Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women

E. Jean C Hay‐Smith; Roselien Herderschee; Chantale Dumoulin; G Peter Herbison

doi:10.1002/14651858.CD009508

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Figure 1

Study flow diagram.

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Figure 2

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Analysis 1.1

Comparison 1 More versus less contact with health professionals, Outcome 1 Patients' perception of change in incontinence ‐ not cured.

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Analysis 1.2

Comparison 1 More versus less contact with health professionals, Outcome 2 Patients' perception of change in incontinence ‐ not improved.

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Study	QoL measurement	Measure	More health professional contact	Less health professional contact	Difference
Additional group supervision (with no difference in PFMT)
Diniz Zanetti 2007	Incontinence ‐ Quality of Life (I‐QoL) (Note: higher score = better quality of life)	Median	89, n = 23	79, n = 21	Not estimable
Felicissimo 2010	International Consultation on Incontinence Questionnaire ‐ short form (ICIQ‐SF) (Note: lower score = better quality of life)	Median (IQR)	8 (5 to 13), n = 29	8 (6 to 12), n = 30	Not estimable

Analysis 1.3

Comparison 1 More versus less contact with health professionals, Outcome 3 Incontinence specific quality of life.

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Study	Symptom distress measurement	Measure	More health professional contact	Less health professional contact	Difference
Additional group supervision (with no difference in PFMT)
Bø 1990	Social Activity Index	Mean (95% CI)	9.3 (9.0 to 9.6), n = ?	Not stated	Not estimable
Konstantinidou 2007	(unvalidated) "Quality of life index" (7‐item Likert response to "How would you feel if you had to spend the rest of your life with the same urinary problem?) (Note: lower score = better quality of life)	Mean (SD)	1.7 (0.8) n = 12	3.6 (1.5) n = 10	MD (95% CI) ‐1.90 (‐2.93 to ‐0.87)
Additional phone calls (with no difference in PFMT)
Ng 2008	Symptom Impact Index translated into Mandarin. Individual comparisons between groups of each item: a) Worried about smell b) Worried about wet clothes c) Worried that pad will leak d) Worried that pad will be obvious e) Affects holidays/recreation f) Affects family life g) Affects social activities h) Affects interests/hobbies i) Affects sex life j) Affects sexual activity k) Leakage restricts activity	Odds ratio (95% CI for difference)			a) 0.67 (0.44 to 1.04) b) 0.57 (0.36 to 0.92) c) 0.58 (0.37 to 0.88) d) 0.85 (0.56 to 1.30) e) 0.92 (0.57 to 1.50) f) 0.96 (0.5 to 1.83) g) 0.79 (0.48 to 1.30) h) 0.85 (0.53 to 1.37) i) 0.62 (0.34 to 1.13) j) 0.52 (0.29 to 0.95) k) 0.86 (0.51 to 1.44)
Individual supervision versus no supervision (difference in PFMT)
Hung 2010	Chinese version of the Symptom Impact Index. Number of participants who responded "sometimes", "often" or "always" to the following items: a) avoiding activities due to worry about leaking b) avoiding activities due to needing a toilet	a) Number out of total b) Number out of total	a) 8 of 31 b) 7 of 31	a) 15 of 31 b) 16 of 31	RR (95% CI) a) 0.53 (0.27 to 1.07) b) 0.44 (0.21 to 0.91)

Analysis 1.4

Comparison 1 More versus less contact with health professionals, Outcome 4 Symptom impact.

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Analysis 1.5

Comparison 1 More versus less contact with health professionals, Outcome 5 Frequency of leakage ‐ leakage episodes in 24 hours.

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Study	Outcome	Measure	More health professional contact	Less health professional contact	Difference
Additional group supervision (with no difference in PFMT)
Bø 1990	1. Urinary leakage index. Total score /5 2. Urinary leakage index. Number of women for each item who did not have reduced leakage with: a) walking b) walking downhill c) jumping d) running e) lifting	1. Mean 2. Number out of total	1. Not reported 2. n = 23 a) 13 b) 15 c) 6 d) 6 e) 8	1. 1.9, n = ? 2. n = 29 a) 15 b) 18 c) 16 d) 17 e) 18	1. Not estimable 2. RR (95% CI) a) 1.09 (0.66 to 1.81) b) 1.05 (0.70 to 1.59) c) 0.47 (0.22 to 1.01) d) 0.45 (0.21 to 0.94) e) 0.56 (0.30 to 1.05)

Analysis 1.6

Comparison 1 More versus less contact with health professionals, Outcome 6 Frequency of leakage ‐ other measures.

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Study	Pad or towel test	Measure	More health professional contact	Less health professional contact	Difference
Additional group supervision (with no difference in PFMT)
Bø 1990	90‐second pad test with standardised bladder volume	Mean pad weight gain in grams (95% CI)	7.1(0.8 to 13.4), n = 23?	22 (9.1 to 34.9), n = 29?	MD (95% CI) ‐14.90 (‐29.24 to ‐0.56)
Diniz Zanetti 2007	1‐hour pad test	Median pad weight gain in grams	3.2, n = 23	15, n = 21	Not estimable
Felicissimo 2010	24‐hour pad test a) Pad weight gain 24 hours b) Negative pad test (< 2 g)	a) Median pad weight in grams (IQR) b) Number out of total	a) 3.2 (1.2 to 8), n = 29 b) 11 of 29	a) 2.8 (1.5 to 8.5), n = 30 b) 10 of 30	a) Not estimable b) RR (95% CI) 1.14 (0.57 to 2.26)
Konstantinidou 2007	24‐ hour pad test. Positive pad test (> 4 g)	Number out of total	2 of 6	4 of 4	RR (95% CI) 0.40 (0.14 to 1.12)
Individual versus no supervision (with difference in PFMT)
Hung 2010	20‐minute pad test with standardised bladder volume a) pad weight gain b) no leakage on pad test	a) median pad weight in grams (IQR) b) number out of total	a) 0 (0 to 0) b) 21 of 31	a) 0 (0 to 0.5) b) Not stated	a) Not estimable b) Not estimable

Analysis 1.7

Comparison 1 More versus less contact with health professionals, Outcome 7 Amount of leakage ‐ pad, paper towel and cough tests.

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Study	Leakage severity	Measure	More health professional contact	Less health professional contact	Difference
Additional group supervision (with no difference in PFMT)
Konstantinidou 2007	Wet underwear	Number out of total	0 of 12	3 of 10	RR (95% CI) 0.12 (0.01 to 2.09)
Konstantinidou 2007	Number of pads in 24 hours	Mean (SD)	0.8 (0.1), n = 12	2.4 (1.3), n = 10	MD (95% CI) ‐1.60 (‐2.41 to ‐0.79)

Analysis 1.8

Comparison 1 More versus less contact with health professionals, Outcome 8 Amount of leakage ‐ other measures.

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Study	Outcome	Measure	More health professional contact	Less health professional contact	Difference
Additional group supervision (with no difference in PFMT)
Diniz Zanetti 2007	Voids in 24 hours	Median	1.0, n = 23	10.0, n = 21	Not estimable
Konstantinidou 2007	Voids in 24 hours	Mean (SD)	6.9 (0.7), n = 12	7.3 (0.7), n = 10	MD (95% CI) ‐0.40 (‐0.99 to 0.19)
Konstantinidou 2007	Nocturia	Number out of total	1 of 12	5 of 10	RR (95% CI) 0.17 (0.02 to 1.20)
Additional phone calls (with no difference in PFMT)
Ng 2008	BFLUTS, 2 items asking if a) symptoms of frequency b) symptoms of nocturia	OR (95% CI)			a) 0.57 (0.35 to 0.95), n = 68 b) 0.52 (0.30 to 0.93), n = 68
Individual versus no supervision (with difference in PFMT)
Hung 2010	Voids per day	Median (IQR)	8.7 (6.7 to 10.7), n = 31	9.0 (6.6 to 10.0), n = 29	Not estimable

Analysis 1.9

Comparison 1 More versus less contact with health professionals, Outcome 9 Voiding frequency.

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Study	Assessment of PFM performance	Measure	More health professional contact	Less health professional contact	Difference
Additional group supervision (with no difference in PFMT)
Bø 1990	Vaginal squeeze pressure (unit of pressure not stated)	Mean (SDI)	22.5 (11.7) n = 23?	15.3 (9.1) n = 29?	MD (95% CI) 7.20 (1.38 to 13.02)
Felicissimo 2010	Digital vaginal palpation (Oxford scale 1 to 5)	Median (IQR)	3 (3 to 4) n = 29	3 (2 to 4) n = 30	Not estimable
Konstantinidou 2007	Weak contraction hold with cough	Number out of total	7 of 10	4 of 12	RR (95% CI) 0.48 (0.19 to 1.17)
Konstantinidou 2007	Digital vaginal palpation (Oxford scale 1 to 5)	Mean (SD)	3.6 (0.5), n = 12	3.1 (0.3), n = 10	MD (95% CI) 0.50 (0.16 to 0.84)
Konstantinidou 2007	Digital vaginal palpation a) endurance, (in seconds?) b) number of repetitions c) number of fast contractions	Mean (SD)	a) 6.3 (1.5) b) 6.5 (1.2) c) 11.7 (2.6) n = 12	a) 4.2 (1.6) b) 4.0 (0.5) c) 8.0 (3.3) n = 10	MD (95% CI) a) 2.10 (0.79 to 3.41) b) 2.50 (1.75 to 3.25) c) 3.70 (1.18 to 6.22)
Individual versus no supervision (with difference in PFMT)
Hung 2010	Vaginal squeeze pressure a) maximal pressure (cm H₂O). b) hold (seconds)	Mean (SD)	a) 31.5 (17.7), n=31 b) 11.0 (5.9), n=31	a) 30.6 (17.5), n=29 b) 11.4 (5.7), n=29	MD [95% CI] a) 0.90 [‐8.01, 9.81] b) ‐0.40 [‐3.34, 12.54]

Analysis 1.10

Comparison 1 More versus less contact with health professionals, Outcome 10 PFM performance.

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Study	Treatment adherence	Measure	More health professional contact	Less health professional contact	Difference
Additional group supervision (with no difference in PFMT)
Bø 1990	Compliance (training diary)	Percentage	'close to 100%'	'close to 100%'	Not estimable
Felicissimo 2010	Number of times exercised per week	Median (IQR)	4 (2 to 6.5), n = 29	5 (2 to 6), n = 30	Not estimable
Individual versus no supervision (with difference in PFMT)
Hung 2010	Clinic attendance.	Number who attended all 8 visits.	21 of 31	Not applicable as no scheduled visits	Not estimable

Analysis 1.11

Comparison 1 More versus less contact with health professionals, Outcome 11 Treatment adherence.

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Study	Outcome	Measure	More health professional contact	Less health professional contact	Difference
Additional group supervision (with no difference in PFMT)
Bø 1990	Data at 15 years follow‐up Frequency of leakage ‐ other measures: Urinary Leakage Index	Mean (SD)	2.0 (0.5), n = ?	1.96 (0.9), n = ?	Not estimable
Bø 1990	Data at 5 years follow‐up Symptom impact: Social Activity Index	Mean (95% CI)	9.1 (8.61 to 9.56), n = 20	No data	Not estimable
Bø 1990	Data at 5 years follow‐up Treatment adherence: exercising > 2 times a week	Number out of total	13 of 23	No data	Not estimable
Bø 1990	Data at 5 years follow‐up PFM performance: vaginal squeeze pressure	Mean (95% CI)	19.1 (13.2 to 24.9), n = 20	No data	Not estimable
Bø 1990	Data at 5 years follow‐up Frequency of leakage ‐ other measures: Urinary leakage index	Mean (95% CI)	2.1 (1.11 to 2.44), n = 20	No data	Not estimable
Bø 1990	Data at 5 years follow‐up Amount of leakage ‐ pad, paper towel and cough test: 90 second pad test.	Mean pad weight in grams (95% CI)	9 (2 to 21), n= 20	No data	Not estimable

Analysis 1.12

Comparison 1 More versus less contact with health professionals, Outcome 12 Follow‐up data.

