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Base de datos Cochrane de Revisiones Sistemáticas Revisión - Intervención

Entrenamiento muscular del piso pelviano para la prevención y tratamiento de la incontinencia fecal y urinaria en pacientes antes y después del parto

Declaraciones de intereses de los autores

Versión publicada: 07 mayo 2020 Historial de versiones

https://doi.org/10.1002/14651858.CD007471.pub4
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Antecedentes

Cerca de un tercio de las mujeres presentan incontinencia urinaria (IU) y hasta una décima parte presenta incontinencia fecal (IF) después del parto. Con frecuencia se recomienda el entrenamiento muscular del piso pelviano (EMPP) durante el embarazo y después del parto para la prevención y el tratamiento de la incontinencia.

Esta es una actualización de una revisión Cochrane publicada anteriormente en 2017.

Objetivos

Evaluar los efectos del EMPP para la prevención o el tratamiento de la incontinencia urinaria y fecal en las mujeres embarazadas o luego del parto, y resumir los hallazgos principales de las evaluaciones económicas pertinentes.

Métodos de búsqueda

Se hicieron búsquedas en el Registro Especializado del grupo Cochrane de Incontinencia (Cochrane Incontinence Specialised Register), que contiene ensayos identificados del Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, ICTRP de la OMS y búsquedas manuales de revistas y actas de congresos (búsqueda 7 mayo 2019), y en listas de referencias de artículos relevantes.

Criterios de selección

Se incluyeron ensayos aleatorizados o cuasialeatorizados en los que un brazo incluía el EMPP. Otro brazo incluyó ningún EMPP, atención prenatal o posnatal habitual, otra condición de control o una intervención alternativa de EMPP.

Las poblaciones incluyeron a mujeres que, al momento de la asignación al azar, no presentaban incontinencia (EMPP para prevención), pacientes con incontinencia (EMPP para tratamiento) y una población mixta de mujeres con o sin incontinencia (EMPP para prevención o tratamiento).

Obtención y análisis de los datos

Los estudios se evaluaron de manera independiente respecto de la inclusión y el riesgo de sesgo. Se extrajeron los datos y se evaluó la calidad de la evidencia mediante el uso de los criterios GRADE.

Resultados principales

Se incluyeron 46 ensayos en los que participaron 10 832 mujeres de 21 países. En general, los ensayos fueron de tamaño pequeño a moderado. Los programas de EMPP y las condiciones de control variaron de forma considerable y a menudo se describieron de forma deficiente. Muchos ensayos presentaron un riesgo de sesgo moderado a alto. Dos participantes en un estudio de 43 mujeres embarazadas que realizaron el EMPP para la prevención de la incontinencia se retiraron debido al dolor del piso pelviano. Ningún otro ensayo informó de ningún efecto adverso del EMPP.

Prevención de la IU: en comparación con la atención habitual, las mujeres embarazadas continentes que realizaron el EMPP prenatal probablemente tienen un menor riesgo de informar de IU en la última etapa del embarazo (62% menos; riesgo relativo [RR] 0,38; intervalo de confianza [IC] del 95%: 0,20 a 0,72; 6 ensayos, 624 mujeres; evidencia de calidad moderada). El EMPP prenatal disminuyó ligeramente el riesgo de IU en el período posnatal medio (más de tres a seis meses después del parto) (29% menos; RR 0,71; IC del 95%: 0,54 a 0,95; 5 ensayos, 673 mujeres; evidencia de calidad alta). No se dispuso de información suficiente sobre el la última etapa del período posnatal (más de seis a 12 meses) para determinar los efectos en ese momento (RR 1,20; IC del 95%: 0,65 a 2,21; 1 ensayo, 44 mujeres; evidencia de calidad baja).

Tratamiento de la IU: en comparación con la atención habitual, no hay evidencia de que el EMPP prenatal en mujeres con incontinencia disminuya la incontinencia en la última etapa del embarazo (evidencia de calidad muy baja), o en la etapa media (RR 0,94; IC del 95%: 0,70 a 1,24; 1 ensayo, 187 mujeres; evidencia de calidad baja) o en la última etapa del período posnatal (evidencia de calidad muy baja). De manera similar, en las mujeres en la etapa posnatal con IU persistente, no hay evidencia de que el EMPP resulte en una diferencia en la IU más de seis a 12 meses después del parto (RR 0,55; IC del 95%: 0,29 a 1,07; 3 ensayos; 696 mujeres; evidencia de calidad baja).

Enfoque mixto de prevención y tratamiento de la IU: el EMPP prenatal en mujeres con o sin IU probablemente disminuye el riesgo de IU en la última etapa del embarazo (22% menos; RR 0,78; IC del 95%: 0,64 a 0,94; 11 ensayos, 3307 mujeres; evidencia de calidad moderada), y puede reducir ligeramente el riesgo en el período posnatal medio (RR 0,73; IC del 95%: 0,55 a 0,97; 5 ensayos, 1921 mujeres; evidencia de calidad baja). No se encontró evidencia de que el EMPP prenatal reduzca el riesgo de IU en la última etapa del período posparto (RR 0,85; IC del 95%: 0,63 a 1,14; 2 ensayos, 244 mujeres; evidencia de calidad moderada). En el caso del EMPP iniciado después del parto, hubo incertidumbre acerca del efecto sobre el riesgo de IU en el último período de la etapa posnatal (RR 0,88; IC del 95%: 0,71 a 1,09; 3 ensayos, 826 mujeres; evidencia de calidad moderada).

Incontinencia fecal: ocho ensayos informaron sobre resultados de la IF. En las pacientes en el período posnatal con IF persistente, no estuvo claro si el EMPP redujo la incontinencia en la última etapa del período posnatal en comparación con la atención habitual (evidencia de calidad muy baja). En las mujeres con o sin IF, no hubo evidencia de que el EMPP prenatal diera lugar a una diferencia en la prevalencia de la IF en la última etapa del embarazo (RR 0,64; IC del 95%: 0,36 a 1,14; 3 ensayos, 910 mujeres; evidencia de calidad moderada). De manera similar, para el EMPP posnatal en una población mixta, no hubo evidencia de que el EMPP redujera el riesgo de IF en la última etapa del período posnatal (RR 0,73; IC del 95%: 0,13 a 4,21; 1 ensayo, 107 mujeres, evidencia de calidad baja).

Hubo poca evidencia sobre los efectos en la IU o la IF más allá de los 12 meses luego del parto. Hubo muy pocos datos sobre la calidad de vida asociada con la incontinencia y poco consenso acerca de cómo medirla.

Conclusiones de los autores

Esta revisión aporta evidencia de que el EMPP temprano y estructurado en la primera etapa del embarazo para las mujeres continentes puede prevenir la aparición de IU en la última etapa del embarazo y luego del parto. Los enfoques poblacionales (que reclutan a mujeres en el período prenatal independientemente del estado de continencia) pueden tener un efecto más pequeño sobre la IU, aunque los motivos no están claros. No es probable que un enfoque basado en la población para la administración del EMPP posnatal reduzca la IU. No hay seguridad con respecto a los efectos del EMPP como tratamiento para la IU en las pacientes antes y después del parto, lo que contrasta con la efectividad más establecida en las pacientes de mediana edad.

Es posible que los efectos del EMPP puedan ser mayores con enfoques dirigidos en lugar de enfoques mixtos de prevención y tratamiento, así como en ciertos grupos de pacientes. Hipotéticamente, por ejemplo, las mujeres con un índice de masa corporal (IMC) alto están en riesgo de IU. Dichas incertidumbres requieren un estudio adicional y también se necesitan datos sobre la duración del efecto. Para aumentar el conocimiento sobre qué funciona y con quién, se deben describir los aspectos fisiológicos y conductuales de los programas de ejercicio para los grupos de EMPP y los grupos de control, así como cuántas mujeres con EMPP deben incluirse en ambos grupos.

Existen pocos datos sobre la IF y es importante que se incluyan en cualquier ensayo futuro. Es fundamental que los ensayos futuros utilicen medidas válidas de la calidad de vida asociada con la incontinencia para la incontinencia urinaria y fecal. Además de estudios clínicos adicionales, se necesitan evaluaciones económicas que evalúen la coste‐efectividad de las diferentes estrategias de tratamiento de la IF y la IU.

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

¿Cuán efectivos son los ejercicios musculares del piso pelviano realizados durante el embarazo o después del parto para prevenir o tratar la incontinencia?

Pregunta de la revisión

Evaluar si la realización del entrenamiento muscular del piso pelviano (EMPP) durante el embarazo o después del parto reduce la incontinencia.

Antecedentes

Más de un tercio de las mujeres presenta pérdida no intencional (involuntaria) de orina (incontinencia urinaria) en el segundo y tercer trimestres del embarazo y cerca de un tercio presenta pérdida de orina en los tres primeros meses después del parto. Cerca de un cuarto de las mujeres tiene alguna pérdida involuntaria de flatos (gases) o heces (incontinencia anal) en la última etapa del embarazo y un quinto presenta pérdida de flatos o heces al año después del parto. El tratamiento de la incontinencia después del embarazo no solo es importante para las propias mujeres, sino que también puede tener un costo considerable para las personas y para los sistemas de salud.

Los profesionales sanitarios habitualmente recomiendan la realización del EMPP durante el embarazo y después del parto para prevenir y tratar la incontinencia. Con la realización regular del EMPP los músculos se fortalecen y se mantienen funcionales. Los músculos se contraen varias veces consecutivas, más de una vez al día, varios días a la semana y se continúa de forma indefinida.

¿Cuál es el grado de actualización de esta revisión?

La evidencia está actualizada hasta el 7 de agosto 2019.

Características de los estudios

Se incluyeron 46 ensayos en los que participaron 10 832 mujeres de 21 países. Los estudios incluyeron a mujeres embarazadas o mujeres que habían dado a luz en los últimos tres meses y que habían informado de pérdidas de orina, heces, tanto de orina como de heces, o ninguna pérdida. Fueron asignadas al azar para realizar el EMPP (para tratar y prevenir la incontinencia o como un tratamiento para la incontinencia) o no y se compararon los efectos.

Fuentes de financiación de los estudios

Veinticinco estudios fueron financiados con fondos públicos, uno de los cuales recibió subvenciones de fuentes tanto públicas como privadas. Tres estudios no recibieron financiamiento y 18 no declararon las fuentes de financiamiento.

Resultados clave

Mujeres embarazadas sin pérdida de orina que realizaron el EMPP para prevenir la pérdida: las mujeres probablemente informan de menos pérdidas de orina en la última etapa del embarazo y el riesgo es ligeramente menor a los tres o seis meses después del parto. No hubo información suficiente para determinar si estos efectos persistieron más allá del primer año después del parto.

Mujeres con pérdidas de orina, embarazadas o después del parto, que realizaron el EMPP como tratamiento: no hay evidencia de que la realización del EMPP durante el embarazo redujera las pérdidas en la última etapa del embarazo o en el año siguiente al parto.

Mujeres con o sin pérdidas de orina (grupo mixto), embarazadas o después del parto, que realizaron el EMPP para prevenir o tratar las pérdidas: las mujeres que comenzaron a hacer ejercicio durante el embarazo probablemente presentan una reducción leve en las pérdidas en la última etapa del embarazo, lo cual puede continuar hasta seis meses después del parto. No hay evidencia de efectos un año después del parto. En las pacientes que comenzaron los ejercicios después del parto, el efecto sobre la pérdida al año después del parto no estuvo claro.

Pérdidas de heces: solo ocho estudios presentaron evidencia sobre la pérdida de heces. Un año después del parto no estuvo claro si el EMPP ayudó a disminuir la pérdida de heces en las pacientes que comenzaron los ejercicios después del parto. Para las mujeres con o sin pérdida de heces (grupo mixto) que comenzaron el EMPP mientras estaban embarazadas, no hubo evidencia de una diferencia en la pérdida de heces al final del embarazo; para las que comenzaron el EMPP después del parto no hubo evidencia de una disminución de la pérdida hasta un año después del parto.

Hubo información escasa acerca de cómo el EMPP puede afectar la calidad de vida asociada con la pérdida. Hubo dos informes de dolor del piso pelviano, pero no se observaron otros efectos perjudiciales del EMPP.

No hubo evidencia sobre si el EMPP era coste‐efectivo.

Calidad de la evidencia

En general, los estudios fueron pequeños, y la mayoría tuvo problemas de diseño, que incluyeron detalles limitados sobre cómo las pacientes fueron asignadas al azar a los grupos, así como un informe deficiente de las mediciones. Algunos de los problemas eran de esperar porque fue imposible cegar a los profesionales sanitarios o las pacientes a si se ejercitaban o no. El EMPP difirió de forma considerable entre los estudios y a menudo se describió de forma deficiente. Por lo general, la calidad de la evidencia fue de baja a moderada.

Authors' conclusions

Implications for practice

This review provides evidence that early structured pelvic floor muscle training (PFMT) in early pregnancy for continent women probably prevents the onset of urinary incontinence in late pregnancy and reduces the risk of urinary incontinence slightly postnatally. Population approaches, that is, recruiting antenatal women regardless of their continence status, might also reduce the risk of urinary incontinence in late pregnancy and up to > 3‐6 months postpartum, but the effect may be less pronounced. However, the reasons for this are unclear. The findings about the effects of PFMT as a treatment for antenatal urinary incontinence are uncertain.

Similarly, it is uncertain whether a population‐based approach for delivery of postnatal PFMT (i.e. recruitment of women regardless of continence status immediately following delivery) is effective. It is possible that a 'high‐risk' approach (e.g. women who have an assisted delivery or deliver a large baby) leads to more clinical benefit than a population approach.

It is also appears that PFMT is not likely an effective treatment for persistent urinary incontinence symptoms (i.e. women recruited at three months' postdelivery). This uncertainty around the efficacy of PFMT as a treatment for urinary incontinence in the immediate postnatal period is perhaps surprising given the summary findings of Dumoulin 2018, which suggested that PFMT is an effective treatment for established urinary incontinence symptoms in non‐postnatal women.

We can suggest some plausible reasons for the differences in findings of the effectiveness of PFMT as a treatment for persistent postnatal urinary incontinence, compared to the findings of Dumoulin 2018, in non‐postnatal women. First, there are differences in the participants in the included trials. In this review, trials included postnatal women who may have altered physiological capabilities (muscle, nerve and connective tissue) consequent on the changes of pregnancy and delivery (Nygaard 2017). Postnatal women may find it particularly difficult to adopt or sustain exercise behaviour postdelivery, especially when they are distracted and occupied with caring for a new baby (Gillard 2010; Mason 2001). In contrast, Dumoulin 2018 reported outcomes from trials in non‐postnatal women, which may not have the same barriers. Second, there are differences in the comparator or control groups. In this review, the comparator group in the two large trials which carried the greatest weighting in the pooled estimate was usual care (which may have included PFMT), whereas the control group received no treatment in the majority of studies included in Dumoulin 2018 (Analysis 4.1). It is possible that the potential lack of contrast between the intervention and control groups in this review contributed to the uncertainty surrounding the effect of PFMT as a treatment for postnatal urinary incontinence. Interestingly, in the one small study that compared an intensively supervised strengthening PFMT programme versus no treatment, rather than two larger trials that compared a minimally supervised PFMT programme with uncertain physiological effect, the benefit of PFMT was more marked (Analysis 4.1).

There are insufficient data on faecal incontinence to state whether or not PFMT is effective in preventing or treating this problem in pregnant or postpartum women. Furthermore, there are insufficient data to determine whether or not PFMT is effective to prevent urinary incontinence more than one year after birth. However, it is acknowledged that assessing the long‐term effects of PFMT is challenging, as women may go on to have subsequent pregnancies, be offered a specific PFMT programme if they had taken part in the control arm of a trial, or initiate their own PFMT (Mørkved 2003).

Only two adverse events were reported with PFMT. It is possible that PFMT during pregnancy might influence labour and delivery outcomes). This does not seem to be the case based on findings from non‐systematic Cochrane Reviews (Du 2015; Schreiner 2018). However, based on data from 11 antenatal PFMT trials included in this review, there was no evidence of a difference between PFMT and control groups.

Implications for research

Since the previous version of this review, eight new studies have been added, most of which were small‐ to moderate‐sized trials (i.e. fewer than 500 women per arm). Unfortunately, the variability in rigour of methods and quality of reporting continued and this affords an opportunity to make some recommendations for further research (Woodley 2017).

First, the lack of faecal incontinence data was notable. It is encouraging to see some attention is being directed specifically towards investigations of faecal incontinence in antenatal and postnatal women with 11 ongoing trials expecting to recruit about 1600 women (Haruna 2014; Haruna 2016; Hendler 2017; Lijun 2018; NCT02270008; NCT02334397; NCT02682212; NCT03247660; Sobhgol 2019; Torabipour 2019; Velez‐Sanchez 2015). Because fewer women may have faecal incontinence, every trial conducted on antenatal and postnatal incontinence must collect faecal as well as urinary incontinence data so we can learn more about this problem.

As there is insufficient evidence about the continuing effects of PFMT, trialists should, at a minimum, collect follow‐up data about antenatal training at three months' postpartum and about postnatal training at 12 months' postpartum. Ideally, for both antenatal and postnatal training, data should also be collected in both the intervention and control groups beyond one year.

The descriptions of the PFMT and control interventions and choice of outcome measures require attention. It is important that both the physiological and behavioural aspects of exercise are thoroughly described in both the intervention and control groups (Frawley 2017), which may be facilitated by using a Consensus on Exercise Reporting Template (Hay‐Smith 2019; Slade 2016). In particular, there is a need to know what types of PFMT advice and behaviour occur in the usual care group, as these details are infrequently measured or reported, which can influence the effect sizes and precision (Levack 2019). In addition, it is recommended that all future trials collect valid measures of incontinence‐specific quality of life for both urinary and faecal incontinence (e.g. International Consultation on Incontinence Questionnaire‐Short Form (ICIQ‐SF) for urinary incontinence and an agreed measure for faecal incontinence) (Avery 2007). In antenatal trials, the effect of PFMT on labour and delivery outcomes is worthy of further investigation. This would help to elucidate whether or not there are any associations between PFMT parameters, such as the type, frequency, intensity and duration of pelvic floor muscle (PFM) exercises and outcomes for mother and baby.

Half of the included trials reported some type of adherence data for women in the intervention or control groups but only nine studies asked women in both PFMT and control groups about their exercise behaviour (see Included studies). Adherence data should be collected in both study groups, although it is acknowledged that measuring it may change exercise behaviour. In turn, this may lead to an overestimate of the likely effect in 'real' life and may diminish the difference in effect between structured PFMT and control conditions.

The evidence to date about the benefit of mixed prevention and treatment approaches is uncertain in antenatal populations and not at all clear in postnatal populations. From the record of ongoing studies, four clearly appear to investigate PFMT delivered to women with or without existing incontinence symptoms, but all of these studies are small (total of approximately 700 women) and, therefore, unlikely to provide sufficient data for certainty about the effects of this approach. However, it is possible that the effect of PFMT in these mixed approaches is diluted by some women who will never become incontinent and also those in whom PFMT is unlikely to be effective, such as those with denervation. Perhaps the focus in future population type trials should be to target women who are at heightened risk of developing urinary or faecal incontinence (such as women with a high body mass index (BMI) or women who have had an assisted vaginal delivery).

The effect of PFMT for treating urinary and faecal incontinence, especially in antenatal women, is a high priority for further investigation. It is noted that only one of the 19 ongoing trials (Moossdorf‐Steinhauser 2019) appears to address this question in antenatal women, and as this is a small study (of 240 women), it is unlikely to provide sufficient information for certainty about the effect. Any further large pragmatic trials will ideally include process evaluation and fidelity checking, so some evaluation of treatment can be provided (Moore 2015).

In addition, given the resource implications of faecal and urinary incontinence, there is also a need for high‐quality economic evaluations assess strategies for managing urinary and faecal incontinence in postpartum populations.

Summary of findings

Open in table viewer
Summary of findings 1. Antenatal pelvic floor muscle training compared to control for prevention of urinary and faecal incontinence

Antenatal pelvic floor muscle training compared to control for prevention of urinary and faecal incontinence

Patient or population: pregnant women who were continent when randomised

Setting: hospital or outpatient settings in Canada, Italy, Mexico, Norway, Spain, Thailand, Turkey, UK and USA

Intervention: antenatal PFMT

Comparison: control (no PFMT or usual care)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with antenatal PFMT

Urinary incontinence in late pregnancy

421 per 1000

160 per 1000
(84 to 303)

RR 0.38
(0.20 to 0.72)

624
(6 RCTs)

⊕⊕⊕⊝
MODERATE1

Urinary incontinence mid‐postnatal period
(> 3 to 6 months)

251 per 1000

179 per 1000
(136 to 239)

RR 0.71
(0.54 to 0.95)

673
(5 RCTs)

⊕⊕⊕⊕
HIGH

Urinary incontinence late postnatal period
(> 6 to 12 months)

440 per 1000

528 per 1000
(286 to 972)

RR 1.20
(0.65 to 2.21)

44
(1 RCT)

⊕⊝⊝⊝
LOW2

Faecal incontinence in late pregnancy

‐

‐

‐

(0 studies)

‐

Not reported.

Faecal incontinence mid‐postnatal period
(> 3 to 6 months)

‐

‐

‐

(0 studies)

‐

Not reported.

Faecal incontinence late postnatal period
(> 6 to 12 months)

‐

‐

‐

(0 studies)

‐

Not reported.

Urinary incontinence‐specific quality of life (ICIQ‐SF)
Scale from: 0 to 10 (higher worse)

Mean 2.66, SD 4.1

Mean 0.24, SD 1.2

MD 2.42 lower
(3.32 lower to 1.52 lower)

152
(1 RCT)

⊕⊕⊕⊝
MODERATE3

Measured in the late postnatal period (> 6 to 12 months). Upper and lower limits of the CI of summary statistic suggest clinical importance in ICIQ‐SF (Nyström 2015).

Faecal incontinence‐specific quality of life

‐

‐

‐

(0 studies)

‐

Not reported.

Adverse events

‐

‐

‐

‐

‐

No events reported.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; ICIQ‐SF: International Consultation on Incontinence‐Short Form; MD: mean difference; PFMT: pelvic floor muscle training; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation.

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Downgraded one level for serious inconsistency (substantial statistically significant heterogeneity; I² = 78%).

2Downgraded two levels for very serious imprecision (single, small trial with wide confidence interval, including benefit no effect, and possible harm).

3Downgraded one level for serious imprecision (single trial, fewer than 400 participants).

The outcome measures relate to the presence of incontinence symptoms rather than absence. Symptoms of urinary and faecal incontinence were measured based on self‐report.

Open in table viewer
Summary of findings 2. Antenatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence

Antenatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence

Patient or population: pregnant women who were incontinent when randomised

Setting: health services or obstetric clinics in Brazil, Canada, the Netherlands and Turkey

Intervention: antenatal PFMT

Comparison: control (usual care)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with antenatal PFMT

Urinary incontinence in late pregnancy

776 per 1000

543 per 1000
(341 to 877)

RR 0.70
(0.44 to 1.13)

345
(3 RCTs)

⊕⊝⊝⊝
VERY LOW1,2,3

Urinary incontinence mid‐postnatal period
(> 3‐6 months)

528 per 1000

496 per 1000
(369 to 654)

RR 0.94
(0.70 to 1.24)

187
(1 RCT)

⊕⊕⊝⊝
LOW4,5

Urinary incontinence late postnatal period
(> 6‐12 months)

232 per 1000

116 per 1000
(30 to 448)

RR 0.50
(0.13 to 1.93)

869
(2 RCTs)

⊕⊝⊝⊝
VERY LOW6,7,8

Faecal incontinence in late pregnancy

‐

‐

‐

(0 studies)

‐

Not reported.

Faecal incontinence mid‐postnatal period
(> 3‐6 months)

‐

‐

‐

(0 studies)

‐

Not reported.

Faecal incontinence late postnatal period
(> 6‐12 months)

‐

‐

‐

(0 studies)

‐

Not reported.

Urinary incontinence‐specific quality of life (ICIQ‐SF)
Scale from: 0 to 10 (higher worse)

Mean 4.7, SD 5.6

Mean 1.2, SD 2.5

MD 3.5 lower
(6.13 lower to 0.87 lower)

41
(1 RCT)

⊕⊕⊕⊝
MODERATE9

Measured in late pregnancy. MD suggests clinically important effect but the upper limit of the CI is close to no effect.

Faecal incontinence‐specific quality of life

‐

‐

‐

(0 studies)

‐

Not reported.

Adverse events

‐

‐

‐

‐

‐

No events reported.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; ICIQ‐SF: International Consultation on Incontinence‐Short Form; MD: mean difference; PFMT: pelvic floor muscle training; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation.

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Downgraded one level due to serious risk of bias (one trial with heavy weighting in the pooled estimate at high risk).

2 Downgraded one level for inconsistency (substantial statistically significant heterogeneity; I² = 71%).

3 Downgraded one level for imprecision (fewer than 400 participants, wide confidence interval).

4Downgraded one level due to serious risk of bias.

5Downgraded one level for imprecision (single trial, fewer than 400 participants).

6Downgraded one level due to very serious risk of bias.

7Downgraded one level for inconsistency (considerable statistically significant heterogeneity; I² = 94%).

8Downgraded one level for imprecision (wide confidence interval).

9Downgraded one level due to serious imprecision (single trial, fewer than 400 participants, wide confidence interval).

The outcome measures relate to the presence of incontinence symptoms rather than absence. As this comparison addresses the effect of PFMT for treatment of existing continence symptoms, the data are "negative," that is continuing incontinence rather than cure. Symptoms of urinary and faecal incontinence were measured based on self‐report.

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Summary of findings 3. Antenatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence

Antenatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence

Patient or population: pregnant women, some of who were incontinent symptoms and some who were not when randomised

Setting: health services, obstetric clinics or hospitals in Brazil, Canada, China, France, Italy, Norway, Poland, UK or USA

Intervention: antenatal PFMT

Comparison: control (no PFMT, usual care or unspecified control)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with antenatal PFMT

Urinary incontinence in late pregnancy

565 per 1000

441 per 1000
(361 to 531)

RR 0.78
(0.64 to 0.94)

3307
(11 RCTs)

⊕⊕⊕⊝
MODERATE1

RR suggests clinically important effect but the upper limit of the CI suggests lack of clinical importance. The substantial statistically significant heterogeneity is more likely due to imprecision in estimating the magnitude, rather than direction of effect, because the upper and lower limits of the CI suggest benefit.

Urinary incontinence mid‐postnatal period
(> 3 to 6 months)

363 per 1000

265 per 1000
(200 to 352)

RR 0.73
(0.55 to 0.97)

1921
(5 RCTs)

⊕⊝⊝⊝
LOW2,3

RR suggests clinically important effect but the upper limit of the CI suggests lack of clinical importance.

Urinary incontinence late postnatal period
(> 6 to 12 months)

448 per 1000

381 per 1000
(282 to 511)

RR 0.85
(0.63 to 1.14)

244
(2 RCTs)

⊕⊕⊕⊝
MODERATE4

Faecal incontinence in late pregnancy

59 per 1000

38 per 1000
(21 to 67)

RR 0.64
(0.36 to 1.14)

910
(3 RCTs)

⊕⊕⊕⊝
MODERATE5

Faecal incontinence mid‐postnatal period
(> 3 to 6 months)

‐

‐

‐

(0 studies)

‐

Not reported.

Faecal incontinence late postnatal period
(> 6 to 12 months)

‐

‐

‐

(0 studies)

‐

Not reported.

Urinary incontinence‐specific quality of life (ICIQ‐SF)
Scale from: 0 to 10 (higher worse)

Mean 2.1, SD 3.3

Mean 1.9, SD 3.7

MD 0.20 lower
(1.2 lower to 0.80 higher)

190
(1 RCT)

⊕⊕⊕⊝
MODERATE6

Measured in the late postnatal period (> 6 to 12 months). MD and CI suggest lack of clinically important effect.

Faecal incontinence‐specific quality of life (CRAIQ‐7)

7 items (higher score worse)

Mean 5, SD 11.7

Mean 2.4, SD 11.3

MD 2.60 lower (7.84 lower to 2.64 higher)

74

(1 RCT)

⊕⊕⊝⊝
LOW7,8

Measured in the early postnatal period (0 to 3 months).

Adverse events

‐

‐

‐

‐

‐

No events reported.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; CRAIQ‐7: Colorectal‐Anal Impact Questionnaire; ICIQ‐SF: International Consultation on Incontinence‐Short Form; MD: mean difference; PFMT: pelvic floor muscle training; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation.

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Downgraded one level due to serious inconsistency (substantial statistically significant heterogeneity; I² = 79%).

2Downgraded one level due to serious risk of selection bias (no information about random allocation concealment in three trials carrying more than 50% of weighting in the pooled estimate).

3Downgraded one level for serious imprecision (substantial statistically significant heterogeneity; I² = 65%).

4 Downgraded one level due to serious imprecision (fewer than 400 participants, wide CI).

5Downgraded one level due to serious imprecision (wide CI that includes appreciable harm and appreciable benefit).

6Downgraded one level due to serious imprecision (fewer than 400 participants, wide CI).

7Downgraded one level due to serious risk of attrition bias.

8Downgraded one level due to serious imprecision (single trial, fewer than 400 participants, wide CI).

The outcome measures relate to the presence of incontinence symptoms rather than absence. For those comparisons that addressed the effect of PFMT for treatment of existing continence symptoms, the data were "negative," that is continuing incontinence rather than cure. Symptoms of urinary and faecal incontinence were measured based on self‐report.

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Summary of findings 4. Postnatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence

Postnatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence

Patient or population: postnatal women who were incontinent when randomised

Setting: health services or obstetric clinics in Canada, Republic of Korea, New Zealand and UK

Intervention: postnatal PFMT

Comparison: control (no PFMT or usual care)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with postnatal PFMT

Urinary incontinence late postnatal period
(> 6 to 12 months)

724 per 1000

398 per 1000
(210 to 775)

RR 0.55
(0.29 to 1.07)

696
(3 RCTs)

⊕⊕⊝⊝
LOW1,2

Faecal incontinence late postnatal period
(> 6 to 12 months)

137 per 1000

93 per 1000
(33 to 266)

RR 0.68
(0.24 to 1.94)

620
(2 RCTs)

⊕⊝⊝⊝
VERY LOW3,4,5

Urinary incontinence‐specific quality of life
(BFLUTS)

34 items (higher score worse)

Mean 21.22, SD 2.11

Mean 19.56, SD 1.88

MD 1.66 lower
(3.51 lower to 0.19 higher)

18
(1 RCT)

⊕⊕⊝⊝
LOW6,7

Measured at 8 weeks' post‐treatment

Faecal incontinence‐specific quality of life

‐

‐

‐

(0 studies)

‐

Not reported

Adverse events

‐

‐

‐

‐

‐

No events reported.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

BFLUTS: British Female Lower Urinary Tract Symptoms questionnaire; CI: confidence interval; MD: mean difference; PFMT: pelvic floor muscle training; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation.

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Downgraded one level due to very serious risk of bias (two trials with 90% of weighting in pooled estimate at high risk).

2Downgraded one level for inconsistency (considerable statistically significant heterogeneity; I² = 90%).

3Downgraded one level due to very serious risk of bias (two trials with 100% of weighting in pooled estimate at high risk).

4Downgraded one level for inconsistency (substantial statistically significant heterogeneity; I² = 74%).

5Downgraded one level for imprecision (wide confidence interval, with appreciable harm and appreciable benefit).

6Downgraded one level due to very serious risk of selection bias.

7Downgraded one level for imprecision (fewer than 400 participants, wide CI).

The outcome measures relate to the presence of incontinence symptoms rather than absence. As this comparison addresses the effect of PFMT for treatment of existing continence symptoms, the data are "negative," that is continuing incontinence rather than cure. Symptoms of urinary and faecal incontinence were measured based on self‐report.

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Summary of findings 5. Postnatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence

Postnatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence

Patient or population: postnatal women some of whom had incontinent symptoms and some of whom had not when randomised

Setting: health services or hospitals in Australia, Brazil, Canada, China and Switzerland

Intervention: postnatal PFMT

Comparison: control (no PFMT or usual care)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with postnatal PFMT

Urinary incontinence late postnatal period
(> 6 to 12 months)

294 per 1000

212 per 1000
(115 to 400)

RR 0.88
(0.71 to 1.09)

826
(3 RCTs)

⊕⊕⊕⊝
MODERATE1

Faecal incontinence late postnatal period
(> 6 to 12 months)

54 per 1000

39 per 1000
(7 to 226)

RR 0.73
(0.13 to 4.21)

107
(1 RCT)

⊕⊕⊝⊝
LOW2,3

Urinary incontinence‐specific quality of life

(IIQ‐7)
Scale from: 0 to 100 (higher worse)

Mean 3.2, SD 8.4

Mean 3.7, SD 5.6

MD 0.50 higher
(5.53 lower to 6.53 higher)

23
(1 RCT)

⊕⊕⊝⊝
LOW4,5

Measured after the 16 week intervention.

Faecal incontinence‐specific quality of life

(FIQOL scale)

29 items, 4 domain scores, each item scored 1‐5 (higher better)

‐

‐

‐

170

(2 RCTs)

‐

Measured at 3 months' postpartum. There were no reported differences between the groups in either study.

Adverse events

‐

‐

‐

‐

‐

No events reported.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; FIQOL: Faecal incontinence quality of life; PFMT: pelvic floor muscle training; RCT: randomised controlled trial; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Downgraded one level due to inconsistency (substantial statistically significant heterogeneity; I² = 75%).

2Downgraded one level due to serious risk of selection bias.

3Downgraded one level for imprecision (fewer than 400 participants, wide CI).

4Downgraded one level due to serious risk of selection bias.

5Downgraded one level for imprecision (fewer than 400 participants, wide CI).

The outcome measures relate to the presence of incontinence symptoms rather than absence. For those comparisons that address the effect of PFMT for treatment of existing continence symptoms, the data are "negative," that is continuing incontinence rather than cure. Symptoms of urinary and faecal incontinence were measured based on self‐report.

Background

Description of the condition

Accumulating epidemiological evidence suggests that women who have had a baby are at increased risk of developing urinary incontinence (UI). It seems that both pregnancy and delivery are risk factors (Foldspang 1999; Milsom 2017; Rortveit 2003a; Rortveit 2003b; Viktrup 2006). Similarly, these women seem to be at greater risk of faecal incontinence (FI), particularly those who have had vaginal deliveries (Eason 2002; MacArthur 2001; Pollack 2004; Sultan 1999).

Urinary incontinence (UI)

Urinary incontinence (involuntary leakage of urine) is a common problem amongst adults living in the community (Milsom 2017). It is more frequent in women, and pregnancy or the postnatal period may be the first time many women experience UI. Stress urinary incontinence (involuntary urine leakage with physical exertion) and urgency urinary incontinence (involuntary leakage associated with, or immediately following, a sudden compelling need to void) are the two most common types of urine leakage in women. Many women have symptoms of both stress and urgency urinary incontinence. This is called mixed urinary incontinence. Of these types, stress urinary incontinence is most commonly associated with pregnancy and the postnatal period, although there is a small but significant increase in risk of urgency urinary incontinence (Milsom 2017).

It seems that the prevalence of UI increases during pregnancy (particularly in the second trimester) and then gradually decreases during the first postpartum year (Milsom 2017). Variation is evident in prevalence estimates of all types of UI during pregnancy, but this may be as high as 58%, with stress urinary incontinence affecting about 31% of nulliparous women and 42% of parous women (Wesnes 2007). The prevalence of persistent UI in the first three months following delivery is approximately 30% (Thom 2010).

Findings from moderate‐ to large‐sized cohorts of women suggest that factors associated with a greater risk of postpartum UI are: parity (Milsom 2017); higher maternal body mass index (BMI) (Durnea 2017; Gyhagen 2013; Pizzoferrato 2014; Quiboeuf 2016; Svare 2014); age (Quiboeuf 2016); UI before or during pregnancy (Durnea 2017; Gartland 2016; Pizzoferrato 2014; Svare 2014); vaginal delivery (Gartland 2016; Gyhagen 2013); operative vaginal deliveries or perineal or anal sphincter trauma (Durnea 2017; Gartland 2012; Svare 2014); high birthweight of the baby (Gyhagen 2013; Pizzoferrato 2014; Wesnes 2017). These associations have been observed anywhere between four to six months' postpartum through to 12 to 20 years following first delivery (Gartland 2012; Gyhagen 2013; Pizzoferrato 2014; Wesnes 2017).

There are significant healthcare resource implications associated with the management of UI. Coyne 2014 estimated the costs of stress urinary incontinence in the American healthcare system and found that the average annual direct medical cost of Ul was $1433 (USD 2007) per patient. This demonstrates the importance of understanding the most efficient strategies of managing UI in a healthcare context.

Faecal incontinence (FI)

Faecal incontinence (involuntary loss of solid or liquid stool) is less common than UI, but is particularly distressing both psychologically and physically (Johanson 1996). Women may also experience involuntary loss of flatus (wind). The term anal incontinence is used to encompass involuntary loss of faeces or flatus.

The prevalence of FI is difficult to estimate as the definition of this condition varies between studies, different assessment tools are used and because women may be reluctant to admit to FI (MacArthur 2013). In addition, variation is also apparent in the time points at which FI is measured during pregnancy and following delivery and in which groups of women (e.g. primiparous versus multiparous). For the purpose of this review, FI was considered a generic term that encompassed involuntary loss of solid stool, liquid stool, flatus, or a combination of these.

Some form of FI may be present during pregnancy in first‐time mothers, with a prevalence anywhere up to 12% to 35% for flatal incontinence and 2.0% to 9.5% for loss of formed stool (Johannessen 2016; Svare 2016). Persistent symptoms at three months' postpartum may be 19% to 46% for flatus and 2.4% to 8.0% for the involuntary loss of formed stool (Brown 2012; Signorello 2000). In the longer term, these rates seem to persist, with about 31% of primiparous women reporting involuntary loss of flatus at six and 12 years after delivery and 9% to 12% reporting loss of formed stool (MacArthur 2013). One systematic review suggested that the aetiological factor most strongly associated with postpartum FI is a third‐ or fourth‐degree rupture of the external anal sphincter (Bols 2010).

Faecal incontinence is also associated with significant resource use, with average direct costs being estimated at $2353 annually per patient (USD 2010) (Xu 2012). There are also potential indirect costs associated with both UI and FI. For example, Xu 2012 also estimated productivity losses of $1549 per patient annually in the US population (USD 2010). This highlights the need to identify strategies that are efficient from both the perspective of the patient and the healthcare system.

Description of the intervention

Pelvic floor muscle training (PFMT) refers to the performance of repeated voluntary contractions of the pelvic floor muscles (PFM), according to a protocol that outlines the frequency, intensity and progression of exercises, as well as the duration of the training period. A PFMT programme typically includes one or more sets of exercises per day, performed on at least several days of the week, for at least eight weeks. It is recommended that initial training be followed by maintenance PFM exercises to ensure duration of effect in the longer term (Bø 2004; Mørkved 2014).

In many countries, it is common for women to receive information about, and encouragement to perform, some PFM exercises during pregnancy and after delivery. During pregnancy, information on PFMT may be received from a health professional or obtained from other sources (e.g. leaflets and websites), but this advice may not lead to effective training if the exercise parameters and behaviour are insufficient. Nevertheless, we continued to use the term PFMT to make the review easier to read.

For women who are continent during pregnancy, PFMT is undertaken to prevent leakage. Women who develop symptoms of incontinence during pregnancy or postpartum may be referred to a health professional specifically for treatment and supervision of exercise.

Prevention of urinary and faecal incontinence with pelvic floor muscle training (PFMT)

Prevention is primary, secondary or tertiary prevention (Hensrud 2000). Primary prevention aims to remove the causes of a disease. As an example, a trial that compares two obstetric practices (e.g. liberal versus restrictive episiotomy policies) and the effect on the prevalence of postnatal incontinence amongst previously continent women is a primary prevention trial. Secondary prevention aims to detect asymptomatic dysfunction and treat it early to stop progression. A trial that compares a treatment to improve the muscular supports of the bladder with no treatment in postnatal women who had weak PFM but no UI symptoms is classified as a secondary prevention trial. Tertiary prevention is the treatment of existing symptoms to prevent progression of disease.

Clinically, it may be difficult to screen all potential trial participants to see if a disease process is either absent altogether or present but asymptomatic. In addition, with a condition such as incontinence there might be more than one factor that could contribute to development of the problem, for example denervation, fascial deficits and poor muscle function. It is impractical to screen for all possible factors and, in many cases, there are no reliable or valid clinical tests available. Consequently, prevention trials may enrol people purely on the basis of the absence of symptoms. This is commonly the case in incontinence studies and the findings of these studies are probably a combination of primary and secondary prevention effects. This review makes no attempt to distinguish between primary and secondary effects and considers them together.

