Stress urinary incontinence (SUI), defined as “the complaint of involuntary leakage of urine on effort, exertion, sneezing, or coughing” by the International Continence Society [
Although surgical treatment is the more effective treatment for SUI, conservative treatment is now recommended as first-line treatment in elderly women or those with mild symptoms [
Therefore, the effects of Kegel exercises on urinary incontinence will be verified through a systematic review of the results of the randomized controlled trials (RCTs) in the literature, forming a basis for the suggestion that Kegel exercises are an economic intervention which can be understood and performed by both patients and nurses alike.
This study was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions [
Participants: women with SUI. Interventions: Kegel exercises being defined as a program of repeated voluntary pelvic floor muscle contractions taught and supervised by a health care professional. Comparators: no treatment or routine care cases, such as advice and instruction being offered on the use of the continence guard. Outcomes: patient self-reported cure or improvement, urinary incontinence symptoms from recommended questionnaires, urinary incontinence episodes over 7 days, the pad test (1-hour pad test, standardized bladder volume on pad test), and pelvic floor muscle pressure. Type of studies: only randomized controlled trials being included.
KoreaMed, National Discovery for Science Leaders (NDSL), Ovid Medline, Embase, and Scopus were used as the main search databases, and the websites of the Korean Urological Association, Korean Continence Society, Korean Society of Obstetrics and Gynecology, Korean Society of Nursing Science, Korean Society of Women Health Nursing, and Korean Society of Adult Nursing were searched to include all Korean academic journals dealing with associated fields. The search date was April 2012.
Among the references searched, randomized control trials on female urinary incontinence patients undergoing Kegel exercises as the main intervention that report one or more major or secondary results were selected. Excluded were studies combining Kegel exercises with biofeedback or electrical stimulation therapy and those not published in either English or Korean.
After removing overlapping references from the primary search, papers were selected to match the inclusion and exclusion criteria. The first round of selection was based first on the title and abstract of each reference and the second on a more in-depth analysis. The reference selection process was first independently performed, and then a discussion was to be conducted in case of disagreement, and the third party intervention principle was applied if necessary. However, no disagreement occurred.
The methodological quality of selected studies was analyzed by two review authors independently using risk of bias (RoB) tool developed by Cochrane Collaboration. Disagreements were resolved by discussion and consensus.
Relevant data, such as the subject inclusion or exclusion criteria, baseline demographic and clinical characteristics of the study participants, treatment protocols, the follow-up period, and the outcome variables of each study, were consolidated using a standardized form. The magnitudes of the effects of Kegel exercises were calculated using the pooled relative risk (RR) for dichotomous outcome data and the mean difference (MD) and the standardized mean difference (SMD) for continuous outcome data with 95% confidence intervals (CIs) using the Mantel-Haenszel test. The selected eleven studies were analyzed using Review Manager (RevMan) version 5.1. For all statistical comparisons, differences with a
A total of 562 candidate papers were obtained through electronic reference searches, and 436 remained after excluding 126 overlapping ones. After exclusion of papers according to the inclusion and exclusion criteria by titles and abstracts, 41 papers remained and from those 11 were finally selected, leaving a total of 510 subjects. The detailed reference selection process is presented in the flow chart (Figure
Flow diagram of studies selection.
Kegel exercises have been regularly studied from 1989 to 2012 by 11 selected references. They were most actively studied in Europe in the 1990s and in Brazil since 2007, not to mention two Korean studies, indicating a worldwide interest in Kegel exercises as a nursing intervention. The general age of the subjects was 40s to 50s in seven papers and 60s and over in four papers. There were 510 subjects in total, all of whom were middle-aged women of 40 and over exhibiting SUI and the studies themselves were relatively small scale, involving between 20 and 82 subjects each. The Kegel exercises were mainly taught by professional physical therapists and varied by the number of contractions, five to six, and the number of times a day, 24 to 100. Other variations involved elevation of the intensity of the contraction. The followups were mostly done within three months, and only one study [
Characteristics of the selected studies.
