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Types of Pelvic Floor Muscle Training

In 1948, Kegel was the first to report that pelvic floor muscle training was effective in treating female urinary incontinence. Despite his reports of cure rates higher than 84%, surgery quickly became the preferred treatment. It wasn't until the 1980s that interest in conservative treatments like pelvic floor muscle training resurfaced. This renewed interest likely arose from increased awareness among women about incontinence and health, the cost of surgery, and the complications and relapses reported after surgical procedures.

Although many systematic reviews and consensus statements have recommended pelvic floor muscle training as the first choice for treating urinary incontinence, many surgeons still prefer minimally invasive surgery over pelvic floor muscle training.

This skepticism towards muscle training might stem from:

Recently, mid-urethral sling surgery has come under scrutiny due to concerns about long-term complications. In the UK, the use of synthetic mid-urethral slings has been paused following a 2020 parliamentary review. The review concluded that while many women had successful outcomes, the lack of reliable information on complications meant that some women suffered significantly. 


The NICE (2019) guidelines concluded that pelvic floor muscle training is as effective as surgery for about half of the women with stress urinary incontinence. Given the risks associated with surgery and the lack of adverse events with muscle training, they recommend three months of supervised pelvic floor muscle training as the first-line treatment for stress urinary incontinence and mixed urinary incontinence.

Rationale for Pelvic Floor Muscle Training    

There are four main theories on how pelvic floor muscle training may prevent and treat stress urinary incontinence:

Theory 1:  Women learn to contract their pelvic floor muscles before and during an increase in intra-abdominal pressure to prevent the pelvic floor from descending.


Intentional contraction of the pelvic floor muscles before and during an increase in abdominal pressure lifts the pelvic floor and squeezes around the urethra, vagina, and rectum. Studies using ultrasonography and MRI have verified this lift. This voluntary counter-bracing contraction has been named "the Knack" and has been found to reduce urinary leakage during coughing 73% to 98.2%. 

Theory 2: Women perform regular strength training over time to build up the stiffness and structural support of the pelvic floor.


Intensive strength training of the pelvic floor muscles might build structural support, elevating the levator plate and enhancing the pelvic floor muscle's stiffness. This would help prevent pelvic floor descent during increased abdominal pressure. Ultrasound studies showed that women who completed a 12-week muscle training program reduced bladder neck mobility and increased urethral cross-sectional area. Another study reported increased thickness and volume of the striated urethral sphincter after muscle training, along with reduced incontinence episodes.

Theory 3:  Pelvic floor muscles are trained indirectly by contracting the internal abdominal muscles, especially the transversus abdominus (TrA) muscle.


It is possible to train the pelvic floor muslces indirectly by training the Transverse abdominus muscle. This is because the pelvic floor muscles are part of the abdominal capsule, which includes the lumbar vertebrae, respiratory diaphragm, TrA, and pelvic floor muscles. Several studies have shown co-contraction of the pelvic floor muscles with abdominal muscle contractions in healthy women. 

Theory 4:  Functional training involves women performing pelvic floor muscle contractions during daily tasks like lifting or sneezing.


Some physical therapy practices include teaching patients to co-contract the pelvic floor muscles during all daily activities. This approach aims to develop an automatic function to prevent incontinence. One study found this method effective compared to general diet and exercise advice. However, it remains unclear if this functional training alone is enough to prevent incontinence during more complex activities like running or dancing.

Research Evidence for Pelvic Floor Muscle Training


Key points summarized:

With Biofeedback    

Biofeedback involves using an external sensor to give feedback on body processes to help improve muscle function. Although some women find biofeedback helpful, studies show that pelvic floor muscle training without biofeedback is also effective. 

With Vaginal Weighted Cones    

Vaginal cones are weights inserted into the vagina, which require the pelvic floor muscles to contract to keep them from slipping out. Although these may be effective, many women find them uncomfortable and have low compliance.

Other Programs  (Yoga, Pilates, "Core training")   

Programs like yoga, Pilates, and other core training exercises have been studied for their effects on stress urinary incontinence. None have proven to be better than or add significant benefits to pelvic floor muscle training. 


For example, a study on yoga showed improvement in incontinence frequency, but it was not significantly better than control exercises.

Hypopressive Exercise 

A study was conducted where 90 women with stress urinary incontinence were randomly divided into two groups. 


Both groups did their exercise program for 12 weeks. The pelvic floor muscle training group had better results in reducing the number of leakage episodes over seven days, as well as  greater improvement in pelvic floor muscle strength as compared to the hypopressive exercise.

Group Training vs. Individual Training

Studies have compared group and individual pelvic floor muscle training. Both types of training include teaching women how to correctly contract their pelvic floor muscles. Results show that group muscle training is as effective as individual training for treating female urinary incontinence. In a well-designed study, women who did group training had similar results to those who did individual training, with a significant reduction in leakage episodes.

Motivation and Adherence

Motivation and sticking to the exercise program are important for success. Many factors, like proper teaching and a supportive environment, help women stay committed to muscle training programs. Some studies use strategies to improve adherence, like reminders or apps, but results vary. Overall, creating a positive and enjoyable training environment is crucial.

Pelvic Floor Muscles Training Alone

For people who haven't trained before, any exercise can improve function. Including pelvic floor muscle training in fitness programs for women is beneficial. Studies show that the actual pelvic floor muscle training, not other exercise concepts like yoga or Pilates, makes the difference.  However, many women need proper instruction to do pelvic floor muscle exercises correctly. Incorrect contractions can reduce the effectiveness of general programs.

Key points of study sources

What are Hypopressive Exercises?

Hypopressive exercises are a type of fitness routine that focuses on the core muscles without putting pressure on the pelvic floor. They involve specific breathing techniques and postures designed to reduce intra-abdominal pressure. 


These exercises are believed to help strengthen the core muscles, improve posture, and potentially reduce waist circumference. Many people find them beneficial for addressing issues like lower back pain and improving overall abdominal strength. Hypopressive exercises are often practiced under the guidance of a trained instructor to ensure they are done correctly for maximum benefit.

References: Bo, K., Berghmans, B., Mørkved, S., & Van Kampen, M. (Eds.). (2023). Evidence-Based Physical Therapy for the Pelvic Floor (3rd ed.). Elsevier.