Pelvic Floor Muscle Training – Let’s Get It Right!

There is Level 1 evidence (recommendation A) that pelvic floor muscle training (PFMT) should be first line treatment for Urinary Incontinence (UI) and Pelvic Organ Prolapse (POP) in women1.  The NICE guideline2 also states that PFMT is just as effective as surgery for approximately half of women with stress urinary incontinence (SUI). 

The high evidence base is only true in a clinical setting if the PFMT is performed correctly and effectively, which requires the following patient factors to be considered;

  • Past obstetric, general and surgical history
  • Symptoms and their impact on quality of life
  • Pelvic floor muscle dysfunction 
  • Pelvic Health Goals
  • Functional and cognitive capacity 
  • Psychosocial factors impacting program adherence

An Effective PFMT Program Must Start with a Thorough Assessment

In 2021, lead author Associate Professor Helena Frawley and colleagues published an International Continence Society report on the terminology for pelvic floor muscle assessment3. This 44 page document covers symptoms, signs, investigations and diagnoses associated with perineal and levator ani function and dysfunction.  It emphasises that assessment findings must be interpreted within a framework of clinical reasoning. The report highlights the complexity of PFM assessment and why it is important this is performed thoroughly by trained health professionals.
Aspects of pelvic floor muscle function that should be assessed include:
  • Correct contraction (see below for more detail)
  • Strength
  • Endurance
  • Fatigue
  • Speed
  • Relaxation
  • Co-ordination
  • Co-contraction
  • Levator hiatus closure
  • Tone 
  • Spasm
Specific assessment of ALL of these aspects of muscle function is critical to determine the most appropriate exercise prescription. For example, prescription of a strength-based exercise program to a patient who has increased resting tone may further increase tone leading to a worsening of their symptoms.  

A Correct Pelvic Floor Muscle Contraction (PFMC) is Essential

The ICS terminology report outlines that a correct PFMC should be self‐initiated and, during an internal examination is felt as a tightening, lifting, and squeezing action under the examining finger3.  There should be a cephalad and ventral movement that is isolated and specific to the pelvic floor, without breath holding and accessory muscle use.  A PFMC includes both the ability to contract AND relax completely.3
Given the pelvic floor muscles cannot be seen externally and the representation of the pelvic floor in the homunculus in the brain is small, it is common for people to find it difficult to isolate and perform a correct PFMC.  Clinically, we often find that a patient believes they are correctly contracting their PFM, when in fact, internal assessment reveals they are not.  
In 2019, researchers conducted a study assessing women’s self-perception of their PFMC compared with a vaginal PFM assessment performed by a physiotherapist4.  They found that two thirds of women had an incorrect self-perception of their PFMC compared to the physiotherapy assessment.   This evidence, again, highlights the need for individual assessment.

How Does PFMT Work?

The application of PFMT and how it works to improve symptoms of bladder, bowel, prolapse and pelvic pain conditions will vary depending on the identified PFM dysfunction and the many factors considered during the clinical reasoning process. 
For example, PFM weakness identified in a woman with UI or POP will require strength training. This aims to improve muscular structural support so that the PFM can effectively offset increased intra-abdominal pressure, detrusor pressure and ground reaction forces.  A pelvic floor muscle contraction (PFMC) increases urethral closure pressure, leading to synchronised co-contraction of the urethral sphincter and reduces the levator hiatus area5
It is proposed that PFMT leads to the following permanent changes to the pelvic floor muscles, all of these are required for urinary continence and pelvic organ support5;
  • Lift of the pelvic floor to a higher anatomical location inside the pelvis
  • Increased cross-sectional area of the PFM
  • Increased ‘stiffness’ of connective tissue within and around the PFM
  • Reduced levator hiatus area

What should a PFMT Program Include?

Once confirmation of a correct PFMC has been obtained through an assessment, a strength training program should include repeated, voluntary, maximal contractions.  Just as two patients with high blood pressure don’t require the same medication and same dosage - there isn’t one PFMT program that suits everyone.  It is crucial that the patient is able to achieve a therapeutic dosage that allows muscle hypertrophy to occur – this will involve a specific prescription of length of hold, rest time, repetitions, sets per day and often a variety of positions.  
The PFMT program must be progressed and challenged based on re-assessment and applied to functional positions and activities.  For example, a PFMT program performed in crook lying may not yield enough strength changes, nor symptomatic improvement, if they lose urine jumping and running during a netball game.

It Takes Time

Just like making strength gains in the gym, or improving cardiovascular fitness, it takes time to make morphological changes in the PFM.  It also takes time for motor learning and coordination to occur so that functional use of the PFM becomes automatic ie PFM automatically contracts with a cough.  
The American College of Sports Medicine outlines that strength training exercise is needed for more than 5 months to show effect.  In relation to the PFM, guru researcher Professor Kari Bø consistently designs PFMT protocols that involve intensive training over 6 months6.  We need to be realistic with our expectations of change and consider this in our clinical reasoning and communication to patients.  
Motivation and adherence to the exercise program is also vital. If the patient is not completing the exercise program with the required intensity or frequency, they will likely not make the necessary physiological changes to their PFM.  This is why, Frawley et al in 20177 argued that PFMT is both a physical therapy and a behavioural one.  The ability to enhance motivation and adherence requires a strong therapeutic alliance, trust, knowledge of patient barriers and enablers, good listening and strong communication skills.  

Maximise The Benefits Of PFMT

To ensure your patients get the most benefit from committing time to PFMT, they must:
  • receive accurate assessment
  • perform their PFMT to a level that results in physiological changes
  • receive feedback and progression of the training program over a long enough period of time
  • adhere to a longer term maintenance program. 
If the PFMT program is incorrect or they are doing a sub-optimal dose, the conclusion could incorrectly be that PFMT doesn’t work!  High level evidence supports that it is only through invidualised assessment and adherence to exercise prescription, that patients with a variety of pelvic floor dysfunctions and pelvic health conditions will achieve their goals and desired outcomes.  
1. Dumoulin C, Adewuyi T, Booth J, Bradley C, Burgio B, Hagen S, et al. Adult conservative management. In: Abrams P, Cardozo, Wagg A, Wein A, eds. Incontinence. 6th Ed. Vol. 2. Committee 1; 2017:1443–1628. 
2. National Institute for Health and Care Excellence. NICE guideline. Urinary incon- tinence and pelvic organ prolapse in women: management [NG123] Published date: April 2019 Last updated: June 2019 
3. Frawley H, Shelly B, Morin M, Bernard S, Bø K, Digesu GA et al. m An International continence society (ICS) report on the terminology for pelvic floor muscle assessment  Neurourol Urodyn. 2021;1–44. 
4. Uechi N,  Fernandes A,  Bø K,  de Freitas LM, de la Ossa AMP and Bueno S. Does the Contractile Capability of Pelvic Floor Muscles Improve with Knowledge Acquisition and Verbal Instructions in Healthy Women? A Systematic Review Neurourology and Urodynamics. 2019;1–6. 
5. Bø K.  Physiotherapy Management of Urinary Incontinence in Females.  Journal of Physiotherapy; 2020:66; 147-154
6. Frawley HC, Dean SG, Slade SC and Hay-Smith EJC. Is Pelvic-Floor Muscle Training a Physical Therapy or a Behavioral Therapy? A Call to Name and Report the Physical, Cognitive, and Behavioral Elements Physical Therapy, 2017; 97 (4):425–437
7. Bø K, Berghmans B, Mørvek S and Van Kampen K. Evidence Based Physical Therapy for the Pelvic Floor. Churchill Livingstone Elsevier 2007

December 2022