Treatment of urinary and faecal incontinence with pelvic floor muscle training (PFMT)

PFMT for the treatment of UI was popularised by Arnold Kegel (Kegel 1948). However, in one review of the literature prior to 1949, Bø 2004 identified several records of the use of PFM exercise. PFMT was principally recommended in the treatment of stress and mixed urinary incontinence but was increasingly part of treatment offered to women with urgency urinary incontinence. The use of PFMT in the treatment of UI is based on two functions of the PFM: support of the pelvic organs and a contribution to the sphincteric closure mechanism of the urethra. More detail about how PFMT might work to treat UI can be found in the background to a previous Cochrane Review of PFMT (Dumoulin 2018).

PFMT is used in the treatment of FI, although there are fewer studies of its effectiveness than for UI. Theoretically, the external anal sphincter muscle (which is continuous with the puborectalis muscle component of the PFM) could be trained in a similar way and it is unclear whether it is possible for people to know the difference between a voluntary external anal sphincter contraction and a voluntary PFM contraction (Norton 2012).

PFMT is recommended as a first‐line therapy for UI (Abrams 2017; Dumoulin 2018). However, a wide range of options is available to treat UI and FI, including conservative interventions (PFM rehabilitation including use of electrical stimulation and biofeedback), lifestyle interventions, bladder training, anti‐incontinence devices, pharmaceutical interventions and surgery.

How the intervention might work

There are a variety of plausible reasons why PFMT might help prevent UI. For example, trained muscle might be less prone to injury and previously trained muscle might be easier to retrain after damage as the appropriate motor patterns are already learned. It may be that previously trained muscle has a greater reserve of strength so that injury to the muscle itself, or its nerve supply, does not cause sufficient loss of muscle function to reach the threshold where reduced urethral closure pressure results in leakage. During pregnancy, training the PFM might help to counteract the increased intra‐abdominal pressure caused by the growing fetus, the hormonally‐mediated reduction in urethral closure pressure, and the increased laxity of fascia and ligaments in the pelvic area. A similar rationale might be used to support the use of PFMT to improve the function of the external anal sphincter and thus prevent FI.

Essentially, a PFMT programme may be prescribed for women to:

  • increase strength (the maximum force generated by a muscle in a single contraction);

  • increase endurance (ability to contract repetitively, or to sustain a single contraction over time);

  • co‐ordinate muscle activity (such as the precontraction of PFM prior to a rise in intra‐abdominal pressure, or to suppress urgency); or

  • address a combination of these (Bø 2014).

However, based on the plausible reasons above, strength training tends to be emphasised for pregnant and postnatal women. Characteristic features of strength training include low numbers of repetitions with high loads, and one way to increase load is to increase the amount of voluntary effort with each near maximal voluntary contraction (Bø 2014).

There is a subgroup of women where there are particular uncertainties about whether the intervention might work and how it might work (Hilde 2013). These are women with avulsion (separation) of the PFM from the pelvic wall or other major defects in the PFM that are palpated or seen on imaging (e.g. ultrasound, magnetic resonance imaging). It is possible that these women might benefit from PFMT after the birth, helping the injury 'heal' (Hilde 2013). However, it is also possible that PFMT does not assist the return of function if the muscle no longer has the attachments that anatomically enable it to compress and lift the urethra with a muscle contraction.

Why it is important to do this review

Urinary and faecal incontinence are experienced by many women during pregnancy and following childbirth and can have a significant impact on quality of life (Handa 2007; Rogers 2017). In addition to the individual burden of managing incontinence, there are also significant healthcare resource implications associated with the management of both UI and FI. It is important to consider which management strategies are the most efficient use of resources from the perspective of the healthcare system. There are direct costs borne by women, such as buying continence products, laundry costs and visits to a general practitioner or continence service. Less direct, but no less important costs for women may include the social or physical activity limits they adopt to prevent embarrassment of leakage in public. Preventing or treating the condition with PFMT is likely to incur considerable cost to health services because supervised (e.g. several one‐to‐one contacts with a health professional) conservative therapies such as PFMT are more expensive than usual care (Wagner 2017). However, cost‐effectiveness modelling of non‐surgical treatments for stress urinary incontinence in women found more intensive forms of PFMT were likely to be worthwhile (Imamura 2010). It is unclear if PFMT would offer greater value for money to prevent the condition than treat it.

Although PFMT is recommended as the first choice of conservative management for incontinence, uncertainties about its effectiveness in antenatal and postnatal women remain (Dumoulin 2017), such as whether PFMT might be more effective if targeted to specific groups, or more effective as a prevention or treatment intervention. Also, with increasing pressure on constrained healthcare budgets worldwide, it is important to clarify whether the intervention offers value for money to ensure efficient allocation of resources.

Since the last update of this review in 2017 (Woodley 2017), other systematic reviews have been published that address the effects of PFMT during pregnancy and after delivery for the prevention and treatment of UI and the effects of antenatal PFMT on labour and delivery outcomes (Davenport 2018; Saboia 2018; Schreiner 2018).

Objectives

To assess the effects of pelvic floor muscle training (PFMT) in the prevention or treatment of urinary incontinence (UI) and faecal incontinence (FI) in pregnant or postnatal women; and summarise the principal findings of relevant economic evaluations.

Methods

Criteria for considering studies for this review

Types of studies

We included randomised controlled trials (including cluster and cross‐over trials) and quasi‐randomised studies (e.g. allocation by alternation). We excluded other forms of controlled clinical trials.

Types of participants

We included trials that recruited antenatal (i.e. pregnant) or postnatal women (i.e. women immediately following delivery or women with persistent urinary or faecal incontinence symptoms up to three months after their most recent delivery). Women could be with or without urinary, faecal, or both urinary and faecal incontinence symptoms at recruitment.

We compared three populations of women:

  • prevention trials in antenatal women who were continent when randomised;

  • treatment trials in antenatal or postnatal women who were incontinent when randomised;

  • mixed prevention and treatment trials in antenatal or postnatal women where some women had incontinence symptoms and some did not when randomised.

We paid close attention to the distinction between treatment and prevention trials because the effect of PFMT might differ for these two purposes. For the trials that recruited antenatal or postnatal women, whether they had symptoms of incontinence or not, the PFMT intervention was a prevention strategy for the non‐symptomatic women and treatment for symptomatic women. The two effects could not be distinguished in these trials.

Types of interventions

One arm of all eligible trials included a PFMT programme to improve the function of the PFM, the external anal sphincter or both. PFMT was a programme of repeated voluntary PFM contractions, although this was a limited definition compared with the fuller ideal (Dumoulin 2018). We considered all types of PFMT, including variations in the purpose and timing of PFMT (e.g. PFMT for strengthening, PFMT for urgency suppression), ways of teaching PFMT, types of contractions (fast or sustained), and number of contractions.

Acceptable control interventions were usual antenatal and postnatal care, placebo treatment or no treatment. Usual antenatal or postnatal care in many countries included advice about PFMT. We included studies in which the control group had, or might have, received PFMT advice providing the PFMT arm was more intensive in some way than the control arm. For example, in the PFMT arm, women were taught the exercises by a health professional, whereas usual care involved distribution of a leaflet about PFMT on the postnatal wards.

We included trials in which PFMT was combined with other physical therapy modalities such as biofeedback, electrical stimulation or multi‐modal exercise programmes. Studies where advice on strategies for symptoms of urgency and frequency (but without a scheduled voiding regimen characteristic of bladder training) were also eligible for inclusion.

We excluded trials in which PFMT was combined with another stand‐alone therapy such as bladder training, drug therapy (e.g. anticholinergic drug) or herbal medicine; and trials of electrical stimulation (without PFMT). We also excluded trials if they did not report UI or FI as this suggests that the intervention was not being tested for its effect on UI or FI.

We assessed the following comparisons.

  • Antenatal PFMT versus no PFMT, usual care or other control condition for the:

    • primary or secondary prevention of incontinence;

    • treatment of incontinence;

    • mixed prevention or treatment of incontinence (i.e. treating a mixed population with PFMT).

  • Postnatal PFMT versus no PFMT, usual care, or other control condition for the:

    • treatment of incontinence;

    • mixed prevention or treatment of incontinence.

Types of outcome measures

With regards to prevention, it seemed that the most appropriate measure of outcome was the self‐reported absence of urinary or faecal incontinence symptoms. For treatment, a wider range of outcomes was considered significant, although the self‐reporting of cure or improvement in urinary or faecal incontinence symptoms was thought to be of most importance. These outcomes are the opposite of each other, being either the presence or absence of incontinence symptoms. For consistency throughout the review, we chose to report the presence of incontinence symptoms rather than the absence. For the comparisons that addressed the effect of PFMT for treatment of existing continence symptoms, readers should be aware that the data were 'negative' i.e. continuing incontinence rather than curing it.

Primary outcomes

  • Self‐reported urinary or faecal incontinence.

  • Urinary incontinence‐specific quality of life (e.g. International Consultation on Incontinence Questionnaire (ICIQ; 4 items, higher score worse), Incontinence Impact Questionnaire (IIQ; 30 items, higher score worse), Urogenital Distress Inventory (UDI; 19 items, higher score worse) (Avery 2004; Avery 2007; Shumaker 1994).

  • Faecal incontinence‐specific quality of life (e.g. Faecal Incontinence Quality of Life questionnaire (FIQOL; 29 items, 4 domain scores, each item scored 1‐5, higher score better) (Rockwood 2000).

Secondary outcomes

  • Self‐reported severity of incontinence (e.g. Incontinence Index score, slight, moderate or severe (Sandvik 1993)).

  • Number of urinary or faecal incontinence episodes.

  • Loss of urine under stress test (e.g. cough or pad test).

  • Self‐reported measures of pelvic floor dysfunction (e.g. UDI‐6)

  • Other self‐reported well‐being measures

  • Adverse effects, particularly discomfort or pain associated with PFMT.

  • Labour and delivery outcome (e.g. type of delivery, perineal trauma, episiotomy, length of second stage) for women who did antenatal PFMT.

While not outcomes per se, we also extracted data on two particular variables that might help explain variations in PFMT effect:

  • PFM function (e.g. electromyography, vaginal or anal squeeze pressures);

  • treatment adherence (e.g. surrogates such as class attendance, and more direct measures such as home exercise frequency).

Search methods for identification of studies

We imposed no restrictions, unless otherwise stated, on language of publication, publication status (i.e. full publication, grey literature, etc.) or any other restrictions on the searches described below.

Electronic searches

Search for clinical effectiveness studies

We identified relevant trials from the Cochrane Incontinence Specialised Register. For more details of the search methods used to build the Specialised Register, please see the Group's webpages where details of the Register's development (from inception) and the most recent searches performed to populate the Register can be found. To summarise, the Register contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, Be Part of Research, and handsearching of journals and conference proceedings. Many of the trials in the Cochrane Incontinence Specialised Register are also contained in CENTRAL.

The terms used to search the Cochrane Incontinence Specialised Register are given in Appendix 1.

Date of the most recent search of the Register for this review: 7 August 2019.

Search for economic evaluations

We performed additional searches for the brief economic commentary (BEC). We searched:

  • NHS EED on the Centre for Reviews and Dissemination (CRD) website (covering from the earliest record in NHS EED, dating from 1968, up to and including 31 December 2014 when their coverage ended) (date of search: 30 January 2020).

As NHS EED is no longer actively updated, we performed additional searches of the following databases to identify eligible studies added to these databases from 1 January 2015 onwards (date of search: 29 January 2020):

  • MEDLINE on OvidSP (covering 1 January 1946 to January Week 3 2020); and

  • Embase (on OvidSP) (covering 1 January 1974 to 2020 Week 4).

Details of the searches that were performed, including date restrictions to ensure the searches complied with current Cochrane methods guidance, can be found in Appendix 2 (Shemilt 2019).

Searching other resources

We searched for other possible relevant studies in the reference lists of relevant articles.

Data collection and analysis

Selection of studies

Two review authors assessed all potentially eligible studies without prior consideration of the results. We resolved any disagreements by discussion. Where these were not resolved, a third review author had final responsibility. We included only randomised or quasi‐randomised controlled trials, and excluded trials that made comparisons other than those prespecified.

Data extraction and management

Two review authors independently undertook data extraction onto a proforma and cross‐checked them. We resolved any differences by discussion. Where trial data were possibly collected but not reported, or data were reported in a form that could not be used in the formal comparisons, we sought further clarification from the trialists. We processed all included trial data as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

Assessment of risk of bias in included studies

Two review authors independently assessed the risk of bias of the included trials using Cochrane's 'Risk of bias' tool (Higgins 2011). We considered random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data and other bias and deemed each category at low, high or unclear risk of bias. Where there was insufficient information to make a clear decision, we rated trials as 'unclear risk.' We resolved any disagreements by discussion.

Allocation (selection bias)

When considering random sequence bias, we assessed whether the method used to generate the allocation sequence in each study would allow an assessment of whether it produced comparable groups. We assessed the method as:

  • low risk of bias: any truly random process such as computer‐generated random number sequences;

  • high risk of bias: any non‐random process such as allocation by birth date or bed number;

  • unclear risk of bias.

For assessing allocation concealment, we determined the methods to conceal allocation to interventions prior to assignment and whether intervention allocation could have been foreseen in advance or during recruitment, or changed after assignment. We assessed the methods as:

  • low risk of bias: all forms of remote or web‐based allocation and sequentially numbered, sealed and opaque envelopes;

  • high risk of bias: open random allocation, envelopes where not all the above criteria were met (not sequentially numbered, unsealed, non‐opaque), all methods of alternation;

  • unclear risk of bias.

Blinding (performance bias and detection bias)

We did not have any criteria for performance bias as it was not considered feasible due to the nature of the intervention to blind the personnel or participants to group allocation. It is likely that this lack of blinding would unfortunately influence the results of the review.

We did not have any criteria for detection bias as it was not considered feasible to blind participants to the assessment of the two a priori outcomes of this review (prevalence of incontinence and incontinence quality of life) as both were self‐reported. We assessed blinding separately for other outcomes, such as the pad test and PFM function measures.

Incomplete outcome data (attrition bias)

For each outcome, we described the completeness of data, including attrition and exclusions from the analysis. In making a judgement about attrition bias, we considered the:

  • proportion of the total sample lost to follow‐up and the adequacy of any imputation methods used for missing data;

  • similarity in proportion of losses by group;

  • whether reasons were provided for losses and whether these differed by group;

  • if participants were analysed in the group to which they were assigned.

We assessed the methods as:

  • low risk of bias: trials with 10% or less loss to follow‐up and without a differential loss to follow‐up;

  • high risk of bias: trials with more than 20% loss to follow‐up without appropriate imputation methods or trials in which participants were not analysed in the group to which they were randomised;

  • unclear risk of bias: when the proportion of dropouts was between 10% and 20% without appropriate imputation methods (with no major differential or lack of similar reasons between groups) or when there was no reporting of losses to follow‐up.

Selective reporting (reporting bias)

For each included trial, we determined the possibility of selective outcome reporting bias and described what we found based on the following criteria:

  • low risk of bias: it was clear that all of the trial's prespecified outcomes were reported;

  • high risk of bias: not all of the trial's prespecified outcomes were reported, a primary outcome was not prespecified, outcomes of interest to the review, and for which data were collected, were reported incompletely and so could not be used;

  • unclear risk of bias: a lack of detail in reporting made it difficult to assess whether all prespecified outcomes were presented.

Other bias

For each included study, we described any important concerns we had about other possible sources of bias that had not previously been considered in the categories above. In particular, we looked for a declaration of conflict of interest and the funding source.

Measures of treatment effect

For categorical outcomes, we related the numbers reporting an outcome to the numbers at risk in each group to derive a risk ratio (RR) or standardised mean difference (SMD) and its 95% confidence interval (CI). For continuous variables, we used means and standard deviations (SD) to derive mean differences (MD).

Where a trial took measures at two time points within a single category (e.g. at eight and 12 months after delivery), we used the data from the longer time period. If data were available for specific time points but could not be combined or entered into RevMan, we reported these data in the text.

Unit of analysis issues

The primary unit of analysis was per women randomised. For the meta‐analysis of multi‐arm studies, we combined the data from the PFMT intervention arms for comparison with the control arm. We calculated the mean and SD for the combined data according to the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

Dealing with missing data

Where possible, we analysed trial data according to the intention‐to‐treat (ITT) principle; that is by the randomised groups and irrespective of whether women received treatment according to their randomised allocation. We did not impute missing outcome data.

Assessment of heterogeneity

We assessed the extent of heterogeneity in three ways: visual inspection of data plots, Chi² test for heterogeneity (Chi² test, P < 0.10) and the I² statistic (Higgins 2011). We sought and discussed possible explanations for heterogeneity through subgroup analysis. Heterogeneity was considered using the following ranges (Higgins 2011):

  • 0% to 40%: might not be important;

  • 30% to 60%: may represent moderate heterogeneity;

  • 50% to 90%: may represent substantial heterogeneity;

  • 75% to 100%: considerable heterogeneity.

Assessment of reporting biases

To minimise reporting bias, we undertook a comprehensive search for eligible trials and were vigilant for duplication of data.

Had data allowed, we would have generated funnel plots to examine the possibility of small study bias, including publication bias.

Data synthesis

We used the Mantel‐Haenszel methods with a fixed‐effect model approach in the meta‐analyses in this review, unless statistically significant heterogeneity (Chi² test, P < 0.10) suggested a more conservative random‐effects model was indicated. Where possible, data from different studies were pooled using a fixed‐effect model.

Subgroup analysis and investigation of heterogeneity

In each comparison, we used subgroup analysis to demonstrate the effect of the type of control comparison on outcome. The subgroups were:

  • PFMT versus no PFMT;

  • PFMT versus unspecified control (i.e. the trialist gave insufficient information about the control condition to classify it as one of the others);

  • PFMT versus usual care.

The final subgroup explored differences in intensity of PFMT:

  • PFMT (more intensive, e.g. addition of biofeedback) versus PFMT (less intensive).

Sensitivity analysis

Sensitivity analysis with respect to trial quality was planned, as there is some evidence that the adequacy of randomisation (sequence generation and allocation concealment) may have an impact on the findings of a meta‐analysis (Moher 1998). However, there were insufficient trials and too many other potential causes of heterogeneity to make this useful.

Incorporating economics evidence

Following the search outlined in the Search methods for identification of studies, we developed a brief economic commentary (BEC) to summarise the availability and principal findings of the full economic evaluations that assess pelvic floor muscle training for the prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women (Shemilt 2019). This BEC encompassed full economic evaluations (i.e. cost‐effectiveness analyses, cost‐utility analyses and cost‐benefit analyses), conducted as part of a single empirical study like a randomised controlled trial, a model based on a single such study, or a model based on several such studies.

Summary of findings and assessment of the certainty of the evidence

We used the five GRADE considerations (study limitations, inconsistency of effect, imprecision, indirectness and publication bias) to assess the quality of the body of evidence as it related to the studies that contributed data to the meta‐analyses for the prespecified outcomes (Atkins 2004). We used the methods and recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions using GRADEpro GDT software (GRADEpro GDT; Higgins 2011). We justified all decisions to downgrade the quality of studies using footnotes and made comments to aid the reader's understanding of the review where necessary.

We created 'Summary of findings' tables for antenatal PFMT, using the following outcomes:

  • urinary incontinence in late pregnancy;

  • urinary incontinence mid‐postnatal period;

  • urinary incontinence late postnatal period;

  • faecal incontinence in late pregnancy;

  • faecal incontinence mid‐postnatal period;

  • faecal incontinence late postnatal period;

  • urinary incontinence‐specific quality of life;

  • faecal incontinence‐specific quality of life;

  • adverse events.

For antenatal PFMT trials, we assessed the evidence in late pregnancy (postintervention effect) and the mid‐ and late‐postnatal periods (durability of effect postdelivery).

We created 'Summary of findings' tables for postnatal PFMT, using the following outcomes:

  • urinary incontinence late postnatal period;

  • faecal incontinence in late pregnancy;

  • urinary incontinence‐specific quality of life;

  • faecal incontinence‐specific quality of life;

  • adverse events.

In postnatal training trials, we assessed the evidence in the late postnatal period (sustained postintervention effect).

Results

Description of studies

Results of the search

Search for clinical effectiveness studies

The flow of literature through the assessment process is shown in the PRISMA flowchart (Figure 1).

Figure 1
PRISMA study flow diagram ‐ search for clinical effectiveness studies

PRISMA study flow diagram ‐ search for clinical effectiveness studies

The previous version of the review included 94 reports of 38 studies (Woodley 2017). The search update yielded 831 titles and abstracts and 121 records were obtained for further assessment. We included 21 reports from eight new studies. The updated review now synthesises data from 115 reports of 46 studies that randomised 10832 women (5478 : pelvic floor muscle training (PFMT), 5354 controls) from 21 countries.

Sixty‐four reports of 52 studies were excluded from the update and reasons are given in the Characteristics of excluded studies. In addition, 19 studies were classified as ongoing (see Characteristics of ongoing studies) and five require further assessment to determine eligibility (see Characteristics of studies awaiting classification).

Four papers were published in Chinese and the data were extracted by translators for screening and further analysis (Kou 2013; Liu 2011; Sun 2015; Wen 2010).

Search for economic evaluations

Our search for economic evaluations yielded 416 records which were screened; 13 appeared to meet the eligibility criteria for the review and the full‐text articles were retrieved. No published economic evaluations were found, but one protocol for an ongoing economic evaluation being conducted alongside a randomised controlled trial (RCT) was identified (Moossdorf‐Steinhauser 2019). The PRISMA flow diagram showing the literature assessment process is given in Figure 2.

Figure 2
PRISMA study flow diagram ‐ search for economic evaluations for the BEC

PRISMA study flow diagram ‐ search for economic evaluations for the BEC

Included studies

The review includes 46 trials and further details are provided in the Characteristics of included studies. Thirty‐eight of the 46 studies were included in the previous version of this review (Ahlund 2013; Assis 2015; Barakat 2011; Bø 2011; Chiarelli 2002; Cruz 2014; Dinc 2009; Dokmeci 2008; Dumoulin 2004; Ewings 2005; Fritel 2015; Frost 2014; Frumenzio 2012; Gaier 2010; Glazener 2001; Gorbea 2004; Hilde 2013; Hughes 2001; Kim 2012; Ko 2011; Kocaoz 2013; Kou 2013; Liu 2011; Meyer 2001; Miquelutti 2013; Mørkved 2003; Peirce 2013; Pelaez 2014; Reilly 2002; Sampselle 1998; Sangsawang 2016; Skelly 2004; Sleep 1987; Stafne 2012; Stothers 2002; Wen 2010; Wilson 1998; Woldringh 2007). The remaining eight included studies are new to this update (Dufour 2019; Hyakutake 2018; Oakley 2016; Sacomori 2019; Sut 2016; Szumilewicz 2019; Torsdatter Markussen 2017; Yang 2017).

Twenty‐five of the 46 included studies were publicly funded (university or national research funds or charitable trust), and one received grants from both public and private sources (Glazener 2001). Three studies did not receive any specific funding (Ahlund 2013; Barakat 2011; Kim 2012). Eighteen studies did not declare funding sources (Assis 2015; Bø 2011; Dokmeci 2008; Frost 2014; Frumenzio 2012; Gaier 2010; Gorbea 2004; Hughes 2001; Kim 2012; Kocaoz 2013; Kou 2013; Liu 2011; Pelaez 2014; Sacomori 2019; Skelly 2004; Stothers 2002; Wen 2010; Yang 2017). Twenty‐one trials declared no conflicts of interest (Ahlund 2013; Bø 2011; Chiarelli 2002; Dinc 2009; Dokmeci 2008; Dufour 2019; Fritel 2015; Glazener 2001; Hilde 2013; Hyakutake 2018; Ko 2011; Miquelutti 2013; Oakley 2016; Peirce 2013; Pelaez 2014; Sangsawang 2016; Stafne 2012; Sut 2016; Szumilewicz 2019; Torsdatter Markussen 2017; Yang 2017). The remaining 25 trials did not report conflicts of interest.

In all, 42 of the 46 trials contributed data to one or more meta‐analysis.

Design

The majority of the included studies in this review (41 of 46) were two‐arm parallel group RCTs investigating the impact of PFMT on urinary and/or faecal incontinence in pregnant and postnatal women. Of the five included studies that were not of this design, one was classified as a quasi‐RCT (Kocaoz 2013), one as a cluster‐RCT (Sacomori 2019), while three utilised a three‐arm study design (Assis 2015; Dumoulin 2004; Yang 2017). One‐to‐one allocation ratio was the predominant method of randomisation, employed in all but two studies (Peirce 2013; Szumilewicz 2019).

Eight trials were primary or secondary prevention trials (i.e. none of the women had incontinence symptoms at the start of training) (Barakat 2011; Gaier 2010; Gorbea 2004; Kocaoz 2013; Pelaez 2014; Reilly 2002; Sangsawang 2016; Stothers 2002). Two trials provided subgroup data for women continent at randomisation (Mørkved 2003; Sampselle 1998). All 10 investigated the effect of beginning PFMT antenatally. Nine were treatment trials (i.e. all women had incontinence symptoms at the start of training). These investigated the effects of beginning PFMT antenatally and postnatally (Ahlund 2013; Cruz 2014; Dinc 2009; Dumoulin 2004; Glazener 2001; Kim 2012; Skelly 2004; Wilson 1998; Woldringh 2007). Twenty‐nine were mixed prevention or treatment trials as some women did, and others did not, have incontinence symptoms at the start of training. These trials investigated the effects of starting PFMT antenatally or postnatally (Assis 2015; Bø 2011; Chiarelli 2002; Dokmeci 2008; Dufour 2019; Ewings 2005; Fritel 2015; Frost 2014; Frumenzio 2012; Hilde 2013; Hughes 2001; Hyakutake 2018; Ko 2011; Kou 2013; Liu 2011; Meyer 2001; Miquelutti 2013; Mørkved 2003; Oakley 2016; Peirce 2013; Sacomori 2019; Sampselle 1998; Sleep 1987; Stafne 2012; Sut 2016; Szumilewicz 2019; Torsdatter Markussen 2017; Wen 2010; Yang 2017).

The primary reference for eight trials was a conference abstract (Cruz 2014; Dokmeci 2008; Frost 2014; Frumenzio 2012; Gaier 2010; Hughes 2001; Skelly 2004; Stothers 2002). No further published reports were found for seven of these eight trials and one trialist kindly provided additional data from a thesis (Hughes 2001). One‐to‐one randomisation was assumed (the numbers in the intervention (139 women) and control (129 women) groups suggested this was likely) for one trial so that data could be used in the meta‐analysis (Skelly 2004).

Sample size

Four trials were small, with fewer than 25 women per comparison group (Dufour 2019; Dokmeci 2008; Dumoulin 2004; Kim 2012). Fourteen were of moderate size, with between 25 and 50 women per group (Ahlund 2013; Assis 2015; Barakat 2011; Cruz 2014; Dinc 2009; Frumenzio 2012; Gorbea 2004; Hyakutake 2018; Oakley 2016; Sampselle 1998; Sangsawang 2016; Stothers 2002; Sut 2016; Torsdatter Markussen 2017). Twenty‐four trials allocated more than 50 women per group (Bø 2011; Chiarelli 2002; Ewings 2005; Fritel 2015; Frost 2014; Gaier 2010; Glazener 2001; Hilde 2013; Hughes 2001; Ko 2011; Kocaoz 2013; Kou 2013; Liu 2011; Meyer 2001; Miquelutti 2013; Mørkved 2003; Pelaez 2014; Reilly 2002; Sacomori 2019; Sleep 1987; Stafne 2012; Wen 2010; Woldringh 2007; Yang 2017). Three of these were large, with more than 300 women per comparison group (Chiarelli 2002; Glazener 2001; Stafne 2012). Two were very large trials of more than 500 women per group (Hughes 2001; Sleep 1987).

Setting

Women were recruited from various health services including antenatal and urology clinics, outpatient physiotherapy clinics, gynaecology and obstetric departments, and hospital settings in the following 21 countries: Australia (Chiarelli 2002), Brazil (Assis 2015; Cruz 2014; Miquelutti 2013; Sacomori 2019), Canada (Dumoulin 2004; Dufour 2019; Hyakutake 2018; Skelly 2004; Stothers 2002), China (Ko 2011; Kou 2013; Liu 2011; Wen 2010; Yang 2017), England (Ewings 2005; Glazener 2001; Reilly 2002; Sleep 1987), France (Fritel 2015), Ireland (Peirce 2013), Italy (Frumenzio 2012; Gaier 2010), Mexico (Gorbea 2004), the Netherlands (Woldringh 2007), New Zealand (Glazener 2001; Wilson 1998), Norway (Bø 2011; Hilde 2013; Mørkved 2003; Stafne 2012; Torsdatter Markussen 2017), Poland (Szumilewicz 2019), Republic of Korea (Kim 2012), Scotland (Glazener 2001), Spain (Barakat 2011; Pelaez 2014), Sweden (Ahlund 2013), Switzerland (Meyer 2001), Thailand (Sangsawang 2016), Turkey (Dinc 2009; Dokmeci 2008; Kocaoz 2013; Sut 2016), and the USA (Frost 2014; Oakley 2016; Sampselle 1998).

Participant characteristics
Parity (number of births)

Eight studies did not report parity or gravidity (Cruz 2014; Frost 2014; Frumenzio 2012; Kocaoz 2013; Kou 2013; Skelly 2004; Stothers 2002; Wen 2010). Trials that investigated the effects of antenatal PFMT for prevention of urinary incontinence recruited only continent women in their first pregnancy or having their first baby (or both). Treatment trials recruited women having their first or subsequent baby and had symptoms of urinary or faecal incontinence. In the mixed prevention and treatment studies, whether women were recruited antenatally or postnatally, the women were having their first or subsequent baby and did or did not have urinary or faecal incontinence symptoms. In the trials with mixed parity samples, it is unknown if parity was comparable in seven trials (Cruz 2014; Frumenzio 2012; Kocaoz 2013; Kou 2013; Skelly 2004; Stothers 2002; Yang 2017). It was not comparable in one trial (Barakat 2011).

Age

Participant age was variously described, although six trials did not report this (Cruz 2014; Dokmeci 2008; Frost 2014; Peirce 2013; Sacomori 2019; Skelly 2004). Three trials reported an age range, with women aged between their early 20s to early 40s (Kou 2013; Stothers 2002; Wen 2010). In two trials, about 50% to 60% of the women were aged 20 to 29 years (Chiarelli 2002; Ewings 2005). Median age was about 28 years in two trials (Hughes 2001; Reilly 2002), and 36 years in another trial (Dumoulin 2004). In the remaining 31 studies, the mean age was in the early 20s (Miquelutti 2013), mid to late 20s for 17 trials (Assis 2015; Dinc 2009; Fritel 2015; Gaier 2010; Gorbea 2004; Kocaoz 2013; Liu 2011; Meyer 2001; Mørkved 2003; Oakley 2016; Pelaez 2014; Sampselle 1998; Sangsawang 2016; Sleep 1987; Sut 2016; Wilson 1998; Yang 2017), and early 30s for 14 trials (Ahlund 2013; Barakat 2011; Bø 2011; Dufour 2019; Frumenzio 2012; Glazener 2001; Hilde 2013; Hyakutake 2018; Kim 2012; Ko 2011; Stafne 2012; Szumilewicz 2019; Torsdatter Markussen 2017; Woldringh 2007). Age was comparable at baseline between groups in 34 trials but was unclear in the other 12 (Cruz 2014; Dokmeci 2008; Dufour 2019; Frumenzio 2012; Hyakutake 2018; Kou 2013; Meyer 2001; Peirce 2013; Sacomori 2019; Skelly 2004; Stothers 2002; Wen 2010).

Weight

Twenty‐seven of the 46 trials reported body weight or body mass index (BMI). For the women recruited antenatally, mean or median BMI was in the low to mid 20s (Barakat 2011; Bø 2011; Fritel 2015; Gaier 2010; Hughes 2001; Ko 2011; Miquelutti 2013; Mørkved 2003; Oakley 2016; Pelaez 2014; Reilly 2002; Sangsawang 2016; Stafne 2012; Szumilewicz 2019; Woldringh 2007), or high 20s (Sut 2016). Two trials reported that mean body weight in kilograms was in the mid 60s on average (Assis 2015, 67 kg; Gorbea 2004, 66 kg). Another two studies recruited antenatal women with a BMI in the overweight or obese range, accounting for 30% of participants in one (Kocaoz 2013) and all participants in the other (Torsdatter Markussen 2017). In three trials that recruited postnatal women with persistent incontinence symptoms, the mean or median BMI was in the normal range (Ahlund 2013; Dumoulin 2004; Kim 2012). BMI was about 26 kg/m² in two mixed treatment and prevention studies which recruited women postnatally (Hilde 2013; Yang 2017), and approximately 30% of women in two further trials had a BMI in the overweight or obese range (Chiarelli 2002; Ewings 2005). BMI or body weight was comparable at baseline between groups for all of these trials, although two trials noted that weight gain in pregnancy differed significantly between the groups, being greater in either the PFMT group or in the control group (Barakat 2011; Gorbea 2004).

Type of delivery

Some details on delivery were given by 14 of 19 trials that began PFMT after delivery. In nine of these trials, all women delivered vaginally (Chiarelli 2002; Frost 2014; Hilde 2013; Kim 2012; Liu 2011; Peirce 2013; Sleep 1987; Wen 2010; Yang 2017). In Chiarelli 2002, all women had a forceps or ventouse delivery, while the proportion with instrumental delivery varied in two others (about 39% in Peirce 2013 and 69% in Yang 2017); the types of delivery appeared comparable across the PFMT and control groups in these trials. In three trials, some women had a caesarean section (about 8% in Glazener 2001, 18% in Wilson 1998 and 41% in Sacomori 2019), with the proportion of caesarean sections being similar in both the PFMT and control groups for all trials. Glazener 2001 also reported that about 14% of women in both the PFMT and control groups had assisted vaginal deliveries. Women in the study by Dufour 2019 delivered vaginally or by caesarean section, but the proportions were not reported. In the remaining small trial by Meyer 2001, it was unclear if all 107 women delivered vaginally, but it was reported that 30% of PFMT group and 16% of control group women had forceps delivery; this difference was not "statistically significant" (P = 0.10).

For the trials in which PFMT began antenatally, it is possible that the type of delivery was affected by PFMT. For these trials, the type of delivery was a possible confounder of the postnatal incontinence outcome but may itself be an outcome of importance. A short summary of the data is given here. The data are also reported in more detail in the analysis. Some details on the type of delivery, by group, were given by only 15 of the 27 trials in which PFMT began antenatally. In 12 trials, the delivery type was similar across both comparison groups (Barakat 2011; Fritel 2015; Frost 2014; Hughes 2001; Hyakutake 2018; Ko 2011; Miquelutti 2013; Mørkved 2003; Reilly 2002; Sampselle 1998; Stothers 2002; Woldringh 2007). However, in two trials, there seemed to be fewer vaginal deliveries in the PFMT group (Dinc 2009; Gorbea 2004), and in one trial a significantly greater number of vaginal deliveries (P = 0.018) in the PFMT group (Sut 2016). Miquelutti 2013 reported a "statistically significantly" longer duration of delivery in the PFMT group (mean difference (MD) 9.48, 95% confidence interval (CI) 0.32 to 18.64; P < 0.05).

Exclusion criteria

The most common exclusion criterion (in 33 trials) was a comorbidity that contraindicated exercise in pregnancy or made PFMT difficult (or both), or might have altered the outcome of training, such as serious medical or neuromuscular conditions. Twelve trials excluded women with high‐risk pregnancies (Bø 2011; Dokmeci 2008; Fritel 2015; Gorbea 2004; Ko 2011; Meyer 2001; Miquelutti 2013; Mørkved 2003; Sangsawang 2016; Stafne 2012; Sut 2016; Torsdatter Markussen 2017). Eighteen trials included women with singleton pregnancies or excluded women with twins, or other multiple pregnancies or births (Ahlund 2013; Barakat 2011; Bø 2011; Cruz 2014; Fritel 2015; Gorbea 2004; Hilde 2013; Liu 2011; Meyer 2001; Miquelutti 2013; Mørkved 2003; Pelaez 2014; Sangsawang 2016; Stafne 2012; Stothers 2002; Sut 2016; Torsdatter Markussen 2017; Wen 2010). Nine trials excluded women if the baby was stillborn or was very ill or died after birth (Chiarelli 2002; Ewings 2005; Glazener 2001; Hilde 2013; Mørkved 2003; Peirce 2013; Sacomori 2019; Sleep 1987; Stafne 2012). Five trials excluded women if language difficulties meant it was difficult to seek informed consent (Chiarelli 2002; Dumoulin 2004; Ewings 2005; Peirce 2013; Woldringh 2007). An additional 10 trials outlined language requirements as part of their inclusion criteria (Bø 2011; Cruz 2014; Dufour 2019; Fritel 2015; Hilde 2013; Hyakutake 2018; Oakley 2016; Peirce 2013; Pelaez 2014; Sacomori 2019). Four trials specifically excluded women who experienced pain with a PFM contraction (Dinc 2009; Ko 2011; Mørkved 2003; Sangsawang 2016). One trial excluded women who were unable to perform a PFM contraction as assessed with electromyography (Szumilewicz 2019).

Pelvic floor muscle training regimens and control interventions

The PFMT and control interventions are described in the Characteristics of included studies (overview) and in Table 1 (details of exercise parameters and adherence).

Open in table viewer
Table 1. Pelvic floor muscle training programmes and adherence

Study ID

Voluntary pelvic floor muscle contraction confirmed?

PFMT parameters

PFMT supervision

Control comparison

Adherence

Notes

Ahlund 2013

(treatment trial)

Vaginal palpation performed by study midwife: after randomisation and at each of the 3 visits to midwife (PFMT and control groups).

PFMT started with 3 fast contractions, followed by 3 sets of 8‐12 slow velocity, near maximal contractions, 6‐sec hold; 7 days per week for 6 months. Received written instructions on PFMT, but no information provided on PFMT progression.

Visit to the study midwife every 6th week (3 times during study period).

Usual care: written information describing PFM anatomy and PFMT. Received instructions on how to correctly perform PFM contraction (vaginal palpation) from midwife.

Women in the PFMT group were asked at each midwife visit how often they did PFMT; results not reported.

PFMT in lying or sitting positions.

Assis 2015

(prevention trial)

Perineometry (at 1st meeting), but unclear by whom (PFMT group).

5‐10 slow PFM contractions with 6‐sec hold, rest 6 sec between contractions with 3 rapid contractions at the end (as per Mørkved 2003). Daily PFMT in 4 positions, and 1 group (27 women) had 5 supervised sessions with a physiotherapist. Received manual of home PFMT exercises and asked to complete an exercise diary.

Supervised PFMT (27 women): received up to 5 monthly supervised exercise sessions with physiotherapist (22, 26, 30, 34, 38 weeks' gestation). Unsupervised PFMT (27 women): trained to perform PFMT by physiotherapist (1 session).

Did not receive intervention and did not exercise.

Not reported, although it stated that no dropouts occurred throughout the duration of the study due to all women in the PFMT group complying with the exercise protocol.

PFMT in a variety of positions including left side lying, sitting, reclined sitting, sitting with legs crossed, standing.

Translation (Portuguese).

Barakat 2011

(prevention trial)

Not reported.

PFMT included in the 7‐ to 8‐min cool‐down period as part of a 35‐ to 45‐min exercise session, 3 days per week for duration of pregnancy (potential mean of 85 sessions in total). No specific details provided about PFMT programme.

Group exercise classes, supervised by a qualified fitness specialist, with the assistance of an obstetrician.

Not reported.

Adherence to PFMT was 90%.

General exercises targeted major muscles of arms and abdomen to promote good posture and prevent low back pain, and in the 3rd trimester strengthen the muscles of labour and PF. 1 session of aerobic dance per week. Accompanied by music.

Bø 2011

(mixed prevention and treatment trial)

Participants did not have individual assessment of correct voluntary PFM contraction (due to pragmatic nature of study). Instructors were trained in how to explain a correct PFM contraction.

PFMT included as part of 15‐min strength training session within a 60‐min group exercise class. PFMT: 3 sets of 8‐12 maximal contractions, 6‐ to 8‐sec hold; strong verbal motivation to perform close to maximum PFM contractions. Women encouraged to participate in at least 2 out of 3 fitness classes per week for 12 weeks. Daily PFMT at home: 3 sets of 8‐12 close to maximum PFM contractions. Also encouraged to be physically active for at least 30 min per day. Received a specific PFMT brochure.

