Mobile app for pelvic floor muscle training for urinary incontinence during the coronavirus disease 2019 pandemic: clinical trial.

OBJECTIVE: The objective of this study was to evaluate the effects of home-based pelvic floor muscle training in women with urinary incontinence, addressing the difficulties arising from social isolation due to the coronavirus disease 2019 pandemic by utilizing a specialized mobile app. METHODS: This randomized, single-group clinical trial aimed to assess the efficacy of pelvic floor muscle training guided by a mobile app (Diario Saúde) in women with stress urinary incontinence. Participants were instructed via telephone to engage in pelvic floor muscle training exercises twice a day for 30 days. Pre- and post-treatment, participants completed validated questionnaires regarding urinary symptoms and quality of life through telephone interviews. Additionally, treatment adherence was evaluated. RESULTS: A total of 156 women were enrolled in the study, with a mean age of 49.3±14.2 years. Significant improvements in urinary incontinence symptoms and quality of life were observed following pelvic floor muscle training guided by the mobile app (p<0.001). Notably, 74.3% of the participants reported performing the exercises with appropriate frequency. Of the participants, 62% reported either complete or substantial improvement in urinary symptoms post-treatment. CONCLUSION: This study revealed notable enhancements in stress urinary incontinence, urinary storage, and overall quality of life subsequent to pelvic floor muscle training guided by a mobile app, particularly during the coronavirus disease 2019 pandemic. The mobile app demonstrated robust acceptance and adherence among women experiencing urinary incontinence.

Pelvic floor muscle training in female functional fitness exercisers: an assessor-blinded randomised controlled trial.

OBJECTIVE: Stress urinary incontinence (SUI) is common among females during functional fitness training, such as CrossFit. The aim of this study was to assess the effect of pelvic floor muscle training (PFMT) on SUI in female functional fitness exercisers. METHODS: This was an assessor-blinded randomised controlled trial with a PFMT group (n=22) and a control group (n=25). The PFMT group followed a 16-week home-training programme with 3 sets of 8-12 maximum pelvic floor muscle (PFM) contractions daily and weekly follow-up/reminders by phone. The primary outcome was change in a total score of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF). The secondary outcomes were perceived change of symptoms of SUI, change of PFM strength measured by vaginal manometry and symptoms of anal incontinence (AI) and pelvic organ prolapse (POP). RESULTS: 47 women, mean age of 33.5 years (SD: 8.1), participated. At 16 weeks, there was a mean difference between groups of -1.4 (95% CI: -2.6 to -0.2) in the change of the ICIQ-UI-SF score in favour of the PFMT group. The PFMT group completed a mean of 70% (SD: 23) of the prescribed protocol. 64% in the PFMT group versus 8% in the control group reported improved symptoms of SUI (p<0.001, relative risk: 7.96, 95% CI, 2.03 to 31.19). There were no group differences in the change of PFM strength or AI/POP symptoms. CONCLUSION: A 16-week home-training programme of the PFM led to improvements in SUI in female functional fitness exercisers. However, PFM strength and AI and POP symptoms did not improve significantly in the PFMT group compared with the control group.

The effect of pelvic floor muscle training on urinary incontinence in patients with stroke: a systematic review and meta-analysis.

BACKGROUND: No other systematic review presented the effectiveness of pelvic floor muscle training (PFMT) in individual with stroke. AIMS: The purpose of this systematic review and meta-analysis was to demonstrate the effectiveness of PFMT for urinary incontinence in patients with stroke. METHODS: "Web of Science (WoS), Cochrane Library, PubMed and Scopus" databases were searched. "Revised Cochrane risk-of-bias tool randomized trials (RoB 2)" and "PEDro" were used to assess the risk of bias and methodological quality of the studies. Narrative synthesis and meta-analysis were conducted to present the results. RESULTS: A total of 8 articles were included in the review. Seven articles were classified as "good" level evidence. Four articles were considered to have "high risk" of bias for the overall score. Regarding two homogenous studies, PFMT-based rehabilitation was not superior standard urinary incontinence therapy on SF-36-Social Function score at 12-week follow-up (ES 0.47, 95% CI - 0.16-0.96). Data pooling of two studies did not provide an additional advantage of pelvic muscle training on 3 days voiding diary (night, total day) score at 12-week follow-up (ES 28, 95% CI - 0.61-0.48; ES 0.30, 95% CI - 0.23-0.95). On the other hand, low-quality evidence demonstrated that pelvic muscle training yielded better results on daytime voiding (ES 0.28, 95% CI 0.04-1.16). CONCLUSIONS: The results demonstrated that PFMT had positive effects in terms of daytime urination frequency and incontinence. Although some studies have reported positive effects on symptoms, function, strength, and endurance, the generalizability of these results is controversial. Further studies should assess the quality-of-life and function with urinary incontinence and stroke-specific tools.

