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#346 Stress Urinary Incontinence: Pelvic floor exercises or pessary? (Free)

How effective are pelvic floor exercises or pessaries for stress urinary incontinence?

Pelvic floor exercises increase the proportion of women with symptom improvement (74% versus 11%) and patient satisfaction (71% versus 13%) compared to control over 1-6 months. Pessaries may reduce incontinence episodes compared to no treatment based on one small, 2-week study. Exercise may be slightly better than pessary at three months (example: more patients without bothersome symptoms) with less vaginal discharge at 12 months.

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  • Results statistically different unless indicated. Focusing on systematic reviews from the last 10 years.
  • Pelvic floor exercises:
    • Largest systematic review, 18 randomized controlled trials (RCTs), 26-133 women, compared to no treatment/control.1 At 6-24 weeks:
      • Self-reported cure/improvement: 74% versus 11% (control), number needed to treat (NNT)=2.
      • Leakage (example baseline: 1-2 episodes/day):2 Reduced by one episode/day over control.
      • Patient satisfaction: 71% versus 13% (control), NNT=2.
    • Other systematic reviews and newer RCTs report similar.3-9
  • Pessaries:
    • Meta-analyses10-11 did not combine RCTs.
    • RCT, 55 women, pessary versus no treatment.12 After two weeks:
      • Total incontinence episodes reduced: 32% versus 7.6% (control).
      • Satisfaction (scale 0-100, higher=better): 60 versus 5 (control).
      • Limitations: Industry funded; baseline incontinence episodes imbalanced: 36 versus 58 (control) in two weeks before trial.
    • RCT, 446 women, pelvic floor exercises versus pessary:13
      • At 3 months:
        • Proportion without bothersome symptoms: 49% versus 33% (pessary), NNT=7.
        • Improved/much improved: Not different.
        • Satisfaction: 54% versus 50% (pessary), NNT=27.
        • Withdrawals due to adverse effects: No difference.
      • At 12 months:
        • No difference in above outcomes.
        • Vaginal discharge: 6% versus 16% (pessary), NNT=10.
      • Exercise plus pessary versus exercise alone: No difference.
      • Limitations: Pessary dropouts higher at 3 months, no different at 12 months.
    • Limitations: RCTs unblinded and outcomes often subjective.12,13

  • Pelvic floor exercises considered first-line.14
    • If supervised programs inaccessible, can provide written information15 or video16 to patients.
    • At least 8 contractions three times daily recommended.14
  • Pessaries:
    • Can last 5-10 years and be fitted in primary care.17,18
      • ~10-40% women have unsuccessful first fittings.13,19
    • Cost:17 $50-150.

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  • Anthony Train MBChB MSc CCFP
  • Samantha Moe PharmD

1. Dumoulin C, Cacciari LP, Hay-Smith EJC. Cochrane Database Syst Rev. 2018: CD005654.

2. Asklund I, Nyström E, Sjöström M, et al. Neurourol Urodyn. 2017; 36(5):1369-76.

3. Stenzelius K, Molander U, Odeberg J. Age Ageing. 2015; 5:736-44.

4. Moroni RM, Magnani PS, Haddad JM, et al. Rev Bras Ginecol Obstet. 2016; 38(2):97-111.

5. Nie XF, Ouyang YQ, Wang L, et al. Int J Gynaecol Obstet. 2017; 138(3):250-5.

6. Garcia-Sanchez E, Avila-Gandia V, Lopez-Roman J, et al. Int J Environ Res Public Health. 2019; 16(22).

7. Okayama H, Ninomiya S, Naito K, et al. Int Urogynecol J. 2019: 7:1093-99.

8. Al Belushi ZI, Al Kiyumi MH, AlMazuri AA, et al. Neurourol Urodyn. 2020; 39:5:1557-1566.

9. Kamali S, Ozengin N, Topcuoglu MA. Women Health. 2023; 63(6): 473-83.

10. Lipp A, Shaw C, Glavind K. Cochrane Database Syst Rev. 2014; CD001756.

11. Ayeleke Ro, Hay-Smith EJC, Omar MI. Cochrane Database Syst Rev. 2015: CD010551.

12. Cornu JN, Mouly S, Amarenco G, et al. Int Urogynecol J. 2012; 23(12): 1727-34.

13. Richter HE, Burgio KL, Brubaker L, et al. Obstet Gynecol. 2010; 115(3): 609-17.

14. National Institute for Health and Care Excellence. Urinary incontinence and pelvic organ prolapse in women: management. Available at: Accessed May 5, 2023.

15. The Canadian Continence Foundation. Incontinence Treatments. Available at:

16. MDConversation. Pelvic Floor Muscle Training. Available at: Accessed on July 2, 2023.

17. Ontario Health. Ont Health Technol Assess Ser. 2021; 21(3): 1-155.

18. Bordman R, Telner D, Jackson B, et al. Can Fam Physician. 2007; 53(3): 485-7.

19. Harvey MA, Lemieux MC, Robert M, et al. JOGC. 2021; 411: 255-66.

Authors do not have any conflicts of interest to declare.