Group exercise classes, 2 or 3 per week for 12 weeks, led by certified aerobic instructors. Instructors were taught by a physiotherapist with > 20 years of experience in assessing, treating and researching women with PF dysfunction.

Usual antenatal care.

Mean adherence to exercise classes was 17.2 out of a possible 24 sessions. 40% (21/52) of women attended at least 80% of sessions.

PFMT integrated into aerobic dance class (accompanied by music): 5‐min warm‐up; 30‐min low‐impact aerobics; 15‐min strength training (including PFMT); 5‐min stretching and relaxation.

PFMT in a variety of position including sitting, kneeling and standing. Informed of deep abdominal muscle co‐contraction during maximal PFM contraction.

Chiarelli 2002

(mixed prevention and treatment trial)

Visual inspection of perineum (PFMT group).

Maximum of 6 voluntary PFM contractions per set; 3‐6 sec hold; 3 sets per day; for 8 weeks.

PFMT taught 1‐to‐1 with physiotherapist. 1 (20 min) contact in hospital, and another (30 min) 8 weeks later at home or hospital.

Routine postnatal care; usual postnatal leaflet given; invitation to join postnatal class on ward; no restriction on PFMT if recommended by other health professional.

84% (292/348) of women in the PFMT group and 58% (189/328) of controls were performing PFMT at "adequate" level at 3 months' postpartum.

Women were "asked if they were performing their PF exercises."

Cruz 2014

(treatment trial)

Not reported.

5‐6 biweekly sessions. No specific details provided about PFMT.

Supervised by a physiotherapist.

Similar unsupervised PFMT at home.

Not reported.

Conference abstract.

Dinc 2009

(treatment trial)

Vaginal digital palpation (both PFMT and control groups).

Progressive PFMT programme.

Level 1: 3 sets of 10 near maximal contractions; 3‐sec hold, 3‐sec rest; quick contraction, 1‐sec hold, 1‐sec rest; twice daily. Level 2: 3 sets of 10 near maximal contractions; 5‐sec hold, 5‐sec rest; quick contraction, 2‐sec hold, 2‐sec rest; twice daily. Level 3: 3 sets of 15 near maximal contractions; 10‐sec hold, 10‐sec rest; quick contraction, 2‐sec hold, 2‐sec rest; 3 per day.

Trained by a researcher on how to do PFMT in accordance with booklet of PFM exercises.

Usual care: instructed on how to perform a correct PFM contraction, but did not receive training about exercises.

Not reported.

In 2nd stage of study, 68% of women in study group were contracting the proper muscle group. The rest were given more training and reassessed 1 week later.

Dokmeci 2008

(mixed prevention and treatment trial)

Not reported.

Not reported.

Not reported.

Not reported.

Not reported.

Conference abstract.

Dufour 2019 (mixed prevention and treatment trial)

Vaginal digital palpation (both PFMT and control groups), to instruct and ensure correct performance of PFM contraction. Performed by two of the investigators.

Recommended to undertake 3 sets of 10 exercises, 3‐4 times a week, for the duration of the intervention period (12 to 16 weeks). As per Mørkved et al 2014, but specific PFMT exercises not stated. In addition, used the iBall (a mobile health device) in conjunction with PFMT.

Supervised individual PFMT at initial session. “Booster” email at the mid‐point of the intervention reminding of benefits of postpartum PFMT and features of the iBall.

PFMT only, without the use of the iBall device.

Not reported. Implied within the discussion that there was a lack of adherence.

No information on the specific PMFT exercises and positions these were performed in

Dumoulin 2004

(treatment trial)

Not reported.

8‐12 close to maximal voluntary PFM contraction per set; 6‐ to 8‐sec hold each with 3‐4 fast contractions at the end of each contraction; 6‐sec rest between contractions; 3 sets per day; 5 days per week; for 8 weeks. Also taught 'the knack' (voluntary PFM contraction prior to hard cough and maintained through cough until abdominal wall relaxed).

PFMT taught 1‐to‐1 with physiotherapist.
Weekly physiotherapy appointments for 8 consecutive weeks.

Same number of physiotherapy contacts for relaxation massage of back and extremities; asked not to do PFMT at home.

Not reported.

In addition to PFMT 15 min of electrical stimulation (biphasic rectangular form, 50 Hz, pulse width 250 msec, duty cycle 6 sec on and 18 sec off for 1st 4 weeks, then 8 sec on and 24 sec off for next 4 weeks, at maximal tolerated current intensity) and 25 min of electromyographic biofeedback per appointment.

Ewings 2005

(mixed prevention and treatment trial)

Not reported.

6 months.

PFMT taught 1‐to‐1 with physiotherapist in hospital.
Invitation to attend PFMT class at 2 and 4 months postnatally.

Standard care including verbal promotion of PFMT and leaflet on PFMT.

Of 117 women in the PFMT group, 114 were visited by the physiotherapist in hospital, 21 attended the 2‐month PFMT group, and 5 attended the 4‐month group.

‐

Fritel 2015

(mixed prevention and treatment trial)

Vaginal digital palpation at each session (possibly by physiotherapist, but not stated; PFMT group).

1 session per week (20‐30 min), total of 8 sessions between 6th and 8th month of pregnancy. Also 'the knack' (voluntary PFM contraction prior to increasing intra‐abdominal pressure). Provided with written information on PF anatomy and PFMT, and encouraged to perform daily PFMT at home, 10‐20 contractions.

Individually supervised by a physiotherapist or midwife at each session. In total, 37 different therapists (all trained by the same specialist physiotherapist) were involved in delivering the exercises.

Usual care, including written information on PF anatomy and PFMT (encouraged to perform daily at home, 10‐20 PFM contractions).

69.3% (97/140) of women in the PFMT group completed all planned sessions, and 82.8% (116/140) completed at least 1 session (4‐8, median 8). At the end of pregnancy, women in both groups reported a similar frequency and duration of PFMT (including number of contractions). PFMT was performed daily at home by 4.3% (6/140) of PFMT women and 10.6% (15/142) of controls, at the end of pregnancy.

PFMT performed in standing (5 min) and lying (10 min).

Frost 2014

(mixed prevention and treatment trial)

Not reported.

Standard postpartum discharge instructions plus written and verbal instructions for PFMT.

Not reported.

Standard postpartum discharge instructions.

Not reported.

Conference abstract.

Frumenzio 2012

(mixed prevention and treatment trial)

Not reported.

2 weekly session of Kegel exercises; 8 weeks. Daily home exercises (20 min) and stretching.

Not reported.

Did not receive any PFMT, no other details provided.

Not reported.

Conference abstract.

Gaier 2010

(prevention trial)

Not reported.

12‐week PFMT programme.

PFMT supervised by a physiotherapist and midwife.

Routine care and PFM exercises, customary instruction at intake visit.

Not reported.

Conference abstract.

Glazener 2001

(treatment trial)

Not reported.

8‐10 sessions of fast and slow voluntary PFM contraction per day with aim of 80‐100 per day; for up to 8 months.

PFMT taught 1‐to‐1 with nurse, health visitor or continence advisor.
Visited at home at 5, 7 and 9 months' postnatally.

Usual antenatal and postnatal care that may have included advice on PFMT.

78% (218/278) of women in the PFMT group and 48% (118/244) of controls had done some PFMT in the 11th postnatal month. Mean (SD) number of voluntary PFM contractions per day at 12 months' postnatal: PFMT group 20 (29) and controls 5 (15).

Frequency and urgency strategies added if needed at 7 or 9 months postnatally.

52.7% (394/747) of women at 6 years' follow‐up and 70.1% (471/672) of women at 12 years' follow‐up completed a questionnaire. About 50% of women in PFMT and control groups were performing any PFMT at both time points. Daily PFMT was undertaken by 6% (17/263) of PFMT women compared to 12% (29/253) of control women at 6 years; and 7% (15/227) of PFMT group compared to 8% (20/241) of control women at 12 years.

Gorbea 2004

(prevention trial)

Surface electromyography (electrodes either side of anus; PFMT group).

10 voluntary PFM contraction; 8‐sec hold followed by 3 fast, 1‐sec contractions; 6‐sec rest between contractions; for up to 20 weeks. Asked to complete an exercise diary.

PFMT taught 1‐to‐1 with physiotherapist.
Clinic appointments (1 hour each) weekly for 8 weeks, then weekly telephone calls.

Requested not to do PFMT during pregnancy or postnatally.

63% attended all 8 physiotherapy appointments, 21% attended 7 appointments.

Electromyographic biofeedback at each appointment.

Hilde 2013

(mixed prevention and treatment trial)

Vaginal digital palpation (PFMT and control groups).

Progressive supervised PFM training programme (as per Mørkved 1997) for 16 weeks. Daily PFMT at home, 3 sets of 8‐12 close to maximal contractions. Customary written information on discharge from postnatal ward. Asked to complete an exercise diary.

Supervised exercise class from 6 weeks' postpartum, led by an experienced physiotherapist, once per week for 16 weeks. Class attendance was documented.

Usual care. Received customary written information on discharge from postnatal ward. At 6 weeks were instructed on how to perform a correct PFM contraction (verified with vaginal digital palpation).

96% (72/75) of women in the PFMT group who completed the trial adhered to 80% of the class and daily home training. In the control group (retrospective questioning), 16.5% reported performing daily PFMT at home ≥ 3 times per week.

4% (7/175) of women were unable to perform a voluntary PFM contraction at baseline. At baseline (6 weeks' postpartum) more women in the control group were performing PFMT ≥ 3 times or more per week.

Hughes 2001

(mixed prevention and treatment trial)

Vaginal digital palpation (PFMT and control groups).

Daily; for up to 11 months.

1 individual session with physiotherapist, and 1 group PFMT session led by physiotherapist at 22‐25 weeks' gestation with maximum of 6 women per group.

Usual antenatal and postnatal care that may have included advice on PFMT (personal communication).

79% (461/586) of women in PFMT group attended group PFMT session (personal communication).

3.5% (16/460) of women who attended group PFMT session could not perform a voluntary PFM contraction after teaching, and 2.8% (13/460) of women could contract but not sustain a contraction (personal communication). Conference abstract.

Hyakutake 2018

(mixed prevention and treatment trial)

Not performed.

PFMT 3 times daily at home starting with 5 contractions (1‐sec hold), progressing to 10 contractions (10‐sec hold), for the rest of their lives. Educated on the benefits of PFMT, how to increase awareness of their perineum and perform PFMT. Provided with a take‐home pack and encouraged to contact a local PF physiotherapist.

A single 2‐hour physician‐led pelvic floor workshop.

Routine prenatal care with their existing maternity care provider (midwife, family physician or obstetrician). Not specifically stated but likely to have received advice on PFMT.

58.34% of women in the PFMT group and 22.9% of controls had done PFMT at least daily.

Possible additions to PFMT such as vaginal cones or weights and the use on a mobile app were suggested.

Kim 2012

(treatment trial)

Perineometer (vaginal probe) used to ensure PFM contraction and assess control of contraction in both PFMT and control groups. Unclear if this was performed every session with the PFMT women.

20 maximal voluntary PFM contractions, 10‐sec hold, 3 times per week; for 8 weeks (as part of a class), and daily at home. Progressed by changing position (prone, sitting and standing). Initial session included information on PFM anatomy and function. Also provided with a booklet which included a training programme and an exercise diary.

Supervised training sessions (1‐hour duration) with a specialist physiotherapist (23 in total, unclear if individual contacts or group classes).

Usual care. Received the same information and demonstration session as PFMT group and instructions on how to correctly perform PFM contraction (perineometer). Unsupervised, daily PFMT for 8 weeks.

Not reported.

PFMT integrated with trunk stabilisation exercises (progressive abdominal strengthening, bridging, and side‐bridge).

Ko 2011

(mixed prevention and treatment trial)

Observation of inward movement of perineum during contraction (PFMT group).

3 repetitions of 8 PFM contractions, 6‐sec hold each, 2‐min rest between repetitions; repeated twice daily at home with additional training in groups once per week for 45 min for 12 weeks. Asked to complete an exercise diary.

Group training sessions (10 women) supervised by a physiotherapist once per week for 12 weeks.

Regular antenatal care and the customary written postpartum instructions that did not include PFMT from the hospital.

Not discouraged from performing PFMT on their own.

> 80% attended every training session and 0 were absent more than twice.

At 35 gestational weeks, 87% of PFMT group reported practice of PFMT ≥ 75% of the time.

Group training was performed in sitting and standing positions with legs apart to emphasise specific strength training of the PFM and relaxation of other muscles.

Kocaoz 2013

(prevention trial)

Observation of inward movement of perineum or digital vaginal palpation, or both (PFMT group). Vaginal digital palpation used to teach PFM contraction in 23.5% (16/68) of women.

3 sets of 10 maximal voluntary PFM contractions at level 3 (2‐sec hold, 2‐sec rest for strength; 10‐sec hold, 10‐sec rest for endurance); 3 sessions per day during pregnancy and postpartum. Women received education about the anatomy and functions of the PFM and PFMT (unclear from whom) and were asked to complete an exercise diary (including progressions).

Exercise compliance was checked at every hospital visit (9‐10 visits on average, over a minimum of 12 weeks), and pregnant women were called once per month to encourage regular exercise.

Not instructed to do PFMT. Once data collection complete, controls received PFMT and a brochure with the relevant information during the 12th week home visit.

Women asked to record the number of times they did their exercises. No data reported.

Vaginal digital palpation was refused by 52/68 women due to concerns about pregnancy, cultural/religious reasons. Unclear if women progressed through levels 1‐3 or started at level 3, whether they did 3 sets of 10 exercises per day or 3 sets of 10 exercises 3 times per day, or how the sets were divided between endurance and strength training.

Kou 2013

(mixed prevention and treatment trial)

Not reported.

PFM (Kegel) exercises undertaken 2‐3 times per day for 20‐30 min or 150‐200 contractions (3‐sec hold then relax), performed until 12 months' postpartum. Biofeedback used twice per week (no further details available).

Not reported who supervised the programme, or the number and type of contacts with health professional(s).

Usual care: received standard postpartum information.

Not reported.

Translation (Chinese).

Liu 2011

(mixed prevention and treatment trial)

Not reported.

PFMT 2‐3 times per day, 15‐30 min each set (4‐ to 6‐sec hold, 10‐sec relaxation), started after birth and continued for ≥ 10 weeks.

Exercises taught by experienced midwives who also supervised the programme (number and type of contacts/visits unclear).

Usual care: standard postpartum information. Unclear if this included PFMT.

Not reported.

Translation (Chinese).

Positions of exercises included supine, sitting or any other position, with legs slightly separated, with instructions to contract anus, vaginal and urinary tract while breathing in, and to relax with expiration.

Meyer 2001

(mixed prevention and treatment trial)

Not reported.

Up to 8 months; no details of PFMT provided. Each clinic session was followed by 20 min of biofeedback and 15 min of electrical stimulation.

12 sessions (6 weeks) with a physiotherapist between 2 and 10 months postnatally.

No intervention. Women received PFMT education after 3rd assessment at 10 months' postpartum.

Not reported.

In addition to PFMT, 20 min of biofeedback and 15 min of electrical stimulation (vaginal electrode, biphasic rectangular waveform, pulse width 200‐400 msec, frequency 50 Hz, intensity 15‐15 mA, contraction time 6 sec, rest time 12 sec) per appointment.

Miquelutti 2013

(mixed prevention and treatment trial)

Instructed on correct contraction, but not verified (due to pragmatic nature of study).

PFMT (maximal rapid and sustained PFM contractions) performed as part of a class (50 min) for a median of 5 (range 2‐10) sessions between 18‐24 weeks' to 36‐38 weeks' gestation. Provided with an exercise guide and asked to do daily PFMT at home (30 rapid, 20 sustained (10‐sec hold) contractions), as well as 30‐min daily aerobic exercise (no specific examples provided). Received standard antenatal education and asked to complete an exercise diary.

Supervised by a trained study physiotherapists on a monthly basis. Either group or individual training sessions, depending on the number of women present.

Usual care: received standard antenatal and postnatal education (on labour, breastfeeding and pain relief) by trained physiotherapy, nursing and medial staff.

Analysis of adherence in intervention group was not possible as women failed to complete or return their exercise diaries.

PFMT performed in standing and sitting position. PFMT integrated into non‐aerobic exercise programme designed to reduce back pain. Included abdominal, stretching and relaxation exercises and exercises designed to promote venous return.

Mørkved 2003

(mixed prevention and treatment)

Vaginal digital palpation and observation of perineum (both PFMT and control groups).

8‐12 near maximal voluntary PFM contractions; 6‐ to 8‐sec hold each, 3‐4 fast contractions at the end of each contraction; 6‐sec rest between contractions; twice daily at home; for ≤ 8 months. Also asked to attend weekly 60‐min PFMT class for 12 weeks. Women asked to complete an exercise diary.

Group training session (10‐15 women), once per week for 12 weeks, supervised by physiotherapists (5 in total).

Usual antenatal and postnatal care that may have included advice on PFMT. Correct PFM contraction verified. Not discouraged from doing PFMT on their own.

19% (28/148) of PFMT women attended less than half the 12 weekly PFMT classes and did not return training diaries.

During exercise class voluntary PFM contraction undertaken in a range of body positions (lying, sitting, kneeling and standing with legs apart). PFMT interspersed with abdominal, back and thigh muscle exercises (accompanied by music).

62% (188/280) of women completed a questionnaire at 6‐year follow‐up, and 45% of women in both the former PFMT and control groups were doing PFMT at least weekly.

Oakley 2016

(mixed prevention and treatment trial)

Vaginal digital palpation (both PFMT and control groups), electromyography, and anorectal manometry used to confirm absence or presence of PFM contraction. Performed by two of the investigators.

Four PFMT sessions (60 min), every 2 weeks, beginning at 6 weeks’ postpartum (i.e. weeks 6, 8 10 and 12) combined with behavioural therapy. PF and core muscle neuromuscular, strength and endurance techniques; PF and rectus diastasis protection techniques. Home exercise component, and women also received routine postnatal care with their primary obstetrician and gynaecologist.

Unclear if a group or 1‐to‐1 session.

Usual care, with included routine postnatal care from their see primary obstetrician and gynaecologist.

Not reported

Independent to the study, 54.0% (combined groups) reported not receiving any instructions on PFMT and/or behavioural therapy; 46.0% received behavioural therapy and 16.0% had received instruction on PFMT from other health professionals. No differences were noted between groups.

Peirce 2013

(mixed prevention and treatment trial)

Contraction assessed with anal biofeedback as part of training session (by obstetrician or specialist nurse); PFMT group.

Sets of 10 PFM contractions (Kegel exercises), 5‐sec hold; 10‐sec rest between contractions; twice daily for 5 min with biofeedback; for 3 months. Standard postpartum education by midwives or physiotherapists, including written information. Women asked to complete an exercise diary.

Biofeedback (electromyographic) training provided at initial session, but no further contact with health professionals.

Usual care: "conventional PFM training," but no details provided. Women asked to complete an exercise diary.

Poor adherence defined as performing < 70% of the intended home exercise sessions. 7/30 women in the PFMT group reported poor adherence.

The portable biofeedback machines were programmed to the electromyography setting with the work period set to 10 contractions (5‐sec duration) with a 10‐sec rest between each contraction. PFMT for treatment of FI.

Pelaez 2014

(prevention trial)

Instructed on correct contraction, but not formally verified. Women were asked to test themselves at home by stopping the flow of urine, vaginal digital palpation or using a mirror to observe the perineum (PFMT group).

PFMT programme, 3 times per week; for ≥ 22 weeks. Started with 1 set of 8 contractions increasing to 100; divided into different sets of slow (6 sec) and fast (5 as fast as possible) contractions. Unclear if this progression related to class or home exercises. Daily PFMT at home, 100 contractions in different sets. Received standard antenatal education about PFM.

Group training sessions (8‐12 women) designed and supervised by a physical activity and sport sciences graduate; 55‐ to 60‐min duration (10 min of PFMT); 70‐78 sessions in total.

Usual care: follow‐up by midwives, standard information about PFMT. Women were not asked not to do PFMT.

All women included in analysis attended ≥ 80% of exercise sessions.

PFMT integrated into supervised exercise programme; 30 min low‐impact aerobics including general strength training, PFMT and cool down (stretching, relaxation or massage); sometimes accompanied by music. PFMT in a variety of positions. Women wore heart rate monitors to control exercise intensity.

Reilly 2002

(prevention trial)

Unclear, but seems likely as physiotherapists gave individualised programmes to those unable to follow exercise regimen due to inability to do voluntary PFM contraction (PFMT group).

8‐12 voluntary PFM contractions; 6‐sec hold each; 2‐min rest between each set of contractions; 3 sets of 8‐12 contractions twice daily; for about 20 weeks (as described by Bø 1995).
Also asked to do voluntary PFM contraction with every cough and sneeze, and complete an exercise diary.

About 5 (monthly) contacts with physiotherapist between 20 weeks' gestation and delivery.

Usual antenatal and postnatal care that may have included advice on PFMT. Women appeared to have had same number of clinic visits as the PFMT group, and were asked if doing PFMT at each of these visits.

43% (52/120) of women in the PFMT group did not return an exercise diary; 11% (13/120) completed < 28 days of PFMT; and 46% (55/120) completed ≥ 28 days. When asked postnatally, 28% (33/120) of PFMT women and 34% (37/110) of controls were doing occasional or no PFMT.

If unable to follow PFMT regimen then individualised programme until able to do so.

71% (164/230) of women completed a telephone questionnaire at 8‐year follow‐up, and 68.4% of women were doing PFMT, with 38% stating they were doing PFMT twice or more per week.

Sacomori 2019

(mixed prevention and treatment trial)

Assessed PFM muscles using visual inspection (PFMT group).

PFMT at home, 10 sets of up to 10‐sec holds (contraction starts lightly and intensifies until a maximal contraction is reached) [Strength and endurance]. Five (1 sec) fast and strong contractions [Strength]. Also taught to perform the “knack”, before and during a sneeze or cough. PFMT performed twice daily at home. Received verbal and written educational information about PF anatomy, physiology, PF dysfunction and PFMT.

One 1‐to‐1 session with a “pelvic floor specialist” who “was certified to participate in the study only after demonstrating total competence and understanding of the execution of PFM assessment and PFMT”.

No PFMT. Women did not receive any kind of intervention or PFMT as this is usual clinical practice in Brazil.

55 (85.1%) women reported overall adherence to PFMT.
22 (32.3%) performed exercises 1‐2 times per week and 33 (49.3%) did so 3‐7 times per week.
33 (49.3%) performed both strength and endurance training, 14 (20.9%) only strength training and 10 (14.9%) focused only on endurance training.
21 (31.3%) performed PFMT for 3 months postpartum, others for around 2 months
38 (39.2%) multiparous and 23 (31.9%) primiparous women adhered to PFMT

Researchers made up to ten attempts to contact participants by phone for follow‐up at 3 months’ postpartum.

Sampselle 1998

(mixed prevention and treatment trial)

Yes, but unclear how or by whom (PFMT group).

PFMT tailored to individual ability. 30 maximal or near maximal voluntary PFM contraction per day; for ≤ 17 months.

Not reported.

Usual antenatal and postnatal care; no systematic PFMT programme.

At 35 weeks' gestation, 85% of women in the PFMT group reported to be doing PFMT 75% of the time. At 1 year, PFMT adherence reported to vary between 62% and 90%.

‐

Sangsawang 2016

(treatment trial)

Assessed by ability to stop or slow the flow of urine for 1‐2 sec (PFMT group).

20 sets of PFM exercises, twice daily, at least 5 days per week, for 6 weeks. 1 set of PFM exercises was 1 slow contraction (10‐sec hold), followed by 10 fast contractions; no progression in number of contractions per set. Also received a handbook with information on stress UI, PFM function, instructions on PFMT and a urinary diary.

Supervised group sessions (4‐5 women) with a midwife; 45 min; once every 2 weeks for 6 weeks (3 sessions in total).

Usual care: from health professionals, obstetricians or midwives. Did not receive information about UI and received no training support about performing correct PFM exercises.

No women were excluded for failing to perform the PFMT for < 28 (of approximately 42) days.

PFMT performed in various positions including lying down, sitting and standing.

Skelly 2004

(treatment trial)

Not reported.

Not reported.

"One to one teaching about pelvic floor exercises."

"Conventional care (hand‐out information about pelvic muscle exercises)."

Not reported.

Conference abstract.

Sleep 1987

(mixed prevention and treatment trial)

Not reported.

As for controls with additional section in leaflet recommending a specific exercise each week that integrated voluntary PFM contraction with usual activities of daily living; up to 3 months. Asked to complete a daily exercise diary for 4 weeks.

1‐to‐1 session with midwife co‐ordinator each postnatal day in hospital.

Usual antenatal and postnatal care including PFMT leaflet; might include PFMT at antenatal class or postnatal class on ward (or both); instructed to do voluntary PFM contraction as often as remembered and mid‐stream urine stop.

At 10 days postnatally, 78% of PFMT group and 68% of controls were doing some PFMT; with 58% of PFMT group and 42% of controls doing some PFMT at 3 months.

‐

Stafne 2012

(mixed prevention and treatment trial)

Vaginal digital palpation (PFMT group).

8‐12 near maximal voluntary PFM contractions; 6‐ to 8‐sec hold each with 3 fast contractions at the end of each contraction. Asked to perform PFM exercises as part of a 45‐min home programme at least twice per week or a weekly 60‐min exercise class (or both). Received written information including brochure with an evidence‐based PFMT programme, and asked to complete an exercise diary.

Group training sessions (8‐15 women) supervised by physiotherapist, 60 min, once per week for 12 weeks

Usual care: received customary information from midwife or GP. Also given a detailed information brochure including evidence‐based PFMT programme. Women were not discouraged from exercising.

Adherence to the general exercise protocol (exercising ≥ 3 days per week, moderate to high intensity) was 55% (217/397) in the PFMT group and 10% (36/365) in the control group. 67% of the PFMT group performed PFMT ≥ 3 times per week compared to 40% in the control group

PFMT integrated into standardised exercise programme: 30‐ to 35‐min low‐impact aerobics; 20‐ to 25‐min strengthening exercises (including PFMT, 3 sets of 10 reps); 5‐ to 10‐min stretching and relaxation. PFMT performed in a variety of positions, with legs apart to emphasise specific strengthening of the PFM.

Stothers 2002

(prevention trial)

Not reported.

12 contractions, 3 times daily.

Seen twice monthly throughout pregnancy, and every 3 months postnatally for 1 year.

"Other (placebo) including no pelvic floor exercises."

Not reported.

Conference abstract.

Sut 2016 (mixed prevention and treatment trial)

Not reported. Instructions provided on how to perform exercises but did not report if correct performance of contractions were confirmed.

Home PFMT programme. Instructed to contract PFM by “pulling inward as with urine or gas output” and hold for 10 sec. Then relax completely after 10sec of contraction. Three sets of 10 exercises, 3 times daily at home.

Participants instructed by a researcher on how to perform Kegel exercises. Participants in the PFMT group were called by telephone at two‐week intervals to remind to perform exercises.

No intervention: “no instruction was given to the patients in the control group”.

Not reported

Participants instructed that bladder must be emptied prior to exercise, with exercises done in supine or sitting (bending the legs at the knee).

Szumilewicz 2019 (mixed prevention and treatment trial)

Correct contraction confirmed by EMG biofeedback (PFMT groups).

Progressive PFMT for 5‐10 min as part of strength training within a 60‐min group exercise class. Week 1 (quick flicks): 5 x 10 short contractions with 30‐sec rest between sets (5 min).
Week 2 (stacking): a/a but each repetition contains 3 increasingly stronger contractions. Week 3 (endurance): a/a, maintaining a sustained hold and gradually extending from 3 to 10 sec), before slowly relaxing, 3 x 10, 30‐sec rest between sets (10 min). Week 4 (high‐intensity): a/a, maintaining hold until feeling tired, then 3 x 5 pulsating ticks before relaxing. 5 repetitions max hold, 10 sec between repetitions, 30 sec between sets.
Week 5 (complex activation): 5 quick maximal contractions, with 5‐sec rest between contractions, 5 repetitions, (10‐sec hold, 10 sec pause) sustained for 60 sec then relax. 3 times, 30‐sec rest between sets. Week 6 (maintenance): performance of regular tasks as for week 4. 5 repetitions in series, with 10‐sec rest between, maintenance of maximal hold (> 10 sec) Extended with short pulsating contractions, at least 2 sets with 30‐sec rest between sets. Women encouraged to attend 3 sessions per week for 6 weeks.

Supervised exercise sessions led by a certified pregnancy and postnatal exercise specialist whose competencies met the European educational standard for this profession. The principle researcher checked the quality of exercise programme implementation once every 2 weeks.

No PFMT.

Email and phone contact were used to ensure adherence. The exercise specialist checked and registered attendance for each session. “On average,
women from the experimental group attended 13±3 exercise
sessions (from a maximum of 18), which constituted 71±19% of the planned exercise program.”

“During the study, participants were lying supine with hips flexed and knees bent to approximately 90°

Torsdatter Markussen 2017

(mixed prevention and treatment trial)

Digital vaginal palpation to ensure correct PFM contraction by a gynaecologist, and instruction provided on correct PFM contraction (PFMT and control groups).

PFMT included as part of resistance training (25 min) within a 60‐min group exercise class or individual session. PFMT consisted of 3 x 10 reps of 6‐8 sec sustained maximum contractions, followed by 3‐5 quick contractions, with 1 min rest between sets. Women encouraged to attend 3 sessions per week from study inclusion to delivery, and to do the same programme at home at least once per week, and daily home PFMT (same parameters as above). All were invited to attend a 30 min motivational interview session at the beginning of the training period and received a standardised pamphlet containing general advice including PFMT

Supervised by a physiotherapist.

Usual care which consisted of 8 routine prenatal visits to midwife and/or general practitioner and a routine ultrasound at 8 weeks. Women were not told to restrain from exercise, physical activity or PFMT. Received standardised pamphlet containing general advice including PFMT.

Performance of home PFMT ≥ 3 times per week:
70% (n= 14) of PFMT and 52% (n = 12) of control women at late pregnancy; 50% (n =9) of PFMT and 41% (n = 9) of control women at 3 months’ postpartum.
Median number of PFM contractions daily was 20 (min‐max 0‐80) in the PFMT group, and 12.5 (min‐max 3‐60) in the control group at 3 months’ postpartum.

PFMT could be performed in standing, kneeling on all fours or sitting (based on personal preference, progression of skill or improved strength).
Women were instructed to “pull up and hold the pelvic floor, hold, hold, hold! Release slowly”.

Wen 2010

(mixed prevention and treatment trial)

Assessment of PFM strength and contraction by an obstetrician (PFMT group; no further details)

Anal contraction; 3‐sec hold (while inhaling) followed by relaxation with 3‐5 faster contractions at the end of each contraction; 15‐30 min each set; twice daily; 6‐8 weeks.

Exercises taught by experienced midwives but unclear who supervised the programme of the number and type of contacts/visits.

Usual care: no other details provided other than "conventional guidance."

Not reported.

PFMT performed in a variety of positions including lying down, sitting or standing.

Translation (Chinese).

Wilson 1998

(treatment trial)

Not reported.

Mix of fast and slow voluntary PFM contractions 8‐10 times per day with aim of 80‐100 voluntary PFM contraction daily; up to 9 months.

1‐to‐1 sessions with physiotherapist at 3, 4, 6 and 9 months postnatally.

Usual PFMT as taught in antenatal and postnatal classes.

Mean (95% CI) number of daily voluntary PFM contraction at 12 months' postnatally was 86 (69‐104) in the PFMT group and 35 (30 to 40) in the control group.

Perineometry for biofeedback at each appointment.

Mean time to teach PFMT to the PFMT group was 32 (95% CI 30 to 34) min.

Woldringh 2007 (treatment trial)

Observation and palpation of perineal body by physiotherapists. Women also encouraged to practice self‐palpation (PFMT group).

Not reported. At each visit, women were asked about the frequency and duration of PFMT.

1‐to‐1 30‐min sessions with physiotherapist. 4 in total: 3 antenatally and 1 at 6 weeks postnatally. In total, 25 physiotherapists (specialised in PFMT) were involved in delivering the exercises.

Usual antenatal and postnatal care including advice on PFMT; nearly two‐thirds received some instruction on PFMT.
Women were also asked the same questions about frequency and duration of PFMT as the PFMT group

At 35 weeks' gestation, 6% reported no PFMT, 17% reported some PFMT, 40% were doing PFMT at low intensity and 37% were exercising intensively in the PFMT group vs 36% reported no PFMT, 25% reported some PFMT, 26% were doing PFMT at low intensity and 14% were exercising intensively in the control group.

‐

Yang 2017

(mixed prevention and treatment trial)

Digital vaginal palpation to ensure correct PFM contraction (PFMT group).

PFMT (1): PFMT performed at home, 2‐3 times per day, as described by Jonasson and colleagues 1989. Instructed to shrink hypogastria, perineum and anal muscles for 5 sec while inhaling; relax while exhaling for 5 sec.
PFMT (2): In addition to PFMT, this group also received electrical stimulation for 30 min, 3 times per week beginning at 6 weeks’ postpartum (approximately 15 sessions in total).

PFMT (1): One 1‐to‐1 PFMT at 2 days’ postpartum, taught by specialised staff members (each training session went for 20 min with the exercises performed 6 times per min).
PFMT (2): As above plus 1‐to‐1 supervised sessions of electrical stimulation with specialised training staff.

No PFMT, unclear if instructed not to perform PFMT. At 2 hours postpartum, two specialised training staff provided 1 hour of routine postpartum guidance.

Three cases failed to complete the PFMT in accordance with the prescribed frequency and timing in the training group.

Kegel exercises were performed in supine, legs unbent, hands placed at sides.

CI: confidence interval; FI: faecal incontinence; min: minute; PF: pelvic floor; PFM: pelvic floor muscle; PFMT: pelvic floor muscle training; SD: standard deviation; sec: second; UI: urinary incontinence.

First, the PFMT programmes were classified by their possible physiological effect(s) (strength, endurance, co‐ordination or a combination), based on the described exercise parameters. Second, the amount of contact or supervision from health professionals (low fewer than five contacts; moderate six to 12 contacts; high more than 12 contacts); confirmation of a correct PFM contraction and nature of the control interventions were examined. Third, adherence data were considered to assess whether exercise behaviour was likely to support a physiological effect. Trials were classified according to whether they provided data for both the intervention and control groups, the intervention group only, or neither group. The likely impact of the exercise programmes on PFM function and the clinical difference between the intervention and control conditions are considered in the Discussion.

We categorised 14 trials as providing strength training and nine as probably strength training trials. Fourteen trials clearly provided exercise parameters that favoured strength training; short duration contractions of maximal or near maximal effort and a relatively small number of repetitions (Ahlund 2013; Bø 2011; Dinc 2009; Dumoulin 2004; Hilde 2013; Kim 2012; Kocaoz 2013; Miquelutti 2013; Mørkved 2003; Sacomori 2019; Sampselle 1998; Stafne 2012; Szumilewicz 2019; Torsdatter Markussen 2017). The exercise protocol described by Bø 1995 was the PFM strength training protocol on which the trials by Bø 2011, Mørkved 2003, and Dumoulin 2004 were based. Supervised treatment duration was only six to eight weeks in the trials by Dumoulin 2004, Kim 2012 and Szumilewicz 2019, and this might have been insufficient for muscle hypertrophy to be established. In addition to strength training, three studies (Dumoulin 2004, Sacomori 2019, Szumilewicz 2019) included some co‐ordination type training. Women were encouraged to perform voluntary PFM contraction in conjunction with rises in intra‐abdominal pressure, such as with coughing or sneezing, also known as 'the knack' (Miller 2008). Kim 2012 included trunk stabilisation exercises. With regard to contact with health professionals, this was low in three trials (fewer than five contacts) (Ahlund 2013; Miquelutti 2013, Sacomori 2019), moderate (six to 12 contacts) in four (Dumoulin 2004; Kocaoz 2013; Mørkved 2003; Stafne 2012), and high (more than 12 contacts) in five (Bø 2011; Hilde 2013; Kim 2012; Szumilewicz 2019; Torsdatter Markussen 2017). Six trials stated that PFMT was supervised in an exercise class (Bø 2011; Hilde 2013; Mørkved 2003; Stafne 2012; Szumilewicz 2019; Torsdatter Markussen 2017). Eleven trials confirmed a correct voluntary PFM contraction prior to training (Ahlund 2013; Dinc 2009; Hilde 2013; Kim 2012; Kocaoz 2013; Mørkved 2003; Sacomori 2019; Sampselle 1998; Stafne 2012; Szumilewicz 2019; Torsdatter Markussen 2017). Six of these also confirmed a correct contraction in the control group along with provision of usual antenatal and postnatal care (Ahlund 2013; Dinc 2009; Hilde 2013; Kim 2012; Mørkved 2003; Torsdatter Markussen 2017). In the remaining eight trials, the control conditions were no PFMT (Sacomori 2019), or usual care, which may or may not have included PFMT or no PFMT as controls were asked not to train (Bø 2011; Dumoulin 2004; Kocaoz 2013; Miquelutti 2013; Sampselle 1998; Stafne 2012; Szumilewicz 2019). With regard to adherence, seven trials reported some information about exercise behaviour and five of these compared group exercise classes and home PFMT versus usual care (Bø 2011; Hilde 2013; Mørkved 2003; Stafne 2012; Torsdatter Markussen 2017). The other two trials with adherence data compared standardised instruction and home PFMT with usual care (Sampselle 1998), or no PFMT (Sacomori 2019). In Stafne 2012, 67% of the PFMT group performed home PFMT at least three times per week compared to 40% of controls in late pregnancy. At six months' postpartum, Hilde 2013 found that 96% of the PFMT group who completed the trial adhered to 80% of the class and daily home training, whereas 16.5% of controls reported daily PFMT at home, three or more times per week. At three months' postpartum Torsdatter Markussen 2017 reported adherence to the home PFMT (three times a week) was nine women in each group (91 women randomised). The other four trials reported data only for the intervention group, with adherence to PFMT of about 50% (Sacomori 2019), 70% (Bø 2011) and 80% (Mørkved 2003), or 85% of PFMT women doing PFMT 75% of the time (Sampselle 1998).

Nine trials described PFMT programmes that were characteristic of strength training but did not mention loading (effort) (Assis 2015; Chiarelli 2002; Dufour 2019; Gorbea 2004; Hyakutake 2018; Ko 2011; Peirce 2013; Reilly 2002; Sut 2016). Three trials referenced the exercise protocols of other authors. Reilly 2002 cited Bø 1995 (strength and load training), Ko 2011 cited Reilly 2002 and Dufour 2019 cited Mørkved 2014 (strength training). The supervised treatment duration was only six to eight weeks in two trials (Chiarelli 2002; Hyakutake 2018), and this may have been insufficient for muscle hypertrophy to be established. In addition to strength training, women undertook some co‐ordination type training, daily biofeedback or participated in a weekly exercise class supervised by a physiotherapist (Dufour 2019; Ko 2011; Peirce 2013; Reilly 2002). In three trials, the control groups did not exercise (Assis 2015; Gorbea 2004; Sut 2016). In the other six trials, controls were randomised to usual care which may or may not have included PFMT (Chiarelli 2002; Ko 2011; Hyakutake 2018; Peirce 2013; Reilly 2002) or PFMT (Dufour 2019). A correct PFM contraction for women in the exercise group was confirmed in six of the nine trials (Assis 2015; Chiarelli 2002; Dufour 2019; Gorbea 2004; Ko 2011; Peirce 2013). Only one of the control groups appeared to have confirmation of a correct contraction (Dufour 2019). With regard to adherence, five of the nine trials reported some information about exercise behaviour (Chiarelli 2002; Gorbea 2004; Ko 2011; Peirce 2013; Reilly 2002). Seven trials offered individual supervision (Assis 2015; Chiarelli 2002; Dufour 2019; Gorbea 2004; Peirce 2013; Reilly 2002; Sut 2016). Two offered one or more group sessions (Hyakutake 2018; Ko 2011). At three months' postpartum, Chiarelli 2002 reported that more women in the PFMT group (84%) compared to controls (58%) were doing "adequate" PFMT. Similarly, in Reilly 2002, about 75% of the PFMT group and 66% of the control group were doing more than occasional or no PFMT (27.5% in the PFMT group and 34% in the control group reported occasional or no PFMT). During the antenatal intervention period, nearly half the women in the PFMT group exercised for 28 days or more (which is approximately once per week over 20 weeks). The other three trials reported data only for the intervention group, with two reporting that over 80% of women attended most or all supervised visits (Gorbea 2004; Ko 2011). Ko 2011 and Peirce 2013 reported that more than three‐quarters of women in the PFMT group completed 70% or more of the prescribed exercise.

