Menopause may be associated with developing urinary incontinence as estrogen decline may lead to pelvic floor muscle dysfunction, and pelvic floor muscle training (PFMT) has been recommended as the first‐line conservative treatment for women with urinary incontinence. In addition to the prevalent incontinence associated with postmenopausal status, many women tend to have a more sedentary lifestyle after menopausal transition. Previous studies have shown that a sedentary lifestyle is related to urinary incontinence in older women and indicated the importance of physical activity on preventing incontinence. Regular physical exercise including aerobic exercise and resistance training has been proved to improve bone mineral density, stress management and autonomic functions in postmenopausal women. However, the effect of physical exercise adding to PFMT on pelvic floor muscle function in postmenopausal women with urinary incontinence remains unknown. Therefore, the aim of this study was to investigate the effect of a multimodal exercise program incorporating aerobic exercise, resistance exercise, and PFMT on pelvic floor muscle function in postmenopausal women with urinary incontinence.

This was a parallel group, pilot randomized controlled trial (RCT) conducted from March 2020 to April 2021. The study was approved by the Institutional Review Board of a metropolitan public hospital. Postmenopausal women with urinary incontinence (score of Questionnaire for Urinary Incontinence Diagnosis >0) and a sedentary lifestyle (< 150 minutes of moderate-intensity physical activity throughout the week) were recruited. Exclusion criteria included women aged over 80 years old; had neurological conditions, malignancy for pelvic organ, overflow incontinence or voiding dysfunction; had received hormone therapy, radical surgery for pelvis, sling or prolapse surgery. Eligible participants were randomly allocated to either the intervention group (IG) to receive a multimodal exercise program incorporating aerobic exercise, resistance exercise and PFMT, or the control group (CG) to receive only PFMT. The intervention was provided twice weekly for eight weeks. The assessments were conducted at baseline and after 8-week intervention. The primary outcome was pelvic floor muscle function measured by manometry and through digital palpation scored using the Modified Oxford Scale. The secondary outcomes were symptom severity measured using the International Consultation on Incontinence Questionnaire on Urinary Incontinence – Short Form (ICIQ-UI SF), and health-related quality of life measured using the International Consultation on Incontinence Questionnaire Lower Urinary Tract Symptoms Quality of Life Module (ICIQ-LUTSqol). Data analysis was performed using SPSS version 22.0. To compare the baseline characteristics between two groups, independent-t test and Chi-squared test were used for continuous data and categorical data, respectively. Paired-t tests were used for within-group comparisons, and repeated-measure analysis of variance tests were used for between-group comparisons. The significant level was set at p-value < 0.05.

A total of 22 participants were recruited, and 18 of 22 completed the study (IG n=9, CG n=9). The baseline characteristics of participants including age, body mass index, and parity were not significantly different between IG and CG (Table.1). After 8-week intervention, the pelvic floor muscle strength (p=0.021) and endurance (holding length: p=0.043; number of maximal voluntary contraction [MVC]: p=0.020) measured via digital palpation were significantly increased in IG; however, no significant changes were found in the parameters measured by manometry. The pelvic floor muscle endurance measured through digital palpation (number of MVC: p=0.021) was significantly improved in CG post-intervention. The symptom severity (p=0.010) was significantly improved in IG after intervention, while no significant difference was found in CG. The health-related quality of life did not change in both groups after intervention. Between-group comparisons showed no significant differences in all variables (Table.2).

The results of this pilot RCT suggested that an 8-week multimodal exercise program may improve symptom severity in postmenopausal women with urinary incontinence. This finding is consistent with previous studies, which showed that physical exercise with PFMT effectively reduced symptom severity and leakage episodes in elderly women with urinary incontinence [1, 2]. Although the symptom severity was reduced in IG, the health-related quality of life was not improved after intervention. It may be possible that most of the participants were not symptom-free after intervention, therefore the symptoms may still have a negative impact on different aspects of health-related quality of life, including psychological well-being, social interactions and activities, and sexual and interpersonal relationships [3]. In addition to the symptoms of urinary incontinence, the health-related quality of life of postmenopausal women may also be affected by other factors, such as climacteric symptoms, comorbidity, and personality traits. Future studies could investigate the factors associated with the health-related quality of life in postmenopausal women with urinary incontinence.    
The pelvic floor muscle function of IG was improved measured by digital palpation after intervention, however no significant changes were found in parameters measured by manometry. To date, there is no gold standard for pelvic floor muscle assessment, so digital palpation and manometry were both used in the study. Although a previous study has found a moderate correlation between modified Oxford Scale (digital palpation) and manometry in quantification of pelvic floor muscle function, each method has its limitations. Digital palpation is a relatively subjective measurement method and may be influenced by the level of clinical experience, while the squeeze pressure measured using manometry may be affected by the rise of abdominal pressure and the size differences of vaginal probes. Moreover, the experience of genitourinary syndrome of menopause (i.e. vaginal dryness and urogenital atrophy) may be associated with the development of discomfort with manometry probe insertion as the probe was larger than the examiner’s finger, and this may explain the discrepancies in findings between two pelvic floor muscle assessment methods.      
There are several limitations in this pilot RCT. Although the randomization was conducted, blinding of participant, therapist and assessor was not possible in this study. The convenience sampling may limit the generalizability of our findings. The lack of significant between-group differences may be due to the insufficient sample size and statistical power. As the intensity of physical exercise components (i.e. resistance and aerobic exercise) was based on the rating of perceived exertion reported by the participants, the intensity may be insufficient to produce the desired effects.

An 8-week multimodal exercise program may have a positive effect on pelvic floor muscle function and symptom severity in postmenopausal women with urinary incontinence. Future studies with large sample size are needed to confirm the findings of this study.

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