• Pelvic Floor Muscle Function and Strength

• Modified Oxford grading system:

• 0 - no contraction
• 1 - flicker
• 2 - weak squeeze, no lift
• 3 - fair squeeze, definite lift
• 4 - good squeeze with lift
• 5 - strong squeeze with a lift
• PERFECT mnemonic assessment[29]:
• P - power, may use the Modified Oxford grading scale
E - endurance, the time (in seconds) that a maximum
contraction can be sustained
R - repetition, the number of repetitions of a maximum
voluntary contraction
F - fast contractions, the number of fast (one second)
maximum contractions
ECT - every contraction timed, reminds the therapist to
continually overload the muscle activity for strengthening
• Urinary (Voiding) Diary
• One study found a scale derived from a 7 day
diary was 0.88 sensitive and 0.83 specific for
the diagnosis of detrusor overactivity in
women.[28] The National Institute for Diabetes
and Digestive and Kidney Diseases provides
clinicians with a easy to use Bladder Diary pdf
that may be used in clinical practice[30].
• Physical Therapy Management
• Pelvic Floor Muscle Training (PFMT)
• The pelvic floor muscles are known as the levator ani, made up
of the pubococcygeus - puborectalis complex. Those muscles
form a sling around the anorectal junction. They are made up of
both Type I (slow-twitch) and Type II (fast-twitch) fibers. The
majority are Type I (about 70%) which provide sustained support
and are fatigue resistant. The remaining Type II fibers provide
the quick compressive forces necessary to oppose leakage
during increased abdominal pressure. A contraction of the pelvic
floor muscles also causes a reflex inhibition of the detrusor
muscle.[31]
• Patient specific training is necessary to ensure a
proper contraction of the pelvic floor muscle
group. It is also essential to train both the fast
and slow-twitch muscle fibers. Also, training must
include instruction in volitional contractions
before and during an activity that may cause
incontinence, such as coughing, sneezing, and
lifting.[29] Patients are typically recommended to
perform the exercises four to five times daily.[32][29]
• PFMT for the prevention of postpartum incontinence
• Pelvic floor muscle training (PFMT) performed during
pregnancy help to decrease the short-term risk of urinary
incontinence in women without prior incontinence. A
meta-analysis that included randomised or quasi-
randomised trials on pregnant or postnatal women,
found that women assigned to antenatal PFMT had a
significant decrease in the rate of urinary incontinence at
up to three months postpartum.[33]
• .[34]
• A systematic review including randomised or
quasi-randomised trials on primiparous or
multiparous pregnant or postpartum women
found that PFMT during pregnancy and after
delivery can prevent and treat urinary
incontinence. The authors recommended a
supervised training protocol following strength-
training principles, emphasizing close to maximum
contractions and lasting at least 8 weeks
• PFMT for stress urinary incontinence
• Similarly to the findings stated above, PFMT has been
found to be effective for treating stress urinary
incontinence as well.[35][36] A systematic review looking at
the effects of PFMT by comparing the effects of this
training with no treatment, or with any inactive treatment
(for example, advice on management with pads). The
authors found women with stress urinary incontinence in
the PFMT group were, on average, eight times more likely
to report being cured. In addition the participants
reported an improved QoL.[36]
• A study examining the training parameter for
strengthening the pelvic floor found the most
effective protocol to consists of digital
palpation combined with biofeedback
monitoring and vaginal cones, including 12
week training parameters, and ten repetitions
per series in different positions.[35]
• PFMT for urgency incontinence
• PFMT has been shown to improve or cure symptoms of urge
urinary incontinence.[36] In addition to PFMT, behavioural
therapies and bladder training (described below) may be
beneficial in this population.[37][38]
• Behavioral Therapy
• The focus of behavioral therapy is on lifestyle changes such as
fluid or diet management, weight control, and bowel regulation.
Education about bladder irritants, like caffeine, is an important
consideration. Also, discussing bowel habits to determine if
constipation is an issue as it is important to educate the patient
about avoiding straining.[37] 
• Education and explanation about normal lower urinary
tract function is also included. Patients should
understand the role of the bladder and the pelvic floor
muscles.[39] A randomized clinical trial examined the
effects of a group-administered behavioural therapy for
urinary incontinence in older women and found it to be
a modestly effective treatment for reducing symptoms
of urinary incontinence. The group behavioural therapy
included a one-time, two hour bladder health class,
including written material and an audio CD.[40]
• Bladder Training
• The information gathered from the bladder
diary is used to guide decision making for
bladder re-training, including a voiding
schedule if necessary to increase the capacity
of the bladder for people with frequency
issues. Bladder training attempts to break the
cycle by teaching patients to void on a
schedule, rather than in response to urgency.
• Urge suppression techniques are taught, such
as distraction and relaxation. It is also
important to teach the patient to contract the
pelvic floor to cause detrusor inhibition. A
voluntary contraction of the pelvic floor
muscles helps increase pressure in the
urethra, inhibit detrusor contractions, and
control urinary leakage.[37] [39]
• Differential Diagnosis
• Multi-channel urodynamics testing is the gold
standard for making a condition-specific
diagnosis. This testing is typically done in
secondary care, not in primary care or physical
therapy.[28]