Stress urinary incontinence (SUI) affects up to 1 in 3 women globally and is a major contributor to decreased quality of life, social withdrawal, and even depression in otherwise healthy individuals (Bo et al., 2017). As physiotherapists, we are often the first non-surgical, non-pharmacologic point of contact for these patients. With increasing evidence supporting pelvic floor muscle training (PFMT) as a first-line intervention, this article summarizes key findings from high-quality randomized controlled trials (RCTs) that position physiotherapy as an essential part of multidisciplinary SUI care.
Defining SUI and Its Clinical Impact
SUI is characterized by involuntary urine leakage during effort or physical exertion, such as coughing, sneezing, laughing, or exercising (Haylen et al., 2010). Though often considered a “normal” part of aging or childbirth, untreated SUI leads to avoidable complications, including:
- Reduced physical activity
- Increased fall risk in elderly women
- Sexual dysfunction
- Higher risk of urinary tract infections
For physicians managing this condition, timely referral to physiotherapy can significantly improve patient outcomes and reduce long-term costs.
Pelvic Floor Muscle Training: The Gold Standard in Conservative Management
A large body of RCTs supports PFMT as the gold standard non-invasive treatment for SUI. In a landmark RCT by Dumoulin et al. (2018), women randomized to supervised PFMT showed a 56% cure rate and a 74% improvement rate, significantly outperforming the control group. This study emphasized the importance of supervision by trained pelvic physiotherapists for optimal outcomes.
Another meta-analysis of 31 RCTs involving 1,817 women by Woodley et al. (2020) confirmed that PFMT increases the likelihood of cure or improvement (RR 8.38, 95% CI 3.68–19.07) compared to no treatment or placebo. The findings led to PFMT being recommended as a Grade A recommendation by the International Continence Society and European Association of Urology.
Biofeedback and Adjunct Therapies: Enhancing Results
Biofeedback devices are commonly used to facilitate neuromuscular control, and their efficacy is supported by several RCTs. Glazener et al. (2011) conducted a multicenter trial with 600+ participants and found that adding biofeedback improved adherence and muscle isolation skills, though long-term differences in outcomes were modest. For patients struggling with proprioception or technique, biofeedback remains a useful adjunct, especially in the early stages of therapy.
Other adjuncts include vaginal weights, electrical stimulation, and behavioral therapies. While none of these outperformed PFMT alone in most RCTs, they offer additional options for patients who fail to progress with exercises alone (Berghmans et al., 2013).
PFMT vs. Surgical Options: When to Refer
While mid-urethral slings remain the gold standard for surgical management, many patients prefer to exhaust conservative options first, especially in cases of mild to moderate SUI. According to a Cochrane review (2017), physiotherapy can delay or avoid surgery in up to 65% of cases when followed consistently over 3–6 months.
Moreover, post-operative physiotherapy helps in strengthening the pelvic support structures and preventing recurrence or complications. Therefore, physiotherapy is relevant before and after surgical management.
Physician-Physiotherapist Collaboration: What We Need From You
For optimal outcomes, physicians are encouraged to:
- Refer patients early when symptoms appear, rather than after years of discomfort.
- Share relevant obstetric, surgical, or urological history to aid our evaluation.
- Encourage adherence to home exercise programs, as this is a major predictor of success.
- Collaborate on complex cases (e.g., mixed incontinence, pelvic organ prolapse, or prior pelvic surgery).
Conclusion and Key Takeaway
Stress urinary incontinence is not just a “nuisance” — it is a treatable medical condition with profound quality-of-life implications. Physiotherapists play a critical role in conservative management, and early referral can result in high cure rates without the need for surgery or medication. Physicians who collaborate with pelvic floor physiotherapists provide patients with a holistic, evidence-based approach that aligns with global best practice guidelines.
Key References:
Bo, K., Hilde, G., & Stær-Jensen, J. (2017). Physiotherapy for female stress urinary incontinence: A review of randomized controlled trials. International Urogynecology Journal, 28(6), 887–899. https://doi.org/10.1007/s00192-017-3362-9
Dumoulin, C., Cacciari, L. P., & Hay-Smith, E. J. C. (2018). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews, 10, CD005654. https://doi.org/10.1002/14651858.CD005654.pub4
Glazener, C. M. A., et al. (2011). Pelvic floor muscle training and biofeedback for the treatment of stress urinary incontinence: A multicentre randomized controlled trial. BMJ, 342, d373. https://doi.org/10.1136/bmj.d373
Haylen, B. T., et al. (2010). An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourology and Urodynamics, 29(1), 4–20. https://doi.org/10.1002/nau.20798
Woodley, S. J., et al. (2020). Pelvic floor muscle training for urinary incontinence in women: Cochrane systematic review and meta-analysis. BJOG, 127(10), 1281–1293. https://doi.org/10.1111/1471-0528.16214
Berghmans, B., et al. (2013). Electrical stimulation with non-implanted electrodes for overactive bladder in adults. Cochrane Database of Systematic Reviews, 6, CD010098. https://doi.org/10.1002/14651858.CD010098.pub2
