A review of the role for pelvic floor physiotherapy in postmenopausal women with urinary incontinence

Abstract

Urinary incontinence is a prevalent condition affecting women. Pelvic floor physiotherapy is a specialized field of physiotherapy dedicated to assessing and treating pelvic floor muscles. This therapy has demonstrated benefits in addressing stress urinary incontinence in premenopausal women, with numerous studies supporting its efficacy in this population. However, pelvic floor physiotherapy in the treatment of postmenopausal women is less well-established, and furthermore, the types of urinary incontinence in postmenopausal women are much broader. We provide a comprehensive review of recent literature investigating the effectiveness of pelvic floor physiotherapy therapy for various conditions in postmenopausal women, including urinary incontinence, urgency urinary incontinence, pelvic organ prolapse, genitourinary syndrome of menopause, sexual dysfunction, and urinary incontinence in the context of obesity, frailty, mobility, and dementia. After evaluating the current literature, it is evident that there is insufficient data to definitively endorse or dismiss the utilization of Pelvic floor physiotherapy for treating urinary incontinence in postmenopausal women. Nevertheless, considering the low associated risks of pelvic floor physiotherapy, we advocate for the initiation of comprehensive, large-scale randomized studies aimed at evaluating its effectiveness in addressing urinary incontinence in postmenopausal women with special attention to vulnerable subgroups, including individuals who are obese, frail or experiencing cognitive impairment.

Keywords

Pelvic floor physiotherapy postmenopausal postmenopausal women urinary incontinence genitourinary syndrome of menopause

Introduction

Urinary incontinence describes the unintentional loss of urine. The prevalence of urinary incontinence in women is estimated to be approximately 30% worldwide.^1,2 Stress urinary incontinence (SUI), the involuntary loss of urine with increased intra-abdominal pressure, is reported by approximately 50% of all incontinent women.³ SUI is commonly treated with pelvic floor physiotherapy (PFPT), a non-hormone treatment associated with a low risk of adverse events.¹ PFPT helps strengthen the muscles that support the pelvic organs during rest and participate in the occlusion of the urogenital hiatus, playing an important role in maintaining urinary continence. PFPT has been shown to improve symptoms of SUI in approximately 56% of women.¹ To date, the majority of studies evaluating PFPT efficacy in SUI were conducted in younger female populations, particularly after childbirth.

Some hypothesize that pelvic floor muscle function declines post-menopause due to an ageing process and is therefore less useful in targeting with PFPT treatment in postmenopausal women.⁴ Furthermore, as women age the type of urinary incontinence experienced changes and includes a broad aetiology of SUI, urgency urinary incontinence (UUI), functional incontinence and unconscious incontinence. PFPT is best known to target pure SUI. Herein, we performed a scoping review of PFPT in postmenopausal women with UI as it should not be overlooked if there is some benefit.

In this scoping review we aim to address the gap in the literature to explore the potential benefits of PFPT inpostmenopausal women.

Talasz et al. inspected and digitally examined 177 postmenopausal women with UI and noted inappropriate pelvic floor muscle activation during forced exhalation and coughing, suggesting PFPT may indeed help this form of incontinence (SUI).⁵ In postmenopausal women with SUI, biofeedback studies have demonstrated that muscle strength, myoelectric activity and precontraction of pelvic floor muscles increase with PFPT.⁶ Cacciari et al. demonstrated that PFPT training results in reduced levator hiatus size toward a more ‘circular’ shape, which was consistently associated with greater pelvic floor muscle force and reduced UI severity in 264 older women with UI.⁷ Further, no significant interactions were found between levator hiatus shape changes and any of the potential effect modifiers, suggesting that women will potentially benefit from PFPT training, regardless of age, UI severity, body mass index, and UI type (stress or mixed), with changes that can be observed in the functional anatomy of the pelvic floor and sustained in the long-term. In a randomized non-inferiority trial of older incontinent women, Cacciari et al. showed that after a 12-week PFPT trial one on one or as a group, at 1 year after intervention, both groups demonstrated significant changes in pelvic floor morphometry during coughs, and in pelvic floor muscle function during contractions and coughs.⁸ In 33 postmenopausal women with UI ultrasound guided PFPT had an impact on pelvic floor strength as compared to control (p = 0.01) even at 24 weeks follow-up.⁹ These studies highlight an anatomical mechanism of PFPT and its potential effectiveness in postmenopausal women with UI.

