Medical reference | Pelvic Floor Muscle Exercises and Function:
A review of an online modality of training
The pelvic floor sits at the bottom of our pelvis. It is an important and highly integrated structure consisting of muscles, ligaments and connective tissue. The pelvic floor has a few key functions:
Maintaining continence – the pelvic floor muscles (PFM) form sphincters around the urethra, vagina and rectum enabling voluntary control of these orifices. This maintains urinary and faecal continence.14
Sexual Function – the muscles of the pelvic floor help maintain blood flow to the vaginal region, by contracting rhythmically to enhance sexual pleasure.13
Support – the pelvic floor supports the pelvic organs e.g. bladder, uterus and colon, and keeps these organs in place.14
Pelvic and Spinal Stabilisation – the transversus abdominis, pelvic floor, deep multifidus and diaphragm form a muscular cylinder, which supports the spine and the pelvis; these muscles work together as a unit to ensure and maintain trunk stability.11,12
Childbirth and pregnancy can increase the risk of weakening and injury to the pelvic floor muscles (PFMs) and the perineum1. Approximately half of postpartum women may lose some of the supporting function of the PFMs after delivery1. This weakness can lead to urinary incontinence, faecal incontinence, prolapse of the pelvic floor organs and sexual problems.
Although the exact mechanisms of these physiological changes have yet to be fully established. The increased levels of hormones, which prepare the body for pregnancy and delivery, allow the dense structures to soften and increase the pelvic floor laxity.
As the uterus grows during pregnancy, the pelvic organs are pushed downwards. Resulting in an increase in intra-abdominal pressure; exposing the pelvic floor muscles to stresses and strain4. The hormones and physical changes, as well as the increased pressure on the pelvic floor, play an important role in the development of Pelvic Floor Dysfunction 4,5,6,7.
A systemic review which included over fifteen studies and over six thousand women revealed pelvic floor muscle training reduced urinary incontinence in pregnant women and urinary and faecal incontinence in postpartum women8. Provided there was no serious degree of uterine prolapse and the exercises were followed accurately.8
Prenatal pelvic floor muscle training (PFMT) can decrease symptoms of urinary incontinence9 and improve muscle coordination and produce strong and flexible muscles during labour10. Postnatal PFMT women can effectively reduce the symptoms of pelvic floor dysfunction.8 Furthermore, results of a study looking at pelvic function in nulliparous pregnant women demonstrated the thickness and strength of the pelvic floor muscles in continent pregnant women were found to be higher than in those who suffered from incontinence3.
Mothers to be are most frequently advised to conduct PFMT during the late stage of pregnancy and the early postnatal phase. If PFMT is delayed it is less likely to reduce urinary incontinence.8, 15,16 Guidelines from the National Institute for Health and Care Excellence recommend training pelvic floor muscles as the first point of treatment for women with urinary incontinence and pelvic organ prolapse.19
Currently, PFMT is offered in a range of formats; in person, via internet-based solutions and mobile applications, using devices, through verbal or written instructions provided by health care professionals.
However, performing pelvic floor exercises is not easy; studies have demonstrated that 70% of women were unable to accurately locate and contract their pelvic floor muscles.18 A shortage of PMFT trained physiotherapists, poor attendance at classes and unavailability can add to the challenge in delivering effective in person PFMT.15 Research has also demonstrated there is no additional benefit in combining PFMT with biofeedback, vaginal cones or electrical simulations.20,21
Thus, based on the literature pelvic floor dysfunction interventions need to be started early8, 15,16, must include the provision of effective instructions, must be widely accessible17 and not require a highly trained expert17.
To assess the efficacy of an online exercise portal which provides the provision of accurate and effective instructions is widely accessible and can be conducted from the comfort of an individual’s home.
MUTU System is an online exercise programme for mother’s and women with low risk pregnancies. The programme includes real time videos, which include MUTU core and pelvic rehabilitation techniques.
To study the impact of this programme a questionnaire was constructed to gain feedback on five key areas based on existing clinical questionnaires. Key areas included;
- Ability to accurately identify the pelvic floor
- Bladder symptoms including urinary leakage
- Symptoms of pelvic organ prolapse
- Sexual well being
- Quality of life including body confidence
- Presence of diastasis recti (separation of abdominal muscles)
DESIGN & SURVEY
Two modes of responses were included as relevant to the question including;
YES/NO questions (polar questions) were used to identify existing symptomatology
A Likert scale ranging from ‘very much improved’ to ‘worsened’ was utilised to measure the change in individual symptoms as a result of conducting the MUTU programme.
This survey was sent to individuals who had used MUTU System for 6 weeks for more and the anonymised results were collated.
906 respondents fully completed the questionnaire.
The responses are collated below the relevant category:
Ability to accurately identify the pelvic floor
97% of women who couldn’t successfully locate or engage their pelvic floor muscles previously, were able to after using MUTU System.
Bladder symptoms including urinary leakage
92% of women who had experience bladder symptoms including urinary leakage saw improvement after using MUTU System.
Symptoms of pelvic organ prolapses
88% of women suffering from symptoms of Pelvic Organ Prolapse reported improvement after using MUTU System.