Year | Study | Location |
Group |
Interventions |
Dropout |
Followup | Outcomes | |
---|---|---|---|---|---|---|---|---|
Exp. | Con. | |||||||
2012 | Pereira et al. [ |
Brazil | 15 |
15 |
Kegel exercises: individual training; totally 12 sessions, twice-weekly session of 40 minutes each. Each session 100 contractions held for 3 seconds with 6 seconds of rest; carried out in the supine, sitting, and standing positions. |
No | 6 weeks | (i) UI symptoms by KHO |
|
||||||||
2011 | Pereira et al. [ |
Brazil | 15 |
15 |
Kegel exercises: group training; as above |
4 |
6 weeks | (i) UI symptoms by KHO |
|
||||||||
2009 | Lee et al. [ |
Korea | 10 |
10 |
Kegel exercises: physiotherapist trained; twice a week for 50 minutes, 2 sets of 10–15 contractions a day. |
3 |
8 weeks | (i) UI symptoms by BFLUTS |
|
||||||||
2008 | Castro et al. [ |
Brazil | 26 |
24 |
Kegel exercises: 10 repetitions of 5-second contractions with 5 seconds of recovery time; 20 repetitions of 1-second contractions and recovery; 5 repetitions of 10-second contractions and recovery; all the sessions were held in groups for 45 minutes. |
11 |
6 months | (i) UI episode for 7 days |
|
||||||||
2007 |
Konstantinidou et al. [ |
Greece | 10 |
12 |
Kegel exercises: 1-hour demonstration program; 3 sets of fast contractions and 3-4 sets of slow contractions daily lying, sitting, and standing positions. |
8 |
12 weeks | (i) UI episode for 7 days |
|
||||||||
2007 | Zanetti et al. [ |
Brazil | 23 |
21 |
Kegel exercises: physiotherapist trained; twice a week, for 45 minutes; 10 repetitions of 5-second held contractions with 5 seconds of recovery; 20 repetitions of 1-second contractions and recovery; 5 repetitions of 10 seconds of contractions and recovery followed by 5 repetitions of strong contractions together with a cough, with one-minute intervals between each set. |
No | 3 months | (i) 1-hour pad test |
|
||||||||
2000 | Sung et al. [ |
Korea | 30 | 30 | Kegel exercises: exercise video tape; intensively programmed PFM exercise, which was developed by Bø et al. [ |
No | 6 weeks | (i) UI episode for 7 days |
|
||||||||
1999 | Bø et al. [ |
Norway | 25 |
30 |
Kegel exercises: physical therapist group training; 3 times a day at home, 8–12 high intensity contractions, with holding periods of 6–8 seconds in lying, standing, kneeling, and sitting positions and also additional training in groups once a week for 45 minutes |
6 |
6 months | (i) Subjective assessment of improvement in SUI |
|
||||||||
1993 | Burns et al. [ |
USA | 43 |
39 |
Kegel exercises: 12-minute video tape; 4 sets of 20 (10 quick and 10 sustained) and increased by 10 per set over 4 weeks until daily maximum 200 exercises |
1 |
3–6 months | (i) Subjective assessment of improvement in SUI |
|
||||||||
1991 |
Lagro-Janssen et al. [ |
Netherland | 33 |
33 |
Kegel exercises: general practitioner researcher taught; squeeze pelvic muscle for 6 seconds, performed 5–10 sessions of 10 pelvic muscle contractions each day. |
No | 3 months | (i) Subjective assessment of improvement in SUI |
|
||||||||
1989 |
Henalla et al. [ |
United Kingdom | 26 | 25 | Kegel exercises: physiotherapist trained; 5 seconds and repeat manoeuvre 5 times every hour. |
No | 3 months | (i) Subjective assessment of improvement in SUI |
Exp., experimental group; Con., control group; UI, urinary incontinence; KHO, King’s health questionnaire; BFLUTS, Bristol female lower urinary tract symptoms questionnaire; SUI, stress urinary incontinence.
Eight of the eleven selected studies satisfied all assessment items (Figure
Risk of bias graph.