Prospective evaluation of the connected biofeedback EMY Kegel trainer in the management of stress urinary incontinence.

INTRODUCTION: The aim of this study was to evaluate changes in the quality of life with the connected biofeedback EMY Kegel trainer in patients suffering from stress urinary incontinence. Materiel and methods: This was a prospective, single-center, non-comparative study, which took place between September 2019 and October 2020, in the University Hospitals of Strasbourg. Eligible patients were instructed to use the EMY probe for a minimum of 10 min per day for five days per week. To assess quality of life and urinary symptoms, the Contilife and ICIQ-SF scores were completed each month until the final visit (M3). The PGI-I was also completed at 3 months to assess the benefit of the EMY Kegel Trainer. RESULTS: A total of 55 patients were included. At the inclusion visit (M0), the mean Contilife and ICIQ-SF scores were respectively at 6.6 ± 1.5 and 10.5 ± 3.0 points. At the final visit (M3), the mean Contilife score increased to 9.2 ± 1.0, indicating an improvement in quality of life. The mean ICIQ-SF score decreased to 4.2 ± 4.0, indicating an improvement in urinary symptoms. The PGI-I questionnaire identified a positive assessement of the EMY Kegel trainer. On the 55 patients included, 35 (64%) reported completing at least 36 sessions during the study, i.e. an average of 3 sessions per week. CONCLUSIONS: This study suggests that perineal rehabilitation by biofeedback using the EMY Kegel trainer might be beneficial.

[Impact of biofeedback probes used in the self-rehabilitation of pelvic floor muscles in women with stress urinary incontinence. Literature review]. / Impact des sondes de biofeedback utilisées dans le cadre de l'auto-rééducation des muscles du plancher pelvien chez la femme incontinente urinaire à l'effort. Revue de la littérature.

OBJECTIVE: The purpose of this review was to identify the evaluated effects of the use of biofeedback probes used in the self-rehabilitation of the pelvic floor muscles, on the muscle function, symptom severity, quality of life, and compliance/adherence to exercise for women with stress urinary incontinence. MATERIAL AND METHOD: A literature review was conducted in March 2020 on the PubMed, PEDro and Science Direct databases. RESULTS: A total of 3 randomised controlled trials (n=167 participants) were included and analysed. The different results found show significant improvements in muscle function with a percentage of 87.5% (P=0.003) of patients improved on the modified Oxford scale, as well as perineometry increasing from 23.06 to 32 (P=0.011). Symptom severity is also improved with a decrease in the number of pads and pad weight in the Pad Test (P<0.005). Concerning quality of life, significant improvements in the King's Health Questionnaire (KHQ) and the Visual Analogue Scale of Psychological Stress were found, with an improvement in the number of patients in each group at the end of the study (P<0.0005). No results showed a superiority of pelvic floor muscle training with a biofeedback probe compared to training alone. CONCLUSION: This review didn't provide real recommendations for the use of home biofeedback probes as an adjunct to pelvic floor muscle training in women with stress urinary incontinence. She suggests that the use of biofeedback probes wouldn't be more effective than training without them.

Group-Based vs Individual Pelvic Floor Muscle Training to Treat Urinary Incontinence in Older Women: A Randomized Clinical Trial.

