI primarily relies on a thorough medical history and specialized examination. Questionnaires and laboratory examinations are not suitable for clear differential diagnosis from POP or SUI alone. 2.1. Medical history The typical symptom of POP accompanied by SUI involves protrusion of a mass from the vagina that can be seen, palpated, or otherwise sensed, which may also be accompanied by urine leakage during activities that increase IAP, such as exercise, laughing, coughing, or sneezing. Some patients may also present with frequent urination, urinary urgency, urge incontinence, or difficult urination. 2.2. Specialist examination Patients should be positioned in lithotomy or, if necessary, a standing position for examination. Observation includes checking for urinary leakage from the external urethral meatus, prolapse of pelvic organs, and maximum extent of organ prolapse at rest, during coughing or breath holding. Results should be recorded using the POP-Q system. Vaginal repositioning testing should be performed to avoid missing a diagnosis of OSUI. Specifically, stress induction testing should be performed after repositioning of the prolapsed organs, preferably in the standing position if possible. In addition, pad weight testing should be performed as a preliminary evaluation of urine leakage. Many methods of repositioning are available, with reliable results achieved by restoring the normal position of the vagina using an appropriately sized pessary or sterile cotton gauze.[9,10] 2.3. Urodynamic testing The 2019 National Institute for Health and Care Excellence guidelines serve as the international consensus to determine whether urodynamic testing is required in cases of POP accompanied by SUI. Urodynamic testing is currently recommended in the following situations: (1) mixed urinary incontinence or urinary incontinence of unknown cause; (2) voiding dysfunction as the primary symptom; (3) SUI with concomitant anterior or apical prolapse; (4) previous history of surgical treatment for urinary incontinence. Notably, this testing should be conducted only after repositioning of the prolapsed pelvic organs, distinguishing it from other urodynamic testing methods. 2.4. Differential diagnosis It is necessary to differentiate among the types of urinary incontinence associated with pelvic organ prolapse, primarily including the following: Urge incontinence: Involuntary urine leakage associated with a strong and sudden need to urinate, rather than leakage triggered by activities such as coughing or sneezing that elevate intra-abdominal pressure. Overflow incontinence: Involuntary leakage of urine due to an overdistended bladder. This is commonly encountered in cases of chronic urinary retention caused by various factors, resulting in continuous or intermittent urine leakage when bladder pressure exceeds urethral resistance. Genuine stress incontinence: A loss of urine due to a rise in intra-abdominal pressure, even when the bladder is not full. Common causes include urethral sphincter damage and congenital or acquired neurogenic diseases. 3. Conservative treatment Conservative treatment is recommended for patients with POP of grade ≤2, as assessed by the POP-Q, accompanied by mild or moderate SUI. The selection of treatment depends on the patient's preferences, disease severity, the benefits and risks of the chosen treatment, and other relevant factors. Various treatment methods are available, including follow-up observation, lifestyle interventions, pelvic floor muscle training (PFMT), pelvic floor physical therapy, pessaries, medication, and traditional Chinese medicine and acupuncture. 3.1. Follow-up observation Follow-up observation is a suitable option for asymptomatic patients, but it should be accompanied by lifestyle intervention guidance and health education. 3.2. Lifestyle interventions All patients diagnosed with POP accompanied by SUI should actively receive behavioral guidance to mitigate factors that exacerbate pelvic floor injury. This may involve weight loss, smoking cessation, avoidance of activities that increase pelvic floor stress, and the treatment of constipation and cough. 3.3. Pelvic floor muscle training Numerous PFMT methods are available, with Kegel exercises being simple yet effective in increasing the strength and coordination of weak pelvic floor muscles. Currently, a recommended duration of 3 continuous months of muscle training is advised for improving pelvic floor dysfunction, especially in cases of mild or moderate SUI.[11,12] 3.4. Physical therapy Biofeedback, adjuvant electrical stimulation, and electromagnetic therapy can enhance the effectiveness of PFMT and shorten the duration of therapy. 3.5. Pessaries Pessaries are devices inserted into the vagina to enhance pelvic floor function by restoring the normal anatomical positions of the uterus, vaginal wall, urethra, and bladder. They represent a first-line conservative treatment option for POP. Specifically, pessaries designed to address urinary incontinence can alleviate the majority of symptoms in patients with mild to moderate POP accompanied by SUI[13] and are particularly suitable for patients with fertility requirements or those for whom surgery is contraindicated. However, proper guidance on usage and regular follow-up visits are essential. 