1. Pelvic Floor Muscle training The role of general exercise
Stephanie Knight
Airedale General Hospital

2. Introduction PFMT in treatment of incontinence
Abdominal muscles and continence
The role of exercise
Does general exercise improve continence status?
What should we tell patients?

3. What do patients say? I leak when I run or jump
I have stopped going to the gym because of leakage
I can’t play in the park with my children
I daren’t jump on the trampoline
I don’t go to social functions/dancing
Women leak running for leisure or for the bus. I see a lot of serious fell running women in Yorkshire who are desperate to run without the need for a thick pad. A lot of women now are more aware of the cardiovascular benefits of exercise and join the gym, but every time they do an exercise class they leak, and they stop going to the gym because of the embarrassment. Even running around with children becomes difficult. A relatively new phenomenon is the trampoline in the back garden-women with small children are tempted to join in the tramolining and find they leak, this seem to then become a challenge and they are really keen to overcome this and be able to jump on the trampoline. Leaking prevents a lot of women even enjoying parties as any dancing makes them wet. Yorkshire has a lot of Morris dancing groups and dancing with the heavy clogs is a real impcat activity.

4. Physical Exercise Prevention and therapy for many chronic diseases
Exercise increases muscle strength & improves cardiovascular fitness
Is exercise a risk factor for incontinence?
Can general exercise improve continence?
So we all know exercise is good for you, it makes you fitter, slimmer and stronger. It helps prevent many chronic diseases. Can it cause incontinence/improve continence or does th type of exercise matter.

5. Is leaking with exercise a common problem?
28% nulliparous female athletes reported incontinence (Nygaard et al.1994)
Most common with high impact, jumping, running, trampolining
Possible “continence threshold”
High incidence of UI in high impact sports (Jang et al. 2004)
Describe the concept of a continence threshold

6. Barrier to physical activity
With some women the fact of leakage is a barrier to exercise. I think probably the trampolining should be reserved for the children but maybe mum has been on here first.

7. Pelvic floor muscles

8. Anatomy of the Pelvic Floor
3 Supportive Layers
Endopelvic fascia
Muscle layer (Levator Ani & Coccygeus)
Superficial perineal muscles
Additional urethral closure from striated urethral muscle, smooth muscle and vascular system
Describe the role of PFM in maintaining continence

9. Pelvic Floor Muscle Exercises
Grade A evidence for improvement of stress and mixed urinary incontinence (NICE CG )
NICE recommend vaginal assessment
Need to be performed correctly
Incorrect technique may promote incontinence (straining/Valsalva/using other muscles)

10. How do PFM exercises work
Increase urethral pressure
Elevate bladder neck
Narrow the levator hiatus in AP & transverse direction
Prevent descent of pelvic organs
Increase “stiffness” of PFM
Improve timing and coordination (the “Knack”)
Improve endurance/reduce fatigue
Bo K. 2004

12. Abdominal Muscles Three layers
Deepest layer Transversus Abdominis (TrA)
TrA is part of core stability complex
Synergist of PFM

13. Core muscles

14. Abdominal muscle training
Indirect training of PFM via abdominal muscle training (Sapsford 2001)
Abdominals co-contract with PFM
No additional benefit of PFM + TrA training
(Dumoulin et al. 2003)
No RCT’s to show PFM can be trained indirectly (Hay Smith et al. 2009)
“Paula” method also not effective
(Bo et al. 2011)

15. Anatomical position Unable to provide pelvic organ support
Unable to increase urethral closure pressure
Unable to prevent bladder neck/urethral descent
Potential to increase incontinence

16. Joseph Pilates

17. Pilates
Pilates Method is an exercise system focused on improving flexibility and strength for the total body
The Pilates method relies on strengthening core postural muscles and developing body alignment
Exercise instruction should always start with pelvic floor contraction
No claims to treat incontinence

18. Working together
In normal activity PFM & TrA show synergistic activity to stabilise the spine
Intra-abdominal pressure also increases
Lee & Lee 2004
If continent urethral closure pressure increases simultaneously with IAP
If PFM weak stress leak occurs
Muscle imbalance
“Timing” is important

19. PFMT vs Pilates exercise
Instructors focus on Abd, back,adductors, PFM
Hypothesis: Pilates strengthens PFM if taught in conjunction
62 women little or no pelvic floor dysfunction
2 groups: PFMT/Pilates
Strength measured with perineometer in both groups
PFM symptoms/QoL improved in both-no significant difference
Culligan et al. 2010

20. Obesity and incontinence
Grade A evidence that obesity increases risk for incontinence (Subak et al. 2009)
Weight loss can improve continence status(Subak et al. 2002)
Exercise promotes weight loss!

21. Intensive PFM training
Supervised
Maximal contractions?
Train for function
Encourage long term adherence
Make it FUN!
Combine with other exercises
Vaginal examination to ensure correct contraction
NICE CG

22. Adherence PFMT is long term commitment
Need fun ways to maintain motivation
Using other muscle groups can improve concordance

23. To avoid this……..

24. Try this………

25. Dancing

26. Or this………….

27. In conclusion
No evidence that abdominal or physical exercise alone improves continence status
PFMT does improve continence
Teach correct PFM contraction to combine with general exercises
Weight loss important
Any fun activity to improve long term adherence
Patients need motivation