There was insufficient detail in the other 23 trials to classify them as providing strength or endurance training.

Seven trials provided some information about PFMT but could not be categorised (Glazener 2001; Kou 2013; Liu 2011; Pelaez 2014; Sangsawang 2016; Wen 2010; Wilson 1998). None had any description of effort (i.e. load). Supervised treatment was only six to eight weeks in two trials and this might have been insufficient for muscle hypertrophy to be established if strengthening was intended (Sangsawang 2016; Wen 2010). Five of the seven trials included variously described mixes of fast and slow contractions with relatively large numbers of sets (eight to 10 per day) and few repetitions per set (about 10) or exercise sets of 15‐ to 30‐minute duration (Glazener 2001; Pelaez 2014; Sangsawang 2016; Wen 2010; Wilson 1998). Overall, all appeared to recommend a large number of contractions per day (more than 100) or a minimum of 30 minutes of PFMT per day. The programmes might have affected strength or endurance, or both, depending on the number of contractions performed daily and the amount of voluntary effort with each contraction. The amount of contact with healthcare providers varied. In two trials, women participated in group exercise sessions, either three groups over a period of six weeks or a total of 70 to 80 groups over 22 weeks (Pelaez 2014; Sangsawang 2016). In another two trials, women had one‐to‐one sessions with health professionals, with three or four visits spread over eight to nine months (Glazener 2001; Wilson 1998). In three trials, the number and duration of contacts with healthcare providers was unknown (Kou 2013; Liu 2011; Wen 2010), although it is possible this was twice per week in the trial that included biofeedback (Kou 2013). Only three trials mention confirmation of correct PFM contraction, being verified by an obstetrician or by the women themselves using self‐palpation, mirror observation of the perineum or mid‐stream urine stoppage (Pelaez 2014; Sangsawang 2016; Wen 2010). In all trials, the control group received usual care that may have included advice or opportunities to do PFMT (e.g. in an antenatal class), with the exception of Sangsawang 2016, where women received usual care but no information on urinary incontinence or PFMT. Four trials provided some adherence data. The women in the trials by Glazener 2001 and Wilson 1998 were supervised individually and performed significantly more voluntary PFM contractions per day at 12 months' postpartum in the PFMT groups. The mean number of contractions was 20 (standard deviation (SD) 29) and 86 (95% CI 69 to 104) per day in PFMT women, and 5 (SD 15) and 35 (95% CI 30 to 40) per day in control women. Glazener 2001 followed up women for six years after the index delivery. Similar proportions of women in both groups were doing some PFMT, 50% (132/263) in the intervention group and 50% (127/253) in the control group. The other two trials offered group supervision and reported adherence data for the training groups only. Pelaez 2014 reported that all PFMT women attended at least 80% of the exercise sessions (approximately 70 to 78 in total). In the trial by Sangsawang 2016, it appeared that all women had done PFMT for 28 days (of 42 in total).

Sixteen trials did not specify any details of the PFMT received by intervention group (Barakat 2011; Cruz 2014; Dokmeci 2008; Ewings 2005; Fritel 2015; Frost 2014; Frumenzio 2012; Gaier 2010; Hughes 2001; Meyer 2001; Oakley 2016; Skelly 2004; Sleep 1987; Stothers 2002; Woldringh 2007; Yang 2017). Eight of these were conference abstracts (Cruz 2014; Dokmeci 2008; Frost 2014; Frumenzio 2012; Gaier 2010; Hughes 2001; Skelly 2004; Stothers 2002). Five trials mentioned that women were asked to do daily PFMT at home (Fritel 2015; Frumenzio 2012; Hughes 2001; Stothers 2002; Yang 2017). One trial asked women to complete a daily exercise diary (Sleep 1987). Most trials provided one or more one‐to‐one supervisory sessions with a health professional, two invited women to one or two additional group sessions (Ewings 2005; Hughes 2001). Barakat 2011 provided PFMT within approximately 85 exercise classes over the course of pregnancy. Five trials confirmed a correct PFM contraction either by vaginal digital palpation or observation and palpation of the perineal body (Fritel 2015; Hughes 2001; Oakley 2016; Woldringh 2007; Yang 2017). The control conditions were: no PFMT (Frumenzio 2012; Meyer 2001; Stothers 2002), usual care (which may or may not have included advice on PFMT) (Frost 2014; Gaier 2010; Hughes 2001; Oakley 2016; Skelly 2004; Yang 2017), usual care that included advice about PFMT (Ewings 2005; Sleep 1987; Woldringh 2007), and PFMT at home (Cruz 2014; Fritel 2015). In two trials, the control condition was unclear (Barakat 2011; Dokmeci 2008). In five of the 16 trials, no information was provided about adherence, or the number of contacts with health professionals in either the intervention or control groups (Cruz 2014; Dokmeci 2008; Frost 2014; Frumenzio 2012; Gaier 2010). All were abstracts. Six of the 16 trials provided some information about exercise behaviour (Barakat 2011; Ewings 2005; Fritel 2015; Hughes 2001; Sleep 1987; Woldringh 2007). Three trials reported adherence data for both the intervention and control groups (Fritel 2015; Sleep 1987; Woldringh 2007). In the trial by Fritel 2015, 69% of women in the PFMT group completed all eight supervised weekly exercise sessions and 83% completed at least one. Fewer women in the PFMT group (4.3%) compared to controls (10.6%) were doing daily exercise at home at the end of pregnancy. Woldringh 2007 reported that 37% of the PFMT women were exercising intensively, compared to 14% of controls, at 36 weeks' gestation. Similarly, at three months' postpartum, Sleep 1987 reported that more women in the PFMT group (58%) compared to controls (42%) were doing some PFMT. The other three trials provided data only for the intervention group (Barakat 2011; Ewings 2005; Hughes 2001). Barakat 2011 reported "adherence to training in the experimental group was 90%" (a mean of 85 sessions in total) and Hughes 2001 (personal communication) observed that 79% of women assigned to PFMT attended the single group training session. In contrast, Ewings 2005 invited PFMT women to attend a class at two and four months postnatally and, of the 117 women, only 18% attended at two months and 4% attended at four months.

Outcome measures

Thirty‐one of the 46 trials clearly stated the primary outcome(s) of interest in the trial. In 17 trials, it was self‐reported urinary incontinence (Assis 2015; Bø 2011; Chiarelli 2002; Cruz 2014; Ewings 2005; Fritel 2015; Glazener 2001; Gorbea 2004; Hilde 2013; Ko 2011; Kou 2013; Mørkved 2003; Pelaez 2014; Reilly 2002; Sangsawang 2016; Skelly 2004; Stafne 2012). Three used the International Consultation on Incontinence Questionnaire‐Short Form (ICIQ‐SF) (Cruz 2014; Fritel 2015; Pelaez 2014). Three trials used loss of urine under stress test (Dumoulin 2004; Kocaoz 2013; Stothers 2002). One trial used the Bristol Female Lower Urinary Tract Symptoms (BFLUTS; 34 question tool, higher score worse) questionnaire, quality of life domain (Kim 2012). One trial used the Faecal Incontinence Quality of Life (FIQOL) questionnaire (Oakley 2016). One trial combined data from a urinary diary and questionnaire to give an incontinence severity score (Woldringh 2007). One trial used the unspecified "urinary condition score" (Liu 2011). Three trials used a measure of PFM performance (Ahlund 2013; Sut 2016; Szumilewicz 2019). One used PFMT adherence (Sacomori 2019). One used PFMT knowledge (Hyakutake 2018). One trial used the occurrence of traumatic tears and use of episiotomy (Gaier 2010). One trial used weight gain during pregnancy (Torsdatter Markussen 2017).

While there was some consistency in the choice of outcome measures by trialists, the differences in the measures or the way the data were reported limited the possibilities for combining results from individual trials.

Some trials measured outcomes at more than one time point, usually in trials where PFMT began antenatally. There were some differences in the timing of outcome measures but, for the meta‐analysis, timing seemed to fall into the following clinical categories:

  • late pregnancy (from 20 weeks' gestation up to delivery);

  • early postnatal (zero to three months after delivery);

  • mid‐postnatal (more than three to six months after delivery);

  • late postnatal (more than six to 12 months after delivery);

  • medium term (more than one to five years after index delivery);

  • long‐term (more than five to 10 years after index delivery); and

  • very long‐term (more than 10 years after index delivery).

Only three trials reported long‐term results after the first year (Glazener 2001; Mørkved 2003; Reilly 2002).

Excluded studies

Fifty‐two trials were excluded for the following reasons. More information can be found in the Characteristics of excluded studies.

Thirty‐eight studies did not collect any urinary or faecal incontinence outcome data (Agur 2005; Assis 2013; Barakat 2014; Barakat 2016; Barakat 2018; Brik 2019; Dias 2011; Dias 2018; Dieb 2017; Domingues 2015; Dougherty 1989; El‐Shamy 2018; Golmakani 2015; Hou 2010; Huang 2014; Iervolino 2017; Lekskulchai 2014; Leon‐Larios 2017; Li 2010; Liu 2013; Mahmoodi 2014; Min 2019; Morin 2015; Nielsen 1988; Norton 1990; Oblasser 2016; Okido 2015; Perales 2015; Perales 2016; Pourkhiz 2017; Ruiz 2013; Santos‐Rocha 2015; Siva 2014; Teymuri 2018; Thorp 1994; Wang 2014; Wilson 2015; Zhu 2012). Two studies recruited postnatal women more than three months after their most recent delivery (Johannessen 2017; Khorasani 2017).

Three trials compared the Epi‐No device versus control (Dannecker 2004; Dietz 2014; Kamisan Atan 2016). The women were recruited in very late pregnancy (33 to 37 weeks' gestation) and the primary purpose of the intervention was prevention of perineal trauma. In one trial, it seemed women did PFM contractions with the Epi‐No device in the vagina (Dannecker 2004). However, this was unclear in the other two (Dietz 2014; Kamisan Atan 2016).

Six trials included PFMT as part of an intervention but the actual comparisons were active versus sham magnetic stimulation (Culligan 2005), one type of feedback versus another (Fynes 1999; Mahony 2004), PFMT plus episiotomy versus caesarean section (Taskin 1996) and PFMT plus Chinese herbal medicine (Chen 2018; Han 2018). Another trial compared abdominal exercise with no abdominal exercise (Gouldthorpe 2003).

One study was excluded because of internal inconsistencies and data discrepancies (Mason 2010). We contacted the study authors for clarification but so far have not received a response.

One trial was listed in a trials register but there was no report of this trial available. There was no response to a letter sent to the principal investigator (Mason 1999).

Risk of bias in included studies

We have provided details for each trial in the Characteristics of included studies. A summary of the risk of bias for each individual trial is presented in Figure 3, while Figure 4 summarises the risk of bias across all trials included in the review.

Figure 3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Figure 4
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Due to the brevity of reporting, it was difficult to assess the eight trials that were published as conference abstracts (Cruz 2014; Dokmeci 2008; Frost 2014; Frumenzio 2012; Gaier 2010; Hughes 2001; Skelly 2004; Stothers 2002). In addition, one of these abstracts did not report sample size (Skelly 2004). However, one‐to‐one randomisation was assumed.

Three trials deliberately randomised different numbers to invention and control groups. For Peirce 2013 this ratio was 1:3, and Szumilewicz 2019 used 1:2. Wilson and colleagues randomised just over 100 women to the control and individual treatment groups, with the individual treatment group being further randomised into three groups: PFMT only, PFMT with vaginal cones and vaginal cones only (Wilson 1998).

Of the 46 included trials, 28 reported an a priori power calculation (Ahlund 2013; Assis 2015; Barakat 2011; Chiarelli 2002; Dinc 2009; Dumoulin 2004; Fritel 2015; Glazener 2001; Gorbea 2004; Hilde 2013; Hyakutake 2018; Kim 2012; Ko 2011; Meyer 2001; Miquelutti 2013; Mørkved 2003; Oakley 2016; Peirce 2013; Pelaez 2014; Reilly 2002; Sacomori 2019; Sangsawang 2016; Sleep 1987; Stafne 2012; Sut 2016; Szumilewicz 2019; Torsdatter Markussen 2017; Woldringh 2007). Two of the trials without a power calculation was a pilot trial (Dufour 2019; Ewings 2005).

Allocation

Random sequence generation

Twenty‐seven trials provided enough information on random sequence generation for us to be reasonably sure that they had a low risk of bias (Assis 2015; Barakat 2011; Bø 2011; Chiarelli 2002; Cruz 2014; Dumoulin 2004; Ewings 2005; Fritel 2015; Glazener 2001; Gorbea 2004; Hilde 2013; Hughes 2001; Hyakutake 2018; Miquelutti 2013; Mørkved 2003; Oakley 2016; Peirce 2013; Pelaez 2014; Reilly 2002; Sampselle 1998; Sangsawang 2016; Stafne 2012; Szumilewicz 2019; Torsdatter Markussen 2017; Wilson 1998; Woldringh 2007; Yang 2017). Seventeen trials provided insufficient information for a judgement to be made and therefore these trials were at unclear risk of bias (Ahlund 2013; Dinc 2009; Dokmeci 2008; Dufour 2019; Frost 2014; Frumenzio 2012; Gaier 2010; Ko 2011; Kou 2013; Liu 2011; Meyer 2001; Sacomori 2019; Skelly 2004; Sleep 1987; Stothers 2002; Sut 2016; Wen 2010). Two trials were categorised as high risk of bias (Kim 2012; Kocaoz 2013). Kocaoz 2013 used methods suggestive of alternation and Kim 2012 provided participants with an envelope from which they drew one of two cards.

Allocation concealment

Twenty studies reported adequate allocation concealment and were at low risk of bias (Ahlund 2013; Bø 2011; Chiarelli 2002; Cruz 2014; Dumoulin 2004; Ewings 2005; Fritel 2015; Gorbea 2004; Hilde 2013; Hyakutake 2018; Miquelutti 2013; Mørkved 2003; Oakley 2016; Peirce 2013; Reilly 2002; Sacomori 2019; Sampselle 1998; Sangsawang 2016; Stafne 2012; Torsdatter Markussen 2017). Two trials were at high risk of bias, being unable to adequately conceal randomisation (Kim 2012; Kocaoz 2013). The remaining 26 trials were at unclear risk of bias as insufficient information (e.g. not described or stated "randomised") was provided.

Blinding

Blinding of participants and therapists

Given the nature of the intervention, it was not feasible for the included trials to blind the treatment provider or participants to group allocation and so all 46 trials were at high risk of performance bias. The difficulty of blinding exercise‐based interventions is a common problem.

Blinding of outcome assessment

Because the two main outcomes of interest in this review, urinary incontinence and incontinence‐specific quality of life, are self‐reported, these are unblinded measures. As a result, all 46 trials were deemed to be at high risk of detection bias. Blinded outcome assessment should be possible for some secondary outcomes, such as pad testing, and 13 trials attempted this (Bø 2011; Chiarelli 2002; Cruz 2014; Dumoulin 2004; Fritel 2015; Glazener 2001; Hilde 2013; Kim 2012; Mørkved 2003; Reilly 2002; Sampselle 1998; Stothers 2002; Torsdatter Markussen 2017).

Incomplete outcome data

Based on the criteria for assessment of attrition bias reported in the methods, 17 trials were at low risk of attrition bias (Assis 2015; Chiarelli 2002; Dufour 2019; Dumoulin 2004; Gaier 2010; Gorbea 2004; Hilde 2013; Kim 2012; Ko 2011; Meyer 2001; Mørkved 2003; Oakley 2016; Peirce 2013; Pelaez 2014; Sangsawang 2016; Stothers 2002; Sut 2016). Another 12 were at unclear risk (Ahlund 2013; Bø 2011; Barakat 2011; Ewings 2005; Frumenzio 2012; Kou 2013; Liu 2011; Reilly 2002; Skelly 2004; Sleep 1987; Stafne 2012; Wen 2010) with two of these being abstracts (Frumenzio 2012; Skelly 2004). The remaining 17 trials were at high risk. All trials appeared to analyse participants in the groups to which they were assigned.

Selective reporting

All outcomes appeared to have been reported in the majority of trials, with 36 trials assessed at low risk of bias for this domain. Eight trials were at high risk of bias. Six of these did not report all of the prespecified outcome measures (Ahlund 2013; Assis 2015; Bø 2011; Dokmeci 2008; Frumenzio 2012; Gaier 2010). Of these, two did not state the a priori primary outcome measure (Dokmeci 2008; Frumenzio 2012). A further two were at high risk due to not presenting data relating to self‐reported urinary incontinence, which could reasonably be expected to be an outcome of trials in this area (Frost 2014; Kocaoz 2013). Three of these were conference abstracts (Dokmeci 2008; Frost 2014; Frumenzio 2012). Two trials were at unclear risk of bias as it was uncertain if selective reporting had taken place (Skelly 2004; Stothers 2002).

Other potential sources of bias

We considered 26 trials to be free of issues (such as conflict of interest) that could put them at risk of other bias. We considered the risk of other bias as unclear for 20 trials (Ahlund 2013; Cruz 2014; Dokmeci 2008; Dufour 2019; Frost 2014; Frumenzio 2012; Gaier 2010; Gorbea 2004; Hughes 2001; Kou 2013; Liu 2011; Miquelutti 2013; Oakley 2016; Pelaez 2014; Sampselle 1998; Skelly 2004; Sleep 1987; Stothers 2002; Szumilewicz 2019; Wen 2010).

Effects of interventions

See: Summary of findings 1 Antenatal pelvic floor muscle training compared to control for prevention of urinary and faecal incontinence; Summary of findings 2 Antenatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence; Summary of findings 3 Antenatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence; Summary of findings 4 Postnatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence; Summary of findings 5 Postnatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence

There were some data available to explore whether PFMT is better than usual antenatal and postnatal care, or no treatment, for the prevention or treatment of urinary and faecal incontinence. The primary analysis investigated the prevalence of urinary and faecal incontinence. Data for outcomes of secondary interest (in 'Other data' tables) are only briefly discussed to give an indication of whether the findings were broadly consistent with the pooled data, or not. All but five trials contributed data to the forest plots (Ahlund 2013; Dokmeci 2008; Frost 2014; Liu 2011; Oakley 2016).

The 'Summary of findings' tables present the selected outcomes for each of the five main comparisons.

Antenatal pelvic floor muscle training for prevention of incontinence

Ten trials reported antenatal PFMT for prevention of incontinence (Barakat 2011; Gaier 2010; Gorbea 2004; Kocaoz 2013; Mørkved 2003; Pelaez 2014; Reilly 2002; Sampselle 1998; Sangsawang 2016; Stothers 2002). Seven recruited nulliparous or primiparous or primigravid women during pregnancy (Gaier 2010; Gorbea 2004; Mørkved 2003; Pelaez 2014; Reilly 2002; Sampselle 1998; Sangsawang 2016). The other three recruited "pregnant women" or both primiparous and multiparous women (Barakat 2011; Kocaoz 2013; Stothers 2002). All women were continent at recruitment.

In all 10 trials, PFMT began during pregnancy. Controls were asked not to do PFMT, did not receive instruction on PFMT, received usual care that might have included information on PFMT, or the control condition was not specified (Barakat 2011; Gaier 2010; Gorbea 2004; Kocaoz 2013; Mørkved 2003; Pelaez 2014; Reilly 2002; Sampselle 1998; Sangsawang 2016; Stothers 2002).

Two of these trials were mixed prevention and treatment trials but published or unpublished data were available for women who were continent at recruitment (Mørkved 2003; Sampselle 1998). In Sampselle 1998, 54/72 women were continent based on a standing stress test at 20 weeks' gestation. After dropouts, there were unpublished data from 37 previously continent women (16 PFMT and 21 controls). Mørkved 2003 published data for 207/301 women who were continent before pregnancy and at 20 weeks' gestation. After dropouts, there were data from 193 previously continent women (94 PFMT and 99 controls). Neither trial was powered to find differences in the previously continent subgroup, as the subgroup sizes were small.

Primary outcomes
Self‐reported urinary or faecal incontinence

Women randomised to PFMT are probably about 62% less likely to report urinary incontinence in late pregnancy compared to controls (risk ratio (RR) 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women, random‐effects, I² = 78%, T² = 0.44; moderate‐quality evidence; Analysis 1.1). There was statistically significant heterogeneity in this comparison and in both subgroups (PFMT versus no PFMT, PFMT versus usual care). A random‐effects model was used because of the heterogeneity. Two trials appeared to contribute most to the heterogeneity (Gorbea 2004; Pelaez 2014), and both found many fewer cases of urinary incontinence in the intervention than control groups. Gorbea 2004 was the only trial that specifically asked controls not to do PFMT during pregnancy. In addition, as none of the PFMT women reported urinary incontinence in late pregnancy, the point estimate and CIs were perhaps less stable given there were no events in one of the two comparison groups. In Pelaez 2014, the PFMT was very intensive and of longer duration than other trials in the same subgroup. The intervention included three supervised exercise classes per week for at least 22 weeks and 80% of women attended the maximum number of classes.

Compared to controls, PFMT women were about 62% less likely to report urinary incontinence in the early postnatal period (RR 0.38, 95% CI 0.17 to 0.83; 5 trials, 439 women, random‐effects, I² = 74%, T² = 0.55; Analysis 1.2). There was statistically significant heterogeneity in this comparison, as well as in one subgroup (PFMT versus usual care), which included the trial by Pelaez 2014 (see above).

PFMT women had a slightly decreased risk of urinary incontinence than controls in the mid‐postnatal period (three to six months), although the difference in risk had reduced to 29% (RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women, fixed‐effect, I² = 0%; high‐quality evidence; Analysis 1.3). Overall, the pooled estimate favoured PFMT.

Data from one study provided no evidence of a difference in risk of urinary incontinence between PFMT women and women in the control group at 12 months' postpartum (RR 1.20, 95% CI 0.65 to 2.21; 1 trial; 44 women Analysis 1.4; low‐quality evidence).

Two trials measured urinary incontinence at greater than five years (Mørkved 2003; Reilly 2002; seeTable 1). The pooled data provided no evidence that the earlier effectiveness of PFMT persisted in the long term (RR 1.07, 95% CI 0.77 to 1.48; 2 trials, 352 women, fixed‐effect, I² = 25%; Analysis 1.5). Reilly 2002 found that 68.4% of women randomised to the intervention group were still performing PFMT, with 38% doing PFMT at least twice per week after eight years. Mørkved 2003 reported that the same number of women in the PFMT and control groups (45%) were exercising at least weekly, six years after the primary study. The lack of evidence of a difference in prevalence rates of incontinence in these three trials suggests that perhaps PFMT may not be effective in the long term. There could be three immediately plausible explanations for this. The women may have stopped exercising, they may have had subsequent pregnancies or, as shown by Mørkved 2003, women were performing similar PFMT regimens regardless of which group they had initially been randomised.

None of the 10 trials reported data on the risk of either antenatal or postpartum faecal incontinence.

Urinary incontinence‐specific quality of life

Reilly 2002 (King's Health Questionnaire) and Pelaez 2014 ( International Consultation on Incontinence Questionnaire‐Short Form (ICIQ‐SF)) were the only two trials to mention incontinence‐specific quality of life. Pelaez 2014 reported that there was probably a difference between the two groups in favour of PFMT (mean difference (MD) ‐2.42, 95% CI ‐3.32 to ‐1.52; 2 trials, 152 women; moderate‐quality evidence; Analysis 1.6; lower score indicates better incontinence‐specific quality of life). Reilly 2002 did not report their data but stated there was no difference between the groups on any of the eight subscales.

Faecal incontinence‐specific quality of life

Not reported.

Secondary outcomes
Self‐reported severity of incontinence

Seven of the 10 trials reported some data on symptom severity, such as frequency or amount of urine leakage (Barakat 2011; Gorbea 2004; Pelaez 2014; Reilly 2002; Sampselle 1998; Sangsawang 2016; Stothers 2002; Analysis 1.7). The choice of measures (many of these of unknown validity) or the ways of reporting these were highly variable and data reporting was often incomplete. Two of the most recent trials used individual item scores from the ICIQ‐SF; frequency (item 3) and amount of leakage (item 4) (Barakat 2011; Pelaez 2014). There was a consistent pattern of effect in favour of PFMT, when compared to usual care, for frequency, amount and other urinary incontinence severity indices in two trials (Pelaez 2014; Sangsawang 2016).

Number of urinary or faecal incontinence episodes

None of the trials reported number of urinary or faecal incontinence episodes.

Loss of urine under stress test

Three trials reported whether women were continent or not based on a stress test (positive cough or one‐hour pad test) (Gorbea 2004; Kocaoz 2013; Reilly 2002). Women in the PFMT group were less likely to be incontinent in late pregnancy (RR 0.36, 95% CI 0.19 to 0.70; 1 trial, 102 women; Kocaoz 2013; Analysis 1.8) or in the early postnatal period (RR 0.09, 95% CI 0.02 to 0.47; 2 trials, 174 women, fixed‐effect, I² = 0%; Gorbea 2004; Kocaoz 2013; Analysis 1.9) when compared with no treatment controls. There was no evidence of a difference between PFMT versus usual care groups in the early postnatal period (RR 0.88, 95% CI 0.33 to 2.29; 1 trial, 148 women; Reilly 2002; Analysis 1.9).

Self‐reported measures of pelvic floor dysfunction

None of the trials reported this outcome.

Other self‐reported well‐being measures

Two trials used the 36‐Item Short‐Form Health Survey (SF‐36) (Barakat 2011; Reilly 2002). In the general health domain, Reilly 2002 reported that the PFMT group scored significantly higher than the control group at three months' postpartum (MD 7.2, 95% CI 2.36 to 12.04), while Barakat 2011 found that women in the PFMT group were more likely to rate their health as very good (18/34 women in the PFMT group versus 9/33 women in the control group) (Analysis 1.10).

Adverse effects

In one trial, two of 43 PFMT women withdrew due to pelvic floor pain (Stothers 2002). Barakat 2011 stated "there were no exercise‐related injuries experienced during pregnancy." No other trial reported whether there were adverse effects or not.

Labour and delivery outcome

Five trials reported delivery outcome (Barakat 2011; Gaier 2010; Gorbea 2004; Reilly 2002; Stothers 2002). However, the data by Stothers 2002 were not reported by group. Three trials reported the number of caesarean sections (Barakat 2011; Gorbea 2004; Reilly 2002). There was no evidence of a difference between PFMT and control groups in any of these trials (RR 1.28, 95% CI 0.89 to 1.85; 3 trials, 373 women, fixed‐effect, I² = 49%; Analysis 1.11). Two trials reported type of vaginal delivery (normal or instrumental) (Barakat 2011; Reilly 2002). Two trials reported perineal trauma (Barakat 2011; Gaier 2010). There were no apparent differences between groups for either outcome (Analysis 1.12).

Pelvic floor muscle function

Three trials measured PFM function (Gaier 2010; Gorbea 2004; Reilly 2002). However, Gaier 2010 reported no data. Measures were electromyography and vaginal squeeze pressure (Gorbea 2004; Reilly 2002). The lack of explanation of the type of electromyography and unusual presentation of the data in Gorbea 2004 made it difficult to interpret the findings. In Reilly 2002, there was no evidence that mean vaginal squeeze pressure was any greater in the PFMT group than the control group (MD 1.00, 95% CI ‐1.31 to 3.31; Analysis 1.13). Gaier 2010 reported significantly higher PFM strength in women doing PFMT. However, it was unclear how this was measured and the data were not given in the conference abstract.

Antenatal pelvic floor muscle training for treatment of incontinence

Four trials reported antenatal PFMT for treatment of incontinence (Cruz 2014; Dinc 2009; Skelly 2004; Woldringh 2007). Two trials recruited primiparous and multiparous women (Dinc 2009; Woldringh 2007). Two trials reported as abstracts did not state parity (Cruz 2014; Skelly 2004). In all four trials, the control group received usual care.

Primary outcomes
Self‐reported urinary or faecal incontinence

There was no evidence of any difference in risk of urinary incontinence in late pregnancy (RR 0.70, 95% CI 0.44 to 1.13; 3 trials, 345 women, random‐effects, I² = 71%, T² = 0.11; very low‐quality evidence; Analysis 2.1). As this comparison showed statistically significant heterogeneity, we used a random‐effects model to provide a more conservative estimate (Analysis 2.1).

There were no evidence of differences in the early (RR 0.75, 95% CI 0.37 to 1.53; 2 trials, 292 women, random‐effects, I² = 65%, T² = 0.19; Analysis 2.2), or mid‐(RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; low‐quality evidence; Analysis 2.3) postnatal periods.

Two trials measured urinary incontinence in the late postnatal period. A random‐effects model was used because of statistically significant heterogeneity in this comparison; there is no a evidence of a difference between groups (RR 0.50, 95% CI 0.13 to 1.93; 2 trials, 869 women; Skelly 2004; Woldringh 2007; random‐effects, I² = 94%, T² = 0.89; very low‐quality evidence; Analysis 2.4). Skelly 2004 was available only as a conference abstract with limited data on which to base a 'Risk of bias' assessment and about half of the women randomised appeared to have urinary incontinence symptoms pre‐pregnancy. In Woldringh 2007, at 35 weeks' gestation about two‐thirds of women in the control group were doing some form of PFMT, compared to 94% in the PFMT group. These, or other unknown reasons, could have contributed to the observed heterogeneity.

None of the four trials reported data on the prevalence of either antenatal or postpartum faecal incontinence.

Urinary incontinence‐specific quality of life

Two trials used a validated incontinence‐specific quality of life measure (Cruz 2014, ICIQ‐SF; Woldringh 2007, Incontinence Impact Questionnaire; (IIQ)). Cruz 2014 found that PFMT women probably have better quality of life in late pregnancy (MD ‐3.50, 95% CI ‐6.13 to ‐0.87; 1 trial, 41 women, moderate‐quality evidence; Analysis 2.5; lower score better). Woldringh 2007 categorised IIQ scores, which meant that it was not possible to interpret these data.

Faecal incontinence‐specific quality of life

Not reported.

Secondary outcomes
Self‐reported severity of incontinence

Woldringh 2007 reported on leakage severity, but the validity of this measure is unknown (Analysis 2.6).

Number of urinary or faecal incontinence episodes

None of the trials reported number of urinary or faecal incontinence episodes.

Loss of urine under stress test

None of the trials reported loss of urine under stress test.

Self‐reported measures of pelvic floor dysfunction

Woldringh 2007 reported IIQ data but the difference between groups was not able to be calculated (Analysis 2.7).

Other self‐reported well‐being measures

None of the trials reported this outcome.

Adverse effects

None of the trials reported on adverse effects.

Labour and delivery outcome

None of the trials reported this outcome.

Pelvic floor muscle function

Cruz 2014 found no difference between the groups in maximal vaginal squeeze pressure in the third trimester (Analysis 2.8).

Antenatal pelvic floor muscle training for mixed prevention and treatment of incontinence

Fifteen trials reported antenatal PFMT for mixed prevention and treatment of incontinence (Assis 2015; Bø 2011; Dokmeci 2008; Fritel 2015; Frumenzio 2012; Hughes 2001; Hyakutake 2018; Ko 2011; Miquelutti 2013; Mørkved 2003; Sampselle 1998; Stafne 2012; Sut 2016; Szumilewicz 2019; Torsdatter Markussen 2017). The control group consisted of usual care in nine trials (Bø 2011; Fritel 2015; Hughes 2001; Hyakutake 2018; Miquelutti 2013; Mørkved 2003; Sampselle 1998; Stafne 2012; Torsdatter Markussen 2017). There was no PFMT in four trials (Assis 2015; Ko 2011; Sut 2016; Szumilewicz 2019). Two did not specify the control group (Dokmeci 2008; Frumenzio 2012).

Eleven trials were in women who were delivering their first baby (Assis 2015; Bø 2011; Dokmeci 2008; Fritel 2015; Hughes 2001; Hyakutake 2018; Ko 2011; Miquelutti 2013; Mørkved 2003; Sampselle 1998; Szumilewicz 2019). Three recruited both primiparous and multiparous women (Stafne 2012; Sut 2016; Torsdatter Markussen 2017). Parity was not stated in Frumenzio 2012, which was an abstract.

Primary outcomes
Self‐reported urinary or faecal incontinence

Women randomised to PFMT probably have 22% less risk of urinary incontinence in late pregnancy (RR 0.78, 95% CI 0.64 to 0.94; 11 trials, 3307 women, random‐effects, I² = 79%, T² = 0.06; moderate‐quality evidence; Analysis 3.1). There was statistically significant heterogeneity in both subgroups (PFMT versus no exercise and PFMT versus usual care) in this comparison (Analysis 3.1). The point estimates favoured PFMT in all but four trials (Bø 2011; Fritel 2015; Szumilewicz 2019; Torsdatter Markussen 2017). In the seven trials where the point estimates favoured PFMT, there was considerable variation, with RR ranging from 0.07 to 0.93 (Assis 2015; Hughes 2001; Ko 2011; Miquelutti 2013; Mørkved 2003; Sampselle 1998; Stafne 2012). The data that appeared notably different, being markedly in favour of PFMT, were those from Assis 2015 for reasons unknown, although this was one of three trials in which controls were asked not to do PFMT. In the four trials where the point estimates did not favour PFMT, there were plausible explanations for no differences between the two groups. Participants in Bø 2011 were encouraged to attend at least two out of three possible exercise classes every week. These exercise classes were led by general fitness instructors who were taught by a physiotherapist how to deliver PFMT to women. It may be that the women in this trial considered the classes solely as general fitness and did not concentrate on the PFMT component. In Fritel 2015, the authors reported that, at the end of pregnancy, there was no difference in the frequency and duration of PFMT between groups, suggesting no difference in exercise adherence between the PFMT and usual care groups. In Torsdatter Markussen 2017, there was a differential dropout between groups (more from the PFMT group), similar PFMT adherence in the exercise and control groups and a noticeably different risk profile of the recruited population. The fourth, Szumilewicz 2019, was a small study that used 2:1 randomisation, with a three times per week exercise class for six weeks, led by an exercise specialist.

There was a difference in the risk of urinary incontinence between antenatal PFMT and control groups in the early postnatal period (RR 0.83, 95% CI 0.71 to 0.99; 6 trials, 806 women, fixed‐effect, I² = 0%, T² = 0.00; Analysis 3.2). PFMT may reduce the risk of urinary incontinence slightly in the mid‐postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women, random‐effects, I² = 65%, T² = 0.06; low‐quality evidence; Analysis 3.3). There was no evidence of a difference between PFMT and control groups in the late postnatal period (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women, fixed‐effect, I² = 0%; moderate‐quality evidence; Analysis 3.4).

In the one trial with long‐term data (six years), there was no evidence of a difference between groups (RR 1.38, 95% CI 0.77 to 2.45; 1 trial, 188 women; Mørkved 2003; Analysis 3.5). Women in the control group were offered a description of the PFMT programme after the post‐treatment comparison and this and other events (such as subsequent births) may have contributed to a lack of difference.

Three trials collected data on faecal incontinence in late pregnancy (Bø 2011; Stafne 2012; Torsdatter Markussen 2017). Bø 2011 and Torsdatter Markussen 2017 also reported on faecal incontinence in the early postnatal period. There was probably no evidence of a difference between PFMT and usual care groups at late pregnancy (RR 0.64, 95% CI 0.36 to 1.14; 3 trials, 910 women, fixed‐effect, I² = 0%, T² = 0.00; moderate‐quality evidence; Analysis 3.6) or in the early postnatal period (RR 0.76, 95% CI 0.34 to 1.70; 2 trials, 130 women, fixed effect, I² = 0%, T² = 0.00; Analysis 3.7).

Urinary incontinence‐specific quality of life

Six trials used a validated urinary incontinence‐specific quality of life measure (Fritel 2015, ICIQ‐SF and Contilife (higher score better); Dokmeci 2008; Ko 2011; Sut 2016, IIQ‐7; Hughes 2001, BFLUTS questionnaire; Hyakutake 2018, Pelvic Floor Impact Questionnaire (PFIQ‐7), bladder score (Urinary Impact Questionnaire‐7)). While Dokmeci 2008 and Hughes 2001 used validated outcome measures, neither have reported the scores (Analysis 3.16).

There was no evidence of a difference in urinary incontinence‐specific quality of life between antenatal PFMT and control groups in late pregnancy (standardised mean difference (SMD) ‐0.02, 95% CI ‐0.35 to 0.31; 3 trials, 584 women, random‐effects, I² = 71%, T² = 0.06; Analysis 3.8). Similarly, there was no evidence of a difference in urinary incontinence‐specific quality of life between antenatal PFMT and control groups in the early postnatal period (SMD ‐0.24, 95% CI ‐0.67 to 0.20; 4 trials, 645 women, random‐effects, I² = 84%, T² = 0.16; Analysis 3.9). A single trial found a statistically significant difference between the groups in the mid‐postnatal period (IIQ; MD ‐0.79, 95% CI ‐1.27 to ‐0.31; 300 women; Ko 2011; Analysis 3.10), and was the only trial to find statistically significant differences at the previous time points. Fritel 2015 (ICIQ‐SF) found no evidence of difference in urinary incontinence‐specific quality of life between PFMT and usual care groups in the late postnatal period (MD ‐0.20, 95% CI ‐1.20 to 0.81; 190 women, moderate‐quality evidence; Analysis 3.11).

Faecal incontinence‐specific quality of life

A single trial that measured faecal incontinence‐specific quality of life using the bowel subscale (CRAIQ‐7) of the PFIQ‐7 found no evidence of a difference between the groups in the early postnatal period (MD ‐2.60, 95% CI ‐7.84 to 2.64; Hyakutake 2018; 74 women, low‐quality evidence; Analysis 3.12).

Secondary outcomes
Self‐reported severity of incontinence

Four trials reported some data on urinary symptom severity. None of the data suggested that PFMT was superior to control, or vice versa, at the primary endpoint of either early postpartum (Hughes 2001; Sut 2016; Torsdatter Markussen 2017), or 12 months' postpartum (Sampselle 1998; Analysis 3.13).

One trial reported faecal incontinence symptom severity, with no difference in medians and interquartile ranges between groups (Torsdatter Markussen 2017; Analysis 3.13).

Number of urinary or faecal incontinence episodes

One trial reported the number of urinary incontinence episodes in 24 hours (derived from a three‐day voiding diary) and found there was no meaningful difference between the groups in late pregnancy (MD 0.20, 95% CI ‐0.35 to 0.75, 60 women). There were too few leakage events in 24 hours to estimate the difference in the early postpartum period (Sut 2016). No trials reported the number of faecal incontinence episodes.

Loss of urine under stress test

The single trial reporting pad test data (24 hour) found no difference between PFMT and usual care groups (Fritel 2015; Analysis 3.14).

Self‐reported measures of pelvic floor dysfunction

Six trials used a range of validated pelvic floor dysfunction questionnaires:

  • IIQ‐7 (Szumilewicz 2019). Data presented as mean percentage change, so not included in the primary outcome forest plots.

  • Urogenital Distress Index‐Short Form (UDI‐6) (Dokmeci 2008; Hyakutake 2018; Ko 2011; Sut 2016);

  • Female Pelvic Floor questionnaire (bladder, bowel, prolapse and sex scores) (Fritel 2015);

  • Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ; higher score better) (Dokmeci 2008);

  • Pelvic Floor Distress Inventory (includes pelvic organ prolapse, urinary and faecal incontinence) (Hyakutake 2018);

  • Pelvic Floor Impact Questionnaire‐Short Form (includes pelvic organ prolapse, urinary and faecal incontinence) (Hyakutake 2018);

There were no evidence of a difference between groups for the majority of these measures at different time points (Analysis 3.15).

Three trials measured some aspect of sexual function in pregnancy, immediately postpartum and up to six years post‐index delivery (Dokmeci 2008; Fritel 2015; Mørkved 2003). Overall, there was no difference in sexual function or the proportion of women who were sexually active in late pregnancy and up to 12 months' postpartum (Dokmeci 2008; Fritel 2015). At six years, Mørkved 2003 found that PFMT women were twice as likely to report sexual satisfaction compared to controls (Analysis 3.15).

Other self‐reported well‐being measures

Three trials used some other self‐reported well‐being measure: State Trait Anxiety Inventory (Miquelutti 2013); Psychological General Wellbeing Index (Stafne 2012); and Euro‐QoL‐5D (Fritel 2015). There were no differences between groups for these measures of well‐being (Analysis 3.16).

Adverse effects

Three trials reported no adverse effects (Fritel 2015; Miquelutti 2013; Szumilewicz 2019).

