Incontinence is defined as any involuntary loss of urine or the inability to control the bowels (International Continence Society [ICS], 2013). It can affect any age, gender and culture, and much has been written about the devastating psychological, social and financial implications for the individual and their family (Lukacz et al, 2011; Wan and Wang, 2014; Holroyd, 2015). An ageing population means that the incidence of incontinence is on the rise, although it is recognised that many will not seek help due to embarrassment and social stigma (Ng et al, 2014).

Normal bladder filling and storage involves the bladder stretching to accommodate a reasonable volume of urine (it is generally accepted that a normal bladder capacity in an adult is 400–600mls). The detrusor muscle is at rest until the bladder capacity for the individual is reached, whereby a series of nerve impulses communicate between the bladder and brain to start the emptying phase. During the filling and storage phase, the urethra and sphincters must remain closed and the pelvic floor contracted to ensure no leakage occurs. This continues even when intra-abdominal pressure is raised during coughing, sneezing, laughing and physical activity. During the emptying phase, the detrusor contracts, the urethra and sphincters open and the pelvic floor relaxes, and the intravesical pressure increases to effectively empty the bladder contents (Feneley et al, 2015).

Stress urinary incontinence (SUI) is defined as the complaint of involuntary leakage of urine on effort or exercise, or coughing or sneezing (Abrams et al, 2002). It occurs when there are alterations to the anatomy of the pelvic floor or urethral passage, or when something occurs to interrupt the nerve pathways that control the micturition cycle. It is recognisably the most prevalent form of incontinence in women (Wu et al, 2010; Reynolds et al, 2011), and is most common in the over 50s age group (Haslam 2004; Lose, 2005; Shaw et al, 2006); although statistics show that in 50% of women aged 25–49 years reporting symptoms of urinary incontinence, the cause is SUI (Hannestad et al, 2000).

SUI is linked with pudendal nerve damage during vaginal delivery, or incomplete nerve regeneration following childbirth (Clark et al, 2001; Borello-France et al, 2006). There are also links between SUI development and the loss or diminished functionality of the pelvic floor and the supportive ligaments and musculature of the urethra and bladder, and hormonal changes with age in females (Rett et al, 2007; Sangsawang et al, 2011).

 
A variety of treatment options are available. Rovner and Wein (2004) defined the perfect treatment choice that is 100% effective requires the following elements:
  • Durable/permanent
  • Simple, quick, and easy to perform or implement
  • Minimally invasive and completely reversible
  • Applicable and effective for all types of SUI
  • Low morbidity and/ or complications
  • Inexpensive for the patient, healthcare facility, and healthcare system.
Unsurprisingly, the perfect treatment has not yet been identified. Options available include bladder retraining with fluid and dietary modifications. This requires commitment from the patient and takes time to show any significant effect. Various pharmacological preparations are available to treat SUI, but the prescriber needs to consider the possibility of overactive bladder (OAB), as the treatment is very different. Some female patients may be offered the choice of using a pessary, although this can be difficult to size accurately and may be seen as too intrusive for some patients. Permanent catheterisation may be offered in some cases, although this carries well-documented risks of infection (Feneley et al, 2015). Surgery should always be the last option, only considered after other more conservative therapies have been tried and failed to offer substantial improvement. In the author’s clinical experience, some patients choose to manage the symptoms rather than treat, and may be content with the use of containment products.

Pelvic floor muscle exercises (PFME), also known as Kegel exercises, were introduced in the 1940s and are one of the commonest conservative treatment options offered to patients experiencing SUI. They are considered a safe and inexpensive, non-invasive therapy that can cure or improve symptoms (Newman, 2001; Neumann et al, 2005). National Institute for Health and Care Excellence guidance (NICE, 2013) for managing women with urinary incontinence advises that a routine digital assessment to determine the efficacy of pelvic floor muscle contraction should be carried out before any teaching of PFME. In contrast, the male pelvic floor has comparatively less recent evidence or guidance supporting pelvic floor exercises. Before 1996, there was no recognised method of assessing pelvic floor strength in men. Wyndaele et al (1996) recommended digital anal assessment using a grading range from 0–5 (where 0 is no contraction evident and 5 is a good, effective squeeze) as a reliable assessment tool, while Dorey et al (2003) advised anal manometry as an outcome measure for muscle strength. Following a randomised controlled trial (RCT) in men with erectile dysfunction, it was recommended that an additional grade 6 of very strong be added to the existing scale (Dorey et al, 2004).

The current recommendation for physical examination of the pelvic floor function in men is supine position, rather than left lateral, in order to observe the anal wink, penile retraction and scrotal lift (Dorey, 2005a). In the author’s opinion, anal manometry is rarely used in everyday practice and is reserved for specialist urology or colorectal clinics. Traditionally, pelvic floor examination courses aimed at nurses and physios teach female examination with delegates practising on each other to achieve competence. 
The majority of delegates are female, so the opportunity to practice a male assessment is restricted. Furthermore, as many specialist nurses working in the continence field work alone; there is little opportunity to receive supervised practice at assessing the male pelvic floor. In the author’s opinion, this leads to many continence clinics offering routine internal examinations for women, but few will offer a routine digital assessment of the male pelvic floor. Reasons cited by staff are a lack of training, competency or awareness of the technique.

