Bibliographic reference
Group-Based vs Individual Pelvic Floor Muscle Training to Treat Urinary Incontinence in Older Women: A Randomized Clinical Trial. Chantale Dumoulin, PhD; Mélanie Morin, PhD; Coraline Danieli, PhD; Licia Cacciari, PhD; Marie-Hélène Mayrand, MD, PhD; Michel Tousignant, PhD; Michal Abrahamowicz, PhD; for the Urinary Incontinence and Aging Study Group
Summary
More than one-third of women aged 60 years or older experience urinary incontinence – a condition leading to depression, social isolation, caregiver burden, and admission to long-term care facilities. Individual pelvic floor muscle training (PFMT) is the recommended first-line treatment for stress or mixed urinary incontinence in women, but human and financial resources limit its delivery. Whether group-based PFMT performs as well as individual PFMT in this population remains unclear. The goal of this randomized, noninferiority trial was to evaluate group-based PFMT compared with individual PFMT in a group of 362 community-dwelling women, aged 60 years or older, with symptoms of stress or mixed urinary incontinence. The findings of this trial showed that group-based PFMT is non-inferior to the recommended individual PFMT. Its widespread use in clinical practice could therefore increase the treatment capacity for older women with urinary incontinence.
Context and starting point
Urinary incontinence is one of the most prevalent health concerns for women aged over 60 years. It can lead to reduced social interaction and physical activity, interfering with healthy aging. While supervised individual pelvic floor muscle training (PFMT) represents the first-line strategy, inadequate human and financial resources limit the delivery of PFMT. PFMT delivered to a group of women, rather than individually, could overcome these barriers, but it is unclear whether it is as effective as the standard care (individual PFMT). This study was conducted to compare the clinical effectiveness of group-based PFMT with individually delivered PFMT in women aged 60 years or older with stress or mixed urinary incontinence.
The characteristics of the study
The study was conducted from July 2012 to June 2018 in two Canadian research centers: the Institut Universitaire de Gériatrie de Montréal and the Centre Hospitalier Universitaire de Sherbrooke. 362 women living in the metropolitan area of the recruiting centers were enrolled; the patients were 65 years or older, complained of symptoms of stress or mixed incontinence, and reported at least 3 episodes of involuntary urine loss per week during the preceding 3 months. Stress and mixed urinary incontinence were confirmed using the validated Questionnaire for Incontinence Diagnosis. After an individual session with a physiotherapist to learn how to effectively contract the pelvic floor muscles, participants completed a 12-week PFMT as part of a group of 8 women (n=178) or in individual sessions (n=184). Individual and group sessions were held under the direction of an experienced pelvic floor physiotherapist. For both types of training, each weekly session lasted 1 hour and included exercises targeting PFM strength, power, endurance, coordination, and integration into daily living activities. In addition, women in both study groups were expected to perform PFM exercises at home for 5 days/week during the 12-week physiotherapy program, and subsequently for 3 days/week for 9 months. The study aimed at evaluating the non-inferiority of group PFMT over individual PFMT. The primary outcome was the percentage reduction in urinary incontinence episodes at 1 year, as reported in a 7-day bladder diary in relation to pre-treatment baseline. Secondary outcomes included: lower urinary tract–related signs, symptoms, and quality of life immediately following treatment and at 1 year.
The results achieved
165 of the 184 women (90%) from the individual PFMT group and 154 of the 178 women (87%) from the group-based PFMT completed the 1-year follow-up. Compliance to the program schedule was similar between groups. The trial demonstrated a median percentage reduction in urinary incontinence episodes at 1 year of 70% in individual PFMT compared with a 74% reduction in group-based PFMT. The results did not vary based on the study center, type of urinary incontinence, severity of urinary incontinence, participant’s age or BMI. Individual and group-based PFMT had similar effectiveness for all secondary outcomes, showing statistically significant improvement for all outcomes relative to the baseline. There were no significant differences between the 2 treatment groups with regard to urinary signs or symptoms. Moreover, at the 1-year follow-up, a high and almost identical proportion of women in each group reported satisfaction with the treatment: 148 of 164 (90%) individual vs. 139 of 153 (91%) group-based PFMT participants.
The limits of the study
The exclusion criteria and intensive intervention could limit generalizability of the results for frail older women who may not be able to participate in or adhere to this intensive intervention. Furthermore, it must be considered that adherence to the home exercise program, as well as the incidence of adverse events, was self-reported by the study participants.
What’s new
The results obtained by this trial suggest that group-based PFMT is not inferior to the recommended individual PFMT for the treatment of stress and mixed urinary incontinence in older women. Group interventions are considered to be useful tools to promote behavior modifications in the health promotion field, fostering peer support and increasing motivation by reducing stigma and isolation. Therefore, a group-based approach makes it possible to rapidly increase the number of women treated with PFMT, making conservative management more accessible and reducing the need for urinary incontinence surgery.
Edited by Dr. Francesco Murano