Labour and delivery outcome

Eight trials reported the number of caesarean sections, with no evidence of a difference between PFMT and control groups (RR 0.91, 95% CI 0.77 to 1.08; 8 trials, 2030 women, fixed‐effect, I² = 28%; Bø 2011; Fritel 2015; Hyakutake 2018; Ko 2011; Miquelutti 2013; Mørkved 2003; Stafne 2012; Sut 2016; Analysis 3.17). Mørkved 2003 found no difference in the type of delivery, although women in the supervised antenatal PFMT group had a shorter second stage of labour. However, it is worth noting that fetal head circumference was also smaller in the PFMT group. Ko 2011 also reported rates of episiotomy among women and there was no evidence of a difference between the groups (RR 0.86, 95% CI 0.53 to 1.39).

Pelvic floor muscle function

PFM function was measured using perineometry, electromyography and vaginal digital palpation (Assis 2015; Dokmeci 2008; Fritel 2015; Mørkved 2003). In the three trials that reported data, point estimates favoured PFMT women over controls (Assis 2015; Fritel 2015; Mørkved 2003). There were differences in favour of PFMT in both trials that measured vaginal squeeze pressures (Analysis 3.19) (Assis 2015; Mørkved 2003).

Postnatal pelvic floor muscle training for treatment of incontinence

Five trials reported postnatal PFMT for treatment of incontinence and provided supervised PFMT beginning at three or more months' postpartum as treatment for women with persistent urinary incontinence symptoms after delivery (Ahlund 2013; Dumoulin 2004; Glazener 2001; Kim 2012; Wilson 1998). The control group received usual care or were asked not to do PFMT.

Primary outcomes
Self‐reported urinary or faecal incontinence

Women randomised to PFMT were about 22% less likely to have urinary incontinence after treatment compared to controls more than six and up to 12 months postdelivery (RR 0.78, 95% CI 0.69 to 0.87; 3 trials, 696 women, fixed‐effect). However, there was statistical heterogeneity in this comparison (I² = 90%). When the more conservative random‐effects model was used, the there was no evidence of a difference in outcome (RR 0.55, 95% CI 0.29 to 1.07; 696 women, I² = 90%, T² = 0.30; low‐quality evidence; Analysis 4.1).

Women in all three studies were recruited at three months or more postpartum. In the case of Dumoulin 2004, women were recruited after completing an incontinence questionnaire at their annual gynaecological visit, so it seems likely many were much more than three months' postpartum at trial entry. Therefore, after a further two months' intervention, it seemed likely the postintervention outcome was between six and 12 months' postdelivery for most. For this reason, a decision was made to present the data from the trial in the late postnatal category (greater than six to 12 months) along with that from Glazener 2001 and Wilson 1998, who both measured outcome 12 months postdelivery.

In addition to possible differences in timing of outcome measurement, there were other obvious dissimilarities between the three studies. In Dumoulin 2004, women randomised to the control group were specifically asked not to do any PFMT, while women in the control group in Glazener 2001 and Wilson 1998 received usual postnatal care and some did PFMT. Glazener 2001 reported a mean of 20 PFM contractions every day in the PFMT group versus five PFM contractions every day in the control group. A total of 86 (PFMT) versus 35 (control) were performed in the trial by Wilson 1998. The second difference was that Dumoulin 2004 employed a strengthening PFMT regimen, which incorporated electrical stimulation and biofeedback, while participants also had weekly contact with a physiotherapist for eight weeks. In contrast, Glazener 2001 and Wilson 1998 did not clearly aim their PFMT regimens at either strength or endurance and in both studies the intervention group had three or four contacts with health professionals over a six‐month period.

Glazener 2001 reported urinary incontinence prevalence at six years (RR 0.96, 95% CI 0.88 to 1.05; 1 trial, 516 women; Analysis 4.2) and 12 years after the index delivery (RR 1.03, 95% CI 0.94 to 1.12; 1 trial, 471 women; Analysis 4.3), with no evidence of a difference between PFMT and control group at either time‐point.

Two trials reported data on the prevalence of faecal incontinence one year after delivery (Glazener 2001; Wilson 1998). There was statistically significant heterogeneity, therefore a random‐effects model was used to give a more conservative estimate of effect but there is no evidence of a difference between groups (RR 0.68, 95% CI 0.24 to 1.94, random‐effects, I² = 74%, T² = 0.42; 2 trials, 620 women; very low‐quality evidence; Analysis 4.4).

Glazener 2001 reported no evidence of difference in the prevalence of faecal incontinence at six years (RR 0.95, 95% CI 0.60 to 1.50; 509 women; Analysis 4.5) and 12 years (RR 1.36, 95% CI 0.84 to 2.22; 1 trial, 468 women; Analysis 4.6) post‐index delivery. At both these time points, Glazener 2001 reported that about 50% of women in both the intervention and control groups were doing "any" PFMT. When questioned about performing daily PFMT, it was interesting to note that only 6% of the PFMT group were exercising daily, compared to 12% of the control group at six years' follow‐up. After 12 years, 7% of the intervention group and 8% of the control group were performing daily PFMT (Table 1).

Urinary incontinence‐specific quality of life

Two trials used incontinence‐specific quality of life measures (Dumoulin 2004 IIQ and UDI; Kim 2012 BFLUTS). Kim 2012 found no evidence of a difference between PFMT and usual care groups post‐treatment (MD ‐1.66, 95% CI ‐3.51 to 0.19; 18 women; low‐quality evidence; Analysis 4.7). Dumoulin 2004 reported an improvement in IIQ and UDI score in women who were doing PFMT compared with women who were randomised to the control (no PFMT) group (Analysis 4.10).

Faecal incontinence‐specific quality of life

Not reported.

Secondary outcomes
Self‐reported severity of incontinence

All five treatment trials reported some data on incontinence severity, for instance frequency or amount of urine leakage. None of the measures, or the methods of reporting these, were common to the five trials. The data suggest that women randomised to PFMT with symptoms of urinary incontinence might have had less severe symptoms than women in the control groups but this was not a consistent or clear‐cut finding (Analysis 4.8).

Number of urinary or faecal incontinence episodes

None of the trials reported number of urinary or faecal incontinence episodes.

Loss of urine under stress test

None of the trials reported loss of urine under stress test.

Self‐reported measures of pelvic floor dysfunction

One trial reported median and interquartile ranges for the UDI‐6 and IIQ‐7, with no differences between groups (Dumoulin 2004; Analysis 4.9).

Other self‐reported well‐being measures

Glazener 2001 used the Hospital Anxiety and Depression Scale to measure quality of life and found reduced anxiety in the PFMT group (Analysis 4.10).

Adverse effects

Dumoulin 2004 stated that none of the women in the PFMT group reported any adverse events (with PFMT or electrical stimulation).

Labour and delivery outcome

No trials reported this outcome.

Pelvic floor muscle function

One trial measured PFM function using a dynamometer and three trials reported vaginal squeeze pressure (Ahlund 2013; Dumoulin 2004; Kim 2012; Wilson 1998). Dynamometer findings favoured the PFMT group, as did the vaginal squeeze pressure readings in two trials (Ahlund 2013; Dumoulin 2004; Kim 2012; Analysis 4.11).

Postnatal pelvic floor muscle training for mixed prevention and treatment of incontinence

Fourteen trials reported postnatal PFMT for mixed prevention and treatment of incontinence (Chiarelli 2002; Dufour 2019; Ewings 2005; Frost 2014; Hilde 2013; Kou 2013; Liu 2011; Meyer 2001; Oakley 2016; Peirce 2013; Sacomori 2019; Sleep 1987; Wen 2010; Yang 2017). These randomised women to postnatal PFMT versus usual care with the exception of three, in which the controls were not instructed in exercise (Meyer 2001; Sacomori 2019; Yang 2017). The trials recruited previously nulliparous women during their first pregnancy (Meyer 2001), women having their first baby (Dufour 2019; Hilde 2013; Liu 2011; Oakley 2016; Peirce 2013), or postnatal women of mixed parity (Chiarelli 2002; Ewings 2005; Sacomori 2019; Sleep 1987; Yang 2017). Three trials did not report this information (Frost 2014; Kou 2013; Wen 2010).

Primary outcomes
Self‐reported urinary or faecal incontinence

Two trials reported data from the early postnatal period (Sacomori 2019; Yang 2017). One, a conference abstract, reported no usable data (Frost 2014). Women randomised to PFMT were about 46% less likely to report urinary incontinence early postpartum compared to controls (RR 0.54, 95% CI 0.44 to 0.66, fixed‐effects, I² = 0%, T² = 0.00, 2 trials, 321 women; Analysis 5.1). The controls in Sacomori 2019 and Yang 2017 did no PFMT but the level of contrast between PFMT and control groups in exercise supervision and prescription varied. In Sacomori 2019 (low contrast), women were asked to do home PFMT twice daily, with approximately 49% performing PFMT at least three times per week. Half of the PFMT women in Yang 2017 (low contrast) were also prescribed home exercises twice daily, while the other half (high contrast) received 15 sessions of one‐to‐one supervised PFMT in conjunction with electrical stimulation over five weeks.

However, as reported in six trials with longer follow‐up (Chiarelli 2002; Ewings 2005; Hilde 2013; Kou 2013; Meyer 2001; Sleep 1987), there was no evidence of a difference in the risk of urinary incontinence in women randomised to postnatal PFMT or control group in the mid‐postnatal period, up to six months (RR 0.95, 95% CI 0.75 to 1.19, random‐effects, I² = 65%, T² = 0.04; 5 trials, 2800 women; Analysis 5.2). Likewise, there was no evidence of a difference in the risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09, fixed‐effect, I² = 50%, T² = 0.00; 3 trials, 826 women; moderate‐quality evidence; Analysis 5.3).

There was statistically significant heterogeneity in both the mid‐ and late‐postnatal comparisons. No details of the PFMT programmes were provided in three of the five trials contributing data to the mid‐postnatal comparison (Ewings 2005; Meyer 2001; Sleep 1987). In addition, there were other notable dissimilarities, including the risk profile of the recruited population (e.g. Chiarelli 2002), and the degree of contrast between PFMT and control groups in exercise supervision and prescription (e.g. Sleep 1987, low contrast; Kou 2013, high contrast). In the two trials with findings in favour of PFMT, the control groups were offered usual care, while the PFMT interventions were intensively supervised or enhanced with application of health behaviour theory (Chiarelli 2002; Kou 2013). In addition, Chiarelli 2002 recruited women who were potentially at increased risk of postnatal incontinence, such as those who had a large baby or a forceps delivery.

There was considerably less difference in PFMT and control groups in the other three trials for various reasons and none found a difference between the groups. All control groups received usual postnatal care that may have or did include information about PFMT. Ewings 2005 reported that 114/117 women randomised to PFMT received one‐to‐one instruction on PFMT, but only 21 attended one group class, with five attending both available classes. There was no difference between groups. Hilde 2013 randomised women to PFMT delivered in a weekly exercise class plus home exercise, versus a home exercise control condition. Both groups had a correct PFM contraction confirmed prior to training. Sleep 1987 randomised women within 24 hours of delivery to an individual daily session with a midwife co‐ordinator while in hospital and home exercise, versus usual care that included postnatal classes taken by an obstetric physiotherapist. At three months' postpartum, the proportion of women doing PFMT was reasonably similar (58% with PFMT and 42% with control).

Chiarelli 2002 and Kou 2013 also contributed data to the late postpartum comparison with the addition of that from Meyer 2001. Women in Meyer 2001 were randomised to either eight months of supervised PFM rehabilitation with a physiotherapist or no PFMT. Like Kou 2013, there was a high degree of contrast between the PFMT and control groups. However, unlike Kou 2013, Meyer 2001 found no difference between groups in the prevalence of urinary incontinence. Neither of these trials reported details of their randomisation procedures.

Two trials reported the prevalence of postnatal faecal incontinence (Meyer 2001; Sleep 1987). There was no little to no difference between PFMT and control groups in the early postnatal period (RR 0.93, 95% CI 0.51 to 1.67, 1609 women; Sleep 1987; Analysis 5.4). There was no evidence of a difference in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21, 107 women; low‐quality evidence; Analysis 5.5).

Urinary incontinence‐specific quality of life

Two of the 11 trials reported urinary incontinence‐specific quality of life data (Dufour 2019; Sacomori 2019). Data from Sacomori 2019 were not suitable for inclusion in the meta‐analysis (median and interquartile ranges) and showed no difference between groups (Analysis 5.9). Dufour 2019 found little to no difference between PFMT and controls (IIQ‐7; MD 0.50 higher, 95% CI 5.53 lower to 6.53 higher, 23 women; low quality evidence; Analysis 5.6).

Faecal incontinence‐specific quality of life

Two of the 11 trials reported on faecal incontinence‐specific quality of life but the data (median and interquartile ranges and P values alone respectively) were not suitable for meta‐analysis (Oakley 2016; Peirce 2013). There were no reported differences between the groups in either study (Analysis 5.9).

Secondary outcomes
Self‐reported severity of incontinence

Five trials provided some self‐reported data on urinary incontinence symptom severity and there was no apparent consistent pattern of effect (Liu 2011; Sacomori 2019; Sleep 1987; Wen 2010; Yang 2017). None of the trials used the same measure and some of these were unvalidated (Analysis 5.7).

One trial contained self‐reported data on faecal incontinence symptom severity at three months' postpartum (Oakley 2016). The median score favoured the PFMT group over the controls but it was not possible to calculate a difference (Analysis 5.7).

Number of urinary or faecal incontinence episodes

None of the trials reported number of urinary or faecal incontinence episodes.

Loss of urine under stress test

Three trials reported pad test data, with the same cut‐off for a positive test (2 g or more) at three months' postpartum (Yang 2017), or six months' postpartum (Hilde 2013; Wen 2010). Pooled data demonstrated no evidence of a difference in the risk of positive pad test between PFMT and controls (RR 0.83, 95% CI 0.60 to 1.13 3 trials; 512 women, fixed‐effect, I² = 63.4%; Analysis 5.8). Yang 2017 was the only one of the three trials to find fewer positive pad tests in the PFMT group, with plausible reasons for this difference being the different timing (three versus six months) measure and the comparator (no PFMT versus usual care).

Self‐reported measures of pelvic floor dysfunction

Two trials used the UDI‐6 (Dufour 2019; Oakley 2016). Dufour 2019 found no difference between the two groups in the mid‐postnatal period. In Oakley 2016, the median score favoured the PFMT group over usual care at three months' postpartum but it was not possible to calculate a difference (Analysis 5.9).

Two trials used unvalidated measures of sexual function and neither found any difference between groups (Meyer 2001; Sleep 1987; Analysis 5.9).

Two trials reported data on pelvic organ prolapse symptoms or grading (Hilde 2013; Yang 2017). Yang 2017 found a difference in Pelvic Organ Prolapse‐Quantification (POP‐Q) (Stage 1 or 2) between PFMT and no PFMT at three months' postpartum but Hilde 2013 did not find any evidence of a difference between PFMT and usual care at six months postpartum (Analysis 5.9).

Other self‐reported well‐being measures

Two trials used other measures of well‐being: Sleep 1987 used a single unvalidated well‐being question and Oakley 2016 reported the mental and physical components of the SF‐12. There were no differences between the groups (Analysis 5.10).

Adverse effects

Three trials collected data on adverse events, with none reported (Hilde 2013; Peirce 2013; Yang 2017).

Labour and delivery outcome

No trials reported this outcome.

Pelvic floor muscle function

Four studies measured PFM function using the Oxford scale (Liu 2011; Oakley 2016; Wen 2010; Yang 2017). The outcomes at three, six and 12 months' postpartum were in favour of the PFMT group compared to no PFMT or usual care, although not all were statistically significantly different. Four trials assessed vaginal squeeze pressure at three, six, 10 and 12 months' postpartum (Hilde 2013; Kou 2013; Meyer 2001). Yang 2017, who included no PFMT controls, was the only study to find a statistically significant difference in favour of the PFMT group. Three trials measured anal pressure, in cm of water (Meyer 2001) or mmHg (Oakley 2016; Peirce 2013), and none found a difference in squeeze pressure between PFMT and control groups (Analysis 5.11).

Discussion

Summary of main results

There are three possible ways of delivering pelvic floor muscle training (PFMT) interventions to women during pregnancy and in the postpartum period. The first way is to provide PFMT for women who have no symptoms when PFMT begins (i.e. prevention). The second is to prescribe PFMT for women who have already developed symptoms of incontinence (i.e. treatment). The third is to provide PFMT for all women regardless of whether they have urinary incontinence symptoms or not when PFMT begins (i.e. mixed prevention and treatment approach). Comparisons were drawn within the following three populations of women.

  • Women who were continent when randomised to intervention groups (prevention studies).

  • Women who were incontinent at randomisation (treatment studies).

  • Trials including a mixed population i.e. some women were continent and some women were incontinent at randomisation.

Primary or secondary prevention of incontinence

Summary data from six trials suggested that PFMT during pregnancy probably decreases urinary incontinence in late pregnancy compared to usual care. At between three months and up to six months following delivery (mid‐postnatal), summary data from five trials suggested that PFMT slightly decreased the risk of urinary incontinence compared to usual care. With only subgroup data from one small trial of 72 women, there were too few data from six months to one year after delivery (late postpartum) to comment meaningfully (Sampselle 1998). A single trial of 152 women suggested PFMT probably improves incontinence‐specific quality of life in late pregnancy compared to usual care. None of the trials reported data on faecal incontinence in late pregnancy, or in the mid‐ or late‐ postpartum periods (summary of findings Table 1).

Treatment of incontinence

We found uncertain evidence about the effects of PFMT for treatment of urinary incontinence in antenatal and postnatal women. The uncertainty arose from the lack of precision in the pooled estimate of effect; the confidence intervals (CIs) for the summary statistic were generally wide and included a null effect.

Antenatal women

Based on summary data from three trials, we are uncertain whether PFMT decreased existing urinary incontinence in late pregnancy compared to usual care. Similarly, the effect of PFMT to treat antenatal urinary incontinence in the mid‐ and late postnatal periods is uncertain. Data from a single trial of 41 women suggested that PFMT probably improved incontinence‐specific quality of life in late pregnancy compared to usual care. None of the trials reported data on faecal incontinence in late pregnancy, or in the mid‐ and late postpartum periods in this comparison (summary of findings Table 2). Evidence in this comparison was particularly weak, with all trials limited by incomplete reporting of intervention and control conditions and trial methods. Two trials in this comparison were reported only as conference abstracts.

Postnatal women

Summary data from three trials provide no evidence that PFMT to treat postnatal urinary incontinence results in a difference in urinary incontinence in the late postnatal period. We noted that two of the three trials that carried the greatest weighting in the pooled estimate compared PFMT (with limited supervision by a healthcare professional) with usual care and some women in the control groups were doing PFMT (Glazener 2001; Wilson 1998). There was no difference between groups in Wilson 1998 and close to no difference in Glazener 2001. In the third trial, Dumoulin 2004 compared a shorter and more intensively supervised PFMT intervention with no treatment and found a reduction in the risk of urinary incontinence in favour of PFMT. Based on the data from a single very small trial, there was no evidence of a difference in urinary incontinence‐specific quality of life with PFMT (Kim 2012). Based on summary data from two trials, we are uncertain whether PFMT reduces faecal incontinence in the late postnatal period compared to usual care (summary of findings Table 4).

Trials with a mixed prevention and treatment approach

Antenatal women

Summary data from 11 trials suggested that, when delivered to a population of women with or without existing urinary incontinence symptoms, antenatal PFMT probably decreases the risk of urinary incontinence in late pregnancy. The three trials that compared PFMT to no training seemed to show a greater effect than the other eight trials that compared PFMT and usual care (Assis 2015; Ko 2011; Szumilewicz 2019). Summary data from the mid‐postnatal period also suggested that PFMT may reduce the risk of urinary incontinence slightly. Two trials reported data on urinary incontinence in the late postpartum period, and there was no evidence of a difference in urinary incontinence risk between PFMT and usual care. Similarly, there was no evidence that antenatal PFMT led to a difference in the prevalence of faecal incontinence in late pregnancy. There were no data for the prevalence of faecal incontinence in the mid‐ or late‐postnatal periods in this comparison.

A single trial found no evidence that antenatal PFMT led to a difference in urinary incontinence‐specific quality of life in the late postnatal period compared to usual care (Fritel 2015). However, it is important to note that, in Fritel 2015, women in both groups reported a similar frequency and duration of PFMT (including the number of contractions) at the end of pregnancy. This suggested that the lack of difference between groups was because the control group was routinely doing adequate PFMT, which was encouraging in terms of delivering PFMT to the general population. A single small trial showed no evidence of a difference between antenatal PFMT and usual care with respect to faecal incontinence‐specific quality of life (Hyakutake 2018; summary of findings Table 3).

Postnatal women

Based on summary data from three trials, we were uncertain whether postnatal PFMT, delivered to a population of women with or without existing urinary incontinence symptoms, reduced the risk of urinary incontinence in the late postnatal period. Based on evidence from one small trial (Meyer 2001), there is no evidence that PFMT reduces faecal incontinence in the late postnatal period compared to no PFMT. A single trial found that postnatal PFMT may lead to no difference in urinary incontinence‐specific quality of life at 16 weeks following PFMT plus iBall compared to PFMT only (summary of findings Table 5).

Overall completeness and applicability of evidence

The self‐report measures of urinary and faecal incontinence were considered the most important outcomes in this review. However, there was variability in the way urinary and faecal incontinence were defined, how the questions were asked, and how the data were presented. There were few urinary and faecal incontinence‐specific quality of life data and little agreement about a standard measure for each. Further, some trials only partially reported a score (e.g. one domain of several included in the total score), or a statement about difference or lack of it, sometimes with a P value, as these data were collected but not reported or only partially reported this is a form of reporting bias.

Unfortunately, faecal incontinence data were rarely collected in the prevention or mixed prevention and treatment trials; only eight studies presented data (Bø 2011; Glazener 2001; Hyakutake 2018; Meyer 2001; Sleep 1987; Stafne 2012; Torsdatter Markussen 2017; Wilson 1998), with three reporting on faecal incontinence‐specific quality of life (Hyakutake 2018; Oakley 2016; Peirce 2013). Being a less common event than urinary incontinence, larger trials are needed to accurately document the effect of PFMT on this outcome and more trials must collect these data to enable a more precise effect estimate based on pooled data.

The usefulness of evidence was somewhat reduced by the short durations of follow‐up after intervention. This was particularly problematic in the antenatal PFMT trials, where the outcome was either measured at the end of pregnancy or in the three months post birth. At three months' postpartum, there may not have been full resolution of many of the physiological changes associated with pregnancy and childbirth. A minimum follow‐up of six months postnatally is probably more useful to be sure how many cases of urinary or faecal incontinence are persistent. For treatment studies, while a postintervention measure is useful, data on the duration of effect (e.g. one year or longer) are needed. With regard to longer‐term follow‐up, only three studies provided data after five years (Glazener 2001; Mørkved 2003; Reilly 2002). Longer‐term data are difficult to interpret, as control groups may be offered a structured PFMT after the postintervention outcome is measured, women may have more children and so on. However, in the absence of longer‐term data about urinary and faecal incontinence and other variables (parity, bodyweight, etc.), there is an insufficient evidence base to begin to analyse and interpret.

Pregnancy and birth appear to be the most consistent and important factors associated with the development of urinary and faecal incontinence in women. Therefore, all women who have a child, or children, might be considered at risk of later incontinence. In addition, some women (such as those who have a connective tissue disorder, high body mass index (BMI) or an assisted delivery) might be at even greater risk (Durnea 2017; Svare 2014). The bulk of trials reviewed were undertaken in samples of antenatal women, principally those in their first pregnancy and most data were for urinary incontinence. The findings suggested that continent antenatal women benefited more from "structured" PFMT programmes (in terms of content and delivery) than women in usual care groups that may have incorporated some (or ad hoc) PFMT advice or teaching.

Trials of antenatal PFMT for mixed prevention and treatment also mostly recruited women having their first baby and showed a similar pattern of benefit of structured PFMT versus control conditions. However, the pooled data suggested less reduction in risk of urinary incontinence, upper CIs closer to one (i.e. no reduction in risk of urinary incontinence), and overall there was also more uncertainty about the effect.

Efforts to determine what value women, healthcare professionals and their professional organisations, provider and funding bodies give to this body of evidence about urinary incontinence prevention through structured and supervised antenatal PFMT (at least for first‐time mothers) are warranted. If the findings are considered sufficiently certain and of value, then changes to the current ad hoc delivery of PFMT advice in pregnancy within 'usual care' are needed.

We summarised data from all the trials. There were a few that we considered informed us enough about what was done in both PFMT and control groups that we were more confident in the estimate of differences in outcome. These were trials where sufficient information was provided about the intervention and control conditions such that it was possible to reach a judgement about:

  • the soundness of the physiology of the PFMT (i.e. whether the structured PFMT intervention was likely to strengthen muscle);

  • exercise behaviour in both groups (i.e. were both groups doing similar or quite different amounts of PFMT); and

  • the degree of contrast between the two groups (e.g. did the PFMT group attend many exercise classes while the control group had none (high contrast), or did the PFMT group have one instruction session and the controls had none (low contrast)) (see Table 1 and Potential biases in the review process (heterogeneity)).

Five trials contained the necessary amount of information (Chiarelli 2002; Hilde 2013; Reilly 2002; Stafne 2012; Torsdatter Markussen 2017). All were at low risk of selection bias and had moderate to large sample sizes. Three examined the effect of antenatal PFMT for prevention of urinary and faecal incontinence (Reilly 2002, primiparous women with bladder neck hypermobility) and mixed prevention and treatment (Stafne 2012 and Torsdatter Markussen 2017, healthy pregnant women, mixed parity), and two the effect of postnatal PFMT for mixed prevention and treatment of urinary and faecal incontinence (Chiarelli 2002, mixed parity, after ventouse or forceps delivery or baby weighing 4000 g or greater; Hilde 2013, primiparous women after vaginal delivery). Looking at the GRADE‐rated outcomes, data from these individual trials were consistent with the pooled estimates of effect, with the exception of Torsdatter Markussen 2017 at late pregnancy. Antenatal training appeared to have clinically important reductions in urinary incontinence in late pregnancy and between more than three to six months postnatally (Reilly 2002; Stafne 2012). The effect of postnatal training for mixed prevention and treatment may not be clinically important at more than three to six months after delivery for urinary incontinence (Chiarelli 2002; Hilde 2013). However, it is possible that women at higher risk of postnatal incontinence benefited more (Chiarelli 2002).

Quality of the evidence

Overall, the evidence was moderate, low or even very low‐quality (see summary of findings Table 1; summary of findings Table 2; summary of findings Table 3; summary of findings Table 4; summary of findings Table 5). The most common reasons for downgrading the evidence were: imprecision, due to sample sizes less than 400 and wide CIs around the estimates of effect; inconsistency, because many of the meta‐analyses demonstrated statistically significant heterogeneity (Chi² test P < 0.10 or had an I² > 50%); and risk of bias (either overall or selection bias).

Some comparisons were downgraded for selection bias, arising from inadequate reporting of random sequence generation and random allocation. Most comparisons in the 'Summary of findings' tables were affected by more than one of the above and were usually downgraded once or twice.

We evaluated quality from the trial reports, which was limited when the only source of publication was from an abstract (see Included studies). In addition, abstracts reported few data.

The adequacy of reporting randomisation remains disappointing, as fewer than half of the included trials reported both random sequence generation and allocation concealment and 15/46 studies described neither. The nature of the intervention means it was not feasible to blind the treatment provider or participants to group allocation in any of the included trials. The difficulty of blinding exercise‐based interventions is unavoidable. Furthermore, it is impossible to blind either of the primary outcomes in the review because both were self‐reported (prevalence of urinary incontinence or faecal incontinence and incontinence‐specific quality of life). Approximately 80% of the trials (36/46) had a low risk of reporting bias but only just over half (26/46) were deemed to be low risk in terms of potential sources of other biases (Figure 3; Figure 4).

Based on the reported adequacy of randomisation, proportion and management of participant dropouts and withdrawals, and low risk of selective reporting or other biases, six trials appeared to be at low risk of bias (Chiarelli 2002; Dumoulin 2004; Hilde 2013; Mørkved 2003; Peirce 2013; Sangsawang 2016). However, this assessment did not take into account the quality of descriptions of the PFMT interventions or control conditions. If this was taken into account, the trial by Sangsawang 2016 would be downgraded, as the intervention was of short duration and insufficient information was provided to determine the likely physiological effect of the PFMT. Sensitivity analysis on the basis of trial quality was not considered appropriate in view of the small number of trials contributing to each comparison.

Potential biases in the review process

We combined data from a diverse set of studies. This may inevitably impact on the applicability of our findings to practice. We summarise below the issues related to the heterogeneity of the studies we used.

There were three notable sources of clinical heterogeneity. These were the variation in baseline characteristics (e.g. parity, type of delivery, type and duration of incontinence, if women were symptomatic when recruited), the PFMT programmes and the control care. To investigate the effects of baseline characteristics on treatment outcome would require an individual participant data meta‐analysis, which was beyond the scope of this review.

The content of PFMT programmes was often poorly described, and there was lack of information about PFMT and control conditions, PFMT content, and supervision of exercise programmes.

Half the trials provided insufficient information to be sure of the likely physiological effect of the exercise and just under half reported confirmation of a correct PFM contraction prior to training (see PFMT regimens and control interventions, Included studies and Table 1). Consequently, it was difficult to evaluate the potential physiological efficacy of the exercise programmes. Including trials with a suboptimal exercise regimen alongside those with a sufficient regimen could adversely influence the pooled estimate of PFMT effect.

Assessment of the interaction between quality and the effect of the intervention has been recommended but there were too few trials to conduct a formal sensitivity analysis by intervention quality (Herbert 2005). Rather than excluding or including trials on the basis of sufficiency of PFMT, or the likelihood that a clear‐cut comparison between PFMT and the control condition had been made, the preferred approach would be a sensitivity analysis on the basis of PFMT programme characteristics or amount of clinical difference between the PFMT and control interventions. However, more trials would be needed in each of the comparisons in the review before this was possible. We tried to distil information about the physiological and behavioural quality of the PFMT interventions, alongside the degree of contrast between the PFMT and control groups (see 'Sample characteristics' in Included studies and Summary of main results).

The control conditions were also highly variable and usually poorly described, with many including a blanket statement about women in control groups receiving usual or standard care. However, often it was unclear whether usual care encompassed advice about PFMT (i.e. written or verbal instructions) or a more ad hoc arrangement (see 'Sample characteristics' in Included studies, and Table 1).

Agreements and disagreements with other studies or reviews

The overall findings and conclusions in this updated review are generally the same as the previous version, despite this update containing more trials and more data than the previous review (Woodley 2017). Since the last update of this review in 2017, four non‐Cochrane systematic reviews on the effects of PFMT during pregnancy and postpartum for the prevention and treatment of urinary incontinence have been published (Davenport 2018; Mørkved 2014; Saboia 2018; Schreiner 2018). Although some of the reviews considered the data in slightly different categories, they reported that PFMT during pregnancy and after delivery was effective in treating and preventing urinary incontinence (Davenport 2018; Mørkved 2014; Saboia 2018; Schreiner 2018), particularly when women adhered to a strength‐training protocol and were closely supervised (Mørkved 2014). The findings of this review also agreed with those of Mørkved 2014 relating to methodological factors such as the heterogeneity of the populations in the included trials, differences in reported outcome measures, and considerable variation in the PFMT and control conditions between trials.

Brief economic commentary

To supplement the main systematic review of PFMT for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women, we sought to identify relevant economic evaluations as part of the review. No economic studies were identified that analysed the use of PFMT in these groups. The apparent shortage of relevant economic evaluations indicates that there is a paucity of economic evidence on the efficiency of PFMT as a management strategy for urinary incontinence and faecal incontinence in a postnatal and antenatal population. It should be noted that one economic evaluation is currently being conducted alongside a trial, which could be relevant (Moossdorf‐Steinhauser 2019). The trial compares two groups, with one group being given PMFT (stimulated by reinforcement techniques and a mobile app), and the other group usual care. This study will include a within‐trial cost utility analysis alongside the trial, a long‐term economic decision model and a budget impact analysis.

PRISMA study flow diagram ‐ search for clinical effectiveness studies

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Figure 1

PRISMA study flow diagram ‐ search for clinical effectiveness studies

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PRISMA study flow diagram ‐ search for economic evaluations for the BEC

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Figure 2

PRISMA study flow diagram ‐ search for economic evaluations for the BEC

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'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 4

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 1: Urinary incontinence in late pregnancy

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Analysis 1.1

Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 1: Urinary incontinence in late pregnancy

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Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 2: Urinary incontinence early postnatal period (0‐3 months)

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Analysis 1.2

Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 2: Urinary incontinence early postnatal period (0‐3 months)

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Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 3: Urinary incontinence mid‐postnatal period (> 3‐6 months)

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Analysis 1.3

Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 3: Urinary incontinence mid‐postnatal period (> 3‐6 months)

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Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 4: Urinary incontinence late postnatal period (> 6‐12 months)

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Analysis 1.4

Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 4: Urinary incontinence late postnatal period (> 6‐12 months)

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Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 5: Urinary incontinence long term (> 5 years)

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Analysis 1.5

Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 5: Urinary incontinence long term (> 5 years)

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Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 6: Urinary incontinence‐specific quality of life

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Analysis 1.6

Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 6: Urinary incontinence‐specific quality of life

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Severity of incontinence

Study

Measure of

Outcome measure

PFMT data

Control data

Difference

PFMT versus no PFMT

Stothers 2002

Frequency of leakage

Leakage episodes in 5 days

Mean 3.4, SD not reported, n = 7 at 6 months postpartum

Mean 6.0, SD not reported, n = 8 at 6 months postpartum

Not calculable

Amount of leakage

Volume of urine loss (g) on stress test with standardised bladder volume

Mean 18, SD not reported, n = ? at 6 months postpartum

Mean 38, SD not reported, n = ? at 6 months postpartum

Not calculable

Other leakage severity

Not measured

PFMT versus usual care

Gorbea 2004

Frequency of leakage

Less than weekly, weekly or daily UI (not clear if self‐reported or from urinary diary)

4 less than weekly, 2 weekly and none with daily leakage, n = 38 at 6 weeks postpartum

6 less than weekly, 8 weekly and 2 with daily leakage, n = 34 at 6 weeks postpartum

Not calculated as validity/reliability of this measure not known

Other leakage severity

Grade I, II or III leakage, where I=l oss of urine with coughing or lifting, II = urine leakage when walking, and III = urine leakage when upright

6 grade I, and none with grade II or III leakage, n = 38 at 6 weeks postpartum

10 grade I, 6 grade II, and none grade III leakage, n = 34 at 6 weeks postpartum

Not calculated as validity/reliability of this measure not known

Pelaez 2014

Frequency of leakage

Self‐reported leakage frequency categorised as never, once a week, 2‐3 times a week, once a day, several times a day, all the time (item 3, ICIQ‐SF)

60 never, 3 once a week, n = 63 at 36‐40 weeks gestation

54 never, 18 once a week, 9 2‐3 times a week, 7 once a day, 1 several times a day, n = 89

Author reported P value 0.0001

Amount of leakage

Self‐reported amount of leakage categorised as none, small, moderate, large (item 4, ICIQ‐SF)

60 none, 3 small, n = 63 at 36‐40 weeks gestation

54 report none, 27 a small, 5 moderate, 3 large, n=89

Author reported P value 0.0001

Symptom bother

Symptom impact, numbered VAS (0‐10, 10 worse) (item 5, ICIQ‐SF)

Mean 0.10, SD 0.64, n = 63

Mean 0.97, SD 1.8, n = 89

Mean difference ‐0.87 (95% CI ‐1.28 to ‐0.46)

Reilly 2002

Incontinence‐specific quality of life

King's Health Questionnaire

Not reported

Not reported

"No difference between the study groups on any of the 8 scales, and all mean scores were low"

Other leakage severity

Mild, moderate or severe UI (not clear how categorised)

19 mild, 3 moderate and 1 severe, n = 74 at 3 months postpartum

30 mild, 5 moderate and 1 severe, n = 74 at 3 months post partum

Not calculated as validity/reliability of this measure not known

Sampselle 1998

Frequency of leakage

Not measured

Amount of leakage

Not measured

Other leakage severity

Average score from questionnaire re urine leakage with gentle cough, hard cough, sneeze and laugh scored 0 for none, 1 for dampness, 2 for wetness and 3 for soaked

Mean 0.30, standard deviation 0.44, n = 16 at 12 months postpartum

Mean 0.32, standard deviation 0.41, n = 21 at 12 months postpartum

Not calculated as validity/reliability of this measure not known

Sangsawang 2016

Frequency of leakage

Bladder diary, number of leakages per week

Mean 12.4, SD 5.3, n = 9 of 33 at 38 weeks gestation

Mean 23.1, SD 5.7, n = 16 of 30 at 38 weeks gestation

Mean difference ‐8.9 (95% CI ‐13.7 to ‐4.0)

Amount of leakage

Self‐reported: none, small (drops), moderate (wetting underwear), large (wetting outer clothing)

None 24, small 2, moderate 4, large 3

None 14, small 2, moderate 8, large 6

Author reported P value 0.03

Other leakage severity

Perceived severity on VAS (0‐10, 10 worse)

Mean 5.0, SD 0.9, n = 9 of 33

Mean 6.3, SD 1.2, n = 16 of 30

Mean difference ‐2.0 (95% CI ‐3.4 to ‐0.6)

PFMT versus unspecified control

Barakat 2011

Frequency of leakage

Self‐reported leakage frequency categorised as never, once a week, 2‐3 times a week, once a day, several times a day, all the time (item 3, ICIQ‐SF)

24 never, 5 once a week, 2 2‐3 times a week, 2 once a day, 1 several times a day, n = 34

22 never, 5 once a week, 1 2‐3 times a week, 2 once a day, 3 several times a day, n = 33

Author reported P value > 0.05

Amount of leakage

Self‐reported amount of leakage categorised as none, small, moderate, large (item 4, ICIQ‐SF)

Not reported

Not reported

Other leakage severity

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Analysis 1.7

Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 7: Severity of incontinence

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Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 8: Loss of urine under stress test late pregnancy

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Analysis 1.8

Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 8: Loss of urine under stress test late pregnancy

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Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 9: Loss of urine under stress test early postnatal period (0‐3 months)

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Analysis 1.9

Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 9: Loss of urine under stress test early postnatal period (0‐3 months)

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Other self‐reported well‐being measures

Study

Outcome measure

PFMT data

Control data

Difference

PFMT versus usual care

Reilly 2002

SF‐36, general health scale (0‐100, 100 better)

Mean 84.4, SD 13.5, n = 76

Mean 77.2, SD 16.3, n = 72

Mean difference 7.2 (95% CI 2.36 to 12.04)

PFMT versus unspecified control

Barakat 2011

Maternal perception of health status (presume an item derived from SF‐36). Rated as very bad, somewhat bad, good or very good

1 very bad, 14 good, 18 very good, n=34

1 very bad, 5 somewhat bad, 18 good, 9 very good, n=33

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Analysis 1.10

Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 10: Other self‐reported well‐being measures

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Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 11: Delivery outcome: caesarean section

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Analysis 1.11

Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 11: Delivery outcome: caesarean section

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Delivery outcome: other

Study

Outcome measure

PFMT data

Control data

Difference

PFMT versus no control

Stothers 2002

Type of delivery

73.3% vaginal, 26.7% caesarean; not reported per group

PFMT versus usual care

Gaier 2010

Number with episiotomy

2 of 65

6 of 62

Relative risk 0.32 (95% CI 0.07 to 1.52)

Perineal trauma

0.5%

4.2%

Unable to calculate

Reilly 2002

Type of delivery

78 normal vaginal, 13 ventouse, 8 forceps, n = 120

72 normal vaginal, 22 ventouse, 2 forceps, n = 110

Relative risk for normal vaginal delivery 0.99 (95% CI 0.82 to 1.20)

Relative risk for assisted vaginal delivery 0.80 (95% CI 0.47 to 1.36)

PFMT versus unspecified control

Barakat 2011

Type of delivery

20 normal vaginal, 7 assisted vaginal, n = 34

18 normal vaginal, 5 assisted vaginal, n = 33

Relative risk for normal vaginal delivery 1.08 (95% CI 0.71 to 1.64)

Relative risk for assisted vaginal delivery 1.36 (95% CI 0.48 to 3.86)

Perineal trauma

22 intact perineum, 6 grade 1 tear, 5 grade 2 tear, 1 grade 3 tear, n = 34

19 intact perineum, 6 grade 1 tear, 8 grade 2 tear, 0 grade 3 tear, n = 33

Relative risk for perineal tear 0.83 (95% CI 0.45 to 1.52)

