The Effectiveness of Pelvic Floor Muscle Training on Decreasing Urinary Incontinence in Pregnant or Postnatal Women: A Systematic Review

. This study aims to analyze the effectiveness of pelvic floor muscle training in preventing urinary incontinence in pregnant and postpartum women. The study employed a systematic review method by searching data from journal databases such as Pubmed, Science Direct


Introduction
Decreased bladder function and muscle tone around the urinary tract are the main causes of urinary incontinence, which causes the body to experience uncontrolled urine output (Tunn et al. 2023).Major symptoms and signs that appear in this diagnosis include the leakage of urine without distension, nocturia, and residual urine of 100 ml.In addition, several conditions have been associated with urinary incontinence, such as asthma, allergies, neurological diseases, and nerve-demyelinating multiple sclerosis (Johannessen et al. 2021).
Research suggests that patients with a history of urinary incontinence during pregnancy or postpartum will likely have bigger risk factors for suffering urinary incontinence in the future.Therefore, urinary incontinence is a condition that is closely related to pregnancy (Nygaard et al. 2017).The overall prevalence of urinary incontinence ranges from 8.2% to 26.8%, where women have a higher prevalence of 13-38.7%than men, 2.9-9.9%(Sacomori et al. 2020).About 10% of all adult women experience urinary incontinence at least weekly.A higher incidence rate was found in research with pregnant women, where it was 10.4-71.11%(Chen et al. 2023).In particular, the highest prevalence of urinary incontinence occurred in the third trimester of pregnancy until after delivery (Chen et al. 2023).This incident has been basically mentioned by earlier studies that claimed pregnant and postnatal women were more prone to urinary incontinence because they had a shorter anatomy of the urethra and a weaker bladder than men (Szumilewicz et al. 2019).Other scholars supported this idea as they found two mechanisms of urinary incontinence in women, namely urethral hypermobility and intrinsic sphincter deficiency (Schreiner et al. 2018).These two mechanisms are believed to be interrelated as the causes of urinary incontinence in women.However, in some societies, there is a stigma that considers this dysfunction normal.As a result, patients rarely seek help for their urinary incontinence complaints (Molina-Torres et al. 2023).
Several actions can be done to prevent urinary incontinence, such as avoiding constipation, doing light physical activity, and performing a main exercise choice called Pelvic floor muscle training (PFMT).Such training is beneficial since it can improve the ability of muscle contractions, increase intraurethral pressure, maintain the position of urethra, and mechanically presses the urethra against the symphysis (Stafne et al. 2022).In addition, PMFT can strengthen the pelvic floor muscles and is the most cost-effective non-invasive therapy.Unlike other exercise, patients who perform PMFT can do it themselves, anytime, anywhere, without the need for regular visits at home.
Given the fact that PMFT can be very beneficial, this study aims to analyze the effectiveness of such training in preventing urinary incontinence in pregnant and postpartum women.The analysis is based on trusted literature that is published in reliable academic databases.Therefore, the study can recommend appropriate solutions to prevent urinary incontinence.

Studi Design
This study employed a systematic review method by searching data from journal databases such as Pubmed, Science Direct, and Web of Science.These websites are considered premier platforms as they compile publications worldwide that have scientific impact and relevance.

Eligibility criteria
Prior to data analysis, the study must ensure that it only analyzed relevant articles.Thus, it determined a set of inclusion criteria, such as articles published in the last five years (2019)(2020)(2021)(2022)(2023)(2024) and discussing pregnant and postnatal women, pelvic floor muscle training, and urinary incontinence.Furthermore, the articles must come from journals that used the official languages of the United Nations, such as Arabic, Chinese, English, Russian, French, and Spanish.On the other, the exclusion criteria in this study were those not indexed by Scopus and Web of Science.

Procedure
The review process began by screening articles' titles, abstracts, and full texts.These data were then verified and stored in Mendeley software.This process generated a total of 2387 articles from the Pubmed, Science Direct, and Web of Science databases.Next, in the second stage, 88 articles were screened based on the suitability of the title and abstract.In the third stage, 41 articles were advanced to the next stage.At this stage, the articles were filtered based on their overall suitability and suitability.Then, in the final stage, eight articles that met the inclusion criteria were selected and analyzed for this systematic observation.For standard operations, this study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) assessment.Figure 1 below illustrates how the articles in this study were selected using the PRISMA guidelines.