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Analysis 2.1

Comparison 2 Group versus individual supervision of PFMT, Outcome 1 Patients' perception of change in incontinence ‐ not cured.

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Analysis 2.2

Comparison 2 Group versus individual supervision of PFMT, Outcome 2 Patients' perception of change in incontinence ‐ not improved.

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Study	QoL measurement	Measure	Group supervision	Individual supervision	Difference
Individual supervision only versus individual and group supervision (no difference in PFMT)
Felicissimo 2010	ICIQ‐SF	Median (IQR)		8 (6 to 12) n = 31	Not estimable
Konstantinidou 2007	Quality of life index (7‐item Likert response to "How would you feel if you had to spend the rest of your life with the same urinary problem?) (Note: lower score = better quality of life)	Mean (SD)	1.7 (0.8) n = 12	3.6 (1.5) n = 10	MD (95% CI) ‐1.90 (‐2.93 to ‐0.87)
Individual supervision only versus group supervision only (with difference in PFMT)
de Oliveira 2009	King's Health Questionnaire (KHQ) a) general health b) incontinence impact c) physical activity limitation d) physical limitation e) social limitation f) personal relationships g) emotions h) sleep/energy i) severity (Note: lower score = better quality of life)	Mean (SD)	a) 39.2 (21.5) b) 20.0 (25.7) c) 3.3(8.1) d) 4.4 (11.5) e) 0.7 (2.8) f) 0 (0) g) 5.6 (19.3) h) 7.2 (17.9) i) 15.3 (20.3) n = 30	a) 37.5 (20.5) b) 13.3 (24.1) c) 10.6 (17.8) d) 10.6 (11.5) e) 3.7 (10.2) f) 2.3 (7.8) g) 4.8 (11.6) h) 4.4 (10.7) i) 14.4 (20.3) n = 30	MD (95% CI) a) 1.70 (‐8.93 to 12.33) b) 6.70 (‐5.91 to 19.31) c) ‐7.30 (‐14.30 to ‐0.30) d) ‐6.20 (‐12.02 to ‐0.38) e) ‐3.00 (‐6.78 to 0.78) f) Not estimable g) 0.80 (‐7.26 to 8.86) h) 2.80 (‐4.66 to 10.26) i) 0.90 (‐9.37 to 11.17)
Liebergall 2005	Incontinence Quality of Life (I‐Qol) a) change in total score b) change in domain: avoidance and limiting behaviours c) change in domain: psychosocial impact d) change in domain: social embarrassment (Note: higher score = better quality of life)	Mean (SD)	a) ‐4.6 (69.0) b) 9.5 (27.4) c) ‐24.9 (168.0) d) 9.3 (13.0) n= 29	a) 8.6 (18.8) b) 9.8 (17.3) c) 4.6 (29.2) d) 14.0 (23.0) n= 30	MD (95% CI) a) ‐13.20 (‐39.20 to 12.80) b) ‐0.30 (‐12.04 to 11.44) c) ‐34.50 (‐96.53 to 27.53) d) ‐4.70 (‐14.19 to 4.79)
Liebergall 2009	Incontinence Quality of Life (I‐Qol) a) total score b) improvement (Note: higher score = better quality of life)	a) Mean (SD) b) mean change (SD)	a) 78.1 (17.6), n=123 b) 9.8 (19.8)	a) 83.1 (15.1), n=117 b) 10.8 (19.3)	MD (95% CI) a) ‐5.00 (‐9.14 to ‐0.86) b) ‐1.00 (‐5.95 to 3.95)

Analysis 2.3

Comparison 2 Group versus individual supervision of PFMT, Outcome 3 Incontinence‐ specific quality of life.

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Study	Symptom distress measurement	Measure	Group supervision	Individual supervision	Difference
Individual supervision only versus individual and group supervision (no difference in PFMT)
Bø 1990	Social Activity Index	Mean (95% CI)	9.3 (9.0 to 9.6), n = ?	Not stated	Not estimable
Konstantinidou 2007	[unvalidated] "Quality of life index" (7‐item Likert response to "How would you feel if you had to spend the rest of your life with the same urinary problem?) (Note: lower score = better quality of life)	Mean (SD)	1.7 (0.8) n = 12	3.6 (1.5) n = 10	MD (95% CI) ‐1.90 (‐2.93 to ‐0.87)

Analysis 2.4

Comparison 2 Group versus individual supervision of PFMT, Outcome 4 Symptom impact.

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Analysis 2.5

Comparison 2 Group versus individual supervision of PFMT, Outcome 5 Frequency of leakage ‐ leakage episodes in 24 hours.

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Study	Outcome	Measure	Group supervision	Individual supervision	Difference
Individual supervision only versus individual and group supervision (no difference in PFMT)
Bø 1990	1. Urinary leakage index. Total score /5. 2. Urinary leakage index. Number of women for each item who had reduced leakage with: a) walking b) walking downhill c) jumping d) running e) lifting	1. Mean 2. Number out of total	1. Not reported 2. n = 23 a)13 b) 15 c) 6 d) 6 e) 8	1. 1.9, n = ? 2. n = 29 a) 15 b) 18 c) 16 d) 17 e) 18	1. Not estimable 2. RR (95% CI) a) 1.09 (0.66 to 1.81) b) 1.05 (0.70 to 1.59) c) 0.47 (0.22 to 1.01) d) 0.45 (0.21 to 0.94) e) 0.56 (0.30 to 1.05)
Individual supervision only versus group supervision only (with difference in PFMT)
Liebergall 2009	Leakage frequency weekly or more	Number out of total	61 of 87?	65 of 96?	RR (95% CI) 1.04 (0.85 to 1.26)

Analysis 2.6

Comparison 2 Group versus individual supervision of PFMT, Outcome 6 Frequency of leakage ‐ other measures.

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Study	Pad or towel test	Measure	Group supervision	Individual supervision	Difference
Individual supervision only versus individual and group supervision (no difference in PFMT)
Bø 1990	90‐second pad test with standardised bladder volume	Mean pad weight gain in grams (95% CI)	7.1(0.8 to 13.4), n = 23?	22 (9.1 to 34.9), n = 29?	MD (95% CI) ‐14.90 (‐29.24 to ‐0.56)
Felicissimo 2010	24‐hour pad test. a) Pad weight gain 24 hours b) Negative pad test (< 2 g)	a) Median pad weight in grams (IQR) b) Number out of total	a) 3.2 (1.2 to 8), n = 29 b) 11 of 29	a) 2.8 (1.5 to 8.5), n = 30 b) 10 of 30	a) Not estimable b) RR (95% CI) 1.14 (0.57 to 2.26)
Konstantinidou 2007	24‐hour pad test. Positive pad test (> 4 g)	Number out of total	2 of 6	4 of 4	RR (95% CI) 0.40 (0.14 to 1.12)
Individual supervision only versus group supervision only (with difference in PFMT)
de Oliveira 2009	1 hour pad test with standardised bladder volume a) Pad weight gain in grams. b) Negative pad test (< 2 g)	a) Mean (SD) b) Number out of total	a) 1.9 (3.5), n = 30 b) 14 of 30	a) 0.6 (1.4), n = 30 b) 16 of 30	a) MD (95%‐ CI) 1.30 (‐0.05 to 2.65) b) RR (95% CI) 0.88 (0.53 to 1.45)
Liebergall 2005	1 hour pad test. Change in grams.	Mean (SD)	9.5 (16.0) n = 29	5.4 (8.8) n = 30	MD (95% CI) 4.10 (‐2.52 to 10.72)
Liebergall 2009	1 hour pad test. a) Pad weight gain in grams b) Change in pad test c) Pad test no "cure" (< 1 g)	a) Mean (SD) b) Mean change (SD) c) Number out of total	a) 3.0 (7.2), n = 84? b) 8.9 (18.2 ), n = 84? c) 42 of 84	a) 2.8 (4.3), n = 92? b) 7.9 (11.7 ), n = 92? c) 32 of 92	MD (95% CI) a) 0.20 (‐1.57 to 1.97) b) 1.00 (‐3.57 to 5.57) c) RR (95% CI) 1.44 (1.01 to 2.04)

Analysis 2.7

Comparison 2 Group versus individual supervision of PFMT, Outcome 7 Amount of leakage ‐ pad, paper towel and cough tests.

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Study	Outcome	Measure	Group supervision	Individual supervision	Difference
Individual supervision only versus individual and group supervision (no difference in PFMT)
Konstantinidou 2007	Wet underwear	Number out of total	0 of 12	3 of 10	RR (95% CI) 0.12 (0.01 to 2.09)
Konstantinidou 2007	Number of pads in 24 hours	Mean (SD)	0.8 (0.1), n = 12	2.4 (1.3), n = 10	MD (95% CI) ‐1.60 (‐2.41 to ‐0.79)
Individual supervision only versus group supervision only (with difference in PFMT)
Liebergall 2009	Leakage amount moderate or more	Number out of total	25 of 87?	17 of 96?	RR (95% CI) 1.62 (0.94 to 2.79)

Analysis 2.8

Comparison 2 Group versus individual supervision of PFMT, Outcome 8 Amount of leakage ‐ other measures.

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Study	Outcome	Measure	Group supervision	Individual supervision	Difference
Individual supervision only versus individual and group supervision (no difference in PFMT)
Konstantinidou 2007	Nocturia	Number out of total	1 of 12	5 of 10	RR (95% CI) 0.17 (0.02 to 1.20)
Konstantinidou 2007	Voids in 24 hours	Mean (SD)	6.9 (0.7), n = 12	7.3 (0.7), n = 10	MD (95% CI) ‐0.40 (‐0.99 to 0.19)
Individual supervision only versus group supervision only (with difference in PFMT)
Liebergall 2009	Nocturia (voiding once a night or more)	Number of total	43 of 87?	47 of 96?	RR (95% CI) 1.01 (0.75 to 1.36)

Analysis 2.9

Comparison 2 Group versus individual supervision of PFMT, Outcome 9 Voiding frequency.

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Study	Outcome	Measure	Group supervision	Individual supervision	Difference
Individual supervision only versus individual and group supervision (no difference in PFMT)
Bø 1990	Vaginal squeeze pressure (unit of pressure not stated)	Mean (SDI)	22.5 (11.7) n = 23?	15.3 (9.1) n = 29?	MD (95% CI) 7.20 (1.38 to 13.02)
Felicissimo 2010	Digital vaginal palpation (Oxford scale 1 to 5)	Median (IQR)	3 (3 to 4) n = 29	3 (2 to 4) n = 30	Not estimable
Konstantinidou 2007	Digital vaginal palpation a) endurance, (in seconds?) b) number of repetitions c) number of fast contractions	Mean (SD)	a) 6.3 (1.5) b) 6.5 (1.2) c) 11.7 (2.6) n = 12	a) 4.2 (1.6) b) 4.0 (0.5) c) 8.0 (3.3) n = 10	MD (95% CI) a) 2.10 (0.79 to 3.41) b) 2.50 (1.75 to 3.25) c) 3.70 (1.18 to 6.22)
Konstantinidou 2007	Weak contraction hold with cough	Number out of total	7 of 10	4 of 12	RR (95% CI) 0.48 (0.19 to 1.17)
Konstantinidou 2007	Digital vaginal palpation (Oxford scale 1 to 5)	Mean (SD)	3.6 (0.5), n = 12	3.1 (0.3), n = 10	MD (95% CI) 0.50 (0.16 to 0.84)
Individual supervision only versus group supervision only (with difference in PFMT)
de Oliveira 2009	Digital vaginal palpation (Oxford scale 1 to 5)	Mean (SD)	3.6 (0.8), n = 30	4.3 (0.7), n = 30	MD (95% CI) ‐0.70 (‐1.08 to ‐0.32)
Liebergall 2005	Vaginal squeeze pressure (in cm H₂0)	Mean change (SD)	0.14 (3.9), n = 29	‐0.02 (7.4), n = 30	MD (95% CI) 0.16 (‐2.84 to 3.16)

Analysis 2.10

Comparison 2 Group versus individual supervision of PFMT, Outcome 10 PFM performance.