In terms of the clinical efficacy of PFPT, some studies have evaluated these anatomical changes in terms of UI outcomes. In a study, introducing a brief anatomical explanation regarding location of the genital structures and purposes of the PFPT led to better contractions by 20%.¹⁰ In a retrospective review of 96 pre- and postmenopausal women with UI, a period of supervised PFPT resulted in significant improvement in symptoms of stress urinary incontinence, urge urinary incontinence, urgency, frequency and nocturia, irrespective of menopausal status.¹¹

Interestingly, in a study examining pelvic floor muscle strength in nulliparas, parous and postmenopausal women there was a significant correlation with years since menopause and decreased pelvic floor muscle strength. When comparing premenopausal women to postmenopausal women the premenopausal women had more strength.¹² The results of this study correlate with that of Trowbirdge et al. who found a decrease in maximal urethral closure pressure with age.¹³

These studies highlight a theoretical mechanism of how PFPT can help even postmenopausal women with urinary incontinence. Therefore, we delved into the literature to determine if there is also clinical evidence supporting this notion.

Methods

This scoping review aimed to explore the role of pelvic floor physiotherapy (PFPT) in postmenopausal female patients by systematically examining existing literature without assessing individual study quality.

Inclusion criteria encompassed peer-reviewed publications, including systemic reviews, meta-analyses and primary research studies, involving the elderly (50 years or older) or postmenopausal women, with a focus on PFPT interventions. Various outcomes were accepted. The search was limited to English-language articles published within the past 10 years to include recent research. Additionally, full-text availability was required, and studies worldwide were considered. Exclusion criteria involved non-peer-reviewed publications, literature beyond the specified types, studies not involving the target population, and articles focusing on therapies other than PFPT. Non-English publications, studies older than 10 years and those not available in full text were also excluded. To identify relevant studies, a systematic literature search was conducted on May 23, 2023, by a medical librarian using the MEDLINE and CINAHL databases through the EBSCOhost interface. The search terms included ‘pelvic floor’, ‘physio*’, ‘therap*’, ‘exercis*’, ‘rehab*’, ‘muscle,’ ‘incontinence’, ‘genitourinary’, ‘dyspareunia’, ‘postmenopaus*’, ‘post-menopaus*’, ‘post menopaus*’, ‘older’ or ‘elder*’, ‘aged’, ‘senior*’ and ‘geriatric*’. References were also identified in the UpToDate database and relevant clinical guidelines. After removing duplicates, a total of 74 records were identified. The review synthesized findings narratively, without conducting a meta-analysis. Stakeholder consultation included input from pelvic floor physiotherapists, ensuring diverse perspectives.

Evidence for PFPT

All comers UI

In a systematic review of the literature Fricke et al. summarized eight studies on the role of PFPT in women over the age of 50 with UI and noted all interventions were able to improve pelvic floor muscle strength as well as urinary incontinence symptoms, with bigger improvements found in supervised interventions.¹⁴ In another systematic review of the literature by Davidson et al. in summarizing seven studies evaluating PFPT for UI in adults 60 years and older they noted that their outcome assessment was heterogeneous precluding meta-analysis.¹⁵ However, individual studies found statistically and clinically relevant differences in pelvic floor muscle strength and continence outcomes for older adults. Davidson and Moore found that in general PFPT with other lifestyle modification and bladder training reduced leakage episodes compared to control groups. Additionally, there was high adherence to the interventions (73.5%–97%). Interestingly although Davidson and Moore report that PFPT is effective in adults 60 years and older its benefit may be less than in younger patients.

