Urinary Incontinence in Women: Modern Methods of Physiotherapy as a Support for Surgical Treatment or Independent Therapy.

Urinary incontinence (UI) is a common health problem affecting quality of life of nearly 420 million people, both women and men. Pelvic floor muscle (PFM) training and other physiotherapy techniques play an important role in non-surgical UI treatment, but their therapeutic effectiveness is limited to slight or moderate severity of UI. Higher UI severity requires surgical procedures with pre- and post-operative physiotherapy. Given that nearly 30%-40% of women without dysfunction and about 70% with pelvic floor dysfunction are unable to perform a correct PFM contraction, therefore, it is particularly important to implement physiotherapeutic techniques aimed at early activation of PFM. Presently, UI physiotherapy focuses primarily on PFM therapy and its proper cooperation with synergistic muscles, the respiratory diaphragm, and correction of improper everyday habits for better pelvic organ support and continence. The purpose of this work is a systematic review showing the possibilities of using physiotherapeutic techniques in the treatment of UI in women with attention to the techniques of PFM activation. Evidence of the effectiveness of well-known (e.g., PFM training, biofeedback, and electrostimulation) and less-known (e.g., magnetostimulation, vibration training) techniques will be presented here regarding the treatment of symptoms of urinary incontinence in women.


Introduction
Urinary incontinence (UI), characterized by involuntary loss of urine (ICS-International Continence Society), is a serious social and health issue whose incidence is increasing [1]. UI is diagnosed more often in women than in men [2], and in 2018, it was predicted to affect nearly 420 million people (300 million women and 120 million men) worldwide [1]. However, this number may be underestimated because of the intimate nature of UI.
The main types of UI are stress UI (SUI), urge UI (UUI), and mixed UI (MUI) [3]. Briefly, SUI is characterized by loss of urine as a consequence of an increase in intra-abdominal pressure, which results in an increase in intravesical pressure that exceeds the maximum urethral closure pressure. This situation occurs, for example, during coughing, sneezing, or jumping [4]. In UUI, loss of urine occurs with sudden, strong urgency that is inadequate to the degree of bladder filling [5]. MUI combines the symptoms of the above two types, and the involuntary loss of urine is associated with urgency and/or increase in intra-abdominal pressure [6].
The etiology of UI is multifactorial, and its causes are mainly associated with the dysfunction of the bladder, pelvic floor muscles (PFMs) [7], the ligament apparatus [8], connective tissue including, inter alia, endopelvic fascia and/or neural structures [9]. The risk of UI increases with age [10,11], but it can also occur after delivery as well as in young nulliparous women [12]. The main risk factors of UI development include the following: predisposing factors, such as genetic factors and gender, factors associated with damage of the continence mechanism (e.g., abdominal surgery, multiple births), and promotional factors, such as overweight/obesity, menopause, drugs, and urinary tract infections [13]. UI treatment includes surgical and conservative methods, among which physiotherapy is recommended as the first line of therapy because of its effectiveness, low cost, and low risk associated with it.

Incontinence-Impact on Quality of Life and Economic Status
Studies show that UI significantly reduces women's quality of life [14][15][16][17]. Shame, anxiety, and fear of unpleasant smell or uncontrolled loss of urine lead to withdrawal of the affected women from social life. Women suffering from UI are characterized by a higher degree of emotional disorders than those with normal micturition [18,19]. According to Felde et al. [20], women with UI are more likely to suffer from depressive disorders and anxiety. UI also has a negative effect on the women's sex life [21,22] and reduces self-esteem [23]. Women with UI avoid sexual intercourse due to the possibility of urine leakage. Nearly 50%-68% of women with incontinence have been shown to suffer from sexual dysfunction [22]. With the development of UI, the risk of falls and injuries due to frequent necessity to use the toilet increases [24]. Older women diagnosed with UI are 1.5 to 2.3 times more likely to fall, which results in a worsening of overall health and increased healthcare costs [25]. In addition, because of fear of lack of control over voiding, the level of physical activity is also reduced [14]. Attention should also be paid to reduction in the economic level of patients and high treatment costs [16]. UI has a negative effect on women's working lives (absenteeism, lower efficiency, and lower work pace) [17]; moreover, expenses for the purchase of underwear, absorbent pads, and diapers are increasing [26]. The average annual cost of treatment of women with UI in Germany was € 515, in Spain € 655, and in Great Britain/Ireland € 395, where absorbent pads accounted for nearly 51% of the treatment cost [27]. Koening et al. estimated that the total annual cost of treatment for one woman with UI is nearly 22% higher than the average cost of treatment for the general female population in 2017 in Switzerland [28].