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Study	Outcome	Measure	Group supervision	Individual supervision	Difference
Individual supervision only versus individual and group supervision (no difference in PFMT)
Bø 1990	Compliance (training diary)	Percentage	'close to 100%'	'close to 100%'	Not estimable
Felicissimo 2010	Number of times exercised per week	Median (IQR)	4 (2 to 6.5), n = 29	5 (2 to 6), n = 30	Not estimable
Individual supervision only versus group supervision only (with difference in PFMT)
de Oliveira 2009	Not clear. Exercise or attendance for clinic visits?	Percentage	95%	90%	Not estimable
Liebergall 2009	a) participated in < 50% of prescribed supervised sessions b) did not attend any supervision sessions c) documented no exercise at home	Number out of total	a) 16 of 84 b) 11 of 84 c) 100 of 123	a) 6 of 92 b) 12 of 92 c) 86 of 117	RR (95% CI) a) 2.92 (1.20 to 7.12) b) 1.00 (0.47 to 2.15) c) 1.11 (0.96 to 1.27)

Analysis 2.11

Comparison 2 Group versus individual supervision of PFMT, Outcome 11 Treatment adherence.

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Study	Outcome	Measure	Group supervision	Individual supervision	Difference
More group contact versus less individual contact
Bø 1990	Data at 15 years follow‐up Frequency of leakage ‐ other measures: urinary Leakage Index	Mean (SD)	2.0 (0.5), n=?	1.96 (0.9), n=?	Not estimable
Bø 1990	Data at 5 years follow‐up Frequency of leakage ‐ other measures: urinary leakage index	Mean (95% CI)	2.1 (1.11 to 2.44), n = 20	No data	Not estimable
Bø 1990	Data at 5 years follow‐up Symptom impact: Social Activity Index	Mean (95% CI)	9.1 (8.61 to 9.56), n = 20	No data	Not estimable
Bø 1990	Data at 5 years follow‐up PFM performance: vaginal squeeze pressure	Mean (95% CI)	19.1 (13.2 to 24.9), n = 20	No data	Not estimable
Bø 1990	Data at 5 years follow‐up Treatment adherence: exercising > 2 times a week	Number out of total	13 of 23	No data	Not estimable
Bø 1990	Data at 5 years follow‐up Amount of leakage ‐ pad, paper towel and cough test: 90‐second pad test.	Mean pad weight in grams (95% CI)	9 (2 to 21), n = 20	No data	Not estimable

Analysis 2.12

Comparison 2 Group versus individual supervision of PFMT, Outcome 12 Follow‐up data.

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Analysis 3.1

Comparison 3 Direct versus indirect methods of PFMT, Outcome 1 Patients' perception of change in incontinence ‐ not cured.

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Analysis 3.2

Comparison 3 Direct versus indirect methods of PFMT, Outcome 2 Patients' perception of change in incontinence ‐ not improved.

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Study	Outcome	Measure	Direct PFMT	Indirect PFMT	Difference
PFMT versus sham or imitation PFMT
Ghoniem 2005	Incontinence Quality of Life (I‐QoL) (Note: higher score = better quality of life)	Median % increase	7.8	4.8	Not estimable
PFMT versus 'Paula method'
Liebergall 2005	Incontinence Quality of Life (I‐Qol) a) change in total score b) change in domain: avoidance and limiting behaviours c) change in domain: psychosocial impact d) change in domain: social embarrassment (Note: higher score = better quality of life)	Mean (SD)	a) ‐4.6 (69.0) b) 9.5 (27.4) c) ‐24.9 (168.0) d) 9.3 (13.0) n = 29	a) 8.6 (18.8) b) 9.8 (17.3) c) 4.6 (29.2) d) 14.0 (23.0) n = 30	MD (95% CI) a) ‐13.20 (‐39.20 to 12.80) b) ‐0.30 (‐12.04 to 11.44) c) ‐34.50 (‐96.53 to 27.53) d) ‐4.70 (‐14.19 to 4.79)
Liebergall 2009	Incontinence Quality of Life (I‐Qol) a) total score b) improvement (Note: higher score = better quality of life)	a) Mean (SD) b) mean change (SD)	a) 78.1 (17.6), n = 123 b) 9.8 (19.8)	a) 83.1 (15.1), n = 117 b) 10.8 (19.3)	MD (95% CI) a) ‐5.00 (‐9.14 to ‐0.86) b) ‐1.00 (‐5.95 to 3.95)
PFMT versus Pilates
Savage 2005	King's Health Questionnaire (KHQ) 'symptom severity scores'.	Mean (range)	5.5 (2 to 9), n = 5	3.5 (1 to 6), n = 6	Not estimable
Savage 2005	King's Health Questionnaire (KHQ) a) 'composite score' b) change (Note: lower score = better quality of life)	Mean (range)	a) 152.4 (83.82 to 197.2), n = 5 b) ‐36.1	a) 256.9 (147.2 to 416.6), n = 6 b) ‐89.73	a) Not estimated because this measure does not have a total score. b) Not estimable

Analysis 3.3

Comparison 3 Direct versus indirect methods of PFMT, Outcome 3 Incontinence specific quality of life.

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Study	Outcome	Measure	Direct PFMT	Indirect PFMT	Difference
PFMT versus 'Sapsford' approach
Hung 2010	Chinese version of the Symptom Impact Index. Number of participants who responded "never" to the following items: a) avoiding activities due to worry about leaking b) avoiding activities due to needing a toilet	a) Number out of total b) Number out of total	a) 15 of 31 b) 16 of 31	a) 8 of 31 b) 7 of 31	RR (95% CI) a) 1.88 (0.93 to 3.77) b) 1.43 (0.62 to 3.27)

Analysis 3.4

Comparison 3 Direct versus indirect methods of PFMT, Outcome 4 Symptom impact.

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Study	Outcome	Measure	Direct PFMT	Indirect PFMT	Difference
PFMT versus sham or imitation PFMT
Ghoniem 2005	a) < 50% reduction in leakage episode frequency b) Decrease in incontinence episode frequency	a) Number of total b) Median % decrease	a) 36 of 46 b) 34.7	a) 33 of 44 b) 28.9	a) RR (95% CI) 1.04 (0.83 to 1.31) b) Not estimable
PFMT versus 'Paula method'
Liebergall 2009	Leakage frequency weekly or more	number out of total	61 of 87?	65 of 96?	RR (95% CI) 1.04 (0.85 to 1.26)

Analysis 3.5

Comparison 3 Direct versus indirect methods of PFMT, Outcome 5 Frequency of leakage ‐ other measures.

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Study	Outcome	Measure	Direct PFMT	Indirect PFMT	Difference
PFMT versus sham or imitation PFMT
Ramsay 1990	Pad test (type not known) in grams	Mean change	‐ 1.5	2.1	Not estimable
PFMT versus 'Paula method'
Liebergall 2005	1 hour pad test. Change in grams	Mean (SD)	9.5 (16.0) n = 29	5.4 (8.8) n = 30	MD (95%‐ CI) 4.10 (‐2.52 to 10.72)
Liebergall 2009	1 hour pad test. a) Pad weight gain in grams b) Change in pad test c) Pad test no "cure" (> 1 g)	a) Mean (SD) b) Mean change (SD) c) Number out of total	a) 3.0 (7.2), n = 84? b) 8.9 (18.2 ), n = 84? c) 42 of 84	a) 2.8 (4.3), n = 92? b) 7.9 (11.7 ), n = 92? c) 32 of 92	MD (95% CI) a) 0.20 (‐1.57 to 1.97) b) 1.00 (‐3.57 to 5.57) c) RR (95% CI) 1.44 (1.01 to 2.04)
PFMT versus 'Sapsford' approach
Hung 2010	20 minute pad test with standardised bladder volume. a) pad weight gain b) no leakage on pad test	a) median pad weight in grams (IQR) b) number out of total	a) 0 (0 to 0) b) 21 of 31	a) 0 (0 to 0.5) b) Not stated	a) Not estimable b) Not estimable

Analysis 3.6

Comparison 3 Direct versus indirect methods of PFMT, Outcome 6 Amount of leakage ‐ pad, paper towel and cough tests.

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Study	Outcome	Measure	Direct PFMT	Indirect PFMT	Difference
PFMT versus 'Paula method'
Liebergall 2009	Leakage amount moderate or more	Number out of total	25 of 87?	17 of 96?	RR (95% CI) 1.62 (0.94 to 2.79)

Analysis 3.7

Comparison 3 Direct versus indirect methods of PFMT, Outcome 7 Amount of leakage ‐ other measures.

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Study	Outcome	Measure	Direct PFMT	Indirect PFMT	Difference
PFMT versus 'Paula method'
Liebergall 2009	Nocturia (voiding once a night or more)	Number of total	43 of 87?	47 of 96?	RR (95% CI) 1.01 (0.75 to 1.36)
PFMT versus 'Sapsford' approach
Hung 2010	Voids per day	Median (IQR)	8.7 (6.7 to 10.7), n = 31	9.0 (6.6 to 10.0), n = 29	Not estimable

Analysis 3.8

Comparison 3 Direct versus indirect methods of PFMT, Outcome 8 Voiding frequency.

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Study	Outcome	Measure	Direct PFMT	Indirect PFMT	Difference
PFMT versus 'Paula method'
Liebergall 2005	Vaginal squeeze pressure (in cm H₂0)	Mean (SD)	0.14 (3.9), n = 29	‐0.02 (7.4), n = 30	MD (95% CI) 0.16 (‐2.84 to 3.16)
PFMT versus 'Sapsford' approach
Hung 2010	Vaginal squeeze pressure a) maximal pressure (cm H₂O). b) hold (seconds)	Mean (SD)	a) 31.5 (17.7), n = 31 b) 11.0 (5.9), n = 31	a) 30.6 (17.5), n = 29 b) 11.4 (5.7), n = 29	MD (95% CI) a) 0.90 (‐8.01 to 9.81) b) ‐0.40 (‐3.34 to 12.54)
PFMT versus Pilates
Savage 2005	Endurance: duration of sustained contraction in seconds a) post treatment score b) change	Mean (SD)	a) 8.0 (1.6), n = 4 b) 1.8 (0.6), n = 4	a) 9.2 (1.3), n = 6 b) 3.0 (2.1), n = 6	MD (95% CI) a) ‐1.20 (‐3.08 to 0.68) b) ‐1.40 (‐3.18, 0.38)
Savage 2005	Strength: modified Oxford Scale score (0 = no activity to 5 = strong) a) post treatment score b) change	Mean (SD)	a) 3.5 (0.4), n = 4 b) 0.3 (0.7), n = 4	a) 4.4 (0.8), n = 6 b) 1.1 (0.6), n = 6	MD (95% CI) a) ‐0.90 (‐1.65 to ‐0.15) b) ‐0.80 (‐1.64 to 0.04)

Analysis 3.9

Comparison 3 Direct versus indirect methods of PFMT, Outcome 9 PFM performance.

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Study	Outcome	Measure	Direct PFMT	Indirect PFMT	Difference
PFMT versus sham or imitation PFMT
Ghoniem 2005	Compliance after 4, 8 and 12 weeks training	% of prescribed contractions performed	82%, 90%, 89% n = 47	91%, 84%, 88% n = 50	Not estimable
Ramsay 1990	Number of exercise sessions per week (based on records in diary)	Number of sessions	52, n = 22	54, n = 22	Not estimable
PFMT versus 'Paula method'
Liebergall 2009	a) Participated in <50% of prescribed supervised sessions b) Did not attend any supervision sessions c) Documented no exercise at home	Number out of total	a) 16 of 84 b) 11 of 84 c) 100 of 123	a) 6 of 92 b) 12 of 92 c) 86 of 117	RR (95% CI) a) 2.92 (1.20 to 7.12) b) 1.00 (0.47 to 2.15) c) 1.11 (0.96 to 1.27)
PFMT versus 'Sapsford' approach
Hung 2010	Clinic attendance	Number who attended all 8 visits	21 of 31	Not applicable as no scheduled visits	Not estimable

Analysis 3.10

Comparison 3 Direct versus indirect methods of PFMT, Outcome 10 Treatment adherence.