Results
This study identified 2387 articles at the first stage of the search.Among them, eight articles met the inclusion criteria.The summary of these articles is presented in Table 1.Two research midwives led and facilitated initial training sessions lasting approximately two hours.Each intervention cluster included a midwife 'champion' from the team who would receive additional training on supporting and managing women whose UI symptoms may be more severe or giving cause for concern, including appropriate referral pathways.Champions also provide reminders and advice for midwives in their teams.Midwives were given 2 to 3 months (depending on the date of their training) to practice implementing the PFME intervention into their routine care.
High exercise adherence PFME in pregnancy can prevent Urinary incontinence.The measured variables were reported to have no statistically significant differences between the control group at the initial and regular physical activity, no therapeutic interventions in UI in the last three months (PFMT, Extracorporeal Magnetic Innervation (ExMI), electrostimulation, biofeedback), and the presence of contraindications to the treatment.final assessments.(Nipa et al. 2022)

Randomized controlled trial study
Married women aged 18-60 years old, with mild-to-moderate severity on the visual analog scale (i.e., VAS 1/10-7/10) of CLBP (> three months), who had been free from any intervention program for CLBP for at least one month.Had to undergo the one-hour pad test with a weight of 2-20 grams and at least have primary education (i.e., can understand and answer the questionnaires).
Study included married women who had been pregnant, as pregnancy and childbirth act as significant causal factors for UI.
The intervention was provided by a welltrained physical therapist.Participants in both groups performed one set of exercises during each week's intervention.Besides this, telephone calls, feasible appointments, and counseling of family members were conducted each week to encourage compliance with the intervention.
They found that RCT-illustrated improvement of SUI in women with nonspecific chronic low back pain, reduction of frequency, and improvement of the QoL.The improvement was greater from PFME with core stability exercise than from PFME alone.(Wu et al. 2021) Prospective cohort study Primiparous women who had vaginal deliveries and experienced non-extending seconddegree perineal lacerations were invited to participate in this study.
The PFMT started at one week postpartum, and one-on-one EMG-BF assisted pelvic floor muscle training was carried out by a qualified phys iotherapist at the first and fourth week postpartum.All the participants (PFMT þ control groups) were assessed for pelvic floor muscle strength, including baseline strength and maximum voluntary contraction at six weeks postpartum.
Our study showed that supervised biofeedback-assisted pelvic floor muscle training started routinely at one week postpartum did not provide additional improvement in lower urinary tract symptoms.