Importance: Urinary incontinence is one of the most prevalent health concerns experienced by older women (aged ≥60 years). Individual pelvic floor muscle training (PFMT) is the recommended first-line treatment for stress or mixed urinary incontinence in women, but human and financial resources limit its delivery. Whether group-based PFMT performs as well as individual PFMT in this population remains unclear. Objective: To assess the efficacy of group-based PFMT relative to individual PFMT for urinary incontinence in older women. Design, Setting, and Participants: The Group Rehabilitation or Individual Physiotherapy (GROUP) study is a single-blind, randomized, noninferiority trial conducted in 2 Canadian research centers, from July 1, 2012, to June 2, 2018. A total of 362 community-dwelling women aged 60 years or older with symptoms of stress or mixed urinary incontinence were enrolled. Interventions: After an individual session conducted to learn how to contract pelvic floor muscles, participants completed 12-week PFMT as part of a group of 8 women (n = 178) or in individual sessions (n = 184). Main Outcomes and Measures: The primary outcome measure was the percentage reduction in urinary incontinence episodes at 1 year, as reported in a 7-day bladder diary and relative to pretreatment baseline. Secondary outcomes included lower urinary tract-related signs, symptoms, and quality of life immediately following treatment and at 1 year. Per-protocol analysis was used. Results: Among 362 women who were randomized (mean [SD] age, 67.9 [5.8] years), 319 women (88%) completed the 1-year follow-up and were included in the per-protocol analysis. Median percentage reduction in urinary incontinence episodes was 70% (95% CI, 44%-89%) in individual PFMT compared with 74% (95% CI, 46%-86%) in group-based PFMT. The upper boundary of the 95% CI for the difference in the percentage reduction in urinary incontinence episodes at 1 year was lower than the prespecified margin for noninferiority of 10% (difference, 4%; 95% CI, -10% to 7%; P = .58), confirming noninferiority. Individual PFMT and group-based PFMT had similar effectiveness for all secondary outcomes at 1 year. Adverse events were minor and uncommon. Conclusions and Relevance: Results of the GROUP study suggest that group-based PFMT is not inferior to the recommended individual PFMT for the treatment of stress and mixed urinary incontinence in older women. Widespread use in clinical practice may help increase continence-care affordability and treatment availability. Trial Registration: ClinicalTrials.gov Identifier: NCT02039830.

Possibilities of objectivization of pelvic floor muscle exercises in patients with urine leakage after delivery.

BACKGROUND: Examination of pelvic floor muscle function is very important before starting exercises in patients with urine leakage and other pelvic floor dysfunctions. Perineometer and palpation examination is currently being used. A new trend in physiotherapy is the ultrasound examination of pelvic floor muscles. The examination can be performed by abdominal approach or perineal approach. We evaluate 2D and 3/4D images of pelvic floor muscles. METHODS: The International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF). OAB-q - overactive bladder questionnaire - short form. The Urinary Incontinence Quality of Life scale (I-QoL) - self-assessment scale for assessing the quality of life of patients with urinary incontinence. Adjusted Oxford scale to assess pelvic floor muscle strength. PERFECT scheme by Laycock and Jerwood. Pelvic floor examination by perineometer (Peritron-Ontario, L4V, Canada). Pelvic floor examination by 2D and 3/4D ultrasound examination (Volunson-i BT 11 Console, VCI volume contrast imaging software, (GE Healthcare Austria GmbH & Co OG, Zipf, Austria, RAB4-8-RS 3D/4D 4-8 MHz probe). High intensity exercise of pelvic floor muscles with stabilization elements. CONCLUSION: The effect of pelvic floor muscle training was objectively proved by the above mentioned objectivization methods with subjective improvement of quality of life. There was also a significant effect of education in USG exercise.

Association of pubovisceral muscle tear with functional capacity of urethral closure: evaluating maternal recovery from labor and delivery.

BACKGROUND: Vaginal birth is a risk factor for pubovisceral muscle tear, decreased urethral closure pressure, and urinary incontinence. The relationship between these 3 factors is complicated. Urinary continence relies on maintaining urethral closure pressure, particularly when low urethral closure pressure can usefully be augmented by a volitional pelvic muscle (Kegel) contraction just before and during stress events like a cough. However, it is unknown whether a torn pubovisceral muscle decreases the ability to increase urethral closure during an attempted pelvic muscle contraction. OBJECTIVE: We tested the null hypothesis that a pubovisceral muscle tear does not affect the ability to increase urethral closure pressure during a volitional pelvic muscle contraction in the Evaluating Maternal Recovery from Labor and Delivery (EMRLD) study. STUDY DESIGN: We studied 56 women 8 months after their first vaginal birth. All had at least 1 risk factor for pubovisceral muscle tear (eg, forceps and long second stage). A tear was assessed bilaterally by magnetic resonance imaging. Urethral closure pressure was measured both at rest and during an attempted volitional pelvic muscle contraction. A Student t test was used to compare urethral closure pressures. Multiple linear regression was used to estimate the effect of a magnetic resonance imaging-confirmed pubovisceral muscle tear on volitionally contracted urethral closure pressure after adjusting for resting urethral closure pressure. RESULTS: The mean age was just a little more than 30 years, with the majority being white. By magnetic resonance imaging measure, unadjusted for other factors, the 21 women with tear had significantly lower urethral closure pressure during an attempted contraction compared with the 35 women without tear (65.9 vs 86.8 cm H2O, respectively, P = .004), leading us to reject the null hypothesis. No significant group difference was found in resting urethral closure pressure. After adjusting for resting urethral closure pressure, pubovisceral muscle tear was associated with lower urethral closure pressure (beta = -21.1, P = .001). CONCLUSION: In the first postpartum year, the presence of a pubovisceral muscle tear did not influence resting urethral closure. However, women with a pubovisceral muscle tear achieved a 25% lower urethral closure pressure during an attempted pelvic muscle contraction than those without a pubovisceral muscle tear. These women with pubovisceral muscle tear may not respond to classic behavioral interventions, such as squeeze when you sneeze or strengthen through repetitive pelvic muscle exercises. When a rapid rise to maximum urethral pressure is used as a conscious volitional maneuver, it appears to be reliant on the ability to recruit the intact pubovisceral muscle to simultaneously contract the urethral striated muscle.