Role of Pelvic Floor Muscle in Continence
The pelvic floor (PF) consists of passive (ligaments, fascia) and active (muscles) components that support the bladder, reproductive organs, and rectum [29]. The proper cooperation between the soft tissue components and the appropriate action determine the proper closing and opening of the key areas such as the urethra (micturition), vagina (delivery), or rectum (defecation). Therefore, in addition to maintaining organ statics, they also affect the proper course of labor, voids, or defecation as well as fecal and urine continence [30,31].
Studies have shown that pelvic floor muscles (PFMs) together with internal oblique, intercostal muscles, transverse abdominal muscle, and diaphragm are responsible for maintaining proper body posture and breathing [32,33]. Due to numerous myofascial connections between PFM and other muscles all movements are functionally linked, and throughout this system, PFM exists as the basis for local stabilization [33,34]. For this reason, myofascial disorders as well as posture disorders can lead to impaired PFM function and, consequently, their weakness and UI [35].
In physiotherapeutic examination PFM function is evaluated using the PERFECT scale assessing strength of voluntary contraction (P), endurance (E), slow-twitch muscle fiber performance (R), fast-twitch muscle fiber performance (F), PFM contraction pattern (E), co-contraction of the transverse abdominal muscle (C) and involuntary contraction in response to increased intra-abdominal pressure (T) [36,37]. PFM strength is assessed using a 6-stage Modified Oxford Scale [36,38]. The most common diagnoses are overactive or underactive PFM. An overactive PF is not able to relax after any contraction or in a situation where relaxation is required, e.g., voiding or defecation, while underactive PFM is unable to perform voluntary or involuntary contraction necessary for, e.g., pelvic organ stabilization against lowering during increasing of intra-abdominal pressure [3,39].
The improper PFM tonus leads to many disfunction [29,40]. Research indicates that increased tone of PFMs can prolong delivery course, while simultaneously favoring greater damage within them [41,42]. PF hypertonicity frequently occurs in women with chronic pelvic pain [40], but may also leads to incontinence caused by increased intra-abdominal pressure. It is known that the persistent state of excessive muscle tension leads to a weakening of their strength and endurance. Excessive tension of the pubic-rectal muscle, by reducing the anorectal angle, may also result in hindered defecation and increases the need for displacement using a stronger abdominal compressor [43]. Similarly, in the case of voiding, excessive PFM tension may functionally hinder its initiation, resulting in the necessity of using the abdominal pressure [44]. This condition also favors the occurrence of constipation and, consequently, may increase the risk of hemorrhoids [44]. Abuse of the abdominal press is also one of the factors increasing the risk of lowering within the pelvic organs [45]. Therefore, control and normalization of PFM tone can be an important factor for maintaining the functional balance of the complex [46].

Materials and Methods
The aim of this paper is a systematic review showing the possibilities of using physiotherapeutic techniques in the treatment of UI in women with attention to the techniques of PFM activation. The review of the literature was carried out in the Medline-PubMed database. Keywords varied depending on the therapy: PF training AND urinary incontinence; electrotherapy AND urinary incontinence; urinary incontinence AND magnetic stimulation OR Extracorporeal Magnetic Innervation; whole-body vibration OR vibrance OR vibration OR perineal stimulation OR intravaginal vibratory AND urinary incontinence.
Inclusion and exclusion criteria. The review included works that were published in the years 2009-2020 in English. The research should have been carried out on women with diagnosis of UI. Publications should investigate the impact of various physiotherapeutic methods on the treatment of UI. Exclusion criteria included studies not related to women with UI, publications in English made or published before 2009, non-RCTs studies and study protocols. Other exclusion criteria were pregnancy or puerperium period < 6 weeks, cancer, neurological and spine diseases, no access to the full-text version of articles.