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Analysis 1.12

Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 12: Delivery outcome: other

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Pelvic floor muscle function

Study

Outcome measure

PFMT data

Control data

Difference

PFMT versus no PFMT

Gorbea 2004

No or minimal contraction on electromyography. Not clear what type of electromyography or how categorised

14 of 14 at 6 weeks postpartum

10 of 12 at 6 weeks postpartum

Not calculated as validity/reliability of this measure not known

PFMT versus usual care

Gaier 2010

PFM strength (measure not reported)

Significantly higher in the training group at 12
weeks after delivery (P < 0.05)

Reilly 2002

Vaginal squeeze pressure (need unit of measurement), early post‐natal

Mean 11.5, SD 7.8, n = 68

Mean 10.5, SD 5.5, n = 64

Mean difference 1.0 (95% CI ‐1.31 to 3.31)

Figuras y tablas -
Analysis 1.13

Comparison 1: Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence, Outcome 13: Pelvic floor muscle function

Ir a la figura de la revisión

Comparison 2: Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 1: Urinary incontinence late pregnancy

Figuras y tablas -
Analysis 2.1

Comparison 2: Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 1: Urinary incontinence late pregnancy

Ir a la figura de la revisiónAbrir en una pestaña nueva

Comparison 2: Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 2: Urinary incontinence early postnatal period (0‐3 months)

Figuras y tablas -
Analysis 2.2

Comparison 2: Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 2: Urinary incontinence early postnatal period (0‐3 months)

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Comparison 2: Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 3: Urinary incontinence mid‐postnatal period (> 3‐6 months)

Figuras y tablas -
Analysis 2.3

Comparison 2: Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 3: Urinary incontinence mid‐postnatal period (> 3‐6 months)

Ir a la figura de la revisiónAbrir en una pestaña nueva

Comparison 2: Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 4: Urinary incontinence late postnatal period (> 6‐12 months)

Figuras y tablas -
Analysis 2.4

Comparison 2: Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 4: Urinary incontinence late postnatal period (> 6‐12 months)

Ir a la figura de la revisiónAbrir en una pestaña nueva

Comparison 2: Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 5: Urinary incontinence‐specific quality of life

Figuras y tablas -
Analysis 2.5

Comparison 2: Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 5: Urinary incontinence‐specific quality of life

Ir a la figura de la revisiónAbrir en una pestaña nueva

Severity of incontinence

Study

Measure of

Outcome measure

PFMT data

Control data

Difference

PFMT versus usual care

Woldringh 2007

Frequency of leakage

7‐day urinary diary

Not reported

Not reported

Amount of leakage

Not measured

Other leakage severity

A combination of data from a 7‐day bladder diary and a questionnaire (PRAFAB, Vierhout 1990) (0‐10; 0 to 4 mild UI, 5 to 10 moderate to severe UI)

9 with moderate to severe leakage, n = 65 at 12 months postpartum

8 with moderate to severe leakage, n = 99 at 12 months postpartum

Not calculated as validity/reliability of this measure not known

Figuras y tablas -
Analysis 2.6

Comparison 2: Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 6: Severity of incontinence

Ir a la figura de la revisión

Self‐reported measures of pelvic floor dysfunction

Study

Outcome measure

PFMT data

Control data

Difference

PFMT versus usual care

Woldringh 2007

IIQ. Data dichotomised into impact versus no impact in four subscales ‐ impact on social relations, impact on emotional health, impact on recreational activities, and impact on physical activities (not clear how this was done)

Impact on social relations 2, on emotional health 11, on recreational activities 10, and on physical activities 4, n = 65 at 12 months postpartum

Impact on social relations 5, on emotional health 14, on recreational activities 10, and on physical activities 7, n = 99 at 12 months postpartum

Not calculated as validity/reliability of this measure not known

Figuras y tablas -
Analysis 2.7

Comparison 2: Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 7: Self‐reported measures of pelvic floor dysfunction

Ir a la figura de la revisión

Pelvic floor muscle function

Study

Outcome measure

PFMT data

Control data

Difference

PFMT versus usual care

Cruz 2014

Maximal vaginal squeeze pressure, in cm water (Peritron)

Mean 29.8, SD 18.8, n = 20 in third trimester

Mean 24.2, SD 12.9, n = 21 in third trimester

Mean difference 5.6 (95% CI ‐4.32 to 15.52)

Figuras y tablas -
Analysis 2.8

Comparison 2: Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 8: Pelvic floor muscle function

Ir a la figura de la revisión

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 1: Urinary incontinence late pregnancy

Figuras y tablas -
Analysis 3.1

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 1: Urinary incontinence late pregnancy

Ir a la figura de la revisiónAbrir en una pestaña nueva

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 2: Urinary incontinence early postnatal period (0‐3 months)

Figuras y tablas -
Analysis 3.2

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 2: Urinary incontinence early postnatal period (0‐3 months)

Ir a la figura de la revisiónAbrir en una pestaña nueva

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 3: Urinary incontinence mid‐postnatal period (> 3‐6 months)

Figuras y tablas -
Analysis 3.3

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 3: Urinary incontinence mid‐postnatal period (> 3‐6 months)

Ir a la figura de la revisiónAbrir en una pestaña nueva

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 4: Urinary incontinence late postnatal period (> 6‐12 months)

Figuras y tablas -
Analysis 3.4

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 4: Urinary incontinence late postnatal period (> 6‐12 months)

Ir a la figura de la revisiónAbrir en una pestaña nueva

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 5: Urinary incontinence long term (> 5 years)

Figuras y tablas -
Analysis 3.5

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 5: Urinary incontinence long term (> 5 years)

Ir a la figura de la revisiónAbrir en una pestaña nueva

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 6: Faecal incontinence late pregnancy

Figuras y tablas -
Analysis 3.6

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 6: Faecal incontinence late pregnancy

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Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 7: Faecal incontinence early postnatal period (0‐3 months)

Figuras y tablas -
Analysis 3.7

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 7: Faecal incontinence early postnatal period (0‐3 months)

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Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 8: Urinary incontinence‐specific quality of life late pregnancy

Figuras y tablas -
Analysis 3.8

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 8: Urinary incontinence‐specific quality of life late pregnancy

Ir a la figura de la revisiónAbrir en una pestaña nueva

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 9: Urinary incontinence‐specific quality of life early postnatal period (0‐3 months)

Figuras y tablas -
Analysis 3.9

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 9: Urinary incontinence‐specific quality of life early postnatal period (0‐3 months)

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Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 10: Urinary incontinence‐specific quality of life mid postnatal period (> 3‐6 months)

Figuras y tablas -
Analysis 3.10

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 10: Urinary incontinence‐specific quality of life mid postnatal period (> 3‐6 months)

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Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 11: Urinary incontinence‐specific quality of life late postnatal period (> 6‐12 months)

Figuras y tablas -
Analysis 3.11

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 11: Urinary incontinence‐specific quality of life late postnatal period (> 6‐12 months)

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Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 12: Faecal incontinence‐specific quality of life early postnatal period (0‐3 months)

Figuras y tablas -
Analysis 3.12

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 12: Faecal incontinence‐specific quality of life early postnatal period (0‐3 months)

Ir a la figura de la revisiónAbrir en una pestaña nueva

Severity of incontinence

Study

Measure of

Outcome measure

PFMT data

Control data

Difference

PFMT versus no PFMT

Sut 2016

UI

3‐day voiding diary (24‐hour data)

Mean 0.3, SD 1.5, n = 30 late pregnancy; Mean 0.0, SD 0.0, n = 30 early postpartum

Mean 0.1, SD 0.3, n = 30 late pregnancy; Mean 0.1, SD 0.1, n=30 early postpartum

Mean difference 0.2 (95% CI ‐0.35 to 0.75) late pregnancy; not estimable for early postpartum

Urgency

3‐day voiding diary (24‐hour data)

Mean 0.9, SD 1.2, n=30 late pregnancy; Mean 0.1, SD 0.3, n=30 early postpartum

Mean 1.1, SD 1.6, n = 30 late pregnancy; Mean 0.2, SD 0.7, n=30 early postpartum

Late pregnancy mean difference ‐0.2 (95% CI ‐0.92 to 0.52);

Early postpartum mean difference ‐0.1 (95% CI ‐0.37 to 0.17)

Nocturia

3‐day voiding diary (24‐hour data)

Mean 2.3, SD 1.8, n=30 late pregnancy; Mean 0.8, SD 0.9, n=30 early postpartum

Mean 1.5, SD 0.9, n = 30 late pregnancy; Mean 0.6, SD 0.6, n=30 early postpartum

Late pregnancy mean difference 0.8 (95% CI 0.08 to 1.52); Early postpartum mean difference 0.2 (95% CI ‐0.19 to 0.59)

PFMT versus usual care

Hughes 2001

Frequency of leakage

Experiencing occasional or more than occasional urine leakage (not clear how measured)

217 of 585 at 3 months postpartum

210 of 584 at 3 months postpartum

Relative risk 1.03 (95% CI 0.89 to 1.20)

Amount of leakage

Experiencing a drop or more than a drop of urine leakage (not clear how measured)

228 of 585 at 3 months postpartum

234 of 584 at 3 months postpartum

Relative risk 0.97 (95% CI 0.84 to 1.12)

Other leakage severity

Not measured

Sampselle 1998

Frequency of leakage

Not measured

Amount of leakage

Not measured

Other leakage severity

Average score from questionnaire re urine leakage with gentle cough, hard cough, sneeze and laugh scored 0 for none, 1 for dampness, 2 for wetness and 3 for soaked

Mean 0.38, SD 0.56, n=22 at 12 months postpartum

Mean 0.42, SD 0.49, n = 24 at 12 months postpartum

Not calculated as validity/reliability of this measure not known

Torsdatter Markussen 2017

UI severity

Urinary Incontinence Severity Index

Mean 2.8, SD 2.0, n = 11 at late pregnancy

Mean 3.0, SD 1.0, n = 7 at 3 months postpartum

Mean 4.4, SD 1.8, n = 9 at late pregnancy

Mean 2.1, SD 2.0, n = 7 at 3 months postpartum

Mean difference 1.6 (95% CI ‐0.2 to 3.4) at late pregnancy

Mean difference ‐0.9 (95% CI ‐2.7 to 0.9) at early postpartum

FI severity

St. Mark's score

Median 0, IQR 3, n = 19 at late pregnancy

Median 0, IQR 4, n = 18 at 3 months postpartum

Median 0.5, IQR 13, n = 22 at late pregnancy

Median 0, IQR 15, n = 22 at 3 months postpartum

Figuras y tablas -
Analysis 3.13

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 13: Severity of incontinence

Ir a la figura de la revisión

Loss of urine under stress test early postnatal period (0‐3 months)

Study

Measure

PFMT

Control

Difference

PFMT versus usual care

Fritel 2015

24‐hour pad test (g)

Mean 0.9, SD 1.6, n = 78 at 2 months postpartum

Mean 1.3, SD 3.3, n = 85 at 2 months postpartum

Mean difference ‐0.40 (95% CI ‐1.19 to 0.39)

Figuras y tablas -
Analysis 3.14

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 14: Loss of urine under stress test early postnatal period (0‐3 months)

Ir a la figura de la revisión

Self‐reported measures of pelvic floor dysfunction

Study

Outcome measure

PFMT data

Control data

Difference

PFMT versus no PFMT

Ko 2011

UDI‐6 (0‐100, 100 worse)

Mean 3.44, SD 3.26, n = 150 in late pregnancy; Mean 0.81, SD 1.36, n = 150 at 0‐3 months postpartum; Mean 0.35, SD 0.84, n =150 at > 3‐6 months postpartum

Mean 4.66, SD 3.32, n = 150 in late pregnancy; Mean 1.54, SD 1.59, n = 150 at 0‐3 months postpartum; Mean 0.86, SD 1.14, n = 150 at > 3‐6 months postpartum

Mean difference ‐1.22 (95% CI ‐1.96 to ‐0.48) in late pregnancy; Mean difference ‐0.73 (95% CI ‐1.06 to ‐0.40) at 0‐3 months' postpartum; Mean difference ‐0.51 (95% CI ‐0.74 to ‐0.28) at > 3‐6 months postpartum

Sut 2016

UDI‐6

(0‐100, 100 worse)

Mean 46.9, SD 8.7, n = 30 in late pregnancy; Mean 34.1, SD 6.6, n = 30 at early postpartum

Mean 44.1, SD 8.7, n=30 in late pregnancy; Mean 34.0, SD 8.2, n=30 at 0‐3 months' postpartum

Mean difference 2.8 (95% CI ‐1.60 to 7.20) in late pregnancy; Mean difference 0.1 (95% CI ‐3.67 to 3.87) at 0‐3 months' postpartum

Overactive bladder questionnaire (OAB‐q) total score

(0‐100, 100 better)

Mean 85.7, SD 13.5, n = 30 in late pregnancy; Mean 97.2, SD 8.7, n = 30 at early postpartum

Mean 90.0, SD 13.6, n = 30 in late pregnancy; Mean 97.6, SD 6.3, n = 30 at 0‐3 months' postpartum

Mean difference ‐4.3 (95% CI ‐11.16 to 2.56) in late pregnancy; Mean difference ‐0.4 (95% CI ‐4.24 to 3.44) at 0‐3 months' postpartum

Szumilewicz 2019

IIQ‐7 (0‐100; 100 worse)

Mean percentage change 0.20, SD 7.58%, n = 70 in late pregnancy

Mean percentage change 0.12, SD 0.93%, n = 27 in late pregnancy

Mean difference 0.8 (95% CI ‐1.73 to 1.89)

PFMT versus usual care

Fritel 2015

Female Pelvic Floor Questionnaire (FPFQ) bladder score (0‐10, 10 worse)

Mean 1.7, SD 1.3, n = 112 in late pregnancy; Mean 0.8, SD 0.9, n = 105 at 0‐3 months postpartum; Mean 0.9, SD 1.1, n = 94 at > 6‐12 months postpartum

Mean 2.0, SD 1.4, n = 111 in late pregnancy; Mean 0.9, SD 1.0, n = 107 at 0‐3 months postpartum; Mean 1.0, SD 1.1, n = 97 at > 6‐12 months postpartum

Mean difference ‐0.30 (95% CI ‐0.65 to 0.05) in late pregnancy; Mean difference ‐0.10 (95% CI ‐0.36 to 0.16) at 0‐3 months postpartum; Mean difference ‐0.10 (95% CI ‐0.41 to ‐0.12) at > 6‐12 months postpartum

FPFQ bowel score (0‐10)

Mean 1.3, SD 1.1, n = 112 in late pregnancy; Mean 1.2, SD 1.2, n = 104 at 0‐3 months postpartum; Mean 1.0, SD 1.0, n = 94 at > 6‐12 months postpartum

Mean 1.4, SD 1.1, n = 112 in late pregnancy; Mean 1.4, SD 1.2, n = 107 at 0‐3 months postpartum; Mean 1.1, SD 1.0, n = 97 > 6‐12 months postpartum

Mean difference ‐0.10 (95% CI ‐0.39 to ‐0.19) in late pregnancy; Mean difference ‐0.20 (95% CI ‐0.52 to 0.12) at 0‐3 months postpartum; Mean difference ‐0.10 (95% CI ‐0.38 to 0.18) at > 6‐12 months postpartum

Hughes 2001

BFLUTs questionnaire: a negative effect on exercise in response to question "does incontinence affect physical activity?"

47 of 585 at 6 months postpartum

41 of 584 at 6 months postpartum

Relative risk 1.14 (95% CI 0.76 to 1.71)

Hyakutake 2018

PFDI‐20 total score (20 items; 0‐300, 300 worse)

Mean 27.8, SD 31.6, n = 37 at 6 weeks postpartum

Mean 35.5, SD 37.7, n = 37 at 6 weeks postpartum

Mean difference ‐7.70 (95% CI ‐23.55 to 8.15) at 6 weeks postpartum

POPDI‐6 (prolapse subscale) (6 items; 0‐100, 100 worse)

Mean 6.6, SD 8.4, n = 37 at 6 weeks postpartum

Mean 5.9, SD 12.1, n = 37 at 6 weeks postpartum

Mean difference 0.70 (95% CI ‐4.05 to 5.45) at 6 weeks postpartum

Mørkved 2003

Sexual satisfaction at 6 years post‐delivery

34 of 94

17 of 94

Relative risk 2.00 (95% CI 1.20 to 3.32)

PFMT versus unspecified control

Dokmeci 2008

UDI‐6 (6 items; 0‐100, 100 worse)

No data

No data

Authors stated that there was a significant decrease in scores between first trimester and third trimester and between third trimester and 6 weeks postpartum

IIQ‐7

No data

No data

Figuras y tablas -
Analysis 3.15

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 15: Self‐reported measures of pelvic floor dysfunction

Ir a la figura de la revisión

Other self‐reported well‐being measures

Study

Outcome measure

PFMT data

Control data

Difference

PFMT versus usual care

Fritel 2015

EuroQoL‐5D (0‐100, 100 better)

Mean 76.4, SD 20.4, n = 111 at end of pregnancy; Mean 82.8, SD 18.2, n = 105 at 0‐3 months postpartum; Mean 86.8, SD 13.1, n = 94 at > 6‐12 months postpartum

Mean 77.9, SD 16.3, n = 112 at end of pregnancy; Mean 80.4, SD 17.0, n = 107 at 0‐3 months postpartum; Mean 82.9, SD 14.8, n = 97 at > 6‐12 months postpartum

Late pregnancy, mean difference ‐1.50 (95% CI ‐6.35 to 3.35); 0‐3 months postpartum, mean difference 2.40 (95% CI ‐2.34 to 7.14); > 6‐12 months postpartum, mean difference 3.90 (95% CI ‐0.06 to 7.86)

Miquelutti 2013

State Trait Anxiety Inventory (STAI) (20‐80; 50‐64 high, 65‐80 very high)

Trait anxiety 18 of 85

State anxiety 16 of 85

Trait anxiety 20 of 76

State anxiety 14 of 76

Trait anxiety, relative risk 0.80 (95% CI 0.46 to 1.40)

State anxiety, relative risk 1.02 (95% CI 0.53 to 1.95)

Stafne 2012

Psychological General Well‐being Index (PGWBI) (0‐110, 110 better)

Total score at end of pregnancy: Mean 79.5 (95% CI 78.5 to 80.6), n=389

Total score at end of pregnancy: Mean 78.5 (95% CI 77.5 to 79.6), n = 361

Mean difference 0.71 (95% CI ‐0.60 to 2.01)

Figuras y tablas -
Analysis 3.16

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 16: Other self‐reported well‐being measures

Ir a la figura de la revisión

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 17: Delivery outcome: caesarean section

Figuras y tablas -
Analysis 3.17

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 17: Delivery outcome: caesarean section

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Delivery outcome: other

Study

Outcome measure

PFMT data

Control data

Difference

PFMT versus no PFMT

Ko 2011

Episiotomy

99 of 150

104 of 150

Relative risk 0.95 (95% CI 0.81 to 1.11)

Severe perineal lacerations

10 of 150

10 of 150

Relative risk 1.00 (95% CI 0.43 to 2.33)

PFMT versus usual care

Fritel 2015

Spontaneous vaginal delivery

72 of 137

72 of 135

Relative risk 0.99 (95% CI 0.79 to 1.23)

Assisted delivery

29 of 137

35 of 135

Relative risk 0.82 (95% CI 0.53 to 1.26)

Hyakutake 2018

Spontaneous vaginal delivery

15 of 37

15 of 34

Relative risk 0.92 (95% CI 0.53 to 1.58)

Assisted delivery

11 of 37

7 of 34

Relative risk 0.67 (95% CI 0.36 to 1.26)

Miquelutti 2013

Vaginal delivery

44 of 76

38 of 71

Relative risk 1.08 (95% CI 0.81 to 1.44)

Duration active phase labour (min)

Mean 284.5, SD 175, n = 78

Mean 254.2, SD 139.4, n = 71

Mean difference 30.3 (95% CI ‐40.9 to 101.4)

Duration second stage labour (min)

Mean 29.2, SD 23.3, n = 78

Mean 19.7, SD 13.0, n = 71

Mean difference 9.48 (95% CI 0.32 to 18.64)

Mørkved 2003

Type of delivery (excluding twin pregnancy, preterm delivery, planned caesarean section and induced labour)

91 normal vaginal deliveries, 15 asssisted vaginal deliveries, 5 emergency caesarean section, n = 111

91 normal vaginal deliveries, 19 assisted vaginal deliveries, 3 emergency caesarean section, n = 113

Relative risk for normal vaginal delivery 1.02 (95% CI 0.90 to 1.15)

Relative risk for assisted vaginal delivery 0.80 (95% CI 0.43 to 1.50)

Perineal trauma

56 with episiotomy, and 7 with third or fourth degree tears, n = 111

72 with episiotomy, and 9 with third or fourth degree tears, n = 113

Relative risk for episiotomy 0.79 (95% CI 0.63 to 1.00)

Duration second stage labour (min)

Mean 40, 95% CI 33 to 47, n = 111

Mean 45, 95% CI 38 to 52, n = 113

Mean difference ‐5.00 (95% CI ‐14.79 to 4.79)

Stafne 2012

Assisted vaginal delivery

62 of 426

50 of 425

Relative risk 1.24 (95% CI 0.87 to 1.75)

Mean duration labour (min)

Mean 289, n = 426?

Mean 281, n = 425?

Unable to estimate

Mean duration active second stage labor (min)

Mean 32, n = 426?

Mean 29, n = 425?

Unable to estimate

Figuras y tablas -
Analysis 3.18

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 18: Delivery outcome: other

Ir a la figura de la revisión

Pelvic floor muscle function

Study

Measure

PFMT

Control

Difference

PFMT versus no PFMT

Assis 2015

Perinometry, vaginal squeeze pressure (cm water), late pregnancy

Mean 9.45, SD 1.05, n = 58

Mean 4.7, SD 1.7, n=29

Mean difference 4.75 (95% CI 4.07 to 5.43)

Sut 2016

Manometric perionometry, vaginal probe (reports as microvolts, likely cm water/Mercury)

Mean change 3.0, SD 2.5, n=30 baseline to late pregnancy; Mean change 6.4, SD 4.4, n = 30 baseline to early postpartum

Mean change ‐2.2, SD 5.2, n = 30 baseline to late pregnancy; Mean change ‐1.7, SD 6.1, n = 30 baseline to early postpartum

Late pregnancy mean difference 5.20 (95% CI 3.14 to 7.26); Early postpartum 8.10 (95% CI 5.41 to 10.79)

Szumilewicz 2019

Electromyography with vaginal probe (microvolts)

Mean of 5 quick flicks, mean percentage change 11.0, SD 37.0, n = 70 baseline to late pregnancy

Mean of 5 x 10 sec maximal contractions, mean percentage change 2.4, SD 27.0, n = 70 baseline to late pregnancy

Mean of 1 x 60 sec static hold, mean percentage change 11.6, SD 74.0, n = 70 baseline to late pregnancy

Mean of 5 quick flicks, mean percentage change 1.0, SD 26.0, n = 27 baseline to late pregnancy

Mean of 5 x 10 sec maximal contractions, mean percentage change ‐4.0, SD 24.0, n = 27 baseline to late pregnancy

Mean of 1 x 60 sec static hold, mean percentage change ‐3.0, SD 33.0, n = 27 baseline to late pregnancy

PFMT versus usual care

Fritel 2015

PFM strength, modified Oxford scale (0‐5, 5 better)

Mean 3.5, SD 1.5, n = 105 at 2 months postpartum

Mean 3.3, SD 1.3, n = 107 at 2 months postpartum

Mean difference 0.12 (95% CI ‐0.18 to 0.58)

Change in PFM strength, baseline to 2 months postpartum

Mean 0.08, SD 1.32, n = 101

Mean ‐0.25, SD 1.11, n = 103

Mean difference 0.33 (95% CI ‐0.00 to 0.66)

Mørkved 2003

Vaginal squeeze pressure (cm water)

Mean 29.5, 95% CI 26.8 to 32.2, n = 143 at 3 months postpartum

Mean 25.6, 95% CI 23.2 to 27.9, n = 146 at 3 months postpartum

Mean difference 3.90 (95% CI 0.35 to 7.45)

Torsdatter Markussen 2017

Change in PFM strength, modified Oxford scale (0‐5, 5 better)

Median (min‐max) change 0 (‐2 to 2), n = 21, baseline to late pregnancy

Median (min‐max) change 0 (‐4 to 2), n = 16, baseline to 3 months' postpartum

Median (min‐max) change 0 (‐2 to 1), n = 19, baseline to late pregnancy

Median (min‐max) change 0 (‐2 to 1), n = 21, baseline to 3 months' postpartum

Changes in PFM were not significantly different between baseline and late pregnancy (P =0.36), and baseline and 3 months' postpartum (P = 0.44)

PFMT versus unspecified control

Dokmeci 2008

Electromyography with vaginal electrode

No data

No data

Authors stated that "Maximum pelvic floor strength was increased significantly between first and third visits in PFMT group, p=0.03 and between first and post‐partum visits in control group, p=0.03."

Figuras y tablas -
Analysis 3.19

Comparison 3: Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 19: Pelvic floor muscle function

Ir a la figura de la revisión

Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 1: Urinary incontinence late postnatal period (> 6‐12 months)

Figuras y tablas -
Analysis 4.1

Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 1: Urinary incontinence late postnatal period (> 6‐12 months)

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Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 2: Urinary incontinence long term (> 5‐10 years)

Figuras y tablas -
Analysis 4.2

Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 2: Urinary incontinence long term (> 5‐10 years)

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Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 3: Urinary incontinence very long term (> 10 years)

Figuras y tablas -
Analysis 4.3

Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 3: Urinary incontinence very long term (> 10 years)

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Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 4: Faecal incontinence late postnatal period (> 6‐12 months)

Figuras y tablas -
Analysis 4.4

Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 4: Faecal incontinence late postnatal period (> 6‐12 months)

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Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 5: Faecal incontinence long term (> 5‐10 years)

Figuras y tablas -
Analysis 4.5

Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 5: Faecal incontinence long term (> 5‐10 years)

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Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 6: Faecal incontinence very long term (> 10 years)

Figuras y tablas -
Analysis 4.6

Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 6: Faecal incontinence very long term (> 10 years)

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Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 7: Urinary incontinence‐specific quality of life

Figuras y tablas -
Analysis 4.7

Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 7: Urinary incontinence‐specific quality of life

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Severity of incontinence

Study

Measure of

Outcome measure

PFMT data

Control data

Difference

PFMT versus no PFMT

Dumoulin 2004

Frequency of leakage

Not measured

Amount of leakage

Change, in grams, in 20‐min pad test with standardised bladder volume

A: Median change 19.0, interquartile range 6.0 to 25.0, n = 23 after 9 weeks of PFMT

B: Median change 8, interquartile range 4.0 to 2.35, n = 20 after 9 weeks of PFMT

Median change 0, interquartile range ‐3.0 to 9.8, n = 19 after 9 weeks of control condition

Not calculable

Other leakage

Change in VAS for perceived burden of incontinence (Stach‐Lempinen 2001)

A: Median change 3.0, interquartile range 2.0 to 4.0, n = 23 after 9 weeks of PFMT

B: Median change 2.5, interquartile range 0.8 to 5.0, n = 20 after 9 weeks of PFMT

Median change 0, interquartile range ‐0.1 to 0.02, n = 19 after 9 weeks of control condition

Not calculable

PFMT versus usual care

Ahlund 2013

Incontinence score (0‐20, 20 worse)

ICIQ‐FLUTS

Median 4.0, range 0 to 15, n = 40 at 9 months postpartum

Median 4, range 0 to 12, n = 42 at 9 months postpartum

Not calculable

Voiding score (0‐12, 12 worse)

ICIQ‐FLUTS

Median 1.0, range 0 to 5, n = 40 at 9 months postpartum

Median 0.0, range 0 to 8, n = 42 at 9 months postpartum

Not calculable

Incontinence score (0‐20, 20 worse)

ICIQ‐FLUTS

Median 4.0, range 0 to 15, n = 40 at 9 months postpartum

Median 4, range 0 to 12, n = 42 at 9 months postpartum

Not calculable

Glazener 2001

Frequency of leakage

Not measured

Amount of leakage

Using absorbent pads

41 of 276 at 12 months postpartum

55 of 245 at 12 months postpartum

Relative risk 0.66 (95% CI 0.46, 0.95)

Other leakage severity

Visual analogue scale for severity of urine leakage

Mean 2.8, 95% CI 2.4 to 3.1, n = 142 at 12 months postpartum

Mean 3.6, 95% CI 3.1 to 4.0, n = 142 at 12 months postpartum

Mean difference ‐0.80 (95% CI ‐1.37 to ‐0.23)

Kim 2012

Urinary symptoms (? range)

BFLUTS

Mean 40.56, SD 5.36, n = 9 at between 8‐14 weeks postpartum

Mean 46.89, SD 3.62, n = 9 at between 8‐14 weeks postpartum

Wilson 1998

Frequency of leakage

Not measured

Amount of leakage

Urine loss on home pad test (Wilson et al 1989), in grams

Mean 2.1, 95% CI ‐0.3 to 4.5, n = 18 at 12 months postpartum

Mean 2.6, 95% CI 0.1 to 5.1, n = 82 at 12 months postpartum

Mean difference ‐0.50 (95% CI ‐3.81 to 2.81)

Other leakage severity

Not measured

Figuras y tablas -
Analysis 4.8

Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 8: Severity of incontinence

Ir a la figura de la revisión

Self‐reported measures of pelvic floor dysfunction

Study

Outcome measure

PFMT data

Control data

Difference

Dumoulin 2004

Change in UDI (maximum score 57)

A: Median change 4, interquartile range 1 to 10, n = 23 after 9 weeks PFMT

B: Median change 7, interquartile range 3 to 8, n = 20 after 9 weeks PFMT

Median change 0, interquartile range ‐2.3 to 6.5, n = 19 after 9 weeks of control condition

Not calculable

Change in IIQ (maximum score 90)

A: Median change 10, interquartile range 2 to 16, n = 23 after 9 weeks PFMT

B: Median change 13, interquartile range 6 to 25, n = 20 after 9 weeks PFMT

Median change 0.5, interquartile range ‐6.5 to 5.0, n = 19 after 9 weeks of control condition

Not calculable

Figuras y tablas -
Analysis 4.9

Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 9: Self‐reported measures of pelvic floor dysfunction

Ir a la figura de la revisión

Other self‐reported well‐being measures

Study

Outcome measure

PFMT data

Control data

Difference

Glazener 2001

Hospital Anxiety and Depression Score ‐ anxiety score

Mean 6.1, 95% CI 5.6 to 6.5, n = 238 at 12 months

Mean 6.8, 95% CI 6.3 to 7.3, n = 219 at 12 months postpartum

Mean difference ‐0.79 (95% CI ‐1.43 to ‐0.05)

Figuras y tablas -
Analysis 4.10

Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 10: Other self‐reported well‐being measures

Ir a la figura de la revisión

Pelvic floor muscle function

Study

Outcome measure

PFMT data

Control data

Difference

PFMT versus no PFMT

Dumoulin 2004

Maximal strength (Newtons, pelvic floor dynamometer, Dumoulin et al 2003)

A: Median change 0.7, range ‐0.2 to 2.3, n = 23 after 9 weeks PFMT

B: Median change 0.5, range ‐0.6 to 2.5, n = 20 after 9 weeks PFMT

Median change ‐0.5, range ‐1.7 to 1.0, n = 19 after 9 weeks PFMT

Not calculable

PFMT versus usual care

Ahlund 2013

Maximal voluntary contraction (cm mercury, perineometer)

Median 26.0, estimated range 7 to 49, n = 40 at 9 months postpartum

Median 18.2, estimated range 6 to 54, n = 42 at 9 months postpartum

Not calculable

Endurance (secs, continuous contraction until pressure=0)

Median 26.7, estimated range 1 to 65, n = 40 at 9 months postpartum

Median 23.4, estimated range 3 to 60, n = 42 at 9 months postpartum

Not calculable

Oxford scale (0‐5; 0=no activity, 5=strong)

Median 4, estimated range 2 to 5, n = 40 at 9 months postpartum

Median 3, estimated range 2 to 5, n = 42 at 9 months postpartum

Not calculable

Kim 2012

Maximal squeeze pressure (mm mercury, perineometer)

Mean 25.78, SD 10.74, n = 9 at between 8‐14 weeks postpartum

Mean 8.11, SD 2.57, n = 9 at between 8‐14 weeks postpartum

Mean difference 17.67 (95% CI 10.46 to 24.88)

Holding time (sec, perineometer)

Mean 14.34, SD 3.08, n = 9 at between 8‐14 weeks postpartum

Mean 8.89, SD 2.10, n = 9 at between 8‐14 weeks postpartum

Mean difference 5.45 (95% CI 3.01 to 7.89)

Wilson 1998

Maximal vaginal squeeze pressure (cm water)

Mean 13.6, 95% CI 9.8 to 17.4, n = 19 at 12 months postpartum

Mean 13.1, 95% CI 11.3 to 14.9, n = 79 at 12 months postpartum

Mean difference 0.50 (95%CI ‐3.46 to 4.46)

Figuras y tablas -
Analysis 4.11

Comparison 4: Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence, Outcome 11: Pelvic floor muscle function

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Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 1: Urinary incontinence early postnatal period (0‐3 months)

Figuras y tablas -
Analysis 5.1

Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 1: Urinary incontinence early postnatal period (0‐3 months)

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Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 2: Urinary incontinence mid‐postnatal period (> 3‐6 months)

Figuras y tablas -
Analysis 5.2

Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 2: Urinary incontinence mid‐postnatal period (> 3‐6 months)

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Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 3: Urinary incontinence late postnatal period (> 6‐12 months)

Figuras y tablas -
Analysis 5.3

Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 3: Urinary incontinence late postnatal period (> 6‐12 months)

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Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 4: Faecal incontinence early postnatal period (0‐3 months)

Figuras y tablas -
Analysis 5.4

Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 4: Faecal incontinence early postnatal period (0‐3 months)

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Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 5: Faecal incontinence late postnatal period (> 6‐12 months)

Figuras y tablas -
Analysis 5.5

Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 5: Faecal incontinence late postnatal period (> 6‐12 months)

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Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 6: Urinary incontinence‐specific quality of life

Figuras y tablas -
Analysis 5.6

Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 6: Urinary incontinence‐specific quality of life

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Severity of incontinence

Study

Measure of

Outcome measure

PFMT data

Control data

Difference

PFMT versus no PFMT

Sacomori 2019

Frequency of leakage

ICIQ‐SF, frequency domain (0‐5, 5 worse)

Median 0, IQR 0, n = 67 at 3 months postpartum

Median 0, IQR 0, n = 65 at 3 months postpartum

Median difference 0

ICIQ‐SF, amount domain (0‐6, 6 worse)

Median 0, IQR 0, n = 67 at 3 months postpartum

Median 0, IQR 0, n = 65 at 3 months postpartum

Median difference 0

ICIQ‐SF, influence of leakage on quality of life domain (0‐10, 10 worse)

Median 0, IQR 0, n = 67 at 3 months postpartum

Median 0, IQR 0, n = 65 at 3 months postpartum

Median difference 0

Yang 2017

Severity of UI

Continence severity score (number of leakage episodes per week; 0 = none, 1 = once or fewer times per week; 2 = 2‐3 times per week; 3 = 3‐7 times per week, 4 = >7 times per week, 5 = leaking all the time)

Scored 0 63 of 129, scored 1 52 of 129, scored 2 13 of 129, scored 3 1 of 129, scored 4 0 of 129, scored 5 0 of 129

Scored 0 4 of 60, scored 1 4 of 60, scored 2 25 of 60, scored 3 25 of 60, scored 4 2 of 60, scored 5 0 of 60

Relative risk, 0; 7.33 (95% CI 2.80 to 19.19), 1; 6.05 (95% CI 2.29 to 15.95), 2; 0.24 (95% CI 0.13 to 0.44), 3; 0.02 (95% CI 0.00 to 0.13), 4; 0.09 (95% CI 0.00 to 1.93), 5; not estimable

PFMT versus usual care

Hilde 2013

Amount of leakage

Pad test, 1 min with standardised bladder volume (positive test 2g or more)

Median 4.0, range 2.0 to 80.0, n = 87 at 6 months postpartum

Median 6.0, range 2.0 to 114.0, n = 88 at 6 months postpartum

Mann Whitney‐U 213.5, z‐value ‐0.13, p‐value 0.90

Liu 2011

Urinary condition score, not specified (lower score better; 3 months postpartum)

Mean 2.2, SD 0.2, n = 106

Mean 2.8, SD 0.4, n = 86

Mean difference ‐0.60 (95% CI ‐0.69 to ‐0.51)

Urinary condition score, not specified (lower score better; 6 months postpartum)

Mean 2.0, SD 0.4, n = 106

Mean 2.5, SD 0.4, n = 86

Mean difference ‐0.50 (95% CI ‐0.61 to ‐0.39)

Oakley 2016

Severity of FI

FISI (higher score worse)

Median 6.0, IQR 20.5, n = 27 at 12 weeks postpartum

Median 13.5, IQR 22.25, n = 23 at 12 weeks postpartum

Not calculable

Sleep 1987

Frequency of leakage

Urine leakage once or more per week

64 of 816 at 3 months postpartum

57 of 793 at 3 months postpartum

Relative risk 1.09 (95% CI 0.77 to 1.54)

Amount of leakage

Using absorbent pads sometimes or always

38 of 815 at 3 months postpartum

43 of 793 at 3 months postpartum

Relative risk 0.86 (95% CI 0.56 to 1.32)

Other leakage severity

Not measured

Wen 2010

Stress UI

Criteria from International Continence Society (0‐5, 5 worse)

Mean 2.84, SD 0.43, n = 75 at 6 months postpartum

Mean 2.50, SD 0.41, n = 73 at 6 months postpartum

Mean difference 0.34 (95% CI 0.20 to 0.48)

Criteria from International Continence Society (0‐5, 5 worse)

Mean 1.16, SD 0.38, n = 75 at 12 months postpartum

Mean 2.20, SD 0.39, n = 73 at 12 months postpartum

Mean difference ‐1.04 (95% CI ‐1.16 to ‐0.92)

Amount of leakage

Pad test (postive test more than 2g)

7 of 75 at 12 months postpartum

19 of 73 at 12 months postpartum

Relative risk 0.29 (95% CI 0.11 to 0.75)

Figuras y tablas -
Analysis 5.7

Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 7: Severity of incontinence

Ir a la figura de la revisión

Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 8: Loss of urine under stress test postpartum

Figuras y tablas -
Analysis 5.8

Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 8: Loss of urine under stress test postpartum

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Self‐reported measures of pelvic floor dysfunction

Study

Measure of

Outcome measure

PFMT data

Control data

Difference

PFMT plus versus PFMT

Dufour 2019

Distress associated with UI

UDI‐6 (0‐100, 100 worse) at mid‐postnatal period

Mean 7.3, SD 5.9, n = 13

Mean 4.6, SD 6.0, n = 10

Mean difference 2.7 (95% CI ‐8.90 to 2.89)

Yang 2017

Pelvic organ prolapse

POP‐Q, stage 1 or 2

31 of 129 at 3 months postpartum

32 of 60 at 3 months postpartum

Relative risk 0.45 (95% CI 0.31 to 0.66)

PFMT versus no PFMT

Hilde 2013

Pelvic organ prolapse

ICIQ‐Vag, bulging inside vagina (yes, no)

8 of 87 at 6 months postpartum

22 of 88 at 6 months postpartum

Mean difference 0.37 (95% CI 0.17 to 0.78)

Pelvic organ prolapse

ICIQ‐Vag, bulging outside vagina (yes, no)

5 of 87 at 6 months postpartum

6 of 88 at 6 months postpartum

Mean difference 0.84 (95% CI 0.27 to 2.66)

Pelvic organ prolapse

POP‐Q, stage 1 or 2

61 of 87 at 6 months postpartum

64 of 88 at 6 months postpartum

Mean difference 0.88 (95% CI 0.46 to 1.70)

Meyer 2001

Sexual function

Reduced vaginal response at 10 months postpartum

5 of 51

13 of 56

Relative risk 0.42 (95% CI 0.16 to 1.10)

Sacomori 2019

UI specific quality of life

ICIQ‐SF (0‐21, 21 worse)

Median 0, IQR 0, n = 67 at 3 months postpartum

Median 0, IQR 0, n = 65 at 3 months postpartum

Not calculable

PFMT versus usual care

Oakley 2016

Distress associated with UI

UDI‐6 (0‐100, 100 worse) at early‐postnatal period

Median 0.0, IQR 12.5, n = 27 at 12 weeks postpartum

Median 11.11, IQR 37.50, n = 23 at 12 weeks postpartum

Not calculable

FI specific quality of life

FIQOL (29 items, 4 domain scores, each item scored 1‐5, higher better)

Lifestyle: Median 4.0, IQR 0.3, n = 27 at 12 weeks postpartum

Coping/behaviour: Median 3.89, IQR 0.5, n = 27 at 12 weeks postpartum

Depression/self perception: Median 3.89, IQR 0.5, n = 27 at 12 weeks postpartum

Embarrassment: Median 4.0, IQR 0.0, n = 27 at 12 weeks postpartum

Lifestyle: Median 4.0, IQR 0.1, n = 23 at 12 weeks postpartum

Coping/behaviour: Median 3.89, IQR 0.4, n = 23 at 12 weeks postpartum

Depression/self perception: Median 3.89, IQR 0.3, n = 23 at 12 weeks postpartum

Embarrassment: Median 4.0, IQR 0.1, n = 23 at 12 weeks postpartum

Not calculable

Peirce 2013

FI specific quality of life

FIQOL (29 items, 4 domain scores, each item scored 1‐5, higher better)

Lifestyle: no data; coping/behaviour: no data,

depression/self perception: no data,

embarrassment: no data, n = 30 at 3 months' postpartum

Lifestyle: no data, coping/behaviour: no data, depression/self perception: no data, embarrassment: no data, n = 90 at 3 months' postpartum

Lifestyle P = 0.29, coping/behaviour P = 0.27, depression/self perception P = 089, embarrassment P = 0.51

Sleep 1987

Sexual function

Attempted sexual intercourse within 3 months of delivery

714 of 819

681 of 792

Relative risk 1.01 (95% CI 0.98 to 1.05)

Sexual function

Dyspareunia at 3 months postpartum

167 of 819

154 of 792

Relative risk 1.05 (95% CI 0.86 to 1.28)

Figuras y tablas -
Analysis 5.9

Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 9: Self‐reported measures of pelvic floor dysfunction

Ir a la figura de la revisión

Other self‐reported well‐being measures

Study

Measure of

Outcome measure

PFMT data

Control data

Differnce

PFMT versus usual care

Oakley 2016

Health status measure

SF‐12, physical component score (0‐100, 100 better)

Mean 53.51, SD 4.63, n = 27 at 12 weeks postpartum

Mean 53.08, SD 5.92, n = 23 at 12 weeks postpartum

Mean difference 0.43 (95% CI ‐2.55 to 3.41)

SF‐12, mental component score (0‐100, 100 better)

Mean 51.36, SD 7.74, n = 27 at 12 weeks postpartum

Mean 52.79, SD 8.90, n = 23 at 12 weeks postpartum

Mean difference ‐1.43 (95% CI ‐6.09 to 3.23)

Sleep 1987

General wellbeing

5 point Likert scale in response to question "how are you feeling generally?"