3.6. Medication Generally, medication is not considered a first-line treatment for POP accompanied by SUI. However, local estrogen treatment may be considered if the patient presents with genitourinary syndrome of menopause, which can help alleviate vaginal dryness, reduce urinary tract symptoms, and increase the thickness of the urethral mucosa, indirectly improving symptoms of urinary incontinence.[14] 3.7. Traditional Chinese medicine Electroacupuncture, traditional Chinese medicine, and other procedures can improve pelvic floor support and alleviate symptoms of prolapse and urinary incontinence to some extent, serving as adjuvant treatments. 4. Surgical treatment of POP with SUI Nearly 70% of patients with severe POP exhibit symptoms of SUI.[15] For POP patients with evident SUI, surgical treatments solely addressing POP have limited efficacy for SUI. Hence, we recommend simultaneous surgical treatment of SUI (evidence grade C). Surgical interventions for SUI encompass midurethral slings (MUS) and Burch colposuspension (Burch procedure). 4.1. Midurethral sling Midurethral sling corrects urinary incontinence by strengthening the overactive middle segment of the urethra. With a subjective cure rate of 75%–94% and an objective cure rate of 57%–92% for SUI, MUS stands as a superior treatment for urinary incontinence compared with the Burch procedure, establishing itself as the criterion standard for surgical treatment of female SUI. Medical evidence indicates that, in POP patients with evident SUI preoperatively, simultaneous MUS during pelvic floor reconstruction can reduce the subjective incidence of postoperative SUI and further decrease the need for surgical management of SUI.[16] For SUI patients with characteristics such as small bladder volume, urinary retention, or detrusor muscle dysfunction, preoperative urodynamic testing should be conducted to assess bladder function, and the option of surgical SUI management should be carefully considered. In cases where MUS is performed simultaneously with surgical POP management, it is recommended to tighten the sling and adjust tension after completing pelvic floor reconstruction. Complications of MUS may include bladder and urethral injury, difficult urination, pain in the medial thigh and pelvic cavity, and mesh exposure or erosion. 4.2. Burch procedure The Burch procedure addresses urinary incontinence by elevating the neck of the bladder and restoring the posterior urethrovesical angle. It is currently employed in laparoscopic POP reconstruction when surgical SUI management is necessary. Studies have demonstrated that patients undergoing the Burch procedure exhibit significantly lower overall cure rate and objective cure rate than those undergoing MUS. Thus, the Burch procedure is not considered the first choice for surgical SUI management in patients with POP accompanied by SUI. 5. Surgical treatment of POP with OSUI The choice between a "one-step" and a "two-step" treatment for POP accompanied by OSUI remains a matter of debate. Conducting MUS simultaneously with the surgical management of POP has shown advantages, such as reducing the risk of new-onset SUI postoperation, diminishing the need for postoperative SUI treatment, decreasing the requirements of anesthesia, and lowering medical costs. In addition, it does not affect the patient's ability to void and retain urine, nor does it compromise bladder compliance. However, this approach is associated with an increased incidence of overactive bladder, difficult urination, urine retention, urinary tract infections, and elevated risks of sling erosion and bladder perforation.[17,18] Pelvic organ prolapse patients lacking symptoms of SUI are particularly susceptible to developing OSUI, especially in cases of anterior and central POP. Preoperatively, prolapsed tissues should be repositioned through the vagina before detailed examination to confirm the presence or absence of OSUI to prevent postoperative SUI. We recommend the following methods in the formulation of the surgical plan (Fig. 1): For patients with POP in which SUI was not preoperatively confirmed, vaginal repositioning testing should be performed first. If the result is negative, SUI surgery is not necessary. If the result is positive, the strategy should be formulated considering whether the patient has a previous history of SUI. For patients with a confirmed history of SUI that resolved with increasing prolapse and for those without a history of SUI who do not wish to undergo a second operation, simultaneous SUI surgery can be performed. In summary, patients with POP accompanied by OSUI should be examined on an individual basis to weigh the risks and benefits, the surgical procedure should be carefully selected, and communications with the patient and family members should be timely and thorough.Figure 1: Diagnostic flowchart for POP accompanied by OSUI. POP = pelvic organ prolapse; SUI = stress urinary incontinence. POP = pelvic organ prolapse; SUI = stress urinary incontinence.If simultaneous SUI surgery is deemed necessary, the primary options include both the Burch procedure and MUS, with the choice dependent on the surgical approach for POP (transabdominal or transvaginal). Notably, the efficacy of MUS is better than that of the Burch procedure, and the effectiveness of MUS via the retropubic approach or the transobturator approach is comparable. 