Sexual well being
89% of women who experienced pain or discomfort during or after sexual intercourse reported an improvement after doing MUTU System.
Quality of life including body confidence
94% of women who used MUTU System felt an improvement in how they felt about their body and what it is able to do.
Presence of diastasis recti (separation of abdominal muscles)
94% of women with diastasis recti (separation of abdominal muscles) reported an improvement after using MUTU System.
Medical reference and clinical papers consulted for the purposes of this academic review:
- Swift, S. (2000). The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. American Journal of Obstetrics and Gynecology, 183(2), pp.277-285.
- Kahyaoglu Sut, H. and Balkanli Kaplan, P. (2015). Effect of pelvic floor muscle exercise on pelvic floor muscle activity and voiding functions during pregnancy and the postpartum period. Neurourology and Urodynamics, 35(3), pp.417-422.
- MØrkved, S., Salvesen, K., BØ, K. and Eik-Nes, S. (2004). Pelvic floor muscle strength and thickness in continent and incontinent nulliparous pregnant women. International Urogynecology Journal, 15(6), pp.384-390.
- Hospital, C., Birmingham, U., University of Alabama at Birmingham, B., Medicine, U., Luzern, K., Hospital, U. and Hospital, P. (2008). Pelvic Floor Re-education | SpringerLink. [online] Link.springer.com. Available at: http://link.springer.com/10.1007/978-1-84628-505-9
- Pollack, J., Nordenstam, J., Brismar, S., Lopez, A., Altman, D. and Zetterstrom, J. (2004). Anal Incontinence After Vaginal Delivery: A Five-Year Prospective Cohort Study. Obstetrics & Gynecology, 104(6), pp.1397-1402.
- Rortveit, G., Daltveit, A., Hannestad, Y. and Hunskaar, S. (2003). Urinary Incontinence after Vaginal Delivery or Cesarean Section. New England Journal of Medicine, 348(10), pp.900-907.
- Viktrup, L., Rortveit, G. and Lose, G. (2006). Risk of Stress Urinary Incontinence Twelve Years After the First Pregnancy and Delivery. Obstetrics & Gynecology, 108(2), pp.248-254.
- Boyle, R., Hay-Smith, E., Cody, J. and Mørkved, S. (2012). Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews.
- Mørkved, S. and Bø, K. (2013). Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review. British Journal of Sports Medicine, 48(4), pp.299-310.
- Salvesen, K. and Mørkved, S. (2004). Randomised controlled trial of pelvic floor muscle training during pregnancy. BMJ, 329(7462), pp.378-380.
- Willson, J., Dougherty, C., Ireland, M. and Davis, I. (2005). Core Stability and Its Relationship to Lower Extremity Function and Injury. Journal of the American Academy of Orthopaedic Surgeons, 13(5), pp.316-325.
- Akuthota, V., Ferreiro, A., Moore, T. and Fredericson, M. (2008). Core Stability Exercise Principles. Current Sports Medicine Reports, 7(1), pp.39-44.
- Woodard, T. and Diamond, M. (2009). Physiologic measures of sexual function in women: a review. Fertility and Sterility, 92(1), pp.19-34.
- Perucchini, D. and DeLancey, J. (2008). Functional Anatomy of the Pelvic Floor and Lower Urinary Tract. Pelvic Floor Re-education, pp.3-21.
- Reilly, E. T. C., Freeman, R. M., Waterfield, M. R., Waterfield, A. E., Steggles, P., & Pedlar, F. (2002). Prevention of postpartum stress incontinence in primigravidae with increased bladder neck mobility: a randomised controlled trial of antenatal pelvic floor exercises. BJOG: An International Journal of Obstetrics and Gynaecology, 109(1), pp. 68–76.
- Gorbea Chávez, V., Velázquez Sánchez, M. del P., & Kunhardt Rasch, J. R. (2004). Effect of pelvic floor exercise during pregnancy and puerperium on prevention of urinary stress incontinence. Ginecologia Y Obstetricia De Mexico, 72, pp. 628–636.
- Ewings, P., Spencer, S., Marsh, H., & O’Sullivan, M. (2005). Obstetric risk factors for urinary incontinence and preventative pelvic floor exercises: Cohort study and nested randomized controlled trial. Journal of Obstetrics and Gynaecology, 25(6), pp. 558–564.
- Tibaek, S., & Dehlendorff, C. (2014). Pelvic floor muscle function in women with pelvic floor dysfunction: A retrospective chart review, 1992–2008. International Urogynecology Journal, 25(5), pp. 663–669.
- Nice.org.uk. (2019). Overview | Urinary incontinence and pelvic organ prolapse in women: management | Guidance | NICE. [online] Available at: https://www.nice.org.uk/guidance/ng123 [Accessed 22 Jul. 2019].
- Hay-Smith, J., Bo, K., Berghmans, B., Hendriks, E., de Bie, R. and van Waalwijk van Doorn, E. (2008). Pelvic floor muscle training for urinary incontinence in women. Cochrane Database of Systematic Reviews.
- Bø, K. (2003). Is There Still a Place for Physiotherapy in the Treatment of Female Incontinence? EAU Update Series, 1(3), pp.145-153.