Electromyographic characteristics of pelvic floor muscles in women with stress urinary incontinence following sEMG-assisted biofeedback training and Pilates exercises.

The aim of this study was to compare the effect of pelvic floor muscle training with surface electromyographic (sEMG) biofeedback (BF group) and Pilates exercises (P group) on the bioelectrical activity of pelvic floor muscles in women with stress urinary incontinence. The other aim aim was to compare changes in voiding diaries and scores on quality of life questionnaire against baseline values and between the groups. Women in the BF group (n = 18) participated in pelvic floor muscle training with sEMG biofeedback; the P group (n = 13) participated in basic level Pilates workouts. Both protocols were continued for eight weeks. Voiding diary, quality of life and electromyographic characteristics of the pelvic floor muscles were assessed at the three-time points: at baseline, after eight weeks' training, and at month six post-training. The sEMG activity of the pelvic floor muscles was tested during five trials in two positions. There was no marked improvement in bioelectrical activity of the pelvic floor muscles during contraction following training with sEMG biofeedback or Pilates exercises. Following eight weeks of sEMG biofeedback training, a decrease was noted in resting bioelectrical activity of pelvic floor muscles and during relaxation after sustained contraction but only in supine-lying. No such effect was observed in the Pilates group. In the BF group, the number of incontinence episodes after end of treatment (timpepoints: 1vs. 2) and at six month follow-up (timpepoints: 1vs. 3) decreased by 68.5% and 89.3%, respectively. The respective values in the P group were 78.6%, and 86.4%. The intergroup differences did not reach the level of statistical significance. As regards the quality of life, the questionnaire demonstrated that Pilates exercises had significantly better effects compared to biofeedback training both at the end of the eight-week exercise program and (p = 0.003) and at six month follow-up (p = 0.0009). The International Consultation on Incontinence Questionnaire-Short Form (ICIQ- SF) showed comparable efficacy of Pilates exercises and training with sEMG biofeedback. Intragroup improvements in micturition frequency, incontinence (leakage) episodes, and nocturia frequency were comparable. Alleviation of urinary incontinence symptoms was comparable in both groups, whereas the improvement in the quality of life was more notable in the Pilates group. The obtained results failed to demonstrate the superiority of any of the two methods regarding the bioelectrical activity of pelvic floor muscles in patients with stress urinary incontinence.

[Specific features of the treatment of stress urinary incontinence in patients with III-IV stage of anterior vaginal prolapse].

AIM: to improve treatment results of patients with stress urinary incontinence and severe cystocele by optimizing surgical tactics and rehabilitation methods. MATERIALS AND METHODS: a total of 56 women aged 54 to 68 years with stages III-IV of the anterior vaginal wall prolapse (according to the POP-Q classification) and urethral sphincter insufficiency were evaluated. All patients underwent a transvaginal extraperitoneal anterior mesh repair without concomitant sling procedure. The severity of prolapse, a presence or absence of stress urinary incontinence, and ultrasound signs of sphincter insufficiency were re-evaluated two months after procedure. RESULTS: in all cases, the anterior wall prolapse was eliminated or reduced to subclinical stage. Two months after procedure, 48 patients (85,7%) noted the onset of stress urinary incontinence (moderate and severe) with progressive deterioration. In the remaining cases (14,3%), patients did not have any urinary incontinence. All patients underwent active rehabilitation for 6 months. In 6 cases (12,5%), there was a decrease in the severity of urinary incontinence to the level that had virtually didnt affect the quality of life; in remaining cases, conservative treatment was considered ineffective and sling procedure was recommended. DISCUSSION: A diagnosis of latent urinary incontinence remains to be controversial. To detect this form, a cough test with a prolapse reduction is usually performed. In addition, preoperative urodynamic testing can be used, since it has good sensitivity in identifying latent urinary incontinence, but it is an expensive procedure for the routine practice. A determination of the urethral sphincter insufficiency makes it possible to predict the development of the stress urinary incontinence with a high accuracy, but this method also has a number of limitations. CONCLUSION: patients with stages III-IV of the anterior vaginal wall prolapse and ultrasound signs of sphincter insufficiency have a risk of developing stress urinary incontinence after surgical treatment. In this group of patients, a simultaneous surgery can be recommended in order to correct prolapse and to prevent subsequent urinary incontinence.

