Authors:
Dr Bharti Tailor, Staff Nurse Urology, London North West University Healthcare NHS Trust, London
Dr Vikash Patel, Urology Registrar, London North West University Healthcare NHS Trust, London
Dr Hiral Billimoria, ST2 Trainee in Obstetrics and Gynaecology, Imperial NHS Trust, London
Mr Rajesh Kavia, Lead Urology Consultant, London North West University Healthcare NHS Trust, London
 

Abstract

Objective: The aim of this pilot study was to evaluate the efficacy of a group-based structured yoga therapy intervention for women aged 40–70 years with urinary incontinence.
 
Methods: Eight English-speaking women were enrolled into a 12-week hatha yoga therapy programme consisting of a 1-hour group class and three 20-minute home practice sessions per week. The programme was specially designed by the yoga instructor with an emphasis on poses to strengthen pelvic floor muscles. Data were collected through 3-day bladder diaries completed by participants after each class and participants completed the patient global impressions of change scale at the end of the programme.
 
Results: At the end of the programme there was demonstrable and consistent improvement in symptoms of urinary incontinence for those who had attended at least 9 of the 12 classes. Women reported reduction in urgency and urge incontinence, fewer episodes of leaks and nighttime voids, and 90% scored 2 (much improved) on the patient global impressions of change scale.
 
Conclusions: This pilot study supports the efficacy of yoga group therapy intervention in improving symptoms of urinary incontinence in women. The yoga programme is a self-management tool, which is low risk, cost effective and easily accessible in the community. 
 

Introduction 

Nearly a third of women over the age of 40 years will experience urinary incontinence in their lives (Huang et al, 2024). Over 40% of menopausal women and one in two women over 80 years of age experience urinary incontinence (Huang et al, 2019). Urinary incontinence can lead to anxiety, social isolation, embarrassment, depression and risk of falls (Wilcock et al, 2003; Chai et al, 2017; Kelly, 2023).

The conventional treatment for urinary incontinence is medical therapy or surgery depending on the severity of the symptoms, but these both have limitations in terms of side effects and curative success. Pelvic floor exercises are normally recommended as first-line treatment but women find them difficult to learn independently, which limits their therapeutic benefit. Yoga therapy has been extensively used in healthcare and provides an alternative approach to combating symptoms associated with urinary urgency and urge incontinence (Gupta, 2024). Studies have outlined the benefits of yoga in different areas of healthcare such as chronic pain, cancer care and cardiovascular disease (Crevelário de Melo et al, 2021; Giridharan et al, 2024; Murugesan, 2024). It is a holistic approach which addresses anxiety, social isolation embarrassment and depression (Tulloch et al, 2018).

Yoga is a comprehensive mind and body practice. It combines a series of physical poses, breathing exercises and meditation that improve the overall physical and mental wellbeing of the individual. In Sanskrit, yoga means union of the body mind and spirit. By using breath awareness and the body–mind connection, the aim of the yoga postures used in this study is to train the body to bring awareness to the pelvic floor. This enables the person to control these muscles without any prior pelvic floor training.

The physiological ways in which yoga, in particular the poses used in this programme, is believed to strengthen pelvic floor muscles are outlined in Table 1.
 

Research supporting the role of yoga therapy in treating urinary incontinence

A number of studies have looked at the place of yoga in treating women with urinary incontinence. 
 
Tenfelde et al (2021) undertook a non-randomised single arm pilot study to evaluate the effectiveness of a twice-weekly 8-week gentle yoga programme as an intervention to relieve the symptom burden of urinary incontinence. Changes in symptoms were measured using the pelvic floor distress inventory, and 20 secondary measures included quality of life, depression, sleep, anxiety and inflammatory biomarkers. The study provided preliminary evidence that yoga is a feasible complementary therapy that reduces the burden of symptoms of urinary incontinence and improves quality of life.
 
Huang et al (2019) performed a single-centre randomised study to examine the feasibility, efficacy and safety of a group-based yoga intervention for middle-aged women with urinary incontinence. After 6 weeks of intervention the frequency of urinary incontinence decreased by 70% and there were fewer episodes of urinary incontinence in the yoga group than the control group. These findings provided preliminary evidence to support the feasibility and efficacy and safety of group-based yoga therapy intervention to improve urinary incontinence.

Huang et al (2024) followed this up with a multicentre randomised controlled trial that compared the effects of a pelvic floor-specific yoga programme vs those of a non-specific physical conditioning programme on urinary incontinence in women. A total of 240 participants from five centres aged between 40 and 90 years were randomised to take part in either physical muscle skeletal strengthening exercises or a pelvic floor-specific hatha yoga programme. The sessions were delivered twice a week over 12 weeks, and 3-day bladder diaries were analysed after this. Total urinary frequency (primary outcome) decreased by an average of 2.3 episodes per day with yoga and 1.9 episodes per day with physical conditioning, showing that the therapeutic benefits of yoga were more than those of a general strengthening programme, although this difference was not statistically significant.    