Although various difference scales were used to measure patient responses to treatment in the selected studies, whatever the scale was, the data was included in the formal comparisons as long as the trials stated the number of women who perceived that they have been cured or improved, as defined by the trials. Subjective assessments of improvements in SUI were measured in four studies [
The results of effects of Kegel exercises.
Subjective assessment of improvement in stress urinary incontinence
Urinary incontinence symptoms by recommended questionnaire
Urinary incontinence episode for 7 days
One-hour pad test on pad test
Standardized bladder volume on pad test
Pelvic floor muscle pressure
Urinary incontinence symptoms were measured by a questionnaire in three studies [
Three studies measured urinary incontinence episodes for 7 days [
Pad tests were conducted in five studies by two different methods. One used a 1-hour pad test, presenting results as mean urine loss volumes (g), and another used a standardized bladder volume and the third used mean pad weight.
Three studies measured mean urine loss volumes [
Pelvic floor muscle pressure was measured in five studies [
This study was a meta-analysis of the effects of Kegel exercises on SUI as a nursing intervention through the systematic consideration of the characteristics and methods of Kegel exercises of a total of 510 subjects over 11 RCT studies. The references analyzed in this study were determined considering the following. First, many studies of urinary incontinence have analyzed the effects of applying biofeedback or electrical stimulation together with Kegel exercises or the use of vaginal cones, but this paper analyzed only studies of Kegel exercises without the use of other equipment or devices to provide insight into independent nursing intervention. Furthermore, in order to draw reliable conclusions only randomized controlled trials with high levels of evidence were analyzed.
Kegel exercises were originally devised by Dr. Arnold Kegel in 1948 to prevent urinary incontinence in postpartum women [
The effects of Kegel exercises were analyzed with respect to 5 outcome variables, and the results of the meta-analyses revealed statistically significant differences in the sizes of their effects. The self-reports on urinary incontinence symptoms after doing Kegel exercises were logged in 24-hour urinary activity diaries. In the four references that used these diaries, the patients reported improvements in urinary incontinence symptoms after Kegel exercises, and the effects of Kegel exercises were verified because RR was 26.09 (95% CI 8.50 to 80.11) and there was no difference between the references. The Korean Continence Society endorses urination diaries as a reliable source of data on lower urinary tract symptoms. Papers [
The pad test has been used as a source of objective outcome data for recent urinary incontinence diagnoses because there is adequate evidence [
Pelvic floor muscle contractility was measured using a perineometer. The examinee lies down with knees bent, an intravaginal tube of approximately 3.5 cm is inserted using a vaginal balloon catheter, and air is put in using a pump. Finally, the pelvic floor muscles are contracted 3 times and the average volume is used. In the five papers measuring pelvic floor muscle contractility, the variable consistently improved after Kegel exercises (SMD 1.06, 95% CI 0.76 to 1.37). In other words, all these studies showed consistent results.
This study only compared the implementation of Kegel exercises in middle-aged women with SUI with nonintervention and routine intervention such as education. Eleven RCTs were analyzed, but there may be limitations to interpretation of the study results because most of them were of a small scale and the treatment period and the follow-up periods were short, with less than three months. But the effects of Kegel exercise on SUI were verified consistently, and all results showed statistically significant difference. In conclusion, this study provides evidence that Kegel exercises are effective and better than no treatment in the management of women with stress urinary incontinence because the outcome variables used for this meta-analysis showed excellent results for decreasing the frequency of urinary incontinence and alleviating its symptoms.
Significantly the study showed the improvement of SUI symptoms in middle-aged women who did Kegel exercises and included objectively verified data, specifically data from both the pad test and vaginal perineal muscle contractility data. Although the Kegel exercise method has not yet been standardized, these results consistently show the reinforcement of pelvic muscles and verify that Kegel exercises are indeed a safe method of intervention. However, the references used in this study mostly deal with short-term interventions of about three months, and further improvement in the prevention and management of urinary incontinence in perimenopausal middle-aged women using Kegel exercises requires longer-term studies.
The authors declare that there is no conflict of interests regarding the publication of this paper.