Discussion
This research aims to analyze the effectiveness of pelvic floor muscle training (PFMT) in preventing urinary incontinence in pregnant and postpartum women.PFMT is effective in all types of urinary incontinence (Sacomori et al. 2020).In pregnant and postpartum women, the mechanism is characterized by contractions before or during an increase in intra-abdominal pressure and the formation of structural support (Dufour et al. 2019).
The pelvic floor refers to a group of muscles that support several organs in the pelvis, consisting of the pelvic diaphragm, which extends from the pubic symphysis anteriorly to the coccyx posteriorly.The pelvic diaphragm forms a hammock-like structure that supports the pelvic organs (Sacomori et al. 2020).The pelvic floor also consists of the levator ani muscles.The levator ani muscle plays an important role in supporting the pelvic organs and is innervated by the fourth sacral nerve (Miquelutti, Cecatti, and Makuch 2013).It covers the puborectalis, pubococcygeus and iliococcygeus muscles, and the coccygeus muscle (Woldringh et al. 2007).The puborectalis muscle arises from the back of the pubis and forms a Ushaped loop behind the rectum that connects the anorectal junction to the pubic symphysis (Chen et al. 2023).Meanwhile, the pubococcygeus muscle arises from the posterior part of the superior pubic ramus and attaches to the anococcygeal and superior surfaces of the coccyx (Yan et al. 2022).Finally, the iliococcygeus muscle arises from the ischial spine and attaches to the anococcygeal raphe and coccyx.The name of each component muscle comes from its attachment (Figure 2).Previously, the coccygeus and iliococcygeus are thought to be innervated by divisions of the pudendal nerve, inferior rectal nerve, and perineal nerve (Johannessen et al. 2021).In previous studies, most samples were taken from 2024, Retos, 54, 506-512 © Copyright: Federación Española de Asociaciones de Docentes de Educación Física (FEADEF) ISSN: Edición impresa: 1579-1726. Edición Web: 1988-2041 (https://recyt.fecyt.es/index.phppopulations living in the community.Most trials involved a 12-week intervention (Hagen et al. 2020), but some were six weeks or eight weeks long (Bick et al. 2022).Research by Szumilewicz et al. 2020 reported that the intervention group started regular pelvic floor muscle training much earlier after giving birth than the control group (P<0.001).Women with less training reported an impact of urinary incontinence on life at two months (P=0.03) and one year postpartum (P=0.005).Two months after birth, for symptomatic women, IIQ scores were significantly lower in training than in female controls.The number of women affected by incontinence symptoms decreased by 38% in the intervention group and 20% in the control group (Szumilewicz et al., 2020).The present research also found that PFMT can be performed with multiple modes.For example, most samples in PFMT performed exercises at home supervised by a physiotherapist or nurse/midwife.In some trials, PFMT was delivered individually (Chen et al. 2023;Johannessen et al. 2021;Weber-Rajek et al. 2019).Meanwhile, others were delivered in group classes (Hagen et al. 2019;Szumilewicz et al. 2020).Some trials were limited to PFMT with or without functional pelvic floor muscle contractions to prevent episodes of stress urinary incontinence (Wu et al. 2021).
Meanwhile, in studies, PFMT was embedded in a multicomponent program with other behavioral or exercise components.One trial included PFMT within a broader general physical exercise program (Silva et al. 2023).Another interesting report on PFMT is that it is effective as a stand-alone therapy, as part of a multicomponent therapy that combines PFMT with behavioral strategies and lifestyle changes, and as part of a more general physical exercise program to improve physical function in pregnant and postpartum women (Stafne et al. 2022).
The results expand the evidence that promotes the implementation of PFMT via mobile technology, with the potential for broader reach, cost savings, and impact on the health of pregnant women in rural areas.Its benefits were demonstrated in various cultural contexts, using several different training programs, and assessed based on a variety of outcome measures (Woodley et al. 2023).
Another key takeaway from the articles reviewed in this study is the fact that the effects of PFMT in women with stress urinary incontinence do not appear to diminish with age.In trials involving older women, primary and secondary outcome measures were comparable to trials focusing on younger women.Therefore, age should not be a barrier to PFMT (Weber-Rajek et al., 2019;Nipa et al., 2022).Intensive pelvic floor muscle training during pregnancy can prevent urinary incontinence in about three out of six women during pregnancy and four out of eight women after giving birth.Pelvic floor muscle strength was significantly higher in the training group at 36 weeks of gestation (P = 0.008) and three months after delivery (P = 0.048) (Bø 2020).Based on the above evidence, supervised PFMT should be offered as a first-line conservative therapy for women of all ages, especially pregnant and postpartum women who experience stress, or mixed urinary incontinence.

Funding
This research received no external funding.

Figure 1 .
Figure 1.PRISMA flowchart of the article selection process

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their childbirth preparation classes at 28 weeks of gestation.Both groups attended the classes regularly, having their respective topics addressed by their family nurse.The only exception was that only the EG performed the PFMT protocol.At the end of class, both were supervised by a physiotherapist.Meanwhile, at home, they were left unsupervised.This PFMT protocol reduced urinary incontinence in pregnant women.The program significantly improved the quantity of urinary leakage and increased the strength of the pelvic floor muscle.(Weber-Rajeket al.2019)Experimental study Age < 60, BMI under 25, diagnosed urge and mixed urinary incontinence, lack of The experimental group underwent 12 therapy sessions of PFMT (45 minutes each, three times a week for four weeks).

Figure 2 .
Figure 2. Pelvic floor muscle of female anatomy

Figure 3 .
Figure 3.One of the Movements from Pelvic Floor Muscle TrainingConclusionsThis study concludes that intensive pelvic floor muscle training (PFMT) prevents urinary incontinence during pregnancy and after delivery.It was reported that pelvic floor muscle strength increases significantly after intensive pelvic floor muscle training.From the analysis of several scientific evidence, pelvic floor muscle training is recommended for six weeks starting in the third trimester of pregnancy because it can increase the strength of the muscle tone of the blood vessel walls, pelvic floor muscles, and supporting ligament muscles in the pelvis.We highly recommend further research to analyze PMFT during the postpartum period which can prevent urinary incontinence even more.

Table 1 .
Summary of the design and intervention of the studies Both groups were offered six appointments over 16 weeks to receive biofeedback pelvic floor muscle training or basic pelvic floor muscle training.Home biofeedback units were provided to the biofeedback pelvic floor muscle training group.Behavior change techniques were built into both interventions. /retos/index)