11 feeling not very well or not at all well, n = 816 at 3 months postpartum

18 feeling not very well or not at all well, n = 793 at 3 months postpartum

Not calculated as validity/reliability of this measure not known

Figuras y tablas -
Analysis 5.10

Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 10: Other self‐reported well‐being measures

Ir a la figura de la revisión

Pelvic floor muscle function

Study

Outcome measure

PFMT data

Control data

Difference

PFMT plus versus PFMT

Yang 2017

PF muscle strength (Oxford scale) (0‐5, 5 better)

Scored 0 or 1, 0 of 129, scored 2, 1 of 129; scored 3, 15 of 129; scored 4, 68 of 129, scored 5, 45 of 129 at 3 months postpartum

Scored 0 or 1, 0 of 60; scored 2, 21 of 60; scored 3, 28 of 60; scored 4, 10 of 60; scored 5, 1 of 60 at 3 months postpartum

Relative risk, 0; not estimable, 1; not estimable, 2; 0.02 (95% CI 0.00 to 0.16), 3; 0.25 (95% CI 0.14 to 0.43), 4; 3.16 (95% CI 1.76 to 5.70), 5; 20.93 (95% CI 2.95 to 148.27)

Maximal squeeze pressure (cm water)

PFMT only Mean 100.98, SD 15.97, n = 63 add to PFMT + ES Mean 111.75, SD 12.77, n = 69

Combined Mean 106.65, SD 15.30, n = 131

Mean 80.8, SD 16.01, n = 60 at 3 months postpartum

Combined (PFMT) mean difference 25.85 (95% CI 21.03 to 30.67)

PFMT versus no PFMT

Meyer 2001

Strength, vaginal squeeze pressure, in cm water (manometer, 10 months postpartum)

Mean 33, SD 22, n = 51

Mean 41, SD 27, n = 56

Mean difference ‐8.0 (95%CI ‐17.3 to 1.3)

Mean anal squeeze pressure, in cm water (anorectal manometer, 10 months postpartum)

Mean 36, SD 20, n = 51

Mean 43, SD 24, n = 56

Mean difference ‐7.0 (95%CI ‐15.4 to 1.4)

PFMT versus usual care

Hilde 2013

Resting pressure, vaginal squeeze pressure (cm water, manometer)

n = 87 at 6 months postpartum

n = 88 at 6 months postpartum

Mean difference 1.3 (95% CI ‐1.0 to 3.6, p=0.257), reported by authors

Strength, vaginal squeeze pressure (cm water, manometer)

n = 87 at 6 months postpartum

n = 88 at 6 months postpartum

Mean difference 3.3 (95% CI ‐1.4 to 8.0, p=0.172), reported by authors

Endurance, vaginal squeeze pressure (cm sec, manometer)

n = 87 at 6 months postpartum

n = 88 at 6 months postpartum

Mean difference 29.8 (95% CI ‐10.6 to 70.2, p=0.148), reported by authors

Kou 2013

Resting pressure, vaginal squeeze pressure (cm water)

Mean 33.7, SD 15.8, n = 80 at 12 months postpartum

Mean 30.1, SD 15.3, n = 70 at 12 months postpartum

Mean difference 3.60 (95% CI ‐1.38 to 8.58)

Vaginal squeeze pressure (cm water)

Mean 86.5, SD 14.8, n = 80 at 12 months postpartum

Mean 60.4, SD 14.1, n = 70 at 12 months postpartum

Mean difference 26.10 (95% CI 21.47 to 30.73)

Contraction time (sec)

Mean 5.9, SD 2.9, n = 80 at 12 months postpartum

Mean 4.1, SD 2.6, n = 70 at 12 months postpartum

Mean difference 1.80 (95% CI 0.92 to 2.68)

Liu 2011

PF tension (Oxford scale) (0‐5, 5 better)

Mean 3.95, SD 0.32, n = 106 at 3 months postpartum

Mean 3.02, SD 0.28, n = 86 at 3 months postpartum

Mean difference 0.93 (95% CI 0.34 to 1.52)

PF muscle tension (Oxford scale) (0‐5, 5 better)

Mean 4.73, SD 0.35, n = 106 at 6 months postpartum

Mean 3.25, SD 0.41, n = 86 at 6 months postpartum

Mean difference 1.48 (95% CI 1.37 to 1.59)

PF muscle tension (Oxford scale) (0‐5, 5 better)

Mean 4.82, SD 0.38, n = 106 at 12 months postpartum

Mean 3.43, SD 0.39, n = 86 at 12 months postpartum

Mean difference 1.40 (95% CI 1.29 to 1.51)

Oakley 2016

PFMS (Oxford scale) (0‐5, 5 better)

Mean 2.44, SD 0.85, n = 27 at 12 weeks postpartum

Mean 2.09, SD 0.73, n = 23 at 12 weeks postpartum

Mean difference 0.35 (95% CI ‐0.09 to 0.79)

Anal resting maximal pressure (mm Hg, anorectal manometer)

Mean 68.55, SD 38.25, n = 27 at 12 weeks postpartum

Mean 88.67, SD 25.84, n = 23 at 12 weeks postpartum

Mean difference ‐20.12 (95% CI ‐38.00 to ‐2.24)

Anal squeeze maximal pressure (mm Hg, anorectal manometer)

Mean 83.29, SD 47.27, n = 27 at 12 weeks postpartum

Mean 103.77, SD 33.64, n = 23 at 12 weeks postpartum

Mean difference ‐20.48 (95% CI ‐42.99 to 2.03)

Mean anal resting pressure (mm Hg, anorectal manometer)

Mean 52.37, SD 27.41, n = 27 at 12 weeks postpartum

Mean 71.67, SD 21.97, n = 23 at 12 weeks postpartum

Mean difference ‐19.30 (95% CI ‐32.99 to ‐5.61)

Mean anal squeeze pressure (mm Hg, anorectal manometer)

Mean 83.3, SD 38.56, n = 27 at 12 weeks postpartum

Mean 90.43, SD 24.11, n = 23 at 12 weeks postpartum

Mean difference ‐7.13 (95% CI ‐24.70 to 10.44)

Peirce 2013

Mean anal resting pressure (mm Hg, anorectal manometer)

Mean 39, SD 13, n = 30 at 3 months postpartum

Mean 43, SD 17, n = 90 at 3 months postpartum

Mean difference ‐4.00 (95% CI ‐9.83 to 1.83)

Mean anal squeeze pressure (mm Hg, anorectal manometer)

Mean 64, SD 17, n = 30 at 3 months postpartum

Mean 62, SD 23, n = 90 at 3 months postpartum

Mean difference 2.00 (95% CI ‐5.72 to 9.72)

Wen 2010

PFMS (Oxford scale) (0‐5, 5 better)

Mean 3.34, SD 0.35, n = 75 at 6 months postpartum

Mean 3.25, SD 0.41, n = 73 at 6 months postpartum

Mean difference 0.09 (95% CI ‐0.03 to 0.21)

PFMS (Oxford scale) (0‐5, 5 better)

Mean 4.56, SD 0.38, n = 75 at 12 months postpartum

Mean 3.46, SD 0.39, n = 73 at 12 months postpartum

Mean difference 1.10 (95% CI 0.98 to 1.22)

Figuras y tablas -
Analysis 5.11

Comparison 5: Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence, Outcome 11: Pelvic floor muscle function

Ir a la figura de la revisión
Summary of findings 1. Antenatal pelvic floor muscle training compared to control for prevention of urinary and faecal incontinence

Antenatal pelvic floor muscle training compared to control for prevention of urinary and faecal incontinence

Patient or population: pregnant women who were continent when randomised

Setting: hospital or outpatient settings in Canada, Italy, Mexico, Norway, Spain, Thailand, Turkey, UK and USA

Intervention: antenatal PFMT

Comparison: control (no PFMT or usual care)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with antenatal PFMT

Urinary incontinence in late pregnancy

421 per 1000

160 per 1000
(84 to 303)

RR 0.38
(0.20 to 0.72)

624
(6 RCTs)

⊕⊕⊕⊝
MODERATE1

Urinary incontinence mid‐postnatal period
(> 3 to 6 months)

251 per 1000

179 per 1000
(136 to 239)

RR 0.71
(0.54 to 0.95)

673
(5 RCTs)

⊕⊕⊕⊕
HIGH

Urinary incontinence late postnatal period
(> 6 to 12 months)

440 per 1000

528 per 1000
(286 to 972)

RR 1.20
(0.65 to 2.21)

44
(1 RCT)

⊕⊝⊝⊝
LOW2

Faecal incontinence in late pregnancy

‐

‐

‐

(0 studies)

‐

Not reported.

Faecal incontinence mid‐postnatal period
(> 3 to 6 months)

‐

‐

‐

(0 studies)

‐

Not reported.

Faecal incontinence late postnatal period
(> 6 to 12 months)

‐

‐

‐

(0 studies)

‐

Not reported.

Urinary incontinence‐specific quality of life (ICIQ‐SF)
Scale from: 0 to 10 (higher worse)

Mean 2.66, SD 4.1

Mean 0.24, SD 1.2

MD 2.42 lower
(3.32 lower to 1.52 lower)

152
(1 RCT)

⊕⊕⊕⊝
MODERATE3

Measured in the late postnatal period (> 6 to 12 months). Upper and lower limits of the CI of summary statistic suggest clinical importance in ICIQ‐SF (Nyström 2015).

Faecal incontinence‐specific quality of life

‐

‐

‐

(0 studies)

‐

Not reported.

Adverse events

‐

‐

‐

‐

‐

No events reported.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; ICIQ‐SF: International Consultation on Incontinence‐Short Form; MD: mean difference; PFMT: pelvic floor muscle training; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation.

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Downgraded one level for serious inconsistency (substantial statistically significant heterogeneity; I² = 78%).

2Downgraded two levels for very serious imprecision (single, small trial with wide confidence interval, including benefit no effect, and possible harm).

3Downgraded one level for serious imprecision (single trial, fewer than 400 participants).

The outcome measures relate to the presence of incontinence symptoms rather than absence. Symptoms of urinary and faecal incontinence were measured based on self‐report.

Figuras y tablas -
Summary of findings 1. Antenatal pelvic floor muscle training compared to control for prevention of urinary and faecal incontinence
Ir a la tabla de la revisión
Summary of findings 2. Antenatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence

Antenatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence

Patient or population: pregnant women who were incontinent when randomised

Setting: health services or obstetric clinics in Brazil, Canada, the Netherlands and Turkey

Intervention: antenatal PFMT

Comparison: control (usual care)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with antenatal PFMT

Urinary incontinence in late pregnancy

776 per 1000

543 per 1000
(341 to 877)

RR 0.70
(0.44 to 1.13)

345
(3 RCTs)

⊕⊝⊝⊝
VERY LOW1,2,3

Urinary incontinence mid‐postnatal period
(> 3‐6 months)

528 per 1000

496 per 1000
(369 to 654)

RR 0.94
(0.70 to 1.24)

187
(1 RCT)

⊕⊕⊝⊝
LOW4,5

Urinary incontinence late postnatal period
(> 6‐12 months)

232 per 1000

116 per 1000
(30 to 448)

RR 0.50
(0.13 to 1.93)

869
(2 RCTs)

⊕⊝⊝⊝
VERY LOW6,7,8

Faecal incontinence in late pregnancy

‐

‐

‐

(0 studies)

‐

Not reported.

Faecal incontinence mid‐postnatal period
(> 3‐6 months)

‐

‐

‐

(0 studies)

‐

Not reported.

Faecal incontinence late postnatal period
(> 6‐12 months)

‐

‐

‐

(0 studies)

‐

Not reported.

Urinary incontinence‐specific quality of life (ICIQ‐SF)
Scale from: 0 to 10 (higher worse)

Mean 4.7, SD 5.6

Mean 1.2, SD 2.5

MD 3.5 lower
(6.13 lower to 0.87 lower)

41
(1 RCT)

⊕⊕⊕⊝
MODERATE9

Measured in late pregnancy. MD suggests clinically important effect but the upper limit of the CI is close to no effect.

Faecal incontinence‐specific quality of life

‐

‐

‐

(0 studies)

‐

Not reported.

Adverse events

‐

‐

‐

‐

‐

No events reported.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; ICIQ‐SF: International Consultation on Incontinence‐Short Form; MD: mean difference; PFMT: pelvic floor muscle training; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation.

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Downgraded one level due to serious risk of bias (one trial with heavy weighting in the pooled estimate at high risk).

2 Downgraded one level for inconsistency (substantial statistically significant heterogeneity; I² = 71%).

3 Downgraded one level for imprecision (fewer than 400 participants, wide confidence interval).

4Downgraded one level due to serious risk of bias.

5Downgraded one level for imprecision (single trial, fewer than 400 participants).

6Downgraded one level due to very serious risk of bias.

7Downgraded one level for inconsistency (considerable statistically significant heterogeneity; I² = 94%).

8Downgraded one level for imprecision (wide confidence interval).

9Downgraded one level due to serious imprecision (single trial, fewer than 400 participants, wide confidence interval).

The outcome measures relate to the presence of incontinence symptoms rather than absence. As this comparison addresses the effect of PFMT for treatment of existing continence symptoms, the data are "negative," that is continuing incontinence rather than cure. Symptoms of urinary and faecal incontinence were measured based on self‐report.

Figuras y tablas -
Summary of findings 2. Antenatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence
Ir a la tabla de la revisión
Summary of findings 3. Antenatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence

Antenatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence

Patient or population: pregnant women, some of who were incontinent symptoms and some who were not when randomised

Setting: health services, obstetric clinics or hospitals in Brazil, Canada, China, France, Italy, Norway, Poland, UK or USA

Intervention: antenatal PFMT

Comparison: control (no PFMT, usual care or unspecified control)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with antenatal PFMT

Urinary incontinence in late pregnancy

565 per 1000

441 per 1000
(361 to 531)

RR 0.78
(0.64 to 0.94)

3307
(11 RCTs)

⊕⊕⊕⊝
MODERATE1

RR suggests clinically important effect but the upper limit of the CI suggests lack of clinical importance. The substantial statistically significant heterogeneity is more likely due to imprecision in estimating the magnitude, rather than direction of effect, because the upper and lower limits of the CI suggest benefit.

Urinary incontinence mid‐postnatal period
(> 3 to 6 months)

363 per 1000

265 per 1000
(200 to 352)

RR 0.73
(0.55 to 0.97)

1921
(5 RCTs)

⊕⊝⊝⊝
LOW2,3

RR suggests clinically important effect but the upper limit of the CI suggests lack of clinical importance.

Urinary incontinence late postnatal period
(> 6 to 12 months)

448 per 1000

381 per 1000
(282 to 511)

RR 0.85
(0.63 to 1.14)

244
(2 RCTs)

⊕⊕⊕⊝
MODERATE4

Faecal incontinence in late pregnancy

59 per 1000

38 per 1000
(21 to 67)

RR 0.64
(0.36 to 1.14)

910
(3 RCTs)

⊕⊕⊕⊝
MODERATE5

Faecal incontinence mid‐postnatal period
(> 3 to 6 months)

‐

‐

‐

(0 studies)

‐

Not reported.

Faecal incontinence late postnatal period
(> 6 to 12 months)

‐

‐

‐

(0 studies)

‐

Not reported.

Urinary incontinence‐specific quality of life (ICIQ‐SF)
Scale from: 0 to 10 (higher worse)

Mean 2.1, SD 3.3

Mean 1.9, SD 3.7

MD 0.20 lower
(1.2 lower to 0.80 higher)

190
(1 RCT)

⊕⊕⊕⊝
MODERATE6

Measured in the late postnatal period (> 6 to 12 months). MD and CI suggest lack of clinically important effect.

Faecal incontinence‐specific quality of life (CRAIQ‐7)

7 items (higher score worse)

Mean 5, SD 11.7

Mean 2.4, SD 11.3

MD 2.60 lower (7.84 lower to 2.64 higher)

74

(1 RCT)

⊕⊕⊝⊝
LOW7,8

Measured in the early postnatal period (0 to 3 months).

Adverse events

‐

‐

‐

‐

‐

No events reported.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; CRAIQ‐7: Colorectal‐Anal Impact Questionnaire; ICIQ‐SF: International Consultation on Incontinence‐Short Form; MD: mean difference; PFMT: pelvic floor muscle training; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation.

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Downgraded one level due to serious inconsistency (substantial statistically significant heterogeneity; I² = 79%).

2Downgraded one level due to serious risk of selection bias (no information about random allocation concealment in three trials carrying more than 50% of weighting in the pooled estimate).

3Downgraded one level for serious imprecision (substantial statistically significant heterogeneity; I² = 65%).

4 Downgraded one level due to serious imprecision (fewer than 400 participants, wide CI).

5Downgraded one level due to serious imprecision (wide CI that includes appreciable harm and appreciable benefit).

6Downgraded one level due to serious imprecision (fewer than 400 participants, wide CI).

7Downgraded one level due to serious risk of attrition bias.

8Downgraded one level due to serious imprecision (single trial, fewer than 400 participants, wide CI).

The outcome measures relate to the presence of incontinence symptoms rather than absence. For those comparisons that addressed the effect of PFMT for treatment of existing continence symptoms, the data were "negative," that is continuing incontinence rather than cure. Symptoms of urinary and faecal incontinence were measured based on self‐report.

Figuras y tablas -
Summary of findings 3. Antenatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence
Ir a la tabla de la revisión
Summary of findings 4. Postnatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence

Postnatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence

Patient or population: postnatal women who were incontinent when randomised

Setting: health services or obstetric clinics in Canada, Republic of Korea, New Zealand and UK

Intervention: postnatal PFMT

Comparison: control (no PFMT or usual care)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with postnatal PFMT

Urinary incontinence late postnatal period
(> 6 to 12 months)

724 per 1000

398 per 1000
(210 to 775)

RR 0.55
(0.29 to 1.07)

696
(3 RCTs)

⊕⊕⊝⊝
LOW1,2

Faecal incontinence late postnatal period
(> 6 to 12 months)

137 per 1000

93 per 1000
(33 to 266)

RR 0.68
(0.24 to 1.94)

620
(2 RCTs)

⊕⊝⊝⊝
VERY LOW3,4,5

Urinary incontinence‐specific quality of life
(BFLUTS)

34 items (higher score worse)

Mean 21.22, SD 2.11

Mean 19.56, SD 1.88

MD 1.66 lower
(3.51 lower to 0.19 higher)

18
(1 RCT)

⊕⊕⊝⊝
LOW6,7

Measured at 8 weeks' post‐treatment

Faecal incontinence‐specific quality of life

‐

‐

‐

(0 studies)

‐

Not reported

Adverse events

‐

‐

‐

‐

‐

No events reported.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

BFLUTS: British Female Lower Urinary Tract Symptoms questionnaire; CI: confidence interval; MD: mean difference; PFMT: pelvic floor muscle training; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation.

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Downgraded one level due to very serious risk of bias (two trials with 90% of weighting in pooled estimate at high risk).

2Downgraded one level for inconsistency (considerable statistically significant heterogeneity; I² = 90%).

3Downgraded one level due to very serious risk of bias (two trials with 100% of weighting in pooled estimate at high risk).

4Downgraded one level for inconsistency (substantial statistically significant heterogeneity; I² = 74%).

5Downgraded one level for imprecision (wide confidence interval, with appreciable harm and appreciable benefit).

6Downgraded one level due to very serious risk of selection bias.

7Downgraded one level for imprecision (fewer than 400 participants, wide CI).

The outcome measures relate to the presence of incontinence symptoms rather than absence. As this comparison addresses the effect of PFMT for treatment of existing continence symptoms, the data are "negative," that is continuing incontinence rather than cure. Symptoms of urinary and faecal incontinence were measured based on self‐report.

Figuras y tablas -
Summary of findings 4. Postnatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence
Ir a la tabla de la revisión
Summary of findings 5. Postnatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence

Postnatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence

Patient or population: postnatal women some of whom had incontinent symptoms and some of whom had not when randomised

Setting: health services or hospitals in Australia, Brazil, Canada, China and Switzerland

Intervention: postnatal PFMT

Comparison: control (no PFMT or usual care)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control

Risk with postnatal PFMT

Urinary incontinence late postnatal period
(> 6 to 12 months)

294 per 1000

212 per 1000
(115 to 400)

RR 0.88
(0.71 to 1.09)

826
(3 RCTs)

⊕⊕⊕⊝
MODERATE1

Faecal incontinence late postnatal period
(> 6 to 12 months)

54 per 1000

39 per 1000
(7 to 226)

RR 0.73
(0.13 to 4.21)

107
(1 RCT)

⊕⊕⊝⊝
LOW2,3

Urinary incontinence‐specific quality of life

(IIQ‐7)
Scale from: 0 to 100 (higher worse)

Mean 3.2, SD 8.4

Mean 3.7, SD 5.6

MD 0.50 higher
(5.53 lower to 6.53 higher)

23
(1 RCT)

⊕⊕⊝⊝
LOW4,5

Measured after the 16 week intervention.

Faecal incontinence‐specific quality of life

(FIQOL scale)

29 items, 4 domain scores, each item scored 1‐5 (higher better)

‐

‐

‐

170

(2 RCTs)

‐

Measured at 3 months' postpartum. There were no reported differences between the groups in either study.

Adverse events

‐

‐

‐

‐

‐

No events reported.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; FIQOL: Faecal incontinence quality of life; PFMT: pelvic floor muscle training; RCT: randomised controlled trial; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Downgraded one level due to inconsistency (substantial statistically significant heterogeneity; I² = 75%).

2Downgraded one level due to serious risk of selection bias.

3Downgraded one level for imprecision (fewer than 400 participants, wide CI).

4Downgraded one level due to serious risk of selection bias.

5Downgraded one level for imprecision (fewer than 400 participants, wide CI).

The outcome measures relate to the presence of incontinence symptoms rather than absence. For those comparisons that address the effect of PFMT for treatment of existing continence symptoms, the data are "negative," that is continuing incontinence rather than cure. Symptoms of urinary and faecal incontinence were measured based on self‐report.

Figuras y tablas -
Summary of findings 5. Postnatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence
Ir a la tabla de la revisión
Table 1. Pelvic floor muscle training programmes and adherence

Study ID

Voluntary pelvic floor muscle contraction confirmed?

PFMT parameters

PFMT supervision

Control comparison

Adherence

Notes

Ahlund 2013

(treatment trial)

Vaginal palpation performed by study midwife: after randomisation and at each of the 3 visits to midwife (PFMT and control groups).

PFMT started with 3 fast contractions, followed by 3 sets of 8‐12 slow velocity, near maximal contractions, 6‐sec hold; 7 days per week for 6 months. Received written instructions on PFMT, but no information provided on PFMT progression.

Visit to the study midwife every 6th week (3 times during study period).

Usual care: written information describing PFM anatomy and PFMT. Received instructions on how to correctly perform PFM contraction (vaginal palpation) from midwife.

Women in the PFMT group were asked at each midwife visit how often they did PFMT; results not reported.

PFMT in lying or sitting positions.

Assis 2015

(prevention trial)

Perineometry (at 1st meeting), but unclear by whom (PFMT group).

5‐10 slow PFM contractions with 6‐sec hold, rest 6 sec between contractions with 3 rapid contractions at the end (as per Mørkved 2003). Daily PFMT in 4 positions, and 1 group (27 women) had 5 supervised sessions with a physiotherapist. Received manual of home PFMT exercises and asked to complete an exercise diary.

Supervised PFMT (27 women): received up to 5 monthly supervised exercise sessions with physiotherapist (22, 26, 30, 34, 38 weeks' gestation). Unsupervised PFMT (27 women): trained to perform PFMT by physiotherapist (1 session).

Did not receive intervention and did not exercise.

Not reported, although it stated that no dropouts occurred throughout the duration of the study due to all women in the PFMT group complying with the exercise protocol.

PFMT in a variety of positions including left side lying, sitting, reclined sitting, sitting with legs crossed, standing.

Translation (Portuguese).

Barakat 2011

(prevention trial)

Not reported.

PFMT included in the 7‐ to 8‐min cool‐down period as part of a 35‐ to 45‐min exercise session, 3 days per week for duration of pregnancy (potential mean of 85 sessions in total). No specific details provided about PFMT programme.

Group exercise classes, supervised by a qualified fitness specialist, with the assistance of an obstetrician.

Not reported.

Adherence to PFMT was 90%.

General exercises targeted major muscles of arms and abdomen to promote good posture and prevent low back pain, and in the 3rd trimester strengthen the muscles of labour and PF. 1 session of aerobic dance per week. Accompanied by music.

Bø 2011

(mixed prevention and treatment trial)

Participants did not have individual assessment of correct voluntary PFM contraction (due to pragmatic nature of study). Instructors were trained in how to explain a correct PFM contraction.

PFMT included as part of 15‐min strength training session within a 60‐min group exercise class. PFMT: 3 sets of 8‐12 maximal contractions, 6‐ to 8‐sec hold; strong verbal motivation to perform close to maximum PFM contractions. Women encouraged to participate in at least 2 out of 3 fitness classes per week for 12 weeks. Daily PFMT at home: 3 sets of 8‐12 close to maximum PFM contractions. Also encouraged to be physically active for at least 30 min per day. Received a specific PFMT brochure.

Group exercise classes, 2 or 3 per week for 12 weeks, led by certified aerobic instructors. Instructors were taught by a physiotherapist with > 20 years of experience in assessing, treating and researching women with PF dysfunction.

Usual antenatal care.

Mean adherence to exercise classes was 17.2 out of a possible 24 sessions. 40% (21/52) of women attended at least 80% of sessions.

PFMT integrated into aerobic dance class (accompanied by music): 5‐min warm‐up; 30‐min low‐impact aerobics; 15‐min strength training (including PFMT); 5‐min stretching and relaxation.

PFMT in a variety of position including sitting, kneeling and standing. Informed of deep abdominal muscle co‐contraction during maximal PFM contraction.

Chiarelli 2002

(mixed prevention and treatment trial)

Visual inspection of perineum (PFMT group).

Maximum of 6 voluntary PFM contractions per set; 3‐6 sec hold; 3 sets per day; for 8 weeks.

PFMT taught 1‐to‐1 with physiotherapist. 1 (20 min) contact in hospital, and another (30 min) 8 weeks later at home or hospital.

Routine postnatal care; usual postnatal leaflet given; invitation to join postnatal class on ward; no restriction on PFMT if recommended by other health professional.

84% (292/348) of women in the PFMT group and 58% (189/328) of controls were performing PFMT at "adequate" level at 3 months' postpartum.

Women were "asked if they were performing their PF exercises."

Cruz 2014

(treatment trial)

Not reported.

5‐6 biweekly sessions. No specific details provided about PFMT.

Supervised by a physiotherapist.

Similar unsupervised PFMT at home.

Not reported.

Conference abstract.

Dinc 2009

(treatment trial)

Vaginal digital palpation (both PFMT and control groups).

Progressive PFMT programme.

Level 1: 3 sets of 10 near maximal contractions; 3‐sec hold, 3‐sec rest; quick contraction, 1‐sec hold, 1‐sec rest; twice daily. Level 2: 3 sets of 10 near maximal contractions; 5‐sec hold, 5‐sec rest; quick contraction, 2‐sec hold, 2‐sec rest; twice daily. Level 3: 3 sets of 15 near maximal contractions; 10‐sec hold, 10‐sec rest; quick contraction, 2‐sec hold, 2‐sec rest; 3 per day.

Trained by a researcher on how to do PFMT in accordance with booklet of PFM exercises.

Usual care: instructed on how to perform a correct PFM contraction, but did not receive training about exercises.

Not reported.

In 2nd stage of study, 68% of women in study group were contracting the proper muscle group. The rest were given more training and reassessed 1 week later.

Dokmeci 2008

(mixed prevention and treatment trial)

Not reported.

Not reported.

Not reported.

Not reported.

Not reported.

Conference abstract.

Dufour 2019 (mixed prevention and treatment trial)

Vaginal digital palpation (both PFMT and control groups), to instruct and ensure correct performance of PFM contraction. Performed by two of the investigators.

Recommended to undertake 3 sets of 10 exercises, 3‐4 times a week, for the duration of the intervention period (12 to 16 weeks). As per Mørkved et al 2014, but specific PFMT exercises not stated. In addition, used the iBall (a mobile health device) in conjunction with PFMT.

Supervised individual PFMT at initial session. “Booster” email at the mid‐point of the intervention reminding of benefits of postpartum PFMT and features of the iBall.

PFMT only, without the use of the iBall device.

Not reported. Implied within the discussion that there was a lack of adherence.

No information on the specific PMFT exercises and positions these were performed in

Dumoulin 2004

(treatment trial)

Not reported.

8‐12 close to maximal voluntary PFM contraction per set; 6‐ to 8‐sec hold each with 3‐4 fast contractions at the end of each contraction; 6‐sec rest between contractions; 3 sets per day; 5 days per week; for 8 weeks. Also taught 'the knack' (voluntary PFM contraction prior to hard cough and maintained through cough until abdominal wall relaxed).

PFMT taught 1‐to‐1 with physiotherapist.
Weekly physiotherapy appointments for 8 consecutive weeks.

Same number of physiotherapy contacts for relaxation massage of back and extremities; asked not to do PFMT at home.

Not reported.

In addition to PFMT 15 min of electrical stimulation (biphasic rectangular form, 50 Hz, pulse width 250 msec, duty cycle 6 sec on and 18 sec off for 1st 4 weeks, then 8 sec on and 24 sec off for next 4 weeks, at maximal tolerated current intensity) and 25 min of electromyographic biofeedback per appointment.

Ewings 2005

(mixed prevention and treatment trial)

Not reported.

6 months.

PFMT taught 1‐to‐1 with physiotherapist in hospital.
Invitation to attend PFMT class at 2 and 4 months postnatally.

Standard care including verbal promotion of PFMT and leaflet on PFMT.

Of 117 women in the PFMT group, 114 were visited by the physiotherapist in hospital, 21 attended the 2‐month PFMT group, and 5 attended the 4‐month group.

‐

Fritel 2015

(mixed prevention and treatment trial)

Vaginal digital palpation at each session (possibly by physiotherapist, but not stated; PFMT group).

1 session per week (20‐30 min), total of 8 sessions between 6th and 8th month of pregnancy. Also 'the knack' (voluntary PFM contraction prior to increasing intra‐abdominal pressure). Provided with written information on PF anatomy and PFMT, and encouraged to perform daily PFMT at home, 10‐20 contractions.

Individually supervised by a physiotherapist or midwife at each session. In total, 37 different therapists (all trained by the same specialist physiotherapist) were involved in delivering the exercises.

Usual care, including written information on PF anatomy and PFMT (encouraged to perform daily at home, 10‐20 PFM contractions).

69.3% (97/140) of women in the PFMT group completed all planned sessions, and 82.8% (116/140) completed at least 1 session (4‐8, median 8). At the end of pregnancy, women in both groups reported a similar frequency and duration of PFMT (including number of contractions). PFMT was performed daily at home by 4.3% (6/140) of PFMT women and 10.6% (15/142) of controls, at the end of pregnancy.

PFMT performed in standing (5 min) and lying (10 min).

Frost 2014

(mixed prevention and treatment trial)

Not reported.

Standard postpartum discharge instructions plus written and verbal instructions for PFMT.

Not reported.

Standard postpartum discharge instructions.

Not reported.

Conference abstract.

Frumenzio 2012

(mixed prevention and treatment trial)

Not reported.

2 weekly session of Kegel exercises; 8 weeks. Daily home exercises (20 min) and stretching.

Not reported.

Did not receive any PFMT, no other details provided.

Not reported.

Conference abstract.

Gaier 2010

(prevention trial)

Not reported.

12‐week PFMT programme.

PFMT supervised by a physiotherapist and midwife.

Routine care and PFM exercises, customary instruction at intake visit.

Not reported.

Conference abstract.

Glazener 2001

(treatment trial)

Not reported.

8‐10 sessions of fast and slow voluntary PFM contraction per day with aim of 80‐100 per day; for up to 8 months.

PFMT taught 1‐to‐1 with nurse, health visitor or continence advisor.
Visited at home at 5, 7 and 9 months' postnatally.

Usual antenatal and postnatal care that may have included advice on PFMT.

78% (218/278) of women in the PFMT group and 48% (118/244) of controls had done some PFMT in the 11th postnatal month. Mean (SD) number of voluntary PFM contractions per day at 12 months' postnatal: PFMT group 20 (29) and controls 5 (15).

Frequency and urgency strategies added if needed at 7 or 9 months postnatally.

52.7% (394/747) of women at 6 years' follow‐up and 70.1% (471/672) of women at 12 years' follow‐up completed a questionnaire. About 50% of women in PFMT and control groups were performing any PFMT at both time points. Daily PFMT was undertaken by 6% (17/263) of PFMT women compared to 12% (29/253) of control women at 6 years; and 7% (15/227) of PFMT group compared to 8% (20/241) of control women at 12 years.

Gorbea 2004

(prevention trial)

Surface electromyography (electrodes either side of anus; PFMT group).

10 voluntary PFM contraction; 8‐sec hold followed by 3 fast, 1‐sec contractions; 6‐sec rest between contractions; for up to 20 weeks. Asked to complete an exercise diary.

PFMT taught 1‐to‐1 with physiotherapist.
Clinic appointments (1 hour each) weekly for 8 weeks, then weekly telephone calls.

Requested not to do PFMT during pregnancy or postnatally.

63% attended all 8 physiotherapy appointments, 21% attended 7 appointments.

Electromyographic biofeedback at each appointment.

Hilde 2013

(mixed prevention and treatment trial)

Vaginal digital palpation (PFMT and control groups).

Progressive supervised PFM training programme (as per Mørkved 1997) for 16 weeks. Daily PFMT at home, 3 sets of 8‐12 close to maximal contractions. Customary written information on discharge from postnatal ward. Asked to complete an exercise diary.

Supervised exercise class from 6 weeks' postpartum, led by an experienced physiotherapist, once per week for 16 weeks. Class attendance was documented.

Usual care. Received customary written information on discharge from postnatal ward. At 6 weeks were instructed on how to perform a correct PFM contraction (verified with vaginal digital palpation).

96% (72/75) of women in the PFMT group who completed the trial adhered to 80% of the class and daily home training. In the control group (retrospective questioning), 16.5% reported performing daily PFMT at home ≥ 3 times per week.

4% (7/175) of women were unable to perform a voluntary PFM contraction at baseline. At baseline (6 weeks' postpartum) more women in the control group were performing PFMT ≥ 3 times or more per week.

Hughes 2001

(mixed prevention and treatment trial)

Vaginal digital palpation (PFMT and control groups).

Daily; for up to 11 months.

1 individual session with physiotherapist, and 1 group PFMT session led by physiotherapist at 22‐25 weeks' gestation with maximum of 6 women per group.

Usual antenatal and postnatal care that may have included advice on PFMT (personal communication).

79% (461/586) of women in PFMT group attended group PFMT session (personal communication).

3.5% (16/460) of women who attended group PFMT session could not perform a voluntary PFM contraction after teaching, and 2.8% (13/460) of women could contract but not sustain a contraction (personal communication). Conference abstract.

Hyakutake 2018

(mixed prevention and treatment trial)

Not performed.

PFMT 3 times daily at home starting with 5 contractions (1‐sec hold), progressing to 10 contractions (10‐sec hold), for the rest of their lives. Educated on the benefits of PFMT, how to increase awareness of their perineum and perform PFMT. Provided with a take‐home pack and encouraged to contact a local PF physiotherapist.

A single 2‐hour physician‐led pelvic floor workshop.

Routine prenatal care with their existing maternity care provider (midwife, family physician or obstetrician). Not specifically stated but likely to have received advice on PFMT.

58.34% of women in the PFMT group and 22.9% of controls had done PFMT at least daily.

Possible additions to PFMT such as vaginal cones or weights and the use on a mobile app were suggested.

Kim 2012

(treatment trial)

Perineometer (vaginal probe) used to ensure PFM contraction and assess control of contraction in both PFMT and control groups. Unclear if this was performed every session with the PFMT women.

20 maximal voluntary PFM contractions, 10‐sec hold, 3 times per week; for 8 weeks (as part of a class), and daily at home. Progressed by changing position (prone, sitting and standing). Initial session included information on PFM anatomy and function. Also provided with a booklet which included a training programme and an exercise diary.

Supervised training sessions (1‐hour duration) with a specialist physiotherapist (23 in total, unclear if individual contacts or group classes).

Usual care. Received the same information and demonstration session as PFMT group and instructions on how to correctly perform PFM contraction (perineometer). Unsupervised, daily PFMT for 8 weeks.

Not reported.

PFMT integrated with trunk stabilisation exercises (progressive abdominal strengthening, bridging, and side‐bridge).

Ko 2011

(mixed prevention and treatment trial)

Observation of inward movement of perineum during contraction (PFMT group).

3 repetitions of 8 PFM contractions, 6‐sec hold each, 2‐min rest between repetitions; repeated twice daily at home with additional training in groups once per week for 45 min for 12 weeks. Asked to complete an exercise diary.

Group training sessions (10 women) supervised by a physiotherapist once per week for 12 weeks.

Regular antenatal care and the customary written postpartum instructions that did not include PFMT from the hospital.

Not discouraged from performing PFMT on their own.

> 80% attended every training session and 0 were absent more than twice.

At 35 gestational weeks, 87% of PFMT group reported practice of PFMT ≥ 75% of the time.

Group training was performed in sitting and standing positions with legs apart to emphasise specific strength training of the PFM and relaxation of other muscles.

Kocaoz 2013

(prevention trial)

Observation of inward movement of perineum or digital vaginal palpation, or both (PFMT group). Vaginal digital palpation used to teach PFM contraction in 23.5% (16/68) of women.

3 sets of 10 maximal voluntary PFM contractions at level 3 (2‐sec hold, 2‐sec rest for strength; 10‐sec hold, 10‐sec rest for endurance); 3 sessions per day during pregnancy and postpartum. Women received education about the anatomy and functions of the PFM and PFMT (unclear from whom) and were asked to complete an exercise diary (including progressions).