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Analysis 4.1

Comparison 4 Individualised versus generic PFMT, Outcome 1 Patients' perception of change in incontinence ‐ not improved.

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Study

QoL measurement

Measure

Individualised PFMT

Generic PFMT

Difference

de Oliveira 2009

King's Health Questionnaire (KHQ)

a) general health
b) incontinence impact
c) physical activity limitation
d) physical limitation
e) social limitation
f) personal relationships
g) emotions
h) sleep/energy
i) severity

(Note: lower score = better quality of life)

Mean (SD)

a) 37.5 (20.5)

b) 13.3 (24.1)

c) 10.6 (17.8)

d) 10.6 (11.5)

e) 3.7 (10.2)

f) 2.3 (7.8)

g) 4.8 (11.6)

h) 4.4 (10.7)

i) 14.4 (20.3)

n=30

a) 39.2 (21.5)

b) 20.0 (25.7)

c) 3.3 (8.1)

d) 4.4 (11.5)

e) 0.7 (2.8)

f) 0 (0)

g) 5.6 (19.3)

h) 7.2 (17.9)

i) 15.3 (20.3)

n=30

MD [95% CI)

a) ‐1.70 (‐12.33 to 8.93)

b) ‐6.70 (‐19.31 to 5.91)

c) 7.22 (0.22 to 14.22)

d) 6.20 (0.38 to 12.02)

e) 3.00 (‐0.78 to 6.78)

f) Not estimable

g) ‐0.80 (‐8.86 to 7.26)

h) ‐2.80 (‐10.26 to 4.66)

i) ‐0.90 (‐11.17 to 9.37)

j) ‐0.10 (‐0.36 to 0.16)

Analysis 4.2

Comparison 4 Individualised versus generic PFMT, Outcome 2 Incontinence specific quality of life.

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Analysis 4.3

Comparison 4 Individualised versus generic PFMT, Outcome 3 Frequency of leakage ‐ leakage episodes in 24 hours.

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Study	Pad or towel test	Measure	Individualised PFMT	Generic PFMT	Difference
de Oliveira 2009	1 hour pad test with standardised bladder volume a) Pad weight gain in grams. b) Negative pad test (< 2 g)	a) Mean (SD) b) Number out of total	a) 0.6 (1.4), n=30 b) 16 of 30	a) 1.9 (3.5), n=30 b) 14 of 30	a) MD [95%‐ CI] ‐1.30 [‐2.65, 0.05] b) RR [95% CI] 1.14 [0.69, 1.90]

Analysis 4.4

Comparison 4 Individualised versus generic PFMT, Outcome 4 Amount of leakage ‐ pad, paper towel and cough tests.

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Study	Assessment of PFM performance	Measure	Individualised PFMT	Generic PFMT	Difference
de Oliveira 2009	Digital vaginal palpation (Oxford scale 1‐5)	Mean (SD)	4.3 (0.7), n=30	3.6 (0.8), n=30	MD [95% CI] 0.70 [0.32, 1.08]

Analysis 4.5

Comparison 4 Individualised versus generic PFMT, Outcome 5 PFM performance.

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Study	Treatment adherence	Measure	Individualised PFMT	Generic PFMT	Difference
de Oliveira 2009	Not clear. Exercise or attendance for clinic visits?	percentage	90%	95%	Not estimable

Analysis 4.6

Comparison 4 Individualised versus generic PFMT, Outcome 6 Treatment adherence.

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Analysis 5.1

Comparison 5 Near maximal versus submaximal contractions, Outcome 1 Frequency of leakage ‐ leakage episodes in 24 hours.

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Study	Outcome	Measure	Near maximal PFMT	Submaximal PFMT	Difference
Johnson 2001	Leakage episodes in last week of study	Number out of total	6 of 16	4 of 16	RR (95% CI) 1.50 (0.52 to 4.32)

Analysis 5.2

Comparison 5 Near maximal versus submaximal contractions, Outcome 2 Frequency of leakage ‐ other measures.

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Study	Outcome	Measure	Near maximal PFMT	Submaximal PFMT	Difference
Johnson 2001	10 hour pad test	Mean in grams (SD)	3.84 (5.29), n=16	3.41 (4.79), n = 16	MD (95% CI) 0.43 (‐3.07 to 3.93)

Analysis 5.3

Comparison 5 Near maximal versus submaximal contractions, Outcome 3 Amount of leakage ‐ pad, paper towel and cough tests.

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Study	Outcome	Measure	Near maximal PFMT	Submaximal PFMT	Difference
Johnson 2001	Vaginal squeeze pressure with maximal muscle contraction, in cm H₂O	Mean (SD)	18.4 (14.3), n = 16	19.2 (10.5), n = 16	MD (95% CI) 0.8 (‐9.5 to 7.9)
Johnson 2001	EMG amplitude, in microvolts	Mean (SD)	3.69 (2.5), n = 16	4.44 (1.99), n = 16	MD (95% CI) 0.75 (0.8 to ‐2.3)
Johnson 2001	Endurance: sustained contraction, in seconds	Mean (SD)	9.6 (1.5), n = 16	9.1 (2.2), n=16	MD (95% CI) ‐0.5 (‐0.7 to 1.9)

Analysis 5.4

Comparison 5 Near maximal versus submaximal contractions, Outcome 4 PFM performance.

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Analysis 6.1

Comparison 6 Daily versus three times per week PFMT, Outcome 1 Patients' perception of change in incontinence ‐ not cured.

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Analysis 6.2

Comparison 6 Daily versus three times per week PFMT, Outcome 2 Patients' perception of change in incontinence ‐ not improved.

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Study

Outcome

Measure

Daily PFMT

3 times weekly PFMT

Difference

Sriboonreung 2011a

1 hour pad test, in grams

a) pad weight gain

b) change

Mean (SD)

a) 1.4 (0.7)

b) 2.6 (0.8)

n = 20

a) 1.7 (0.7)

b) 2.3 (1.3)

n = 19

MD (95% CI)

a) ‐0.30 (‐0.74 to 0.14)

b) 0.30 (‐0.38 to 0.98)

Analysis 6.3

Comparison 6 Daily versus three times per week PFMT, Outcome 3 Amount of leakage ‐ pad, paper towel and cough tests.

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Study

Outcome

Measure

Daily PFMT

3 times weekly PFMT

Difference

Sriboonreung 2011a

Vaginal squeeze pressure, in cm H₂O

a) pressure

b) change in pressure

Mean (SD)

a) 47.4 (9.6)

b) 18.4 (2.7)

n = 20

a) 42.6 (12.4)

b) 13.9 (2.9)

n = 19

MD (95% CI)

a) 4.80 (‐2.18 to 11.78)

b) 4.50 (2.74 to 6.26)

Analysis 6.4

Comparison 6 Daily versus three times per week PFMT, Outcome 4 PFM performance.

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Study

Outcome

Measure

Upright and supine PFMT

Supine PFMT

Difference

Borello‐France 2006

Incontinence Impact Questionnaire

Mean change (SD)

24.7 (31.0), n = 19?

27.6 (32.7), n = 17

MD (95% CI)

‐2.90 (‐23.78 to 17.98)

Analysis 7.1

Comparison 7 Upright and supine versus supine exercise positions alone, Outcome 1 Incontinence‐specific quality of life.

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Analysis 7.2

Comparison 7 Upright and supine versus supine exercise positions alone, Outcome 2 Frequency of leakage ‐ leakage episodes in 24 hours.

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Study

Outcome

Measure

Upright and supine PFMT

Supine PFMT

Difference

Borello‐France 2006

1 hour pad test

Mean change (SD)

5.1 (3.9), n = 19?

3.9 (3.8), n = 17?

MD (95% CI)

1.20 (‐1.32 to 3.72)

Analysis 7.3

Comparison 7 Upright and supine versus supine exercise positions alone, Outcome 3 Amount of leakage ‐ pad, paper towel and cough tests.

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Study

Outcome

Measure

Upright and supine PFMT

Supine PFMT

Difference

Borello‐France 2006

Brink score

Mean change (SD)

2.2 (1.9), n = 19?

2.0 (1.7), n = 17?

MD (95% CI)

0.20 (‐0.98 to 1.38)

Analysis 7.4

Comparison 7 Upright and supine versus supine exercise positions alone, Outcome 4 PFM performance.

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Study

Outcome

Measure

Upright and supine PFMT

Supine PFMT

Difference

Borello‐France 2006

Number of clinic visits

Mean (SD)

8.9 (3.0), n = 22

8.4 (2.8), n = 22

MD (95% CI)

0.50 (‐1.21 to 2.21)

Analysis 7.5

Comparison 7 Upright and supine versus supine exercise positions alone, Outcome 5 Treatment adherence.

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Analysis 8.1

Comparison 8 Strength and motor learning versus motor learning PFMT alone, Outcome 1 Patients' perception of change in incontinence ‐ not cured.

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Analysis 8.2

Comparison 8 Strength and motor learning versus motor learning PFMT alone, Outcome 2 Patients' perception of change in incontinence ‐ not improved.

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Study

Outcome

Measure

Strengthening and motor learning

Motor learning

Difference

Hay‐Smith 2002

Kings' Health Questionnaire (KHQ)

a) General health perception
b) Incontinence impact
c) Role limitation
d) Physical limitation
e) Social limitation
f) Personal relationships
g) Emotions.
h) Sleep/energy
i) Severity measures

(Note: lower score = better quality of life)

Mean score (SD)

a) 17.1 (19.3), n = 60
b) 49.4 (24.9), n = 60
c) 27.2 (23.7), n = 57
d) 31.3 (22.5), n = 57
e) 11.8 (18.6), n = 56
f) 13.8 (23.2), n = 40
g) 26.1 (28.0), n = 58
h) 28.4 (19.6), n = 54
i) 39.3 (21.6), n = 57

a) 18.2 (17.7), n = 55
b) 38.8 (27.8), n = 55
c) 20.5 (27.7), n = 52
d) 22.6 (22.8), n = 51
e) 10.5 (21.3), n = 51
f) 14.6 (24.8), n = 40
g) 20.0 (24.1), n = 51
h) 32.0 (19.7), n = 51
i) 32.4 (22.4), n = 50

Mean (95% CI).
a) ‐1.1 (‐7.9 to 5.7)
b) 10.6 (0.9 to 20.4)
c) 6.70 (‐3.1 to 16.5)
d) 8.7 (0.1 to 17.3)
e) 1.3 (‐6.3 to 9.0)
f) ‐0.8 (‐11.5 to 9.7)
g) 6.1 (‐4.0 to 16.0)
h) ‐3.6 (‐11.2 to 4.0)
i) 6.9 (‐1.6 to 15.3)

Analysis 8.3

Comparison 8 Strength and motor learning versus motor learning PFMT alone, Outcome 3 Incontinence‐specific quality of life.

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Analysis 8.4

Comparison 8 Strength and motor learning versus motor learning PFMT alone, Outcome 4 Frequency of leakage ‐ leakage episodes in 24 hours.

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Study

Outcome

Measure

Strengthening and motor learning

Motor learning

Difference

Hay‐Smith 2002

Paper towel test, in ml

a) Leakage in ml

b) No leakage

a) Mean (SD)

b) number of total

a) 2.8 (6.9), n = 46

b) 20 of 46

a) 1.7 (3.6), n = 48

b) 25 of 48

a) 1.10 (‐1.14 to 3.34)

b) 0.83 (0.54 to 1.28)

Hay‐Smith 2002

24‐hour pad test, in grams

a) Pad weight gain

b) Not improved (> 4 grams leakage compared to baseline)

a) Mean (SD)

b) number of total

a) 13.7 (23.4), n = 51

b) 33 of 51

a) 12.3 (20.9), n = 49

b) 29 of 49

a) MD (95% CI)
1.40 (‐7.29 to 10.09)

b) 1.09 (0.80 to 1.49)

Analysis 8.5

Comparison 8 Strength and motor learning versus motor learning PFMT alone, Outcome 5 Amount of leakage ‐ pad, paper towel test and cough tests.