[Stress Urinary Incontinence and Female Sexual Dysfunction: The Role of Pelvic Floor Rehabilitation]. / Incontinência Urinária de Esforço e Disfunção Sexual Feminina: O Papel da Reabilitação do Pavimento Pélvico.

INTRODUCTION: The prevalence of urinary incontinence in Portuguese women is 21.4% and has a very negative impact on quality of life including women's sexual activity. Pelvic floor rehabilitation is the first line treatment used in stress urinary incontinence and may be a tool in the treatment of sexual dysfunction in women with urinary incontinence. The aim of this review is to ascertain whether pelvic floor rehabilitation can improve sexual function in women with stress urinary incontinence. MATERIAL AND METHODS: We reviewed 12 articles in PubMed using the keywords: 'urinary incontinence', 'female sexual dysfunction' and 'pelvic floor physical therapy'. RESULTS: Pelvic floor rehabilitation is linked to a decrease in frequency of urinary leakage episodes as well as an improvement of coital incontinence. Furthermore, sexual function evaluation scores post-treatment revealed a positive change. Higher parity, higher adherence to treatment, improvement in the strength of pelvic floor muscles, and a decrease in the frequency of urine leakage were associated with higher improvement in sexual function. DISCUSSION: Sexual function should be considered in the approach of urinary incontinence and standard tools of evaluation are essential tools for clinical assessment and follow-up. More evidence is required to identify the role of pelvic floor rehabilitation in sexual dysfunction of Portuguese women with urinary incontinence. CONCLUSION: Pelvic floor rehabilitation improves sexual function of women with stress urinary incontinence not only because it decreases the episodes of urine leakage but also because it strengthens pelvic floor muscles.

Introdução: A incontinência urinária afeta 21,4% das mulheres portuguesas e tem impacto negativo na qualidade de vida e na esfera sexual. A reabilitação do pavimento pélvico é a primeira linha de tratamento na incontinência urinária de esforço e pode ser uma opção terapêutica na disfunção sexual. O objetivo desta revisão é esclarecer se o tratamento com reabilitação do pavimento pélvico apresenta efeitos benéficos na função sexual em mulheres com incontinência urinária de esforço.Material e Métodos: Realizou-se uma revisão, recorrendo à base de dados PubMed, usando os termos: 'urinary incontinence', 'female sexual dysfunction' e 'pelvic floor physical therapy', recolhendo informação de 12 artigos relevantes.Resultados: A reabilitação do pavimento pélvico está associada à redução dos episódios de perda de urina e à melhoria da incontinência coital. Verifica-se uma melhoria nos scores de avaliação da função sexual após tratamento. Multiparidade, maior adesão ao tratamento, melhoria na força de contração muscular do pavimento pélvico e diminuição da perda de urina são fatores associados a uma melhoria da função sexual.Discussão: A função sexual deve ser avaliada na abordagem desta patologia e a sua estandardização é fundamental na caraterização do quadro clínico e na avaliação do follow-up. São necessários estudos para avaliar o papel da reabilitação do pavimento pélvico na disfunção sexual de mulheres com incontinência urinária na população portuguesa.Conclusão: A reabilitação do pavimento pélvico melhora a função sexual nas mulheres com incontinência urinária de esforço, pela diminuição de episódios de perda de urina e pelo fortalecimento dos músculos do pavimento pélvico.

The effect of a comprehensive care and rehabilitation program on enhancing pelvic floor muscle functions and preventing postpartum stress urinary incontinence.