Exercise compliance was checked at every hospital visit (9‐10 visits on average, over a minimum of 12 weeks), and pregnant women were called once per month to encourage regular exercise.

Not instructed to do PFMT. Once data collection complete, controls received PFMT and a brochure with the relevant information during the 12th week home visit.

Women asked to record the number of times they did their exercises. No data reported.

Vaginal digital palpation was refused by 52/68 women due to concerns about pregnancy, cultural/religious reasons. Unclear if women progressed through levels 1‐3 or started at level 3, whether they did 3 sets of 10 exercises per day or 3 sets of 10 exercises 3 times per day, or how the sets were divided between endurance and strength training.

Kou 2013

(mixed prevention and treatment trial)

Not reported.

PFM (Kegel) exercises undertaken 2‐3 times per day for 20‐30 min or 150‐200 contractions (3‐sec hold then relax), performed until 12 months' postpartum. Biofeedback used twice per week (no further details available).

Not reported who supervised the programme, or the number and type of contacts with health professional(s).

Usual care: received standard postpartum information.

Not reported.

Translation (Chinese).

Liu 2011

(mixed prevention and treatment trial)

Not reported.

PFMT 2‐3 times per day, 15‐30 min each set (4‐ to 6‐sec hold, 10‐sec relaxation), started after birth and continued for ≥ 10 weeks.

Exercises taught by experienced midwives who also supervised the programme (number and type of contacts/visits unclear).

Usual care: standard postpartum information. Unclear if this included PFMT.

Not reported.

Translation (Chinese).

Positions of exercises included supine, sitting or any other position, with legs slightly separated, with instructions to contract anus, vaginal and urinary tract while breathing in, and to relax with expiration.

Meyer 2001

(mixed prevention and treatment trial)

Not reported.

Up to 8 months; no details of PFMT provided. Each clinic session was followed by 20 min of biofeedback and 15 min of electrical stimulation.

12 sessions (6 weeks) with a physiotherapist between 2 and 10 months postnatally.

No intervention. Women received PFMT education after 3rd assessment at 10 months' postpartum.

Not reported.

In addition to PFMT, 20 min of biofeedback and 15 min of electrical stimulation (vaginal electrode, biphasic rectangular waveform, pulse width 200‐400 msec, frequency 50 Hz, intensity 15‐15 mA, contraction time 6 sec, rest time 12 sec) per appointment.

Miquelutti 2013

(mixed prevention and treatment trial)

Instructed on correct contraction, but not verified (due to pragmatic nature of study).

PFMT (maximal rapid and sustained PFM contractions) performed as part of a class (50 min) for a median of 5 (range 2‐10) sessions between 18‐24 weeks' to 36‐38 weeks' gestation. Provided with an exercise guide and asked to do daily PFMT at home (30 rapid, 20 sustained (10‐sec hold) contractions), as well as 30‐min daily aerobic exercise (no specific examples provided). Received standard antenatal education and asked to complete an exercise diary.

Supervised by a trained study physiotherapists on a monthly basis. Either group or individual training sessions, depending on the number of women present.

Usual care: received standard antenatal and postnatal education (on labour, breastfeeding and pain relief) by trained physiotherapy, nursing and medial staff.

Analysis of adherence in intervention group was not possible as women failed to complete or return their exercise diaries.

PFMT performed in standing and sitting position. PFMT integrated into non‐aerobic exercise programme designed to reduce back pain. Included abdominal, stretching and relaxation exercises and exercises designed to promote venous return.

Mørkved 2003

(mixed prevention and treatment)

Vaginal digital palpation and observation of perineum (both PFMT and control groups).

8‐12 near maximal voluntary PFM contractions; 6‐ to 8‐sec hold each, 3‐4 fast contractions at the end of each contraction; 6‐sec rest between contractions; twice daily at home; for ≤ 8 months. Also asked to attend weekly 60‐min PFMT class for 12 weeks. Women asked to complete an exercise diary.

Group training session (10‐15 women), once per week for 12 weeks, supervised by physiotherapists (5 in total).

Usual antenatal and postnatal care that may have included advice on PFMT. Correct PFM contraction verified. Not discouraged from doing PFMT on their own.

19% (28/148) of PFMT women attended less than half the 12 weekly PFMT classes and did not return training diaries.

During exercise class voluntary PFM contraction undertaken in a range of body positions (lying, sitting, kneeling and standing with legs apart). PFMT interspersed with abdominal, back and thigh muscle exercises (accompanied by music).

62% (188/280) of women completed a questionnaire at 6‐year follow‐up, and 45% of women in both the former PFMT and control groups were doing PFMT at least weekly.

Oakley 2016

(mixed prevention and treatment trial)

Vaginal digital palpation (both PFMT and control groups), electromyography, and anorectal manometry used to confirm absence or presence of PFM contraction. Performed by two of the investigators.

Four PFMT sessions (60 min), every 2 weeks, beginning at 6 weeks’ postpartum (i.e. weeks 6, 8 10 and 12) combined with behavioural therapy. PF and core muscle neuromuscular, strength and endurance techniques; PF and rectus diastasis protection techniques. Home exercise component, and women also received routine postnatal care with their primary obstetrician and gynaecologist.

Unclear if a group or 1‐to‐1 session.

Usual care, with included routine postnatal care from their see primary obstetrician and gynaecologist.

Not reported

Independent to the study, 54.0% (combined groups) reported not receiving any instructions on PFMT and/or behavioural therapy; 46.0% received behavioural therapy and 16.0% had received instruction on PFMT from other health professionals. No differences were noted between groups.

Peirce 2013

(mixed prevention and treatment trial)

Contraction assessed with anal biofeedback as part of training session (by obstetrician or specialist nurse); PFMT group.

Sets of 10 PFM contractions (Kegel exercises), 5‐sec hold; 10‐sec rest between contractions; twice daily for 5 min with biofeedback; for 3 months. Standard postpartum education by midwives or physiotherapists, including written information. Women asked to complete an exercise diary.

Biofeedback (electromyographic) training provided at initial session, but no further contact with health professionals.

Usual care: "conventional PFM training," but no details provided. Women asked to complete an exercise diary.

Poor adherence defined as performing < 70% of the intended home exercise sessions. 7/30 women in the PFMT group reported poor adherence.

The portable biofeedback machines were programmed to the electromyography setting with the work period set to 10 contractions (5‐sec duration) with a 10‐sec rest between each contraction. PFMT for treatment of FI.

Pelaez 2014

(prevention trial)

Instructed on correct contraction, but not formally verified. Women were asked to test themselves at home by stopping the flow of urine, vaginal digital palpation or using a mirror to observe the perineum (PFMT group).

PFMT programme, 3 times per week; for ≥ 22 weeks. Started with 1 set of 8 contractions increasing to 100; divided into different sets of slow (6 sec) and fast (5 as fast as possible) contractions. Unclear if this progression related to class or home exercises. Daily PFMT at home, 100 contractions in different sets. Received standard antenatal education about PFM.

Group training sessions (8‐12 women) designed and supervised by a physical activity and sport sciences graduate; 55‐ to 60‐min duration (10 min of PFMT); 70‐78 sessions in total.

Usual care: follow‐up by midwives, standard information about PFMT. Women were not asked not to do PFMT.

All women included in analysis attended ≥ 80% of exercise sessions.

PFMT integrated into supervised exercise programme; 30 min low‐impact aerobics including general strength training, PFMT and cool down (stretching, relaxation or massage); sometimes accompanied by music. PFMT in a variety of positions. Women wore heart rate monitors to control exercise intensity.

Reilly 2002

(prevention trial)

Unclear, but seems likely as physiotherapists gave individualised programmes to those unable to follow exercise regimen due to inability to do voluntary PFM contraction (PFMT group).

8‐12 voluntary PFM contractions; 6‐sec hold each; 2‐min rest between each set of contractions; 3 sets of 8‐12 contractions twice daily; for about 20 weeks (as described by Bø 1995).
Also asked to do voluntary PFM contraction with every cough and sneeze, and complete an exercise diary.

About 5 (monthly) contacts with physiotherapist between 20 weeks' gestation and delivery.

Usual antenatal and postnatal care that may have included advice on PFMT. Women appeared to have had same number of clinic visits as the PFMT group, and were asked if doing PFMT at each of these visits.

43% (52/120) of women in the PFMT group did not return an exercise diary; 11% (13/120) completed < 28 days of PFMT; and 46% (55/120) completed ≥ 28 days. When asked postnatally, 28% (33/120) of PFMT women and 34% (37/110) of controls were doing occasional or no PFMT.

If unable to follow PFMT regimen then individualised programme until able to do so.

71% (164/230) of women completed a telephone questionnaire at 8‐year follow‐up, and 68.4% of women were doing PFMT, with 38% stating they were doing PFMT twice or more per week.

Sacomori 2019

(mixed prevention and treatment trial)

Assessed PFM muscles using visual inspection (PFMT group).

PFMT at home, 10 sets of up to 10‐sec holds (contraction starts lightly and intensifies until a maximal contraction is reached) [Strength and endurance]. Five (1 sec) fast and strong contractions [Strength]. Also taught to perform the “knack”, before and during a sneeze or cough. PFMT performed twice daily at home. Received verbal and written educational information about PF anatomy, physiology, PF dysfunction and PFMT.

One 1‐to‐1 session with a “pelvic floor specialist” who “was certified to participate in the study only after demonstrating total competence and understanding of the execution of PFM assessment and PFMT”.

No PFMT. Women did not receive any kind of intervention or PFMT as this is usual clinical practice in Brazil.

55 (85.1%) women reported overall adherence to PFMT.
22 (32.3%) performed exercises 1‐2 times per week and 33 (49.3%) did so 3‐7 times per week.
33 (49.3%) performed both strength and endurance training, 14 (20.9%) only strength training and 10 (14.9%) focused only on endurance training.
21 (31.3%) performed PFMT for 3 months postpartum, others for around 2 months
38 (39.2%) multiparous and 23 (31.9%) primiparous women adhered to PFMT

Researchers made up to ten attempts to contact participants by phone for follow‐up at 3 months’ postpartum.

Sampselle 1998

(mixed prevention and treatment trial)

Yes, but unclear how or by whom (PFMT group).

PFMT tailored to individual ability. 30 maximal or near maximal voluntary PFM contraction per day; for ≤ 17 months.

Not reported.

Usual antenatal and postnatal care; no systematic PFMT programme.

At 35 weeks' gestation, 85% of women in the PFMT group reported to be doing PFMT 75% of the time. At 1 year, PFMT adherence reported to vary between 62% and 90%.

‐

Sangsawang 2016

(treatment trial)

Assessed by ability to stop or slow the flow of urine for 1‐2 sec (PFMT group).

20 sets of PFM exercises, twice daily, at least 5 days per week, for 6 weeks. 1 set of PFM exercises was 1 slow contraction (10‐sec hold), followed by 10 fast contractions; no progression in number of contractions per set. Also received a handbook with information on stress UI, PFM function, instructions on PFMT and a urinary diary.

Supervised group sessions (4‐5 women) with a midwife; 45 min; once every 2 weeks for 6 weeks (3 sessions in total).

Usual care: from health professionals, obstetricians or midwives. Did not receive information about UI and received no training support about performing correct PFM exercises.

No women were excluded for failing to perform the PFMT for < 28 (of approximately 42) days.

PFMT performed in various positions including lying down, sitting and standing.

Skelly 2004

(treatment trial)

Not reported.

Not reported.

"One to one teaching about pelvic floor exercises."

"Conventional care (hand‐out information about pelvic muscle exercises)."

Not reported.

Conference abstract.

Sleep 1987

(mixed prevention and treatment trial)

Not reported.

As for controls with additional section in leaflet recommending a specific exercise each week that integrated voluntary PFM contraction with usual activities of daily living; up to 3 months. Asked to complete a daily exercise diary for 4 weeks.

1‐to‐1 session with midwife co‐ordinator each postnatal day in hospital.

Usual antenatal and postnatal care including PFMT leaflet; might include PFMT at antenatal class or postnatal class on ward (or both); instructed to do voluntary PFM contraction as often as remembered and mid‐stream urine stop.

At 10 days postnatally, 78% of PFMT group and 68% of controls were doing some PFMT; with 58% of PFMT group and 42% of controls doing some PFMT at 3 months.

‐

Stafne 2012

(mixed prevention and treatment trial)

Vaginal digital palpation (PFMT group).

8‐12 near maximal voluntary PFM contractions; 6‐ to 8‐sec hold each with 3 fast contractions at the end of each contraction. Asked to perform PFM exercises as part of a 45‐min home programme at least twice per week or a weekly 60‐min exercise class (or both). Received written information including brochure with an evidence‐based PFMT programme, and asked to complete an exercise diary.

Group training sessions (8‐15 women) supervised by physiotherapist, 60 min, once per week for 12 weeks

Usual care: received customary information from midwife or GP. Also given a detailed information brochure including evidence‐based PFMT programme. Women were not discouraged from exercising.

Adherence to the general exercise protocol (exercising ≥ 3 days per week, moderate to high intensity) was 55% (217/397) in the PFMT group and 10% (36/365) in the control group. 67% of the PFMT group performed PFMT ≥ 3 times per week compared to 40% in the control group

PFMT integrated into standardised exercise programme: 30‐ to 35‐min low‐impact aerobics; 20‐ to 25‐min strengthening exercises (including PFMT, 3 sets of 10 reps); 5‐ to 10‐min stretching and relaxation. PFMT performed in a variety of positions, with legs apart to emphasise specific strengthening of the PFM.

Stothers 2002

(prevention trial)

Not reported.

12 contractions, 3 times daily.

Seen twice monthly throughout pregnancy, and every 3 months postnatally for 1 year.

"Other (placebo) including no pelvic floor exercises."

Not reported.

Conference abstract.

Sut 2016 (mixed prevention and treatment trial)

Not reported. Instructions provided on how to perform exercises but did not report if correct performance of contractions were confirmed.

Home PFMT programme. Instructed to contract PFM by “pulling inward as with urine or gas output” and hold for 10 sec. Then relax completely after 10sec of contraction. Three sets of 10 exercises, 3 times daily at home.

Participants instructed by a researcher on how to perform Kegel exercises. Participants in the PFMT group were called by telephone at two‐week intervals to remind to perform exercises.

No intervention: “no instruction was given to the patients in the control group”.

Not reported

Participants instructed that bladder must be emptied prior to exercise, with exercises done in supine or sitting (bending the legs at the knee).

Szumilewicz 2019 (mixed prevention and treatment trial)

Correct contraction confirmed by EMG biofeedback (PFMT groups).

Progressive PFMT for 5‐10 min as part of strength training within a 60‐min group exercise class. Week 1 (quick flicks): 5 x 10 short contractions with 30‐sec rest between sets (5 min).
Week 2 (stacking): a/a but each repetition contains 3 increasingly stronger contractions. Week 3 (endurance): a/a, maintaining a sustained hold and gradually extending from 3 to 10 sec), before slowly relaxing, 3 x 10, 30‐sec rest between sets (10 min). Week 4 (high‐intensity): a/a, maintaining hold until feeling tired, then 3 x 5 pulsating ticks before relaxing. 5 repetitions max hold, 10 sec between repetitions, 30 sec between sets.
Week 5 (complex activation): 5 quick maximal contractions, with 5‐sec rest between contractions, 5 repetitions, (10‐sec hold, 10 sec pause) sustained for 60 sec then relax. 3 times, 30‐sec rest between sets. Week 6 (maintenance): performance of regular tasks as for week 4. 5 repetitions in series, with 10‐sec rest between, maintenance of maximal hold (> 10 sec) Extended with short pulsating contractions, at least 2 sets with 30‐sec rest between sets. Women encouraged to attend 3 sessions per week for 6 weeks.

Supervised exercise sessions led by a certified pregnancy and postnatal exercise specialist whose competencies met the European educational standard for this profession. The principle researcher checked the quality of exercise programme implementation once every 2 weeks.

No PFMT.

Email and phone contact were used to ensure adherence. The exercise specialist checked and registered attendance for each session. “On average,
women from the experimental group attended 13±3 exercise
sessions (from a maximum of 18), which constituted 71±19% of the planned exercise program.”

“During the study, participants were lying supine with hips flexed and knees bent to approximately 90°

Torsdatter Markussen 2017

(mixed prevention and treatment trial)

Digital vaginal palpation to ensure correct PFM contraction by a gynaecologist, and instruction provided on correct PFM contraction (PFMT and control groups).

PFMT included as part of resistance training (25 min) within a 60‐min group exercise class or individual session. PFMT consisted of 3 x 10 reps of 6‐8 sec sustained maximum contractions, followed by 3‐5 quick contractions, with 1 min rest between sets. Women encouraged to attend 3 sessions per week from study inclusion to delivery, and to do the same programme at home at least once per week, and daily home PFMT (same parameters as above). All were invited to attend a 30 min motivational interview session at the beginning of the training period and received a standardised pamphlet containing general advice including PFMT

Supervised by a physiotherapist.

Usual care which consisted of 8 routine prenatal visits to midwife and/or general practitioner and a routine ultrasound at 8 weeks. Women were not told to restrain from exercise, physical activity or PFMT. Received standardised pamphlet containing general advice including PFMT.

Performance of home PFMT ≥ 3 times per week:
70% (n= 14) of PFMT and 52% (n = 12) of control women at late pregnancy; 50% (n =9) of PFMT and 41% (n = 9) of control women at 3 months’ postpartum.
Median number of PFM contractions daily was 20 (min‐max 0‐80) in the PFMT group, and 12.5 (min‐max 3‐60) in the control group at 3 months’ postpartum.

PFMT could be performed in standing, kneeling on all fours or sitting (based on personal preference, progression of skill or improved strength).
Women were instructed to “pull up and hold the pelvic floor, hold, hold, hold! Release slowly”.

Wen 2010

(mixed prevention and treatment trial)

Assessment of PFM strength and contraction by an obstetrician (PFMT group; no further details)

Anal contraction; 3‐sec hold (while inhaling) followed by relaxation with 3‐5 faster contractions at the end of each contraction; 15‐30 min each set; twice daily; 6‐8 weeks.

Exercises taught by experienced midwives but unclear who supervised the programme of the number and type of contacts/visits.

Usual care: no other details provided other than "conventional guidance."

Not reported.

PFMT performed in a variety of positions including lying down, sitting or standing.

Translation (Chinese).

Wilson 1998

(treatment trial)

Not reported.

Mix of fast and slow voluntary PFM contractions 8‐10 times per day with aim of 80‐100 voluntary PFM contraction daily; up to 9 months.

1‐to‐1 sessions with physiotherapist at 3, 4, 6 and 9 months postnatally.

Usual PFMT as taught in antenatal and postnatal classes.

Mean (95% CI) number of daily voluntary PFM contraction at 12 months' postnatally was 86 (69‐104) in the PFMT group and 35 (30 to 40) in the control group.

Perineometry for biofeedback at each appointment.

Mean time to teach PFMT to the PFMT group was 32 (95% CI 30 to 34) min.

Woldringh 2007 (treatment trial)

Observation and palpation of perineal body by physiotherapists. Women also encouraged to practice self‐palpation (PFMT group).

Not reported. At each visit, women were asked about the frequency and duration of PFMT.

1‐to‐1 30‐min sessions with physiotherapist. 4 in total: 3 antenatally and 1 at 6 weeks postnatally. In total, 25 physiotherapists (specialised in PFMT) were involved in delivering the exercises.

Usual antenatal and postnatal care including advice on PFMT; nearly two‐thirds received some instruction on PFMT.
Women were also asked the same questions about frequency and duration of PFMT as the PFMT group

At 35 weeks' gestation, 6% reported no PFMT, 17% reported some PFMT, 40% were doing PFMT at low intensity and 37% were exercising intensively in the PFMT group vs 36% reported no PFMT, 25% reported some PFMT, 26% were doing PFMT at low intensity and 14% were exercising intensively in the control group.

‐

Yang 2017

(mixed prevention and treatment trial)

Digital vaginal palpation to ensure correct PFM contraction (PFMT group).

PFMT (1): PFMT performed at home, 2‐3 times per day, as described by Jonasson and colleagues 1989. Instructed to shrink hypogastria, perineum and anal muscles for 5 sec while inhaling; relax while exhaling for 5 sec.
PFMT (2): In addition to PFMT, this group also received electrical stimulation for 30 min, 3 times per week beginning at 6 weeks’ postpartum (approximately 15 sessions in total).

PFMT (1): One 1‐to‐1 PFMT at 2 days’ postpartum, taught by specialised staff members (each training session went for 20 min with the exercises performed 6 times per min).
PFMT (2): As above plus 1‐to‐1 supervised sessions of electrical stimulation with specialised training staff.

No PFMT, unclear if instructed not to perform PFMT. At 2 hours postpartum, two specialised training staff provided 1 hour of routine postpartum guidance.

Three cases failed to complete the PFMT in accordance with the prescribed frequency and timing in the training group.

Kegel exercises were performed in supine, legs unbent, hands placed at sides.

CI: confidence interval; FI: faecal incontinence; min: minute; PF: pelvic floor; PFM: pelvic floor muscle; PFMT: pelvic floor muscle training; SD: standard deviation; sec: second; UI: urinary incontinence.

Figuras y tablas -
Table 1. Pelvic floor muscle training programmes and adherence
Ir a la tabla de la revisión
Comparison 1. Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1.1 Urinary incontinence in late pregnancy Show forest plot

6

624

Risk Ratio (M‐H, Random, 95% CI)

0.38 [0.20, 0.72]

1.1.1 PFMT versus no PFMT

2

174

Risk Ratio (M‐H, Random, 95% CI)

0.14 [0.01, 2.04]

1.1.2 PFMT versus usual care

4

450

Risk Ratio (M‐H, Random, 95% CI)

0.44 [0.22, 0.91]

1.2 Urinary incontinence early postnatal period (0‐3 months) Show forest plot

5

439

Risk Ratio (M‐H, Random, 95% CI)

0.38 [0.17, 0.83]

1.2.1 PFMT versus no PFMT

2

174

Risk Ratio (M‐H, Random, 95% CI)

0.27 [0.11, 0.67]

1.2.2 PFMT versus usual care

2

198

Risk Ratio (M‐H, Random, 95% CI)

0.30 [0.04, 2.31]

1.2.3 PFMT versus unspecified control

1

67

Risk Ratio (M‐H, Random, 95% CI)

0.88 [0.43, 1.79]

1.3 Urinary incontinence mid‐postnatal period (> 3‐6 months) Show forest plot

5

673

Risk Ratio (M‐H, Fixed, 95% CI)

0.71 [0.54, 0.95]

1.3.1 PFMT versus no PFMT

1

86

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.35, 2.20]

1.3.2 PFMT versus usual care

4

587

Risk Ratio (M‐H, Fixed, 95% CI)

0.70 [0.52, 0.94]

1.4 Urinary incontinence late postnatal period (> 6‐12 months) Show forest plot

1

44

Risk Ratio (M‐H, Fixed, 95% CI)

1.20 [0.65, 2.21]

1.4.1 PFMT versus usual care

1

44

Risk Ratio (M‐H, Fixed, 95% CI)

1.20 [0.65, 2.21]

1.5 Urinary incontinence long term (> 5 years) Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.5.1 PFMT versus usual care

2

352

Risk Ratio (M‐H, Fixed, 95% CI)

1.07 [0.77, 1.48]

1.6 Urinary incontinence‐specific quality of life Show forest plot

1

152

Mean Difference (IV, Fixed, 95% CI)

‐2.42 [‐3.32, ‐1.52]

1.6.1 PFMT versus usual care

1

152

Mean Difference (IV, Fixed, 95% CI)

‐2.42 [‐3.32, ‐1.52]

1.7 Severity of incontinence Show forest plot

7

Other data

No numeric data

1.7.1 PFMT versus no PFMT

1

Other data

No numeric data

1.7.2 PFMT versus usual care

5

Other data

No numeric data

1.7.3 PFMT versus unspecified control

1

Other data

No numeric data

1.8 Loss of urine under stress test late pregnancy Show forest plot

1

102

Risk Ratio (M‐H, Random, 95% CI)

0.36 [0.19, 0.70]

1.8.1 PFMT versus no PFMT

1

102

Risk Ratio (M‐H, Random, 95% CI)

0.36 [0.19, 0.70]

1.9 Loss of urine under stress test early postnatal period (0‐3 months) Show forest plot

3

322

Risk Ratio (M‐H, Fixed, 95% CI)

0.35 [0.17, 0.75]

1.9.1 PFMT versus no PFMT

2

174

Risk Ratio (M‐H, Fixed, 95% CI)

0.09 [0.02, 0.47]

1.9.2 PFMT versus usual care

1

148

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.33, 2.29]

1.10 Other self‐reported well‐being measures Show forest plot

2

Other data

No numeric data

1.10.2 PFMT versus usual care

1

Other data

No numeric data

1.10.3 PFMT versus unspecified control

1

Other data

No numeric data

1.11 Delivery outcome: caesarean section Show forest plot

3

373

Risk Ratio (M‐H, Fixed, 95% CI)

1.28 [0.89, 1.85]

1.11.1 PFMT versus no PFMT

1

76

Risk Ratio (M‐H, Fixed, 95% CI)

1.83 [1.07, 3.15]

1.11.2 PFMT versus usual care

1

230

Risk Ratio (M‐H, Fixed, 95% CI)

1.24 [0.66, 2.36]

1.11.3 PFMT versus unspecified control

1

67

Risk Ratio (M‐H, Fixed, 95% CI)

0.68 [0.29, 1.57]

1.12 Delivery outcome: other Show forest plot

4

Other data

No numeric data

1.12.1 PFMT versus no control

1

Other data

No numeric data

1.12.2 PFMT versus usual care

2

Other data

No numeric data

1.12.3 PFMT versus unspecified control

1

Other data

No numeric data

1.13 Pelvic floor muscle function Show forest plot

3

Other data

No numeric data

1.13.1 PFMT versus no PFMT

1

Other data

No numeric data

1.13.2 PFMT versus usual care

2

Other data

No numeric data
Figuras y tablas -
Comparison 1. Antenatal pelvic floor muscle training (PFMT) versus control for prevention of incontinence
Ir a la tabla de la revisión
Comparison 2. Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

2.1 Urinary incontinence late pregnancy Show forest plot

3

345

Risk Ratio (M‐H, Random, 95% CI)

0.70 [0.44, 1.13]

2.1.1 PFMT vs usual care

3

345

Risk Ratio (M‐H, Random, 95% CI)

0.70 [0.44, 1.13]

2.2 Urinary incontinence early postnatal period (0‐3 months) Show forest plot

2

292

Risk Ratio (M‐H, Random, 95% CI)

0.75 [0.37, 1.53]

2.2.1 PFMT versus usual care

2

292

Risk Ratio (M‐H, Random, 95% CI)

0.75 [0.37, 1.53]

2.3 Urinary incontinence mid‐postnatal period (> 3‐6 months) Show forest plot

1

187

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.70, 1.24]

2.3.1 PFMT versus usual care

1

187

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.70, 1.24]

2.4 Urinary incontinence late postnatal period (> 6‐12 months) Show forest plot

2

869

Risk Ratio (M‐H, Random, 95% CI)

0.50 [0.13, 1.93]

2.4.1 PFMT versus usual care

2

869

Risk Ratio (M‐H, Random, 95% CI)

0.50 [0.13, 1.93]

2.5 Urinary incontinence‐specific quality of life Show forest plot

1

41

Mean Difference (IV, Fixed, 95% CI)

‐3.50 [‐6.13, ‐0.87]

2.5.1 PFMT versus usual care

1

41

Mean Difference (IV, Fixed, 95% CI)

‐3.50 [‐6.13, ‐0.87]

2.6 Severity of incontinence Show forest plot

1

Other data

No numeric data

2.6.1 PFMT versus usual care

1

Other data

No numeric data

2.7 Self‐reported measures of pelvic floor dysfunction Show forest plot

1

Other data

No numeric data

2.7.1 PFMT versus usual care

1

Other data

No numeric data

2.8 Pelvic floor muscle function Show forest plot

1

Other data

No numeric data

2.8.1 PFMT versus usual care

1

Other data

No numeric data
Figuras y tablas -
Comparison 2. Antenatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence
Ir a la tabla de la revisión
Comparison 3. Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

3.1 Urinary incontinence late pregnancy Show forest plot

11

3307

Risk Ratio (M‐H, Random, 95% CI)

0.78 [0.64, 0.94]

3.1.1 PFMT versus no PFMT

3

484

Risk Ratio (M‐H, Random, 95% CI)

0.43 [0.08, 2.37]

3.1.2 PFMT versus usual care

8

2823

Risk Ratio (M‐H, Random, 95% CI)

0.84 [0.73, 0.96]

3.2 Urinary incontinence early postnatal period (0‐3 months) Show forest plot

6

806

Risk Ratio (M‐H, Fixed, 95% CI)

0.83 [0.71, 0.99]

3.2.1 PFMT versus no PFMT

1

300

Risk Ratio (M‐H, Fixed, 95% CI)

0.72 [0.51, 1.02]

3.2.2 PFMT versus usual care

4

413

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.74, 1.24]

3.2.3 PFMT versus unspecified control

1

93

Risk Ratio (M‐H, Fixed, 95% CI)

0.77 [0.61, 0.97]

3.3 Urinary incontinence mid‐postnatal period (> 3‐6 months) Show forest plot

5

1921

Risk Ratio (M‐H, Random, 95% CI)

0.73 [0.55, 0.97]

3.3.1 PFMT versus no PFMT

1

300

Risk Ratio (M‐H, Random, 95% CI)

0.60 [0.38, 0.92]

3.3.2 PFMT versus usual care

3

1528

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.65, 1.11]

3.3.3 PFMT versus unspecified control

1

93

Risk Ratio (M‐H, Random, 95% CI)

0.42 [0.20, 0.86]

3.4 Urinary incontinence late postnatal period (> 6‐12 months) Show forest plot

2

244

Risk Ratio (M‐H, Fixed, 95% CI)

0.85 [0.63, 1.14]

3.4.1 PFMT versus usual care

2

244

Risk Ratio (M‐H, Fixed, 95% CI)

0.85 [0.63, 1.14]

3.5 Urinary incontinence long term (> 5 years) Show forest plot

1

188

Risk Ratio (M‐H, Fixed, 95% CI)

1.38 [0.77, 2.45]

3.5.1 PFMT versus usual care

1

188

Risk Ratio (M‐H, Fixed, 95% CI)

1.38 [0.77, 2.45]

3.6 Faecal incontinence late pregnancy Show forest plot

3

910

Risk Ratio (M‐H, Fixed, 95% CI)

0.64 [0.36, 1.14]

3.6.1 PFMT versus usual care

3

910

Risk Ratio (M‐H, Fixed, 95% CI)

0.64 [0.36, 1.14]

3.7 Faecal incontinence early postnatal period (0‐3 months) Show forest plot

2

130

Risk Ratio (M‐H, Fixed, 95% CI)

0.76 [0.34, 1.70]

3.7.1 PFMT versus usual care

2

130

Risk Ratio (M‐H, Fixed, 95% CI)

0.76 [0.34, 1.70]

3.8 Urinary incontinence‐specific quality of life late pregnancy Show forest plot

3

584

Std. Mean Difference (IV, Random, 95% CI)

‐0.02 [‐0.35, 0.31]

3.8.1 PFMT versus no PFMT

2

360

Std. Mean Difference (IV, Random, 95% CI)

0.06 [‐0.66, 0.78]

3.8.2 PFMT versus usual care

1

224

Std. Mean Difference (IV, Random, 95% CI)

‐0.05 [‐0.31, 0.21]

3.9 Urinary incontinence‐specific quality of life early postnatal period (0‐3 months) Show forest plot

4

645

Std. Mean Difference (IV, Random, 95% CI)

‐0.24 [‐0.67, 0.20]

3.9.1 PFMT versus no PFMT

2

360

Std. Mean Difference (IV, Random, 95% CI)

‐0.25 [‐1.28, 0.77]

3.9.2 PFMT versus usual care

2

285

Std. Mean Difference (IV, Random, 95% CI)

‐0.18 [‐0.41, 0.05]

3.10 Urinary incontinence‐specific quality of life mid postnatal period (> 3‐6 months) Show forest plot

1

300

Mean Difference (IV, Random, 95% CI)

‐0.79 [‐1.27, ‐0.31]

3.10.1 PFMT versus no PFMT

1

300

Mean Difference (IV, Random, 95% CI)

‐0.79 [‐1.27, ‐0.31]

3.11 Urinary incontinence‐specific quality of life late postnatal period (> 6‐12 months) Show forest plot

1

190

Mean Difference (IV, Fixed, 95% CI)

‐0.20 [‐1.20, 0.80]

3.11.1 PFMT versus usual care

1

190

Mean Difference (IV, Fixed, 95% CI)

‐0.20 [‐1.20, 0.80]

3.12 Faecal incontinence‐specific quality of life early postnatal period (0‐3 months) Show forest plot

1

74

Mean Difference (IV, Random, 95% CI)

‐2.60 [‐7.84, 2.64]

3.12.1 PFMT versus usual care

1

74

Mean Difference (IV, Random, 95% CI)

‐2.60 [‐7.84, 2.64]

3.13 Severity of incontinence Show forest plot

4

Other data

No numeric data

3.13.3 PFMT versus no PFMT

1

Other data

No numeric data

3.13.4 PFMT versus usual care

3

Other data

No numeric data

3.14 Loss of urine under stress test early postnatal period (0‐3 months) Show forest plot

1

Other data

No numeric data

3.14.2 PFMT versus usual care

1

Other data

No numeric data

3.15 Self‐reported measures of pelvic floor dysfunction Show forest plot

8

Other data

No numeric data

3.15.3 PFMT versus no PFMT

3

Other data

No numeric data

3.15.4 PFMT versus usual care

4

Other data

No numeric data

3.15.5 PFMT versus unspecified control

1

Other data

No numeric data

3.16 Other self‐reported well‐being measures Show forest plot

3

Other data

No numeric data

3.16.4 PFMT versus usual care

3

Other data

No numeric data

3.17 Delivery outcome: caesarean section Show forest plot

8

2030

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.77, 1.08]

3.17.1 PFMT versus no PFMT

2

360

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.71, 1.28]

3.17.2 PFMT versus usual care

6

1670

Risk Ratio (M‐H, Fixed, 95% CI)

0.89 [0.73, 1.10]

3.18 Delivery outcome: other Show forest plot

6

Other data

No numeric data

3.18.3 PFMT versus no PFMT

1

Other data

No numeric data

3.18.4 PFMT versus usual care

5

Other data

No numeric data

3.19 Pelvic floor muscle function Show forest plot

7

Other data

No numeric data

3.19.1 PFMT versus no PFMT

3

Other data

No numeric data

3.19.2 PFMT versus usual care

3

Other data

No numeric data

3.19.3 PFMT versus unspecified control

1

Other data

No numeric data
Figuras y tablas -
Comparison 3. Antenatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence
Ir a la tabla de la revisión
Comparison 4. Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

4.1 Urinary incontinence late postnatal period (> 6‐12 months) Show forest plot

3

696

Risk Ratio (M‐H, Random, 95% CI)

0.55 [0.29, 1.07]

4.1.1 PFMT versus no PFMT

1

62

Risk Ratio (M‐H, Random, 95% CI)

0.29 [0.18, 0.47]

4.1.2 PFMT versus usual care

2

634

Risk Ratio (M‐H, Random, 95% CI)

0.80 [0.61, 1.06]

4.2 Urinary incontinence long term (> 5‐10 years) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.2.1 PFMT versus usual care

1

516

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.88, 1.05]

4.3 Urinary incontinence very long term (> 10 years) Show forest plot

1

471

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.94, 1.12]

4.3.1 PFMT versus usual care

1

471

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.94, 1.12]

4.4 Faecal incontinence late postnatal period (> 6‐12 months) Show forest plot

2

620

Risk Ratio (M‐H, Random, 95% CI)

0.68 [0.24, 1.94]

4.4.1 PFMT versus usual care

2

620

Risk Ratio (M‐H, Random, 95% CI)

0.68 [0.24, 1.94]

4.5 Faecal incontinence long term (> 5‐10 years) Show forest plot

1

509

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.60, 1.50]

4.5.1 PFMT versus usual care

1

509

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.60, 1.50]

4.6 Faecal incontinence very long term (> 10 years) Show forest plot

1

468

Odds Ratio (M‐H, Fixed, 95% CI)

1.36 [0.84, 2.22]

4.6.1 PFMT versus usual care

1

468

Odds Ratio (M‐H, Fixed, 95% CI)

1.36 [0.84, 2.22]

4.7 Urinary incontinence‐specific quality of life Show forest plot

1

18

Mean Difference (IV, Fixed, 95% CI)

‐1.66 [‐3.51, 0.19]

4.7.1 PFMT versus usual care

1

18

Mean Difference (IV, Fixed, 95% CI)

‐1.66 [‐3.51, 0.19]

4.8 Severity of incontinence Show forest plot

5

Other data

No numeric data

4.8.1 PFMT versus no PFMT

1

Other data

No numeric data

4.8.2 PFMT versus usual care

4

Other data

No numeric data

4.9 Self‐reported measures of pelvic floor dysfunction Show forest plot

1

Other data

No numeric data

4.10 Other self‐reported well‐being measures Show forest plot

1

Other data

No numeric data

4.11 Pelvic floor muscle function Show forest plot

4

Other data

No numeric data

4.11.1 PFMT versus no PFMT

1

Other data

No numeric data

4.11.2 PFMT versus usual care

3

Other data

No numeric data
Figuras y tablas -
Comparison 4. Postnatal pelvic floor muscle training (PFMT) versus control for treatment of incontinence
Ir a la tabla de la revisión
Comparison 5. Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

5.1 Urinary incontinence early postnatal period (0‐3 months) Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

5.1.1 PFMT versus no PFMT

2

321

Risk Ratio (M‐H, Fixed, 95% CI)

0.54 [0.44, 0.66]

5.2 Urinary incontinence mid‐postnatal period (> 3‐6 months) Show forest plot

5

2800

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.75, 1.19]

5.2.1 PFMT versus usual care

5

2800

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.75, 1.19]

5.3 Urinary incontinence late postnatal period (> 6‐12 months) Show forest plot

3

826

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.71, 1.09]

5.3.1 PFMT versus no PFMT

1

107

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.31, 2.21]

5.3.2 PFMT versus usual care

2

719

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.71, 1.10]

5.4 Faecal incontinence early postnatal period (0‐3 months) Show forest plot

1

1609

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.51, 1.67]

5.4.1 PFMT versus usual care

1

1609

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.51, 1.67]

5.5 Faecal incontinence late postnatal period (> 6‐12 months) Show forest plot

1

107

Risk Ratio (M‐H, Fixed, 95% CI)

0.73 [0.13, 4.21]

5.5.1 PFMT versus no PFMT

1

107

Risk Ratio (M‐H, Fixed, 95% CI)

0.73 [0.13, 4.21]

5.6 Urinary incontinence‐specific quality of life Show forest plot

1

23

Mean Difference (IV, Fixed, 95% CI)

0.50 [‐5.53, 6.53]

5.6.1 PFMT plus versus PFMT

1

23

Mean Difference (IV, Fixed, 95% CI)

0.50 [‐5.53, 6.53]

5.7 Severity of incontinence Show forest plot

7

Other data

No numeric data

5.7.1 PFMT versus no PFMT

2

Other data

No numeric data

5.7.2 PFMT versus usual care

5

Other data

No numeric data

5.8 Loss of urine under stress test postpartum Show forest plot

3

512

Risk Ratio (M‐H, Fixed, 95% CI)

0.83 [0.60, 1.13]

5.8.1 PFMT versus no PFMT

1

189

Risk Ratio (M‐H, Fixed, 95% CI)

0.53 [0.28, 0.98]

5.8.2 PFMT versus usual care

2

323

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.67, 1.40]

5.9 Self‐reported measures of pelvic floor dysfunction Show forest plot

8

Other data

No numeric data

5.9.1 PFMT plus versus PFMT

2

Other data

No numeric data

5.9.2 PFMT versus no PFMT

3

Other data

No numeric data

5.9.3 PFMT versus usual care

3

Other data

No numeric data

5.10 Other self‐reported well‐being measures Show forest plot

2

Other data

No numeric data

5.10.1 PFMT versus usual care

2

Other data

No numeric data

5.11 Pelvic floor muscle function Show forest plot

8

Other data

No numeric data

5.11.1 PFMT plus versus PFMT

1

Other data

No numeric data

5.11.2 PFMT versus no PFMT

1

Other data

No numeric data

5.11.3 PFMT versus usual care

6

Other data

No numeric data
Figuras y tablas -
Comparison 5. Postnatal pelvic floor muscle training (PFMT) versus control for (mixed) prevention or treatment of incontinence
Ir a la tabla de la revisión