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Study

Outcome

Measure

Strengthening and motor learning PFMT

Motor learning PFMT

Difference

Hay‐Smith 2002

> 1 pad changes in 24 hours

Number of total

9 of 47

11 of 50

RR (95% CI)

0.87 (0.40 to 1.91)

Analysis 8.6

Comparison 8 Strength and motor learning versus motor learning PFMT alone, Outcome 6 Amount of leakage ‐ other measures.

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Study	Outcome	Measure	Strengthening and motor learning	Motor learning	Difference
Hay‐Smith 2002	Voids in 24 hours	Mean (SD)	6.5 (1.2), n = 47	6.5 (2.2), n = 50	MD (95% CI) 0.00 (‐0.70 to 0.70)

Analysis 8.7

Comparison 8 Strength and motor learning versus motor learning PFMT alone, Outcome 7 Voiding frequency.

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Analysis 9.1

Comparison 9 PFMT and abdominal muscle exercise versus PFMT alone, Outcome 1 Patients' perception of change in incontinence ‐ not cured.

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Analysis 9.2

Comparison 9 PFMT and abdominal muscle exercise versus PFMT alone, Outcome 2 Patients' perception of change in incontinence ‐ not improved.

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Study

Outcome

Measure

PFMT + abdominal exercise

PFMT

Difference

Sriboonreung 2011b

1 hour pad test, in grams

a) pad weight gain

b) change

Mean (SD)

a) 1.6 (0.8)

b) 3.1 (1.3)

n = 21

a) 1.7 (0.7)

b) 2.3 (1.3)

n = 19

MD (95% CI)

a) ‐0.10 (‐0.56 to 0.36)

b) 0.80 (‐0.01 to 1.61)

Analysis 9.3

Comparison 9 PFMT and abdominal muscle exercise versus PFMT alone, Outcome 3 Amount of leakage ‐ pad, paper towel and cough tests.

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Study

Outcome

Measure

PFMT + abdominal exercise

PFMT

Difference

Sriboonreung 2011b

Vaginal squeeze pressure, in cm H₂O

a) pressure

b) change in pressure

Mean (SD)

a) 46.3 (8.2)

b) 17.3 (3.0)

n = 21

a) 42.6 (12.4)

b) 13.9 (2.9)

n = 19

MD (95% CI)

a) 3.70 (‐2.89 to 10.29)

b) 3.40 (1.57 to 5.23)

Analysis 9.4

Comparison 9 PFMT and abdominal muscle exercise versus PFMT alone, Outcome 4 PFM performance.

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Analysis 10.1

Comparison 10 PFMT with intravaginal resistance device versus PFMT alone, Outcome 1 Patients' perception of change in incontinence ‐ not cured.

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Analysis 10.2

Comparison 10 PFMT with intravaginal resistance device versus PFMT alone, Outcome 2 Patients' perception of change in incontinence ‐ not improved.

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Study	Outcome	Measure	PFMT with intravaginal resistance device	PFMT	Difference
Delgado 2009	Question 5 from the ICIQ‐LUTSqol: moderate or a lot of effect of leakage on physical activity	Number out of total	5 of 15	5 of 15	None

Analysis 10.3

Comparison 10 PFMT with intravaginal resistance device versus PFMT alone, Outcome 3 Symptom impact.

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Analysis 10.4

Comparison 10 PFMT with intravaginal resistance device versus PFMT alone, Outcome 4 Frequency of leakage ‐ leakage episodes in 24 hours.

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Study	Outcome	Measure	PFMT with intravaginal resistance device	PFMT	Difference
Wells 1999	Same or worse on urinary diary (1 or more wet episodes per day)	Number out of total	16 of 39	21 of 41	RR (95% CI) 0.80 (0.50 to 1.30)

Analysis 10.5

Comparison 10 PFMT with intravaginal resistance device versus PFMT alone, Outcome 5 Frequency of leakage ‐ other measures.

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Study	Outcome	Measure	PFMT with intravaginal resistance device	PFMT	Difference
Ferguson 1990	30‐minute pad test, in grams	Mean (SD)	1.4 (1.7), n = 7	3.4 (4.7), n = 7	MD (95% CI) ‐2.00 (‐5.70 to 1.70)
Ferguson 1990	24‐hour pad test, in grams	Mean (SD)	5.6 (4.7), n = 10	5.8 (5.6), n = 10	MD (95% CI) ‐0.20 (‐4.73 to 4.33)
Wells 1999	Pad test with standardised bladder volume: same or worse (that is same or one category worse (where categories are minimum (< 5 g), moderate (> 5 to 30 g), saturated (> 30 g))	Number of total	28 of 39	34 of 41	RR (95% CI) 1.17 (1.01 to 1.36)

Analysis 10.6

Comparison 10 PFMT with intravaginal resistance device versus PFMT alone, Outcome 6 Amount of leakage ‐ pad, paper towel and cough tests.

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Study

Outcome

Measure

PFMT with intravaginal resistance

PFMT

Difference

Wells 1999

10 point VAS (anchors "no leakage" and "a lot of leakage" over the past week)

Mean (SD)

4.0 (2.6), n = 39

3.3 (2.6), n = 41

MD (95% CI)

0.70 (‐0.44 to 1.84)

Analysis 10.7

Comparison 10 PFMT with intravaginal resistance device versus PFMT alone, Outcome 7 Amount of leakage ‐ other measures.

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Study	Outcome	Measure	PFMT with intravaginal resistance device	PFMT	Difference
Ferguson 1990	Vaginal squeeze pressure, pressure area in cm H₂O seconds	Mean (SD)	234.4 (124.0), n = 10	328.5 (139.7), n = 10	MD (95% CI) ‐94.10 (‐209.87 to 21.67)
Ferguson 1990	Vaginal squeeze pressure, maximum in cm H₂O	Mean (SD)	33.4 (15.1), n = 10	46.5 (20.7), n = 10	MD (95% CI) 13.10 (‐28.98 to 2.71)
Wells 1999	Brink score (minimum 4, maximum 12)	Mean (SD)	8.7 (1.0). n = 39	8.8 (1.0), n = 41	MD (95% CI) ‐0.10 (‐0.54 to 0.34)
Wells 1999	EMG endurance	Mean (SD)	45.0 (36.4), n = 39	48.8 (36.4), n = 41	MD (95% CI) ‐3.80 (‐19.76 to 12.16)

Analysis 10.8

Comparison 10 PFMT with intravaginal resistance device versus PFMT alone, Outcome 8 PFM performance.

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Analysis 11.1

Comparison 11 PFMT and adherence strategy versus PFMT alone, Outcome 1 Patients' perception of change in incontinence ‐ not improved.

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Analysis 11.2

Comparison 11 PFMT and adherence strategy versus PFMT alone, Outcome 2 Frequency of leakage ‐ leakage episodes in 24 hours.

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Study	Outcome	Measure	PFMT with adherence strategy	PFMT	Difference
Sugaya 2003	1 hour pad test, in grams	Mean (SD)	6.8 (13.2), n = 21	18.3 (17.8), n = 20	MD (95% CI) ‐11.50 (‐21.13 to ‐1.87)

Analysis 11.3

Comparison 11 PFMT and adherence strategy versus PFMT alone, Outcome 3 Amount of leakage ‐ pad, paper towel and cough tests.

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Study

Outcome

Measure

PFMT with adherence strategy

PFMT

Difference

Sugaya 2003

Number of pads per day

Mean (SD)

1.5 (1.6), n = 21

2.1 (1.6), n = 20

MD (95% CI)

‐0.60 (‐1.58 to 0.38)

Analysis 11.4

Comparison 11 PFMT and adherence strategy versus PFMT alone, Outcome 4 Amount of leakage ‐ other measures.

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Study	Outcome	Measure	PFMT with adherence strategy	PFMT	Difference
Gallo 1997	Did not do "Routine" (not defined) PFMT	Number out of total	0 of 41	12 of 34	RR (95% CI) 0.03 (0.00 to 0.54)
Gallo 1997	Did not do twice daily PFMT as recommended	Number out of total	7 of 41	30 of 34	RR (95% CI) 0.19 (0.10 to 0.38)

Analysis 11.5

Comparison 11 PFMT and adherence strategy versus PFMT alone, Outcome 5 Treatment adherence.

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Analysis 12.1

Comparison 12 'More intensive' versus 'less intensive' PFMT programmes, Outcome 1 Patients' perception of change in incontinence ‐ not cured.

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Analysis 12.2

Comparison 12 'More intensive' versus 'less intensive' PFMT programmes, Outcome 2 Patients' perception of change in incontinence ‐ not improved.

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Analysis 12.3

Comparison 12 'More intensive' versus 'less intensive' PFMT programmes, Outcome 3 Frequency of leakage ‐ leakage episodes in 24 hours.

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Table 1. More versus less contact with health professionals

Study	Group	Intervention	Duration	Supervision	Category
Bø 1990	Individual supervision: home PFMT	Correct VPFMC confirmed. PFMT: 8 to 12 near maximal contractions (with 6 to 8 sec hold and rests) 3 times daily. Monthly clinic visits for perineometer biofeedback of PFM strength.	6 months	Physiotherapist monthly	Strength
	Group supervision: weekly exercise class	As above, with addition of weekly 45‐min group exercise session which included PFMT, abdominal, gluteal and thigh exercises. The PFMT comprised near maximal contractions for 6 to 8 sec each and 3 to 4 fast contractions, repeated 8 to 12 times, in standing, sitting, lying and kneeling positions.	6 months	As above, plus weekly in a group	Strength
Diniz Zanetti 2007	Individual supervision: home PFMT	PFMT: 10 contractions with 5‐sec hold and 5‐sec rest, 20 contractions of 1‐sec hold and 1‐sec rest, 5 contractions of 10‐sec hold and 10‐sec rest, 5 strong contractions with cough, and 1‐minute intervals between sets. Monthly clinic visits for assessment only.	12 weeks	Physiotherapist monthly	Strength and co‐ordination
	Group supervision: twice‐ weekly supervision	PFMT as above, with 45‐min twice‐weekly supervision (no clear if individual or group)	12 weeks	Physiotherapist monthly, plus fortnightly in a group?	Strength and co‐ordination
Felicissimo 2010	Individual supervision: home PFMT	Correct VPFMC confirmed. PFMT: 10 contractions with 6‐sec hold and 12‐sec rest in different positions 9 (?) times per day. Start with 90 contractions in first week, then 180 a day for remaining 7 weeks.	8 weeks	Physiotherapist at initial session	Endurance
	Group supervision: twice‐ weekly exercise group	As above, with addition of twice‐weekly 50‐min group exercise session.	8 weeks	As above, plus twice weekly in a group	Endurance
Hung 2010	Less supervision: 'direct' PFMT at home and no supervision	Correct VPFMC confirmed. Oral instruction in PFMT. No other detail given.	16 weeks	None	Uncertain
	More supervision: 'indirect' PFMT at home and fortnightly supervision	Correct VPFMC confirmed. 'Indirect' PFMT: weeks 1 to 4 diaphragmatic breathing, weeks 2 to 5 tonic transversus abdominus and PFM activation, weeks 4 to 7 tonic activation with activities of daily living and walking, weeks 6 to 16 muscle strengthening, weeks 8 to 16 functional expiratory patterns, and weeks 10 to 16 impact activities. A very full description of the programme is given in the paper by Hung 2010. Participants in this group were "asked not to perform isolated voluntary pelvic floor muscle contraction exercise during the intervention period".	16 weeks	Fortnightly with physiotherapist	Indirect
Konstantinidou 2007	Individual supervision: home PFMT	Correct VPFMC confirmed. PFMT: Individualised programme of 3 sets of fast contractions, 3 to 4 sets of slow contractions daily in lying, standing and sitting positions. Individual follow‐up in hospital every 4 weeks.	12 weeks	Physiotherapist monthly	Strength
	Group supervision: weekly exercise group	As above, with addition of weekly exercise group	12 weeks	As above, plus weekly in a group	Strength
Ng 2008	Less supervision: PFMT at home and clinic visits	Not clear if correct VPFMC confirmed. Home PFMT progressing to "50 to 75 contractions three times a day”. Taught urgency strategies. One‐hour clinic visits twice a week for 4 weeks with nurse.	6 months?	Nurse twice a week for 4 weeks	Uncertain
	More supervision: PFMT at home, clinic visits and phone calls	As above, then phone calls twice a week from the nurse after cessation of clinic visits to encourage exercise.	6 months?	Nurse twice a week for 4 weeks, then twice weekly phone calls	Uncertain
PFM = pelvic floor muscle(s), PFMT = pelvic floor muscle training, VPFMC = voluntary pelvic floor muscle contraction