In a prospective cohort study of 70 community-dwelling women over the age of 70 a 12-week individualized pelvic floor muscle training prescription with behavioural management strategies was found to have complete satisfaction with incontinence symptom improvement that was low regardless of physical function level (41.8% with physical function impairments vs 44.8% with normal physical function; p = 0.90).¹⁶

This study and the systematic reviews highlight that UI in postmenopausal women is likely more complex than SUI in premenopausal women in terms of PFPT outcomes. There are likely more barriers to overcome in postmenopausal women that can also greatly affect their UI outcomes.

Subtypes

Stress urinary incontinence

The international continence society guidelines for the treatment of urinary incontinence in women, including SUI, suggest PFPT as a first-line therapy in the conservative treatment.¹⁷ Further the Society of Obstetricians and Gynaecologists of Canada recommend the use of PFPT in conservative management of women with SUI, MUI and UUI either alone or in combination with multicomponent therapy that includes lifestyle and behavioural approaches.¹⁸ In a retrospective study of 62 women over the age of 65 there was an improvement of SUI-related questionnaires with PFPT.¹⁹ Bertotto et al. found that there was a significant increase in quality of life (p < 0.0001 vrs baseline), and strength of muscle contraction post-treatment when compared to control groups (p < 0.0001) in postmenopausal women aged 50–65 years when treated with pelvic floor muscle training or pelvic floor muscle training plus biofeedback. They also found that PFPT plus biofeedback was associated with significant improvement in muscle strength, precontraction while coughing, maximum voluntary contraction, maximum voluntary contraction and duration of endurance contraction compared to PFMT alone.⁶ A pilot study of 74 postmenopausal women with SUI found that women in the experimental group of women who completed 12 PFPT sessions during a 4-week period had an improvement in the severity of UI (p = 0.0008) compared to the control group.²⁰

Urgency urinary incontinence

In a study of 88 postmenopausal women with UUI participants were randomized to PFPT or control. The authors demonstrated significant differences between groups in favour of the PFPT group in the daytime frequency of voiding (7.6 to 5.3), in nocturia (2.1 to 0.7), in UUI (1.8 to 1.0), OAB-q SS (40.8 to 17.6) and OAB-q HR (61.2 to 83.8) (p ≤ 0.001) outcomes.²¹

Pelvic organ prolapse

In a randomized controlled trial of 287 women aged 55 or older with mild symptomatic pelvic organ prolapse (POP) patients were split into PFPT and watchful waiting groups. There was a significant improvement bladder, bowel and pain free symptoms in the PFPT group at 3 months compared to the watchful waiting group.²²

However, in women with POP as their main symptom and UI as their secondary symptom there is no evidence for PFPT over POP treatment (i.e. pessary) in postmenopausal women.²³

Genitourinary syndrome of menopause

Genitourinary Syndrome of Menopause (GSM) is a very common condition experienced by postmenopausal women, affecting up to 50%–90% of postmenopausal women.^24,25 GSM can lead to various symptoms, including vaginal dryness, dyspareunia, involuntary urination, soreness, itching, burning and pain. These symptoms can significantly impact patients’ sexual function and quality of life.^26,27 Mercier et al. proposed that PFPT may be useful in treating GSM and the associated symptoms.²⁸ We are currently conducting a retrospective trial to assess the role of PFPT in treating postmenopausal women with GSM on estrogen and results will be forthcoming.

Sexual function

In a study of 113 postmenopausal women, those with sexual dysfunction had lower pelvic floor strength than those without sexual dysfunction as evaluated using vaginal manometry (median 41.8, range 11.3–94.0 cmH 2 O vs median 30.3, range 3–112 cmH 2 O; p = 0.02). The authors also noted a weak correlation between UI severity and sexual function (ρ = −0.21, p = 0.03). Inferring from this study, targeting those women with sexual dysfunction and UI with PFPT may improve clinical outcomes.²⁹