This study was to investigate the incidence and the risk factors of postpartum stress urinary incontinence (SUI), and the effect of comprehensive care and rehabilitation program (CCRP) on preventing postpartum SUI.In stage I, 479 puerperae were recruited within 1 week postpartum, then the postpartum SUI incidence at 8th week and its risk factors were investigated. In stage II, 240 vaginal delivery puerperae were enrolled within 1 week postpartum and randomly assigned to CCRP group or control group as 1:1 ratio. The postpartum SUI incidence and pelvic floor muscle function indexes were evaluated at 8th week.In stage I, the postpartum SUI incidence was 25.7%, and SUI puerperae presented with higher body mass index (BMI), vaginal delivery rate, newborn weight, and larger newborn head diameter compared with non-SUI puerperae. Besides, the vaginal delivery, the elevated age and BMI were independent risk factors for postpartum SUI. In stage II, the postpartum SUI incidence in CCRP group was decreased compared with control group, and the vaginal resting pressure, vaginal squeezing pressure, and vaginal contraction duration were increased in CCRP group compared to control group at 8th week postpartum.The incidence of postpartum SUI is 25.7%, and the vaginal delivery, increased age, and BMI are independent risk factors for postpartum SUI. More importantly, CCRP strengthens pelvic floor muscle functions and decreases postpartum SUI incidence in puerperae.

Pelvic floor muscle activation in stress urinary incontinent women: Impact of a distraction task.

AIMS: Our purpose was to explore the involvement of cognition in voluntary and involuntary pelvic floor muscle (PFM) contraction in stress urinary incontinent women. METHODS: PFM contraction monitored by surface electromyography (EMG) was measured without a mental distraction task (DT), and with a DT called "paced auditory serial additional test" (PASAT). Forty stress incontinent women performed voluntary contractions of the external anal sphincter (EAS), and reflex EAS contractions induced by means of coughing were studied using the external intercostal muscle (EIC) EMG pattern. RESULTS: A DT altered PFM pre-activation when coughing: the reaction time between EIC muscle contraction and EAS contraction (called RT3) was respectively -54.94 ms (IQR -87.12; 3.12) without the PASAT and -3.99 ms (IQR: -47.92; 18.69) with a DT (P = 0.02, Wilcoxon's test). Concerning voluntary contraction, women activated their PFM sooner without than with a DT. CONCLUSION: The PASAT altered voluntary and reflex contractions of the PFM in stress urinary incontinent women. Our study suggests that cognition plays a role in urinary pathophysiology. Future studies should investigate rehabilitation programs that consider the role of cognition in stress urinary incontinent women.

Effectiveness and cost-effectiveness randomised controlled trial of basic versus biofeedback-mediated intensive pelvic floor muscle training for female stress or mixed urinary incontinence: protocol for the OPAL (optimising pelvic floor exercises to achieve long-term benefits) trial mixed methods longitudinal qualitative case study and process evaluation.

INTRODUCTION: Female urinary incontinence (UI) is common affecting up to 45% of women. Pelvic floor muscle training (PFMT) is the first-line treatment but there is uncertainty whether intensive PFMT is better than basic PFMT for long-term symptomatic improvement. It is also unclear which factors influence women's ability to perform PFMT long term and whether this has impacts on long-term outcomes. OPAL (optimising PFMT to achieve long-term benefits) trial examines the effectiveness and cost-effectiveness of basic PFMT versus biofeedback-mediated PFMT and this evaluation explores women's experiences of treatment and the factors which influence effectiveness. This will provide data aiding interpretation of the trial findings; make recommendations for optimising the treatment protocol; support implementation in practice; and address gaps in the literature around long-term adherence to PFMT for women with stress or mixed UI. METHODS AND ANALYSIS: This evaluation comprises a longitudinal qualitative case study and process evaluation (PE). The case study aims to explore women's experiences of treatment and adherence and the PE will explore factors influencing intervention effectiveness. The case study has a two-tailed design and will recruit 40 women, 20 from each trial group; they will be interviewed four times over 2 years. Process data will be collected from women through questionnaires at four time-points, from health professionals through checklists and interviews and by sampling 100 audio recordings of appointments. Qualitative analysis will use case study methodology (qualitative study) and the framework technique (PE) and will interrogate for similarities and differences between the trial groups regarding barriers and facilitators to adherence. Process data analyses will examine fidelity, engagement and mediating factors using descriptive and interpretative statistics. ETHICS AND DISSEMINATION: Approval from West of Scotland Research Ethics Committee 4 (16/LO/0990). Findings will be published in journals, disseminated at conferences and through the final report. TRIAL REGISTRATION NUMBER: ISRCTN57746448.

Effectiveness and cost-effectiveness of basic versus biofeedback-mediated intensive pelvic floor muscle training for female stress or mixed urinary incontinence: protocol for the OPAL randomised trial.