6. Prevention and surveillance 6.1. Prevention Pelvic organ prolapse and SUI have the same epidemiological risk factors and therefore similar preventive measures. Improving health during pregnancy and the postpartum period through interventions such as weight control and PFMT exercises combined with breathing exercises.[19] Avoiding activities that increase IAP, such as managing constipation and minimizing intense physical activity. Controlling body weight, avoiding/quitting smoking, and maintaining nutritional balance. Postmenopausal patients can undergo appropriate hormone replacement therapy after evaluation by a physician, thus improving overall health and managing symptoms of genitourinary syndrome of menopause. 6.2. Surveillance Surveillance of patients with POP accompanied by SUI should include the following: Follow-up for conservative treatment: At 3–6 months of treatment, follow-up should include a 72-hour voiding diary, a 1-hour urine pad test, pelvic floor muscle myoelectric testing, the International Consultation on Incontinence Questionnaire—Urinary Incontinence Short Form (ICI-Q-SF), and urodynamic testing if necessary.[20] Follow-up for surgical treatment: At 6 months postoperatively, the patient should be examined for short-term complications such as infection, bleeding, and tissue injury. After 6 months, the patient should be examined for long-term complications and efficacy of surgical treatment. Follow-up examination should include a 72-hour voiding diary, a 1-hour urine pad test, the ICI-Q-SF, Pelvic Floor Distress Inventory-20, Pelvic Organ Prolapse Distress Inventory-6, Urinary Distress Inventory-6 Colorectal-Anal Distress Inventory-8, Pelvic Floor Impact Questionnaire-7, the American Urological Association Symptom Score, and other questionnaires, as well as urodynamic testing, B-scan ultrasound of the pelvic floor, cystography, and other examinations as necessary to evaluate bladder function and mechanical recovery of the pelvic floor. Patients with mesh exposure should be referred to a trained and experienced pelvic floor specialist for further diagnosis and treatment.[21] The use of standardized CTS terminology and standardized documentation for complications is recommended to facilitate future management and referral. This article is a second publication and English translation of Chinese expert consensus on the diagnosis and treatment of pelvic organ prolapse and stress urinary incontinence, which was first published in Zhonghua Miniao Waike Zazhi, 2023, 44(6):401–404. doi: 10.3760/cma.j.cn12330-20230516-00172

We investigated the effectiveness of pelvic floor muscle (PFM) exercises or biofeedback for the treatment of urinary stress incontinence (USI). Fifty patients with USI were included in this randomized, controlled, prospective study. Twenty patients were taught PFM exercises via digital palpation and instructed to perform regularly as home program. The second group of 20 patients had PFM exercises via biofeedback three times a week for 2 months. The third group of 10 patients did not have any exercises. The patients were evaluated via pad test, perineometry, digital palpation based PFM strength, incontinence frequency, and visual analog scale based social activity index prior to and 8 weeks after the treatment. The first two groups had significant improvement in USI with respect to the control group (p < 0.001). The rise in PFM strength with perineometry of the biofeedback group was higher than in the digital palpation group after treatment (p < 0.001). PFM exercises are effective for the treatment of USI; the biofeedback method revealed better PFM strength results with respect to digital palpation.

INTRODUCTION: The pelvic floor muscle (PFM) training is the most common treatment for urinary incontinence (UI), however many women performed the contraction of PFM with associated contraction of abdominal, gluteus and hip adductors muscles. OBJECTIVE: To assess the effects of pelvic floor muscle (PFM) training on isometric and isokinetic hip adductors peak torque (PT) among women suffering from urinary incontinence (UI). MATERIALS AND METHODS: It is a longitudinal and prospective exploratory study. This study included 15 physically active women aged 45 years old and over, who presented complaints of UI. The PFM function (digital evaluation and perineometry), isometric and isokinetic hip adductors PT and one hour pad test were performed before and after treatment. The PFM training was performed in group, one hour once a week for 12 sessions. RESULTS: Significant improvement of PFM function and pressure level (p = 0.003), and significant decrease of hip adductors isometric PT and one-hour pad test, were found post-treatment. Moderate negative correlations between PFM contraction pressure and hip adductors isokinetic PT for dominant side (DS) (r = -0.62; p = 0.03) and non-dominant side (NDS) (r = -0.64; p = 0.02); and between PFM fast fibers contraction and hip adductors isometric PT for DS (r = -0.60; p = 0.03) and NDS (r = -0.59; p = 0.04) were also found. CONCLUSIONS: The PFM training decreased hip adductors PT and improved PFM functions and UI.