Kannan et al (2022) performed a three-arm parallel group randomised pilot study in three care centres in Hong Kong, which aimed to investigate the preliminary effects of yoga and Pilates on symptoms of urinary incontinence. Study centres were randomly assigned to one of three interventions: yoga, Pilates or pelvic floor exercises. Thirty women were enrolled in the study. The interventions were provided once a week for 4 weeks followed by unsupervised CD-guided home exercises for 8 weeks. Measures included adherence to the intervention, recruitment and retention rates and safety. Outcomes were assessed at baseline, 4 and 12 weeks. Statistical analysis showed that yoga poses intended to address the pelvic floor and core muscles had superior benefits over Pilates and pelvic floor exercises in terms of improved continence.
 

Methods

A pilot study was undertaken to test and evaluate the efficacy of yoga as an intervention for women experiencing urinary incontinence. Funding for the study was provided by the London North West Trust Charity. This yoga programme was specifically designed to strengthen the core pelvic floor muscles and consisted of 12 poses as summarised in Table 2.

Table 1. Physiological effects of yoga on pelvic floor muscles

Pelvic floor support	The aim of strengthening the pelvic floor muscles is to improve the support for the bladder and urethra which in turn will reduce urinary incontinence. There is a physiological connection between these poses and the pelvis
Muscle coordination	Yoga emphasises the integration of physical poses (asanas), controlled breathing (pranayama), and mindfulness. Through breathing and mindfulness, the person becomes aware of the muscles that control the bladder which enables them to contract and relax these muscles, enhancing mind–body coordination
Enhanced body awareness	By focusing on mindful movement, yoga encourages a deeper awareness of pelvic floor function, helping individuals to better control and relax these muscles
Postural alignment	The yoga poses enhance flexibility, help with alignment and flexibility of the core muscles and improve general body alignment. Our posture affects the integrity of the pelvic floor. Yoga improves posture by strengthening the core and encouraging alignment, which reduces the strain on the pelvic floor
Nervous system regulation	Meditation and pranayama, the breathing techniques used in yoga to centre the mind and the body, help regulate the autonomic nervous system thus reducing stress and anxiety. Through breath work and meditation, yoga reduces stress, which affects pelvic floor tension and dysfunction
Muscle flexibility and endurance	Yoga helps to build muscle endurance as the poses used in this programme are designed to strengthen and lengthen the pelvic floor. Yoga strengthens the pelvic floor and the surrounding muscle groups, promoting stability without over-tightening

 

Table 2. Poses used in the programme that strengthen pelvic floor muscles

1	Knee to chest (Apanasana)
2	Bridge (Setu Bandha Sarvangasana)
3	Boat pose (Navasana)
4	Cat and cow (Marjaryasana Bitilasana)
5	Standing forward fold (Uttanasana)
6	Chair pose (Utkatasana)
7	Mountain pose with block (Tadasana)
8	Warrior two pose (Virabhadrasana 2)
9	Triangle pose (Utthita Trikonasana)
10	Wide-legged squat (Malasana)
11	Supported legs up wall (Viparita Karani)
12	Corpse pose (Savasana)

Study design

A convenience sample of eight English-speaking ambulatory women between 40 and 70 years of age were enrolled into a structured 12-week face-to-face group yoga programme. The programme consisted of a 1 hour-long class and three sets of 20 minutes of home exercises per week. The programme was designed to strengthen the pelvic floor muscles using the poses outlined in Table 2. 
 

Inclusion criteria 

Women had to be aged between 40 and 70 years of age, speak English and be physically fit to be eligible to participate in this study. Twenty-five women were screened of whom eight were selected. Women were excluded on grounds of physical fitness and language as the programme was going to be delivered in English. 
 

Evaluating the study

Before the programme satisfactory attendance was considered to be at least 10 out of 12 weeks. However, as the study progressed this had to be re-evaluated as the programme coincided with school holidays and was held midweek. Some women could not commit to the classes because of childcare issues. Delaying the project would have meant loss of the funding.
 

Methodological change

Initially this project started as a quality improvement study, so no ethical approval was required. From a simple, rapid-cycle testing (e.g. plan-do-study-act (PDSA) cycles) the authors moved to a pilot study to give a more rigorous, controlled, and data-driven approach to test the feasibility, adherence, and impact of yoga. While quality improvement aims for immediate improvement through trial and error, a pilot study assesses whether an intervention can be implemented successfully, evaluating its feasibility, scalability, and sustainability.
 