INTRODUCTION: Accidental urine leakage is a distressing problem that affects around one in three women. The main types of urinary incontinence (UI) are stress, urgency and mixed, with stress being most common. Current UK guidelines recommend that women with UI are offered at least 3 months of pelvic floor muscle training (PFMT). There is evidence that PFMT is effective in treating UI, however it is not clear how intensively women have to exercise to give the maximum sustained improvement in symptoms, and how we enable women to achieve this. Biofeedback is an adjunct to PFMT that may help women exercise more intensively for longer, and thus may improve continence outcomes when compared with PFMT alone. A Cochrane review was inconclusive about the benefit of biofeedback, indicating the need for further evidence. METHODS AND ANALYSIS: This multicentre randomised controlled trial will compare the effectiveness and cost-effectiveness of PFMT versus biofeedback-mediated PFMT for women with stress UI or mixed UI. The primary outcome is UI severity at 24 months after randomisation. The primary economic outcome measure is incremental cost per quality-adjusted life-year at 24 months. Six hundred women from UK community, outpatient and primary care settings will be randomised and followed up via questionnaires, diaries and pelvic floor assessment. All participants are offered six PFMT appointments over 16 weeks. The use of clinic and home biofeedback is added to PFMT for participants in the biofeedback group. Group allocation could not be masked from participants and healthcare staff. An intention-to-treat analysis of the primary outcome will estimate the mean difference between the trial groups at 24 months using a general linear mixed model adjusting for minimisation covariates and other important prognostic covariates, including the baseline score. ETHICS AND DISSEMINATION: Approval granted by the West of Scotland Research Ethics Committee 4 (16/LO/0990). Written informed consent will be obtained from participants by the local research team. Serious adverse events will be reported to the data monitoring and ethics committee, the ethics committee and trial centres as required. A Standard Protocol Items: Recommendations for Interventional Trials checklist and figure are available for this protocol. The results will be published in international journals and included in the relevant Cochrane review. TRIAL REGISTRATION NUMBER: ISRCTN57746448; Pre-results.

A group-based yoga program for urinary incontinence in ambulatory women: feasibility, tolerability, and change in incontinence frequency over 3 months in a single-center randomized trial.

BACKGROUND: Because of the limitations of existing clinical treatments for urinary incontinence, many women with incontinence are interested in complementary strategies for managing their symptoms. Yoga has been recommended as a behavioral self-management strategy for incontinence, but evidence of its feasibility, tolerability, and efficacy is lacking. OBJECTIVE: To evaluate the feasibility and tolerability of a group-based therapeutic yoga program for ambulatory middle-aged and older women with incontinence, and to examine preliminary changes in incontinence frequency as the primary efficacy outcome after 3 months. MATERIALS AND METHODS: Ambulatory women aged 50 years or older who reported at least daily stress-, urgency-, or mixed-type incontinence, were not already engaged in yoga, and were willing to temporarily forgo clinical incontinence treatments were recruited into a randomized trial in the San Francisco Bay area. Women were randomly assigned to take part in a program of twice-weekly group classes and once-weekly home practice focused on Iyengar-based yoga techniques selected by an expert yoga panel (yoga group), or a nonspecific muscle stretching and strengthening program designed to provide a rigorous time-and-attention control (control group) for 3 months. All participants also received written, evidence-based information about behavioral incontinence self-management techniques (pelvic floor exercises, bladder training) consistent with usual first-line care. Incontinence frequency and type were assessed by validated voiding diaries. Analysis of covariance models examined within- and between-group changes in incontinence frequency as the primary efficacy outcome over 3 months. RESULTS: Of the 56 women randomized (28 to yoga, 28 to control), the mean age was 65.4 (±8.1) years (range, 55-83 years), the mean baseline incontinence frequency was 3.5 (±2.0) episodes/d, and 37 women (66%) had urgency-predominant incontinence. A total of 50 women completed their assigned 3-month intervention program (89%), including 27 in the yoga and 23 in the control group (P = .19). Of those, 24 (89%) in the yoga and 20 (87%) in the control group attended at least 80% of group classes. Over 3 months, total incontinence frequency decreased by an average of 76% from baseline in the yoga and 56% in the control group (P = .07 for between-group difference). Stress incontinence frequency also decreased by an average of 61% in the yoga group and 35% in controls (P = .045 for between-group difference), but changes in urgency incontinence frequency did not differ significantly between groups. A total of 48 nonserious adverse events were reported, including 23 in the yoga and 25 in the control group, but none were directly attributable to yoga or control program practice. CONCLUSION: Findings demonstrate the feasibility of recruiting and retaining incontinent women across the aging spectrum into a therapeutic yoga program, and provide preliminary evidence of reduction in total and stress-type incontinence frequency after 3 months of yoga practice. When taught with attention to women's clinical needs, yoga may offer a potential community-based behavioral self-management strategy for incontinence to enhance clinical treatment, although future research should assess whether yoga offers unique benefits for incontinence above and beyond other physical activity-based interventions.