In a randomised clinical trial of 97 postmenopausal women aged 40–60, PFPT improved arousal, orgasm and satisfaction scores as compared to placebo (3.10, 4.36 and 4.84 vs 2.75, 3.89 and 4.36, respectively; p < 0.05).³⁰ In another trial of 77 postmenopausal women, women were randomized to PFPT and control. There was no difference on sexual dysfunction scores at 12 weeks, but after 12 weeks, a higher percentage of women without sexual dysfunction was found in the intervention group (PFPT) (95% CI = 27.97–72.03) when compared to the control group (95% CI = 7.13–92.87).³¹

Obesity

In a study of 49 obese postmenopausal women with SUI there was no significant difference in outcomes before and after the PFPT intervention.³² In a study of 104 women with a mean body mass index 30.63 ± 4.41 kg/m², women were randomized to short term PFPT alone versus short term PFPT and bladder retraining. Authors found improved urinary incontinence symptoms and voiding functions (p < 0.05, and p = 0.003, respectively) but neither treatment method had a beneficial impact on urinary incontinence related quality of life or sexual functions (p > 0.05) in this population.³³

Frailty

In a randomized controlled trial of 42 frail women (mean age 84.9 ± 6.4) without dementia women who underwent 150 min of weekly walking and twice weekly strength training classes, not specifically PFPT, had 50% reduction in daily leakage as compared to the control group suggesting that even a small amount of regular physical activity can help this population of women.³⁴

In the randomized trial evaluating PFPT in postmenopausal women with UUI authors included a secondary end point of the impact of interventions on static and dynamic balance, risk of falls and fear of falls. They found that those in the PFPT group versus control had better scores in the Tinetti balance and gait and in the fall risk assessment (19.2 to 23.2) (p ≤ 0.001) outcomes. For fear of falls, significant differences were noted (80.0 to 71.5) (p ≤ 0.05), in favour of the PFPT group as well.³⁵

These studies highlight that PFPT may have a significant impact on reducing falls common in this postmenopausal population.

Mobility

In a study of men and women over age 60 they found that a biofeedback-guided PFPT intervention was equally effective in reducing UI and improving UI-specific quality of life in homebound (limited by mobility) and non-homebound community-dwelling older adults.³⁶

Cognitive impairment

Extrapolating from general exercise studies resistance exercises has the highest probability of being an optimal exercise type in patients with slowing cognitive decline. PFPT may include this type of exercise but not always.³⁷

In a study of 82 women with mild cognitive impairment (as measured by Mini-Mental State Examination and Barthel’s Activities of Daily Living) women were randomized to PFPT versus control. After 12 weeks of PFPT, the mean number of UI episodes per 24 h decreased by 1.6 (from 3.3 to 1.7) in the PFPT group and by 0.5 (from 3.4 to 2.9) in the control group (p < 0.001 between groups). The mean number of micturition episodes and total ICIQ-SF scores improved in the PFPT group to a significantly greater extent than in the control group (p < 0.001). The authors concluded that supervised PFPT can be a good therapeutic option for improving UI in postmenopausal women with cognitive impairment.³⁸

These studies support that cognitive impairment does not exclude this patient population from PFPT. Women with cognitive impairment, however, may benefit from a supervised program that includes resistance exercises.

Compliance

In all comers only 1 in 5 patients referred for PFPT for management of pelvic floor disorders is compliant with recommended therapy. Compliance in postmenopausal women is likely worse (Woodburn et al., 2021). In a study of 647 postmenopausal women, less than half displaced adherence for 2 years in either a 2-h class group or an equivalent content 20-min DVD group to receive PFPT complemented with adherence enhancement strategies. However, the authors did note that early adherence predicted women’s subsequent optimal adherence.³⁹

In contrast, in a study of men and women over age 60 they found that compliance with PFPT in those who were homebound vs. those who were not homebound was the same even though those who were homebound had worse UI, comorbidities and functional impairment.³⁶

In a prospective observational study of 218 patients the strength of patient health-related values measured by the PVQ-II significantly predicted compliance with PFPT, but the nature of health value (intrinsically valued, as opposed to externally controlled) predicted objective outcomes from PFPT.⁴⁰