The first PDSA cycle tested for attendance. In the first week only five women attended the class, which indicated that the communication about the classes needed to be addressed. By sending two reminders weekly attendance increased to eight. The second PDSA cycle involved data collection. Despite being given detailed verbal and written information about how to fill out the bladder diaries, some women had not recorded the information accurately. This was resolved by examining the entries in the diaries each week before the class (Booth et al, 2019). Both these interventions improved the quality of data.
 

Data collection

Three-day bladder voiding diaries from the British Association of Urological Surgeons (2024) were given to all participants, with instructions on accurate recording reinforced with leaflets produced by the urology department. The diaries had to be completed on three consecutive days between classes. Diary entries were collected weekly and data entered on Excel sheets to aid data analysis. The project was evaluated using the patient global impressions of change scale, which is a 7-point, single-item scale used in clinical settings to measure a patient’s self-reported perception of improvement or decline following treatment (National Institute of Mental Health, 1976). The score measures the holistic impression of improvement as perceived by the patients over 12 weeks. It captures a patient’s overall experience, including symptoms and functionality, which might not be fully represented by objective measures alone and is often used in clinical settings. The scale was administered at the end of the 12-week programme and again at 3-month follow up. 

Results

Twelve-week bladder diaries were analysed. As this was a very small sample it was not possible to perform inductive statistics. The patient global impressions of change scale scores from all women were also analysed (Table 3).
 
Comparing the reported number of incontinence symptoms per day experienced before and after the intervention (Table 3), all participants experienced a reduction in the number of symptoms experienced every day. 
 

Table 3. Results of analysis of bladder diaries and patient global impression of change scores

		Number of incontinence symptoms per day
Participant	Issues	Before intervention	After intervention	Number of weeks attended	Patient global impression of change
1	Leaks, nighttime voids	3	0	11	Much improved
2	Nighttime voids	3	1 (normal)	11	Much improved
3	Leaks, nighttime voids	6	2–3	10	Much improved
4	Excessive voiding, nighttime voids	12	7–8	10	Much improved
5	Frequency, leaks, nighttime voids	6	3	10	Much improved
6	Frequency, excessive voiding, nighttime voids	10	6	9	Much improved
7	Frequency, nighttime voids	3	1 (normal)	4	Much improved
8	Frequency, nighttime voids	3	1–2	3	Minimally improved

 

Discussion

The results after the 12-week yoga programme suggest that women experienced improvement in the urinary incontinence episodes. All participants except one reported being ‘much improved’ on the patient global impressions of change scale. Participants reported fewer episodes of urinary urgency, leakage and nocturnal voiding. Six women attended 9 weeks or more of the programme, demonstrating feasibility and high engagement with the group setting. In informal discussions after the classes, the women reported less embarrassment, less social isolation and improved overall wellbeing and welcomed the social aspect of group therapy. The group setting created a supportive environment which encouraged high adherence. Compared to the cost of pelvic floor exercises (average £300 for six sessions delivered over 6 weeks for one person, according to data from the authors’ physiotherapy department), yoga cost £10 per person per class, amounting to £120 per person for 12 classes. This shows the potential cost saving if this programme was introduced more widely. 

The results indicate that yoga therapy is a feasible, low-cost, accessible alternative to conventional treatment for urinary incontinence, particularly in primary and community settings. Yoga addresses the physical and emotional aspects of health, so provides a self-management strategy for women who are reluctant to pursue medical or surgical treatments. Yoga could be integrated into preventative health programmes and support services for women, which could reduce waiting times and burden on urology services. Discussions with participants emphasise that urinary incontinence is a psychosocial condition as well as a physical disorder and interventions like yoga can simultaneously target bladder health as well as overall quality of life. At 3-month follow up the global scores remained the same for all eight participants, and they had all enrolled in community yoga classes of their own accord. 
 

Limitations of the study

The pilot study of eight participants means generalisability is limited, so a larger randomised controlled trial is needed to confirm efficacy, measure statistical significance and explore long-term impact. The programme took place during the school holidays and the classes were held midweek, which prevented some eligible women from taking part. Future studies should take this in consideration. Most yoga classes are conducted in English so language is a barrier for those who do not speak English. Yoga is only suitable for women who are physically able to perform the poses. Yoga therapy needs a long and consistent commitment to strengthen the pelvic floor muscles. 
 

Conclusions 

This pilot study, with a small sample of eight women, has provided evidence that group yoga therapy has the potential to benefit ambulatory women and can be embedded in present services or as a community-based intervention.