Mixed feelings: general practitioners' attitudes towards eHealth for stress urinary incontinence - a qualitative study.

BACKGROUND: Stress urinary incontinence (SUI) is the most prevalent subtype of urinary incontinence and is a bothering condition in women. Only a minority of those with SUI consult a general practitioner (GP). EHealth with pelvic floor muscle training (PFMT) is effective in reducing incontinence symptoms and might increase access to care. The role of the GP regarding such an eHealth intervention is unknown. The aim of the study is to gain insight into the attitudes towards a PFMT internet-based, eHealth, intervention for SUI. METHODS: A qualitative study was conducted. Data were collected through semi-structured interviews among purposively sampled GPs. Audio records were fully transcribed, and analysed thematically. RESULTS: Thirteen GPs were interviewed, nine females and four males. Three themes emerged: appraisal of eHealth as a welcome new tool, mixed feelings about a supportive role, and eHealth is no cure-all. GPs welcomed eHealth for SUI as matching their preferences for PFMT and having advantages for patients. With eHealth as stand-alone therapy GPs were concerned about the lack of feedback, and the loss of motivation to adhere to the intervention. Therefore, GPs considered personal support important. The GP's decision to recommend eHealth was strongly influenced by a woman's motivation and her age. GPs' treatment preferences for elderly are different from those for young women with SUI; both PFMT and eHealth are perceived less suitable for older women. CONCLUSION: EHealth with PFMT fits into the GPs' routine practice of SUI and adds value to it. Although there is evidence that eHealth as a stand-alone intervention is effective, GPs consider personal support important to supplement the perceived shortcomings. Probably GPs are not aware of, or convinced of the existing evidence. Training should address this issue and should also focus on common misunderstandings about regular care for women with SUI, such as the idea that PFMT is not suitable for the elderly. Improving GPs' knowledge that eHealth can be a stand-alone therapy for SUI facilitates the implementation in daily care.

Ankle positions potentially facilitating greater maximal contraction of pelvic floor muscles: a systematic review and meta-analysis.

Objectives: To evaluate the effect of ankle positions on pelvic floor muscles in women. Methods: Multiple databases were searched from inception-July 2017. Study quality was rated using the grading of recommendations, assessment, development, and evaluation system and the "threats to validity tool". Results: Four studies were eligible for inclusion. Meta-analysis revealed significantly greater resting activity of pelvic floor muscles in neutral ankle position (-1.36 (95% CI -2.30, -0.42) p = 0.004) and induced 15° dorsiflexion (-1.65 (95% CI -2.49, -0.81) p = 0.0001) compared to induced 15° plantar flexion. Significantly greater maximal voluntary contraction of pelvic floor was found in dorsiflexion compared to plantar flexion (-2.28 (95% CI -3.96, -0.60) p = 0.008). Meta-analyses revealed no significant differences between the neutral ankle position and 15° dorsiflexion for either resting activity (0.30 (95% CI -0.75, 1.35) p = 0.57) or maximal voluntary contraction (0.97 (95% CI -0.77, 2.72) p = 0.27). Conclusion: Pelvic floor muscle-training for women with urinary incontinence could be performed in standing with ankles in a neutral position or dorsiflexion to facilitate greater maximal pelvic floor muscle contraction. As urethral support requires resting contraction of pelvic floor muscles, decreased resting activity in plantar flexion identified in the meta-analysis indicates that high-heel wearers with urinary incontinence might potentially experience more leakage during exertion in a standing position. Implications for rehabilitation Pooled analyses revealed that maximal voluntary contraction of pelvic floor muscle is greater in induced ankle dorsiflexion than induced plantar flexion. As pelvic floor muscle strengthening involves achieving a greater maximal voluntary contraction, pelvic floor muscle training for women with stress urinary incontinence could be performed in standing either with ankles in a neutral position or dorsiflexion. Decreased resting activity in plantar flexion identified in the meta-analysis indicates that high-heel wearers with stress urinary incontinence might potentially experience more leakage during exertion in a standing position. Women with stress urinary incontinence should be advised to wear flat shoes instead of high-heels and should be cautioned about body posture and ankle positions assumed during exercise and daily activities.