Do features of randomized controlled trials of pelvic floor muscle training for postprostatectomy urinary incontinence differentiate successful from unsuccessful patient outcomes? A systematic review with a series of meta‐analyses

Abstract

Aims: Efficacy of pelvic floor muscle training (PFMT) for postprostatectomy incontinence (PPI) differs between randomized clinical trials (RCT). This might be explained by variation in content/delivery of PFMT (eg, biofeedback, muscles targeted, and time of commencement of training). This review investigated whether outcome of meta-analysis differs based on presence or not of specific RCT features. Methods: PubMed, CINAHL, EMBASE, Physiotherapy Evidence Database (PEDro), and Cochrane were searched for RCTs that investigated efficacy of PFMT on PPI. PFMT details and outcomes were extracted. Methodological quality and comprehensiveness of PFMT reporting was assessed using the PEDro scale and Consensus on Reporting Template, respectively. Effect size and 95% confidence intervals were calculated for incontinence rate at 3 months. To identify features that influenced efficacy, separate meta-analyses were performed for studies with and without specific features. Results: Twenty-two trials were included, and 15 were used for meta-analysis of 3-month outcomes. Overall, meta-analysis showed reduced incontinence with PFMT (risk ratio [RR] = 0.85; I 2 = 55%; P = .005). Meta-analyses showed better outcomes for PFMT than control groups when the study included preoperative PFMT (RR = 0.76; I 2 = 30%; P = .006), biofeedback (RR = 0.73; I 2 = 58%; P = .006), instruction to contract around the urethra (RR = 0.9; I 2 = 43%; P = .009), a control group without PFMT instruction (RR = 0.85; I 2 = 69%; P = .05), inclusion of all men irrespective of continence status (RR = 0.84; I 2 = 30%; P = .003) and continence defined as no leakage (RR = 0.85; I 2 = 48%; P = .05). Conclusions: Preoperative PFMT, biofeedback, urethral instructions, no PFMT instruction for controls, inclusion of all men, and continence defined as no leakage are features associated with successful patient outcomes. Future studies should consider these features in design of interventions and pooling data for meta-analysis. K E Y W O R D Smeta-analysis, pelvic floor muscle training, prostatectomy, systematic review, urinary incontinence | 543 | CONCLUSIONSThis systematic review is the first to deconstruct the details of PFMT program design and implementation in an attempt to explain variation in efficacy of PFMT in men with PPI in RCTs, systematic reviews, and metaanalyses. The multiple meta-analyses provide preliminary evidence for important candidate features.This study was developed in accordance with the PRISMA statement and registered with PROSPERO (CRD42017059589).

Cognitive Ability as a Non-modifiable Risk Factor for Post-prostatectomy Urinary Incontinence: A Double-Blinded, Prospective, Single-Center Trial

“…It remains unclear whether the conclusion that pelvic floor training improves post-operative continence can be drawn at all, despite many studies existing up to date. A systematic review from 2020 showed in the long-term analysis that there was no difference in terms of PPI between patients who started pelvic floor exercises immediately postoperatively and the control group that did not perform any exercises ( 30 ). Similar results are reported by the 2015 Cochrane Review, in which there was no significant difference in the 12-month continence rate in 2.736 men between those who received PFME and/ or PMFT and those who did not (57% UI in the intervention group and 62% in the control group after 12 months (OR 0.85, 95% CI 0.60–1.22) ( 31 ).…”

The repeatability of measurements of male pelvic floor anatomy and function made from transperineal ultrasound images of healthy men and those before and after prostatectomy

“…Perioperative PFM training could help prevent or reduce incontinence by improving the contribution of striated muscles to control continence 1 . Although some data question the efficacy of PFM training to improve continence after prostatectomy, 12 a recent systematic review showed that PFM training is more likely to be effective if it includes biofeedback (e.g., traditionally with electromyography, but also possible with ultrasound imaging), is focused on the urethral muscles (e.g., striated urethral sphincter) and begins before surgery 13 . Before the widespread use of TPUS in practice and research it is necessary to evaluate its clinimetric properties.…”

How to Prevent and Manage Post-Prostatectomy Incontinence: A Review

“…No benefit was however observed at the 6-month assessment. A recent 22-trial-meta-analysis showed significantly better outcomes for those trials where a preoperative PFME was performed [ 34 ]. A finer comprehension of its usefulness will however only be available when studies including standardized protocols of PFME will be carried out.…”

“…, biofeedback, muscles targeted, and time of commencement of the training) and UC definition ( e.g. , 1 hour pad test, 24 hour pad test, International Consultation on Incontinence Questionnaire (ICIQ), bladder diary, and number of pads/d) ( Table 2 ) [ 34 ]. Over the past decade, several RCTs have been conducted to evaluate the effectiveness of PFME.…”

“…Whilst some RCTs supported the benefits of PFME, a recent meta-analysis including 45 RCTs [ 87 ] did not support PFME as first line rehabilitative approach for UC recovery after RP. It is here suggested that the approach of deconstructing the details of PFME protocols, as described in a recent review by Hall et al [ 34 ], can aid in getting a better understanding of the usefulness of this strategy. In their analysis, preoperative PFME, use of biofeedback, and UC defined as no leakage were features associated with successful patient outcomes.…”