Urinary incontinence (UI) is highly prevalent in women and could affect up to 53% of females aged over 20 years in the United States.¹ UI is a debilitating condition that contributes to decreased quality of life, sexual dysfunction, psychological distress, and significant long term morbidity. In addition, UI is a burden for caregivers, with 6%–10% of nursing home admissions in the United States due to UI.² Although the risk of UI increases with age, studies suggest that age is not a significant contributor after adjusting for confounders.³ On the other hand, UI is a costly disorder and the majority of the annual costs are associated with routine care. Women with severe UI pay approximately $900 out of pocket for their routine care annually.⁴

Symptoms of UI can be caused by weakness of the pelvic floor muscles (PFM) in supporting the closure of urethral sphincters, fascial or ligamentous damage following trauma, or dysfunction of neuromuscular components that manage abdominal and bladder neck pressure change.⁵ Considering the beneficial features of PFM training (PFMT) such as noninvasiveness, combination with other treatments, and moderate to low cost, it is known as the first line initial treatment for UI, particularly stress UI.⁶ PFMT involves the regular practice of repeated voluntary PFM contractions, with sufficient exercise progression, in order to produce a training effect on the muscles. PFMT programs can address slow and fast twitch muscle fibers in the pelvic floor. This is achieved by increasing the intensity of contraction with and against gravity to gain strength (fast twitch), and performing high repetitions of low loads for endurance (slow twitch).⁷ The aim of a PFMT program is to increase the strength of the muscles, build up muscle volume, and thus improve structural support. Additionally, it increases contraction endurance, improves muscle resting tone, enhances muscle recruitment through improved nerve function and properties of muscle fibers, and ameliorates cognitive awareness of body posture and a relaxed versus an unrelaxed state of the pelvic floor.

There are several exercise methods and devices for PFMT in women with UI depending on the condition and clinical status of each patient such as Kegel exercises, functional PFM exercises with Swiss ball, motor control exercises, internal pressure or electromyography biofeedback, and intra-vaginal electrical stimulation. It is essential to determine the type of UI (stress, urgency, mixed) prior to initiating a PFMT program since patients have better outcomes with proper technique. For instance, biofeedback is particularly helpful in women who are unable to properly isolate the pelvic floor or use accessory muscles during pelvic floor contractions. Intravaginal electrical stimulation can improve continence rates in women with urgency, stress, or mixed incontinence. Additionally, behavioral modifications (such as weight loss, dietary changes etc) should be recommended as an adjunct treatment.

The interval between onset of UI symptoms and seeking help from a medical professional can be prominent. Therefore, ensuring awareness and ease of access to local health care professionals specializing in the management of UI and other bladder symptoms is vital. It is reported that when patients are asked to carry out a voluntary contraction of the pelvic floor, more than 30% are unable to perform the contraction correctly.⁸ Therefore, assessment of PFM activation prior to supervised PFMT should be done to find those who have difficulty identifying the proper muscles. Supervised PFMT could be superior to home PFMT with regards to subjective improvement and pad testing. However, in some situations such as remote distances from a clinician, an inability to travel, or limited time or resources home PFMT may be a beneficial option as a self-management strategy. A study by Washington et al showed that insurance coverage of PFMT services and insurance type were significantly associated with attendance of a woman to at least a single PFMT session.⁹

With availability of various PFMT devices for purchase on online platforms, it is more convenient than ever for motivated patients to perform PFM exercises at home. Online videos and tutorials for PFMT also add to the accessibility of such treatments. At University of California San Francisco, we recently explored the PMFT products available on Amazon marketed to improve UI symptoms.¹⁰ We performed an in-depth assessment of customer reviews and ratings to identify primary uses, strengths and weaknesses of PFMT devices. We found 4 major types of PFMT devices including vibrating Kegel balls, nonvibrating Kegel balls, pelvic floor/thigh exercisers, and electric probes (fig. 1). Regardless of the intended use, customers were predominantly satisfied with all types of devices. Furthermore, electric probes were the most beneficial devices for relief of UI symptoms (fig. 2). Of note, these devices were the most costly ones as well, which should be considered while consulting a patient about at-home treatment options. It is suggested that patients who have difficulty or no improvement with at-home exercises should be ultimately referred for supervised PFMT.

Figure 1. Characteristics of online pelvic floor muscle training devices. Reprinted with permission.¹⁰

Figure 2. Subjective benefit of online pelvic floor muscle training devices for urinary incontinence, as proportion of total reviews in each device category. Reprinted with permission.¹⁰

Adherence to the PFMT regimen is a real challenge for at-home treatments. Given the widespread use of mobile phones, health applications are cheap and accessible tools to increase access to care, facilitate self-management, and improve adherence to treatments. A recent study evaluated 20 mobile apps designed for UI in women indicating that a marked variability in the quality of UI apps existed.¹¹ Only 1 app was previously evaluated in a clinical trial.¹² By studying 123 Swedish women with stress UI, the authors found that the app was effective and yielded clinically relevant improvement compared to the postponed treatment.

All in all, PFMT is an effective initial nonsurgical modality for treatment of most types of UI in women, which could significantly improve the quality of life of the patient. Several factors should be taken into consideration when choosing the treatment regimen for each patient. Whatever the PFMT regimen, the patient should be encouraged to adhere to it in order to sustain improvement in her UI symptoms.