Table 1. More versus less contact with health professionals

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Table 2. Group versus individual supervision of PFMT

Study	Group	Intervention	Duration	Supervision	Category
Bø 1990	Individual supervision: home PFMT	Correct VPFMC confirmed. PFMT: 8 to 12 near maximal contractions (with 6 to 8‐sec hold and rests) 3 times daily. Monthly clinic visits for perineometer biofeedback of PFM strength.	6 months	Physiotherapist monthly	Strength
	Group supervision: weekly exercise class	As above, with addition of weekly 45‐min group exercise session which included PFMT, abdominal, gluteal and thigh exercises. The PFMT comprised near maximal contractions for 6 to 8 sec each and 3 to 4 fast contractions, repeated 8 to 12 times, in standing, sitting, lying and kneeling positions.	6 months	As above, plus weekly in a group	Strength
De Oliveira Camargo 2009	Individual supervision	Individualised programme based on PERFECT scheme. 10 slow and 10 fast contractions with 10‐sec rest; 10 alternating fast and slow contractions and 5 slow contractions with a cough.	12 weeks	Urogynaecology physiotherapist	Strength and co‐ordination
	Group supervision	VPFMC confirmed by DVP, in 'orthostatic' position. 10 contractions/5‐sec hold/5‐sec rest; and 20 contractions/1‐sec hold/1‐sec rest; and 5x strong contractions with stimulated cough. 1‐minute interval between sets.	12 weeks	Urogynaecology physiotherapist	Strength and co‐ordination
Felicissimo 2010	Individual supervision: home PFMT	Correct VPFMC confirmed. PFMT: 10 contractions with 6‐sec hold and 12‐sec rest in different positions 9 (?) times per day. Start with 90 contractions in first week, then 180 a day for remaining 7 weeks.	8 weeks	Physiotherapist at initial session	Endurance
	Group supervision: twice‐weekly exercise group	As above, with addition of twice‐weekly 50‐min group exercise session	8 weeks	As above, plus twice‐weekly in a group	Endurance
Konstantinidou 2007	Individual supervision: home PFMT	Correct VPFMC confirmed. PFMT: individualised programme of 3 sets of fast contractions, 3 to 4 sets of slow contractions daily in lying, standing and sitting positions. Individual follow‐up in hospital every 4 weeks.	12 weeks	Physiotherapist monthly	Strength
	Group supervision: weekly exercise group	As above, with addition of weekly exercise group	12 weeks	As above, plus weekly in a group	Strength
Liebergall‐Wischnitzer 2007	Control: Direct PFMT	Weekly 30‐minute lesson for 4 weeks in groups of 5. Encouraged to practise at home 15 min/day. Fortnightly phone call from physiotherapist.	12 weeks	Physiotherapist	Uncertain
	Experimental: Indirect PFMT ‐ 'Paula' method	Taught 'Paula' method of sphincter contraction: programme of exercises performed in lying, sitting or standing positions. Exercises were contraction of circular muscles including the pubococcygeal muscle, the anal sphincter, eye and eyelid, mouth, and grip. Programme focusses on strengthening the circular muscles of the body, based on the theory that all sphincters in the body work simultaneously and thus exercising circular muscles in one area of the body will result in strengthening of other sphincters. Weekly individual 45‐min training for 12 weeks. Encouraged to practise daily 15 to 45 min.	12 weeks	Therapist certified in the 'Paula' method	Indirect
Liebergall‐Wirschnitzer 2009	Control: PFMT individual	Unclear if VPFMC was confirmed. Weekly individual sessions of 45 minutes and daily home exercises for 45 minutes for 12 weeks. Paula method was taught; first 2 steps were 'rhythmically' contracting the PFM 'with gradual intensity'. Last 3 steps involved contraction and relaxation of eyelids, movement of the mouth and fingers. Rationale based on the idea that all sphincters in the body work together and can affect one another.	12 weeks	3 registered instructors	Indirect
	Experimental: PFMT group	VPFMC confirmed, based on observation. 6 group classes (1 to 10 women) of 30 minutes each. Once weekly for first 4 weeks, 2 more classes in last 2 months. Exercises in different positions. Separate contractions of levator ani and anal sphincter. Prolonged, rapid and gradual contractions. 1 to 2 minutes between exercises.	12 weeks	10 physiotherapists	Uncertain
DVP = Digital vaginal palpitation, PERFECT = power or pressure, endurance, repetitions, fast contractions, every contraction timed, PFM = pelvic floor muscle(s), PFMT = pelvic floor muscle training, VPFMC = voluntary pelvic floor muscle contraction

Table 2. Group versus individual supervision of PFMT

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Table 3. Direct versus indirect methods of PFMT

Study	Group	Intervention	Duration	Supervision	Category
Ghoniem 2005	Direct PFMT	Correct VPFMC confirmed. PFMT: 3 sets of 10 long (6 to 8‐sec hold) and 2 sets of 10 rapid (1 to 2‐sec hold) contractions 4 days a week, for a total of 200 contractions weekly. Also 'The Knack'. Four clinic visits.	12 weeks	Physiotherapist.	Endurance and co‐ordination
	Indirect PFMT: "imitation" PFMT	Correct VPFMC not confirmed. Programme of exercises above with abduction of the hips with legs crossed at the ankles (and knees and hips flexed while sitting or supine)	12 weeks	Physiotherapist	Indirect
Hung 2010	Direct PFMT	Correct VPFMC confirmed. Oral instruction in PFMT. No other detail given.	16 weeks	None	Uncertain
	Indirect PFMT: 'Sapsford' approach	Correct VPFMC confirmed. 'Indirect' PFMT: weeks 1 to 4 diaphragmatic breathing, weeks 2 to 5 tonic transversus abdominus and PFM activation, weeks 4 to 7 tonic activation with activities of daily living and walking, weeks 6 to 16 muscle strengthening, weeks 8 to 16 functional expiratory patterns, and weeks 10 to 16 impact activities. A very full description of the programme is given in the paper by Hung 2010. Participants in this group were "asked not to perform isolated voluntary pelvic floor muscle contraction exercise during the intervention period".	16 weeks	Fortnightly with physiotherapist.	Indirect
Liebergall‐Wischnitzer 2007	Direct PFMT	Weekly 30‐minute lesson for 4 weeks in groups of 5. Encouraged to practise at home 15 min/day. Fortnightly phone call from physiotherapist.	12 weeks	Physiotherapist	Uncertain
	Indirect PFMT: 'Paula method'	Taught 'Paula' method of sphincter contraction: programme of exercises performed in lying, sitting or standing positions. Exercises were contraction of circular muscles including the pubococcygeal muscle, the anal sphincter, eye and eyelid, mouth, and grip. Programme focusses on strengthening the circular muscles of the body, based on the theory that all sphincters in the body work simultaneously and thus exercising circular muscles in one area of the body will result in strengthening of other sphincters. Weekly individual 45‐min training for 12 weeks. Encouraged to practice daily 15 to 45 min.	12 weeks	Therapist certified in the 'Paula' method	Indirect
Liebergall‐Wirschnitzer 2009	Direct PFMT	Unclear if VPFMC was confirmed. Weekly individual sessions of 45 minutes and daily home exercises for 45 minutes for 12 weeks. Paula method was taught; first 2 steps were 'rhythmically' contracting the PFM 'with gradual intensity'. Last 3 steps involved contraction and relaxation of eyelids, movement of the mouth and fingers. Rationale based on the idea that all sphincters in the body work together and can affect one another.	12 weeks	3 registered instructors	Indirect
	Indirect PFMT: 'Paula method'	VPFMC confirmed, based on observation. 6 group classes (1 to 10 women) of 30 minutes each. Once weekly for first 4 weeks, 2 more classes in last 2 months. Exercises in different positions. Separate contractions of levator ani and anal sphincter. Prolonged, rapid and gradual contractions. 1 to 2 minutes between exercises.	12 weeks	10 physiotherapists	Uncertain
Ramsay 1990	Direct PFMT	4 maximum isometric contractions, 4‐sec hold, 10‐sec rest. Repeated once every waking hour, daily.	12 weeks	Not clear	Endurance
	Indirect PFMT: "placebo" PFMT	4 maximum hip abductor contractions (with feet crossed at ankles), otherwise as above.	12 weeks	Not clear	Indirect
Savage 2005	Direct PFMT	VPFMC confirmed. Individualised PFMT according to PERFECT scheme including maximal contractions with 1 to 2‐sec hold, submaximal contractions, and "staged' contractions (slowly tighten to maximum and slow release). Also 'The Knack. Encouraged to practise several times a day. 6 clinic visits.	12 weeks	Physiotherapist	Strength and co‐ordination
	Indirect PFMT: Pilates	Not clear if VPFMC confirmed in this group. Stage 1: activate and control deep abdominal muscle and PFM co‐contraction. Stage 2: as stage 1 in anti‐gravity positions. Stage 3: added limb movement for low muscle loading consistent with "Pilates principles of concentration, centring, breathing, isolation, routine, precision, control and flowing movement". Encouraged to do 10 to 15 min at home every other day. Not encouraged to do isolated PFM contractions. 6 clinic visits.	12 weeks	Physiotherapist	Indirect
PFM = pelvic floor muscle(s), PFMT = pelvic floor muscle training, VPFMC = voluntary pelvic floor muscle contraction

Table 3. Direct versus indirect methods of PFMT

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Table 4. Individualised versus generic PFMT

Study	Group	Intervention	Duration	Supervision	Category
De Oliveira Camargo 2009	Individual supervision	Individualised programme based on PERFECT scheme. 10 slow and 10 fast contractions with 10‐sec rest; 10 alternating fast and slow contractions and 5 slow contractions with a cough.	12 weeks	Urogynaecology physiotherapist	Strength and co‐ordination
	Group supervision	VPFMC confirmed by DVP, in 'orthostatic' position. 10 contractions/5‐sec hold/5‐sec rest; and 20 contractions/1‐sec hold/1‐sec rest; and 5x strong contractions with stimulated cough. 1 minute interval between sets.	12 weeks	Urogynaecology physiotherapist	Strength and co‐ordination
DVP= Digital vaginal palpitation,PERFECT = power or pressure, endurance, repetitions, fast contractions, every contraction timed, VPFMC = voluntary pelvic floor muscle contraction

Table 4. Individualised versus generic PFMT

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Table 5. Near maximal versus submaximal contractions

Study	Group	Intervention	Duration	Supervision	Category
Johnson 2001	Near maximal PFMT	Correct VPFMC confirmed. VPFMC at 90% maximal force, 15 min, 3 times daily. Given home biofeedback device and exercise diary. Two clinic visits.	6 weeks	"The Investigator"	Strength
	Submaximal PFMT	As above except VPFMC at 60% maximal strength	6 weeks	"The Investigator"	Endurance
PFMT = pelvic floor muscle training, VPFMC = voluntary pelvic floor muscle contraction

