Pelvic floor muscle training in lower-income settings
Authors: E Jean C Hay-Smith
Journal: The Lancet Global Health (2019)

Too many resources have been wasted on underpowered randomised trials that investigate the effects of pelvic floor muscle training (PFMT) on urinary incontinence, do not address important evidence gaps, and essentially repeat a similar study with minor variations in content or delivery. In The Lancet Global Health, Adrian Wagg and colleagues1Wagg A Chowdhury Z Galarneau J-M et al.Exercise intervention in the management of urinary incontinence in older women in villages in Bangladesh: a cluster randomised trial.Lancet Glob Health. 2019; 7: e923-e931Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar report an outstanding contribution to the field because they have extended the trials evidence to include an entirely different setting and participant group. Using an intervention that has previously shown benefit,2Wagg A Cherry N MacDonald D et al.Development and testing of a continence record for use with illiterate older women in rural Bangladesh.Neurourol Urodyn. 2015; 34: S208-S209Google Scholar, 3Dumoulin C Cacciari LP Hay-Smith EJC Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women.Cochrane Database Syst Rev. 2018; 10 (CD005654.)PubMed Google Scholar Wagg and colleagues undertook a matched-pair, cluster randomised trial of 16 pairs of villages in Bangladesh, recruiting women aged 60–75 years with self-reported urinary incontinence; most of the women were illiterate, and two-thirds were poor or very poor. Villages were randomly assigned in their pairs to either group-based PFMT and mobility exercise with healthy-bladder education or education alone, and all interventions were delivered by Bangladeshi paramedics and physiotherapists. The magnitude of achievement in developing2Wagg A Cherry N MacDonald D et al.Development and testing of a continence record for use with illiterate older women in rural Bangladesh.Neurourol Urodyn. 2015; 34: S208-S209Google Scholar, 4MacDonald D Wagg A Cherry N et al.Development and testing of a community based exercise intervention for urinary incontinence in elderly village women in rural Bangladesh.Neurourol Urodyn. 2015; 34: S214-S215Google Scholar and implementing a robust trial in this setting should not be underestimated. To encourage and support others planning incontinence research in lower-income countries, a further publication detailing the challenges and experiences of implementing the trial would be useful, extending observations of authors such as Islam and colleagues.5Islam RM Bell RJ Hossain MB Davis SR Bangladesh Midlife Women's Health Study (BMWHS): methods, challenges and experiences.Maturitas. 2015; 80: 89-94Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar As Wagg and colleagues noted, evidence of the effect of PFMT6Dumoulin C Hay-Smith EJ Mac Habée-Séguin G Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women.Cochrane Database Syst Rev. 2014; 5 (CD005654.)PubMed Google Scholar existed at the time their study began but no trial of PFMT had been done in a lower-income country, let alone a rural village setting. That glaring evidence gap remained until now; a quick examination of the most recent Cochrane systematic review3Dumoulin C Cacciari LP Hay-Smith EJC Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women.Cochrane Database Syst Rev. 2018; 10 (CD005654.)PubMed Google Scholar shows 28 of 31 trials that were included were done in high-income countries and the remaining three in upper-middle-income countries, with all but one—an e-health intervention—requiring women to travel to the health professional and urban clinic or hospital site. The significant and clinically important decrease in the number of urinary leakage episodes over 3 days from baseline to 24 weeks at the village level reported by Wagg and colleagues1Wagg A Chowdhury Z Galarneau J-M et al.Exercise intervention in the management of urinary incontinence in older women in villages in Bangladesh: a cluster randomised trial.Lancet Glob Health. 2019; 7: e923-e931Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar (–7·7 episodes [95% CI −10·6 to–4·8; unadjusted model]; and −6·64 episodes [–7·95 to −5·33; random-effects model accounting for cluster randomisation]) appears consistent with the direction and size of effect shown in these other trials,3Dumoulin C Cacciari LP Hay-Smith EJC Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women.Cochrane Database Syst Rev. 2018; 10 (CD005654.)PubMed Google Scholar suggesting that effects seen in high-income and upper-middle-income countries can be achieved in a lower-middle-income setting. A trial of PFMT in a low-income country is needed. For those excited by the effectiveness of the intervention shown in this setting, as I am, then the big question is what happened next? Did PFMT adherence appear to diminish over time for the participating women, as is commonly observed elsewhere?7Dumoulin C Hay-Smith J Frawley H et al.2014 consensus statement on improving pelvic floor muscle training adherence: International Continence Society 2011 State-of-the-Science Seminar.Neurourol Urodyn. 