In efforts to improve compliance in postmenopausal women Hay-Smith et al. suggest that women are offered reasonably frequent appointments during the training period, because the few data consistently showed that women receiving regular (e.g. weekly) supervision were more likely to report improvement than women doing PFPT with little or no supervision.⁴¹ Chu et al. found that a home exercise program for bladder-training intervention is feasible for postmenopausal women with UI.⁴² They report that half of the participants had a 72% adherence to sessions, and 10.5% had a 100% adherence rate. Women in their home exercise arm reported improved UI and had a lower risk for falls compared to the control group. They also found that the median number of completed sessions declined over the 6-week period from 3 weeks to 1 per week. They suggest that even for women who are motivated behavioural support may be needed to maintain adherence. Together, these studies indicate that if patients are compliant, there is benefit from PFPT. However, they also highlight that compliance is a significant issue, particularly in postmenopausal women. Future studies should evaluate motivational methods and variations of PFPT (i.e. home vs supervised programs) to improve compliance of postmenopausal women to PFPT.

Type of therapy

In a systematic review by Ciemna et al. the authors found that pelvic floor muscle exercises are effective in the treatment of urinary incontinence, strengthen muscle strength and improve patients’ quality of life. A long-lasting, systematic and individual training program with a physiotherapist is the most effective. Biofeedback helps to intensify the therapeutic effect of exercise but also allows you to achieve good results as an independent treatment method. Positive effects are also noticeable in physical therapy, electrostimulation and magnetotherapy are very effective. Physiotherapeutic procedures have a positive effect in the treatment of urinary incontinence in the postmenopausal women. ⁴³ In an Interventional study by Jahromi et al. 50 women, ages 60–74, with urinary incontinence were assigned to either control or intervention of 8 PFPT sessions. Women in the interventional group were found to have an improvement in self-esteem scores and a significant difference between the two groups (p = 0.001) in ICIQ score between the intervention and control groups. The study found that PFPT was an empowerment mechanism in postmenopausal women improving their quality of life.⁴⁴

Discussion

This review provides a comprehensive overview of the existing peer review literature on the role of PFPT in its effectiveness in treating UI in postmenopausal women.

There is a clear benefit of PFPT for the treatment of pure SUI in women.¹ Specifically, PFPT is recommended as first-line therapy according to international guidelines, and for example, review of studies by Neville et al. (2016 b) and Nygaard et al. (2013) highlight the efficacy of PFPT in improving SUI-related outcomes. However, our review of the literature shows only limited data to support or refute the use of PFPT for the treatment of all UI in postmenopausal women due to a limited amount of research supporting its efficacy.^11,19 However, various studies included in this review highlight its potential for further study and benefit to postmenopausal women.

This review was limited by a narrow amount of research in the field of PFPT studies focusing solely on the population of postmenopausal women. We acknowledge the limitations of the existing evidence, such as the heterogeneity of the studies in outcome measures, variations in PFPT interventions and additional interventions, and lack of standardized outcome measurements. All pose challenges in drawing definitive conclusions regarding the effectiveness of PFPT in different types of UI in postmenopausal women.

PFPT has minimial harm associated with it and potential large benefit to the patient. Due to the limitations listed above, there is certainly need for more rigorous research specifically designed to assess the impact of PFPT in postmenopausal women with various conditions affecting urinary continence. Ideally, these studies would have standardized protocols for PFPT intervention, have consistent outcome measures and be large, randomized control trials Particular focus in these trials should also include subgroups of postmenopausal women who are obese, frail and have cognitive impairment. Furthermore, motivational methods and variations of PFPT should be evaluated in terms of maximizing patient compliance.

Footnotes

Author’s note

Pelvic floor physiotherapy has been shown to be an effective treatment for Urinary incontinence in young women. However, there is less research of its utility in postmenopausal women. We provide a comprehensive summary of recent literature investigating the effectiveness of Pelvic floor physiotherapy therapy for various conditions in postmenopausal women.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jennifer Locke

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. The effect of pelvic muscle exercises on urinary incontinency and self-esteem of elderly females with stress urinary incontinency, 2013. Global J Health Sci 2015; 7(2): 71–79. DOI: 10.5539/gjhs.v7n2p71.