Table 5. Near maximal versus submaximal contractions

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Table 6. Daily versus three times per week PFMT

Study	Group	Intervention	Duration	Supervision	Category
Sriboonreung (b)	Daily PFMT	Correct VPFMC confirmed. Eight to 12 maximal contractions with 6 to 8‐sec hold with 6 to 8 fast contractions, with 6 to 8‐sec rest, daily, 3 times a day.	12 weeks	Physiotherapist	Strength
	3 times weekly PFMT	As above except 3 sets a day, 3 days a week.	12 weeks	Physiotherapist	Strength
PFMT = pelvic floor muscle training, VPFMC = voluntary pelvic floor muscle contraction

Table 6. Daily versus three times per week PFMT

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Table 7. Upright and supine versus supine exercise positions alone

Study	Group	Intervention	Duration	Supervision	Category
Borello‐France 2006	Upright and supine PFMT	Correct VPFMC confirmed. Began training with maximum of 2 sets of 10 repetitions of both 3‐sec maximal contraction and 12‐sec contraction twice‐daily, progressing at discretion of therapist. Exercise alternated between supine, sitting and standing. Also 'The Knack'. 12 clinic visits.	9 to 12 weeks	Physiotherapist	Strength and co‐ordination
	Supine PFMT	As above, but exercise only in supine	9 to 12 weeks	Physiotherapist	Strength and co‐ordination
PFMT = pelvic floor muscle training, VPFMC = voluntary pelvic floor muscle contraction

Table 7. Upright and supine versus supine exercise positions alone

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Table 8. Strength and motor learning versus motor learning PFMT alone

Study	Group	Intervention	Duration	Supervision	Category
Hay‐Smith 2002	Strengthening and motor learning PFMT	Correct VPFMC confirmed. Motor learning PFMT: VPFMC in variety of body positions (squat, sit, stand, kneel and so on) and movements (reach, sit to stand, walk and so on). Bracing and hold (transversus abdominus and PFM) with effort (such as cough, sneeze, lift). Progressed from discrete, stable, close tasks to continuous, open, mobile tasks. Strengthening PFMT: individualised progressing to 12 maximal effort contractions with 8 sec hold and 8 sec rest, 3 times a day, daily. Three clinic visits and 3 phone calls.	20 weeks	Physiotherapist	Strength and co‐ordination
	Motor learning PFMT	As above, except motor learning programme only	20 weeks	Physiotherapist	Co‐ordination
PFM = pelvic floor muscle(s), PFMT = pelvic floor muscle training, VPFMC = voluntary pelvic floor muscle contraction

Table 8. Strength and motor learning versus motor learning PFMT alone

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Table 9. PFMT and abdominal muscle exercise versus PFMT alone

Study	Group	Intervention	Duration	Supervision	Category
Sriboonreung (a)	3 times weekly PFMT and abdominal muscle training	Presumed as below except addition of abdominal (specifically transversus abdominus and internal oblique muscle) training. No further detail given.	12 weeks	Physiotherapist	Strength
	3 times weekly PFMT	Correct VPFMC confirmed. Eight to 12 maximal contractions with 6 to 8‐sec hold with 6 to 8 fast contractions, with 6 to 8‐sec rest, 3 times a day, 3 days a week.	12 weeks	Physiotherapist	Strength
PFMT = pelvic floor muscle training, VPFMC = voluntary pelvic floor muscle contraction

Table 9. PFMT and abdominal muscle exercise versus PFMT alone

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Table 10. PFMT with intravaginal resistance device versus PFMT alone

Study	Group	Intervention	Duration	Supervision	Category
Delgado 2010	PFMT with intravaginal resistance device	Correct VPFMC confirmed. PFMT: 5 quick and 5 slow (sustained), high‐intensity contractions daily. Advised to hold contractions as long as possible, relaxing their PFM for an equivalent time before repeating the process. Intravaginal resistance: instructions to use the PelvicToner Device concurrently whilst exercising. Two clinic visits and one phone call.	16 weeks	Urology research nurse	Strength
	PFMT	As above without device	16 weeks	Urology research nurse	Strength
Ferguson 1990	PFMT with intravaginal resistance device	PFMT: exercises at home for strength and endurance, using audiotape to guide exercises at home. Intravaginal resistance: use of intravaginal balloon. Weekly phone call.	6 weeks	?None	Strength and endurance
	PFMT	As above without device	6 weeks	?None	Strength and endurance
Wells	PFMT with intravaginal resistance	Correct VPFMC confirmed. PFMT: minimum of 80 VPFMC with 10‐sec hold and 10‐sec rest per day distributed in individual pattern throughout the day. Intravaginal resistance: Fitted with vaginal dilator to use as resistive device. Monthly clinic visits	5 months	Nurse practitioner	Endurance
	PFMT	As above without device			Endurance
PFM = pelvic floor muscle(s), PFMT = pelvic floor muscle training, VPFMC = voluntary pelvic floor muscle contraction

Table 10. PFMT with intravaginal resistance device versus PFMT alone

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Table 11. PFMT and adherence strategy versus PFMT alone

Study	Group	Intervention	Duration	Supervision	Category
Gallo 1997	PFMT	Correct VPFMC confirmed. Adherence strategy: audiocassette tape for use twice a day (contained verbal instruction and counted aloud 25 consecutive PFM contractions, with 10‐sec hold and 10‐sec relaxation)	4 to 6 weeks	Nurse	Strength
	PFMT with adherence strategy	Encouraged to exercise 10 minutes twice a day, potential times suggested depending on lifestyle	4 to 6 weeks	Nurse	Uncertain
Sugaya 2003	PFMT	PFMT: 1 minute of rapid contractions every 2 sec, followed by 1 minute of slow 10‐sec contractions with 10‐sec rests, performed 3 times a day. Adherence strategy: pocket size device with chime or blinking light to indicate time to exercise (3 times a day) and when activated leads person through PFMT programme, and kept record of exercise. Fortnightly follow‐up.	8 weeks	"Clinician"	Strength
	PFMT with adherence strategy	As above, without device	8 weeks	"Clinician"	Strength
PFMT = pelvic floor muscle training, VPFMC = voluntary pelvic floor muscle contraction

Table 11. PFMT and adherence strategy versus PFMT alone

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Comparison 1. More versus less contact with health professionals

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patients' perception of change in incontinence ‐ not cured Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Additional group supervision (with no difference in PFMT)	2	111	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.78, 1.03]
1.2 Additional phone calls (with no difference in PFMT)	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Individual supervision versus no supervision (with differences in PFMT)	1	64	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.73, 1.02]
2 Patients' perception of change in incontinence ‐ not improved Show forest plot	5		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

2.1 Additional group supervision (with no difference in PFMT)	4	177	Risk Ratio (M‐H, Random, 95% CI)	0.29 [0.15, 0.55]
2.2 Additional phone calls (with no difference in PFMT)	0	0	Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
2.3 Individual supervision versus no supervision (with difference in PFMT)	1	64	Risk Ratio (M‐H, Random, 95% CI)	0.10 [0.01, 0.71]
3 Incontinence specific quality of life Show forest plot			Other data	No numeric data

3.1 Additional group supervision (with no difference in PFMT)			Other data	No numeric data
3.2 Additional phone calls (with no difference in PFMT)			Other data	No numeric data
3.3 Individual supervision versus no supervision (difference in PFMT)			Other data	No numeric data
4 Symptom impact Show forest plot			Other data	No numeric data

4.1 Additional group supervision (with no difference in PFMT)			Other data	No numeric data
4.2 Additional phone calls (with no difference in PFMT)			Other data	No numeric data
4.3 Individual supervision versus no supervision (difference in PFMT)			Other data	No numeric data
5 Frequency of leakage ‐ leakage episodes in 24 hours Show forest plot	1	22	Mean Difference (IV, Fixed, 95% CI)	‐1.38 [‐2.04, ‐0.72]

5.1 Additional group supervision (with no difference in PFMT)	1	22	Mean Difference (IV, Fixed, 95% CI)	‐1.38 [‐2.04, ‐0.72]
5.2 Additional phone calls (with no difference in PFMT)	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.3 Individual supervision versus no supervision (with difference in PFMT)	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Frequency of leakage ‐ other measures Show forest plot			Other data	No numeric data

6.1 Additional group supervision (with no difference in PFMT)			Other data	No numeric data
6.2 Additional phone calls (with no difference in PFMT)			Other data	No numeric data
6.3 Individual supervision versus no supervision (with difference in PFMT)			Other data	No numeric data
7 Amount of leakage ‐ pad, paper towel and cough tests Show forest plot			Other data	No numeric data

7.1 Additional group supervision (with no difference in PFMT)			Other data	No numeric data
7.2 Additional phone calls (with no difference in PFMT)			Other data	No numeric data
7.3 Individual versus no supervision (with difference in PFMT)			Other data	No numeric data
8 Amount of leakage ‐ other measures Show forest plot			Other data	No numeric data

8.1 Additional group supervision (with no difference in PFMT)			Other data	No numeric data
8.2 Additional phone calls (with no difference in PFMT)			Other data	No numeric data
8.3 Individualised versus no supervision (with difference in PFMT)			Other data	No numeric data
9 Voiding frequency Show forest plot			Other data	No numeric data

9.1 Additional group supervision (with no difference in PFMT)			Other data	No numeric data
9.2 Additional phone calls (with no difference in PFMT)			Other data	No numeric data
9.3 Individual versus no supervision (with difference in PFMT)			Other data	No numeric data
10 PFM performance Show forest plot			Other data	No numeric data

10.1 Additional group supervision (with no difference in PFMT)			Other data	No numeric data
10.2 More individual contact versus less individual contact (with no difference in PFMT)			Other data	No numeric data
10.3 Individual versus no supervision (with difference in PFMT)			Other data	No numeric data
11 Treatment adherence Show forest plot			Other data	No numeric data

11.1 Additional group supervision (with no difference in PFMT)			Other data	No numeric data
11.2 Additional phone calls (with no difference in PFMT)			Other data	No numeric data
11.3 Individual versus no supervision (with difference in PFMT)			Other data	No numeric data
12 Follow‐up data Show forest plot			Other data	No numeric data

12.1 Additional group supervision (with no difference in PFMT)			Other data	No numeric data
12.2 Additional phone calls (with no difference in PFMT)			Other data	No numeric data
12.3 Individual versus no supervision (with difference in PFMT)			Other data	No numeric data

Comparison 1. More versus less contact with health professionals

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Comparison 2. Group versus individual supervision of PFMT

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patients' perception of change in incontinence ‐ not cured Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Individual supervision only versus individual and group supervision (no differences in PFMT)	2	111	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.78, 1.03]
1.2 Individual supervision only versus group supervision only (with difference in PFMT)	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Patients' perception of change in incontinence ‐ not improved Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Individual and group supervision only versus individual supervision (no difference in PFMT)	3	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.16 [0.05, 0.46]
2.2 Group supervision only versus individual supervision only (with difference in PFMT)	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	1.2 [0.61, 2.34]
3 Incontinence‐ specific quality of life Show forest plot			Other data	No numeric data

3.1 Individual supervision only versus individual and group supervision (no difference in PFMT)			Other data	No numeric data
3.2 Individual supervision only versus group supervision only (with difference in PFMT)			Other data	No numeric data
4 Symptom impact Show forest plot			Other data	No numeric data

4.1 Individual supervision only versus individual and group supervision (no difference in PFMT)			Other data	No numeric data
4.2 Individual supervision only versus group supervision only (with difference in PFMT)			Other data	No numeric data
5 Frequency of leakage ‐ leakage episodes in 24 hours Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

5.1 Individual supervision only versus individual and group supervision (no difference in PFMT)	1	22	Mean Difference (IV, Fixed, 95% CI)	‐1.38 [‐2.04, ‐0.72]
5.2 Individual supervision only versus group supervision only (with difference in PFMT)	1	60	Mean Difference (IV, Fixed, 95% CI)	0.1 [‐0.16, 0.36]
6 Frequency of leakage ‐ other measures Show forest plot			Other data	No numeric data

