Hypothesis / aims of study
Pelvic floor muscle training (PFMT) is recommended as first-line treatment for stress urinary incontinence (SUI). However, randomized controlled trials (RCTs) report only moderate effectiveness, particularly in women with moderate to severe SUI and demonstrate high cross-over rates to surgical treatment. This discrepancy raises questions about the real-world effectiveness of PFMT and the identification of patients most likely to benefit from conservative treatment. We conducted a survey among pelvic physical therapists (PPTs), to explore perceived effectiveness of PFMT, knowledge of treatment options and their role within the SUI care landscape.
Study design, materials and methods
An online questionnaire was distributed by email and social media by the Dutch Association for Pelvic Physical Therapy. The survey included five closed and two open-ended questions addressing clinical experience, knowledge of conservative, device-based and surgical options, perceived treatment success, referral behaviour, and perceived barriers. Success was defined as patient satisfaction with the situation after treatment. Quantitative data were analysed descriptively and free-text responses were analysed thematically.
Results
A total of 105 PPTs completed the questionnaire, with 29% reporting ≥20 years of experience. Most PPTs estimated that between 75-100% of their patients were treated successfully for SUI. Discussion of continence devices varied widely (Figure 1): incontinence pads (82%), incontinence tampons (80%) and regular tampons (75%) were commonly addressed, whereas pessaries (66%) and adjunctive options (20%) were less frequently discussed. Nearly all respondents were familiar with tension-free vaginal tape (99%) and transobturator tape (88%), while awareness of other surgical interventions was more limited (Figure 2).
Thematic analysis identified key barriers, including restricted referral pathways, system-level issues, inconsistent interdisciplinary communication and patient-related factors such as normalization of symptoms and delayed help-seeking.
Interpretation of results
PPTs play a key role in the diagnostic assessment of pelvic floor dysfunction in patients with SUI. This study identified a clear discrepancy between outcomes reported in RCTs and clinical practice. While PFMT shows moderate effectiveness in RCTs, PPTs reported higher perceived success rates. This difference is largely explained by variation in outcome definitions: PPTs focus on patient satisfaction and subjective improvement, whereas RCTs rely on standardized symptom- or cure-based measurements.
PPTs emphasized that not all patients benefit equally from PFMT and identified the absence of clear patient selection criteria as a key barrier. Rather than focusing solely on treatment choice, the importance of well-defined referral thresholds was highlighted. High crossover rates in RCTs, often interpreted as treatment failure, may instead reflect suboptimal patient selection, rather than intrinsic limitations of PFMT. Additionally, treatment effectiveness is strongly influenced by adherence, with insufficient motivation or difficulty maintaining exercises limiting outcomes.
The PPT’s key role is the diagnostic assessment of pelvic floor function to determine PFMT effectiveness, subsequently deliver conservative care and monitor outcomes.
In RCTs, treatment follows the allocated arm irrespective of individual suitability, and diagnostic assessment is not part of inclusion criteria, leading to less favorable outcomes. Additionally, long-term follow-up is not embedded in PPTs care pathways, limiting insight into long-term effectiveness.