2015; 34: 600-605Crossref PubMed Scopus (65) Google Scholar Did the non-governmental organisation adopt and roll out the intervention in the control villages and elsewhere? Has the apparent effect changed with implementation in real life? What adaptations, if any, were needed for widespread implementation? The answers to these and other important questions are beyond the remit of the trial itself. Follow-up research to investigate ongoing use of the intervention and outcomes would offer valuable insights for those implementing such programmes. If the intervention can be widely implemented with fidelity, then many Bangladeshi women could benefit. In the cross-sectional Bangladesh Midlife Women's Health Study,8Islam RM Bell RJ Billah B Hossain MB Davis SR The prevalence of symptomatic pelvic floor disorders in women in Bangladesh.Climacteric. 2016; 19: 558-564Crossref PubMed Scopus (22) Google Scholar with a nationally representative sample of women aged 30–59 years, Islam and colleagues found that 35·3% (95% CI 32·6–37·9) of women had one or more pelvic floor dysfunctions, measured using validated instruments that were verbally administered by Bangladeshi researchers visiting women at home. Urinary incontinence was the most common dysfunction (23·7%, 95% CI 21·3–26·0), and the odds of urinary incontinence were significantly greater with increasing poverty (odds in least versus wealthiest quintile 3·25, 95% CI 1·86–5·27; p<0·001). Half of women aged 50–59 years had one or more pelvic floor dysfunctions, and the prevalence in even the youngest women (30–39 years) was double that found in a similar study among women of a similar age in the USA.8Islam RM Bell RJ Billah B Hossain MB Davis SR The prevalence of symptomatic pelvic floor disorders in women in Bangladesh.Climacteric. 2016; 19: 558-564Crossref PubMed Scopus (22) Google Scholar Risk of urinary incontinence might be higher in Bangladesh than in the higher-income countries where PFMT trials are typically undertaken, because Bangladeshi women—especially women in rural areas—tend to marry earlier, begin childbearing at a younger age, and have lifestyles that incorporate heavy lifting.8Islam RM Bell RJ Billah B Hossain MB Davis SR The prevalence of symptomatic pelvic floor disorders in women in Bangladesh.Climacteric. 2016; 19: 558-564Crossref PubMed Scopus (22) Google Scholar Given the moderate quality evidence that antenatal PFMT prevents postnatal incontinence in previously continent women,9Woodley SJ Boyle R Cody JD Mørkved S Hay-Smith EJC Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women.Cochrane Database Syst Rev. 2017; 12 (CD007471.)PubMed Google Scholar here is another evidence gap to be addressed in a similar way to that shown by Wagg and colleagues. Existing evidence from trials is wholly derived from high-income country settings, yet the prevalence of urinary incontinence, restricted care, and lifelong symptom burden are increased in lower-income settings with the potential for important gains in wellbeing if incontinence can be prevented or symptoms made less severe. Wagg and colleagues are to be congratulated on their research,1Wagg A Chowdhury Z Galarneau J-M et al.Exercise intervention in the management of urinary incontinence in older women in villages in Bangladesh: a cluster randomised trial.Lancet Glob Health. 2019; 7: e923-e931Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 2Wagg A Cherry N MacDonald D et al.Development and testing of a continence record for use with illiterate older women in rural Bangladesh.Neurourol Urodyn. 2015; 34: S208-S209Google Scholar, 4MacDonald D Wagg A Cherry N et al.Development and testing of a community based exercise intervention for urinary incontinence in elderly village women in rural Bangladesh.Neurourol Urodyn. 2015; 34: S214-S215Google Scholar and for signposting evidence gaps and methods for more innovative and important future PFMT trials. I declare no competing interests. Exercise intervention in the management of urinary incontinence in older women in villages in Bangladesh: a cluster randomised trialA structured group-exercise intervention has the potential to manage urinary incontinence in older women in communities largely outside the reach of pharmaceutical or surgical interventions. Full-Text PDF Open Access