6.1 Individual supervision only versus individual and group supervision (no difference in PFMT)			Other data	No numeric data
6.2 Individual supervision only versus group supervision only (with difference in PFMT)			Other data	No numeric data
7 Amount of leakage ‐ pad, paper towel and cough tests Show forest plot			Other data	No numeric data

7.1 Individual supervision only versus individual and group supervision (no difference in PFMT)			Other data	No numeric data
7.2 Individual supervision only versus group supervision only (with difference in PFMT)			Other data	No numeric data
8 Amount of leakage ‐ other measures Show forest plot			Other data	No numeric data

8.1 Individual supervision only versus individual and group supervision (no difference in PFMT)			Other data	No numeric data
8.2 Individual supervision only versus group supervision only (with difference in PFMT)			Other data	No numeric data
9 Voiding frequency Show forest plot			Other data	No numeric data

9.1 Individual supervision only versus individual and group supervision (no difference in PFMT)			Other data	No numeric data
9.2 Individual supervision only versus group supervision only (with difference in PFMT)			Other data	No numeric data
10 PFM performance Show forest plot			Other data	No numeric data

10.1 Individual supervision only versus individual and group supervision (no difference in PFMT)			Other data	No numeric data
10.2 Individual supervision only versus group supervision only (with difference in PFMT)			Other data	No numeric data
11 Treatment adherence Show forest plot			Other data	No numeric data

11.1 Individual supervision only versus individual and group supervision (no difference in PFMT)			Other data	No numeric data
11.2 Individual supervision only versus group supervision only (with difference in PFMT)			Other data	No numeric data
12 Follow‐up data Show forest plot			Other data	No numeric data

12.1 More group contact versus less individual contact			Other data	No numeric data
12.2 More individual contact versus less individual contact			Other data	No numeric data

Comparison 2. Group versus individual supervision of PFMT

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Comparison 3. Direct versus indirect methods of PFMT

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patients' perception of change in incontinence ‐ not cured Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 PFMT versus sham or imitation PFMT	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 PFMT versus 'Paula method'	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 PFMT versus 'Sapsford' approach	1	64	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.98, 1.36]
1.4 PFMT versus Pilates	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Patients' perception of change in incontinence ‐ not improved Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 PFMT versus sham or imitation PFMT	2	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.69 [0.47, 1.02]
2.2 PFMT versus 'Paula method'	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.3 PFMT versus 'Sapsford' approach	1	64	Risk Ratio (M‐H, Fixed, 95% CI)	10.33 [1.42, 75.41]
2.4 PFMT versus Pilates	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Incontinence specific quality of life Show forest plot			Other data	No numeric data

3.1 PFMT versus sham or imitation PFMT			Other data	No numeric data
3.2 PFMT versus 'Paula method'			Other data	No numeric data
3.3 PFMT versus 'Sapsford' approach			Other data	No numeric data
3.4 PFMT versus Pilates			Other data	No numeric data
4 Symptom impact Show forest plot			Other data	No numeric data

4.1 PFMT versus sham or imitation PFMT			Other data	No numeric data
4.2 PFMT versus 'Paula' method			Other data	No numeric data
4.3 PFMT versus 'Sapsford' approach			Other data	No numeric data
4.4 PFMT versus Pilates			Other data	No numeric data
5 Frequency of leakage ‐ other measures Show forest plot			Other data	No numeric data

5.1 PFMT versus sham or imitation PFMT			Other data	No numeric data
5.2 PFMT versus 'Paula method'			Other data	No numeric data
5.3 PFMT versus 'Sapsford' approach			Other data	No numeric data
5.4 PFMT versus Pilates			Other data	No numeric data
6 Amount of leakage ‐ pad, paper towel and cough tests Show forest plot			Other data	No numeric data

6.1 PFMT versus sham or imitation PFMT			Other data	No numeric data
6.2 PFMT versus 'Paula method'			Other data	No numeric data
6.3 PFMT versus 'Sapsford' approach			Other data	No numeric data
6.4 PFMT versus Pilates			Other data	No numeric data
7 Amount of leakage ‐ other measures Show forest plot			Other data	No numeric data

7.1 PFMT versus sham or imitation PFMT			Other data	No numeric data
7.2 PFMT versus 'Paula method'			Other data	No numeric data
7.3 PFMT versus 'Sapsford' approach			Other data	No numeric data
7.4 PFMT versus Pilates			Other data	No numeric data
8 Voiding frequency Show forest plot			Other data	No numeric data

8.1 PFMT versus sham or imitation PFMT			Other data	No numeric data
8.2 PFMT versus 'Paula method'			Other data	No numeric data
8.3 PFMT versus 'Sapsford' approach			Other data	No numeric data
8.4 PFMT versus Pilates			Other data	No numeric data
9 PFM performance Show forest plot			Other data	No numeric data

9.1 PFMT versus sham or imitation PFMT			Other data	No numeric data
9.2 PFMT versus 'Paula method'			Other data	No numeric data
9.3 PFMT versus 'Sapsford' approach			Other data	No numeric data
9.4 PFMT versus Pilates			Other data	No numeric data
10 Treatment adherence Show forest plot			Other data	No numeric data

10.1 PFMT versus sham or imitation PFMT			Other data	No numeric data
10.2 PFMT versus 'Paula method'			Other data	No numeric data
10.3 PFMT versus 'Sapsford' approach			Other data	No numeric data
10.4 PFMT versus Pilates			Other data	No numeric data

Comparison 3. Direct versus indirect methods of PFMT

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Comparison 4. Individualised versus generic PFMT

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patients' perception of change in incontinence ‐ not improved Show forest plot	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.43, 1.63]

2 Incontinence specific quality of life Show forest plot			Other data	No numeric data

3 Frequency of leakage ‐ leakage episodes in 24 hours Show forest plot	1	60	Mean Difference (IV, Fixed, 95% CI)	‐0.1 [‐0.36, 0.16]

4 Amount of leakage ‐ pad, paper towel and cough tests Show forest plot			Other data	No numeric data

5 PFM performance Show forest plot			Other data	No numeric data

6 Treatment adherence Show forest plot			Other data	No numeric data

Comparison 4. Individualised versus generic PFMT

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Comparison 5. Near maximal versus submaximal contractions

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Frequency of leakage ‐ leakage episodes in 24 hours Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

2 Frequency of leakage ‐ other measures Show forest plot			Other data	No numeric data

3 Amount of leakage ‐ pad, paper towel and cough tests Show forest plot			Other data	No numeric data

4 PFM performance Show forest plot			Other data	No numeric data

Comparison 5. Near maximal versus submaximal contractions

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Comparison 6. Daily versus three times per week PFMT

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patients' perception of change in incontinence ‐ not cured Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2 Patients' perception of change in incontinence ‐ not improved Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3 Amount of leakage ‐ pad, paper towel and cough tests Show forest plot			Other data	No numeric data

4 PFM performance Show forest plot			Other data	No numeric data

Comparison 6. Daily versus three times per week PFMT

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Comparison 7. Upright and supine versus supine exercise positions alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Incontinence‐specific quality of life Show forest plot			Other data	No numeric data

2 Frequency of leakage ‐ leakage episodes in 24 hours Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

3 Amount of leakage ‐ pad, paper towel and cough tests Show forest plot			Other data	No numeric data

4 PFM performance Show forest plot			Other data	No numeric data

5 Treatment adherence Show forest plot			Other data	No numeric data

Comparison 7. Upright and supine versus supine exercise positions alone

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Comparison 8. Strength and motor learning versus motor learning PFMT alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patients' perception of change in incontinence ‐ not cured Show forest plot	1	123	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.98, 1.13]

2 Patients' perception of change in incontinence ‐ not improved Show forest plot	1	123	Risk Ratio (M‐H, Fixed, 95% CI)	0.65 [0.31, 1.40]

3 Incontinence‐specific quality of life Show forest plot			Other data	No numeric data

4 Frequency of leakage ‐ leakage episodes in 24 hours Show forest plot	1	97	Mean Difference (IV, Fixed, 95% CI)	‐0.20 [‐0.55, 0.15]

5 Amount of leakage ‐ pad, paper towel test and cough tests Show forest plot			Other data	No numeric data

6 Amount of leakage ‐ other measures Show forest plot			Other data	No numeric data

7 Voiding frequency Show forest plot			Other data	No numeric data

Comparison 8. Strength and motor learning versus motor learning PFMT alone

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Comparison 9. PFMT and abdominal muscle exercise versus PFMT alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patients' perception of change in incontinence ‐ not cured Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2 Patients' perception of change in incontinence ‐ not improved Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3 Amount of leakage ‐ pad, paper towel and cough tests Show forest plot			Other data	No numeric data

4 PFM performance Show forest plot			Other data	No numeric data

Comparison 9. PFMT and abdominal muscle exercise versus PFMT alone

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Comparison 10. PFMT with intravaginal resistance device versus PFMT alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patients' perception of change in incontinence ‐ not cured Show forest plot	2	120	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.96, 1.20]

2 Patients' perception of change in incontinence ‐ not improved Show forest plot	2	120	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.62, 1.20]

3 Symptom impact Show forest plot			Other data	No numeric data

4 Frequency of leakage ‐ leakage episodes in 24 hours Show forest plot	1	80	Mean Difference (IV, Fixed, 95% CI)	0.20 [‐0.13, 0.53]

5 Frequency of leakage ‐ other measures Show forest plot			Other data	No numeric data

6 Amount of leakage ‐ pad, paper towel and cough tests Show forest plot			Other data	No numeric data

7 Amount of leakage ‐ other measures Show forest plot			Other data	No numeric data

8 PFM performance Show forest plot			Other data	No numeric data

Comparison 10. PFMT with intravaginal resistance device versus PFMT alone

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Comparison 11. PFMT and adherence strategy versus PFMT alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patients' perception of change in incontinence ‐ not improved Show forest plot	1	41	Risk Ratio (M‐H, Fixed, 95% CI)	0.56 [0.34, 0.91]

2 Frequency of leakage ‐ leakage episodes in 24 hours Show forest plot	1	41	Mean Difference (IV, Fixed, 95% CI)	‐0.50 [‐1.55, 0.55]

3 Amount of leakage ‐ pad, paper towel and cough tests Show forest plot			Other data	No numeric data

4 Amount of leakage ‐ other measures Show forest plot			Other data	No numeric data

5 Treatment adherence Show forest plot			Other data	No numeric data

Comparison 11. PFMT and adherence strategy versus PFMT alone

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Comparison 12. 'More intensive' versus 'less intensive' PFMT programmes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patients' perception of change in incontinence ‐ not cured Show forest plot	8		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 'High' contrast	3	175	Risk Ratio (M‐H, Random, 95% CI)	0.89 [0.80, 0.98]
1.2 'Moderate' contrast	0	0	Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 'Low' contrast	5	304	Risk Ratio (M‐H, Random, 95% CI)	1.06 [1.00, 1.13]
2 Patients' perception of change in incontinence ‐ not improved Show forest plot	14		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

2.1 'High' contrast	6	335	Risk Ratio (M‐H, Random, 95% CI)	0.37 [0.17, 0.84]
2.2 'Moderate' contrast	1	44	Risk Ratio (M‐H, Random, 95% CI)	0.34 [0.17, 0.71]
2.3 'Low' contrast	7	405	Risk Ratio (M‐H, Random, 95% CI)	0.75 [0.59, 0.95]
3 Frequency of leakage ‐ leakage episodes in 24 hours Show forest plot	7		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 'High' contrast	1	22	Mean Difference (IV, Random, 95% CI)	‐1.38 [‐2.04, ‐0.72]
3.2 'Moderate' contrast	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.3 'Low' contrast	6	346	Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.19, 0.14]

Comparison 12. 'More intensive' versus 'less intensive' PFMT programmes

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