Teaching methods for PFME vary greatly, particularly in relation to the number of repetitions required, fast or slow exercises, and how long to continue the exercise regimen for. Depending on the source of information (which is not always an appropriately trained healthcare professional), patients may do less repetitions, stronger or weaker contractions, and continue for up to 12 weeks. Compliance is always an issue, as this is not a form of exercise that requires a visit to the gym; it is invisible and appears to require little effort. Patients who show poor compliance often cite reasons as being too busy or unsure that their technique is correct.

There is some evidence to suggest PFME without the benefit of a digital examination may actually worsen the symptoms or be ineffective, as the person may bear down rather than contracting the pelvic floor muscles (Bump et al, 1991). This is quite old evidence and with the advent of internet and phonebased programmes and applications (app), a lot of patients self-teach the procedure. However, it is difficult to determine whether they are practising the correct technique if they have learnt from an app. Best practice evidence recommends an internal digital rectal or vaginal examination to competently assess the pelvic floor and technique for performing PFME (Pomfret et al, 2007). Any intimate examination is reliant on valid consent from the patient and may not always be possible in the event of no chaperone, inadequate training of staff carrying out the examination, or lack of consent.

Several studies have been carried out on the effect on female pelvic floor exercises to improve SUI (Borello-France et al, 2006; Sangsawang and Serisathien, 2011; Tajiri et al, 2014). A study carried out by Sangsawang and Serisathien (2011) looked specifically at the effect of PFME programmes on SUI in pregnant women. Sixtysix women were included in the study and divided into a control and intervention group. The control group were provided with a leaflet that included information on PFME, but nothing specific to SUI. The intervention group were given a structured course of therapy/ exercise to follow over a six-week period. Results showed significant improvement of symptoms of SUI in the intervention group and little or no change in symptoms in the control group.

PFME tips...

Assess pelvic floor strength using vaginal and rectal examination

Demonstrate the correct/ effective technique for fast and slow exercises

Agree the volume and frequency of exercises with the individual based on the initial assessment of muscle tone/strength

Increase intensity/frequency/ number of repetitions every two weeks as the muscle tone improves

Set a maximum number of repetitions and frequency of exercise to avoid muscle fatigue

Reassess muscle tone and strength at eight and 12 weeks.
Taijiri et al (2014) conducted an RCT looking at the effects of contracting both abdominal and pelvic floor muscles to optimise the effect on SUI symptoms. They sampled 15 women who had one or more episode of SUI within a month. These were divided into two groups: group one carried out the cocontraction exercises in a measured and regulated way over a period of days/weeks, while group two was the control group who were advised not to perform any exercises at home. Results showed an improvement in symptoms (55.6% after four weeks) in the group that carried out both sets of exercises (i.e. 40 repetitions, two sets of 20 repetitions of a threesecond co-contraction of both the transanal and pelvic floor muscles), with further improvement the longer they continued on the programme (88.9% after eight weeks). The control group showed no significant changes.

A study carried out by Borello- France et al (2006) followed a similar process to the other studies with randomised groupings. The results of this demonstrated similar outcomes with a significant improvement in the interventional group and little or no change in the control group. This particular study also demonstrated that the position the participants assumed to perform the exercises had no bearing on the level of improvement. While the participant number in this study is small, the level of evidence from an RCT is considered clinically credible and should be considered when reviewing the efficacy of structured pelvic floor exercise.

Dorey (2005b) carried out a review of RCTs that had focused on restoring male pelvic floor function. She identified 11 RCTs which were male-orientated, although they were all restricted to symptoms relating to transurethral resection of the prostate (TURP) and radical prostatectomy. All of these studies focused on the benefits of PFME pre-operatively, post-operatively and the optimum time to teach PFME. There were no identifiable RCTs for men who suffered from incontinence in the absence of a surgical procedure. 
The majority of these RCTs were graded as level I or II evidence and therefore the conclusions drawn can be accepted as clinically relevant based on strong evidence. All of the RCTs reviewed concluded that PFME has a positive effect in treating men post-prostatectomy incontinence and post micturition dribble. There is level II evidence to suggest that continuing the PFME lifelong would be the optimum treatment. However, it is recognised that compliance over many years may wane as people forget to perform the exercises.

From the limited evidence reviewed, it is the author’s opinion that there is sufficient level I and II evidence from clinical research to suggest effective and appropriate teaching of PFME in a structured way will improve symptoms of SUI in both men and women. However, there are still variations in compliance, methods of teaching and resources used in PFME which will affect the efficacy and outcomes for individuals. More work needs to be done on developing a standardised programme for teaching, although it must be recognised that any structured course of PFME should be designed specifically for the individual and based on a thorough clinical assessment that includes a digital examination of the vagina and/ or rectum.

Community nurses can play a vital role in appropriate identification and referral of patients to specialist services who would initiate a programme of PFME. The experienced community nurse can also offer essential coaching and support to ensure compliance with pelvic floor muscle exercises, and assessment of efficacy over the course of treatment.

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