Results
A total of 1602 references were found. Based on the analysis of titles and abstracts, 1538 publications were rejected. A total of 64 articles were left to read in full. Finally, 32 papers were qualified for the review (Figure 1): 11 publications on PFM training, 8 on electrical stimulation, 6 on magnetic stimulation, and 7 on whole-body vibration training were qualified for review.

Pelvic Floor Muscle Training
Pelvic floor muscle training (PFMT) is a well-described, effective, and most commonly used method of physiotherapeutic UI treatment which has been recognized and recommended as the first line of conservative SUI treatment [47]. For the first time, PFM exercises were described in 1948 by Arnold Kegel as a behavioral method in the treatment of UI [48]. Their effectiveness is proven regardless of age and BMI [49]. PFMT is based on two pelvic muscle functions: pelvic support and cooperation in the urethral sphincter closing mechanism [50]. A PFMT can be performed to increase strength, endurance, and muscle coordination [51]. The studies estimate that regular PFMT deceased loss of urine and improved quality of life [52]. However, research shows that nearly 30%-40% of women are unable to perform the correct voluntary PFM contraction despite the instruction [53] and in the population of women with pelvic floor dysfunction, this value increases to 70% [54]. In this situation, it is necessary to use facilitating techniques for the teaching of PFM voluntary contraction, because PFMT alone will not yield the assumed outcomes [46].
De Andrade et al. confirmed that giving only the instruction of PFM exercise increased knowledge about the PF but was not effective in contracting and strengthening the PFM [55]. However, there are also studies that confirm the effectiveness of PFMT performed at home with app-based audio guidance after prior instruction. Exercises with voice guidance are more effective than conventional exercises [56].
Unfortunately, most randomized studies on the effectiveness of PFMT include patients who can perform voluntary PFM contraction in their inclusion criteria [57,58]. According to Mateus-Vasconcelos et al. [59], effective facilitating techniques include vaginal palpation with or without posterior pelvic tilt and electrostimulation, however, with much lower efficiency. These techniques should be used when the strength of PFM contraction is 0-1 on the Modified Oxford Scale (MOS) [59]; patients with higher MOS value (2 and more) respond well to PFMT therapy [57,58]. It should also be noted here that PFMT can be conducted both in a form supervised by a physiotherapist as well as in an unattended form at the patient's home. Studies have shown that unattended training is significantly less effective at relieving UI symptoms than supervised training [60]. However, the effectiveness of home unsupervised training can be increased using additional techniques such as electrostimulation [61], biofeedback (BF) [62], or vaginal cones [63]. A detailed description of the studies included in the review is presented in Table 1. The intervention group showed a reduced bladder neck mobility during coughing and increased cross-sectional area of their urethra (from baseline to the end of the study). Similar results were not obtained in the control group. Intervention group showed statistically significant changes in urine leakage (3-day bladder diary) and in results of IIQ-7. Similar significance was not obtained for pad test and UDI-6. The control group did not achieve significant improvement in any parameters. The IG group showed a significant improvement in urinary leakage (pad test), function of PFM (the PERFECT scale) and PFM pressure (the perineometer) and in some aspects of KHQ. Similar results were not obtained in CG group. In the intergroup analysis in all the above aspects statistically significant differences were obtained in favor of the IG group than CG. Studies show that the effectiveness of PFMT increases significantly if the BF technique is used. It should be emphasized that BF is not a method of therapy but a form of its support, allowing for a better feeling and imaging of the structures and muscles that we want to activate and strengthen. Currently, in PFMT, it is possible to use many forms of BF; the most common is the surface electromyography (sEMG) method using a vaginal probe that allows the physiotherapist to read the electrical activity of the PFMs [69] and use this information to design exercise tasks, programs, or games for the patient depending on her level of advancement. Because of the use of BF, patients can correctly identify contracting muscles and perform their activity depending on the training task, which is usually illustrated by animation or playing a game on the screen. Other forms of BF currently used in urogynecological physiotherapy is pressure BF using a vaginal probe that reads pressure changes caused by PFM contraction-the principle of its operation is analogical to the perineometer [70]. PFM contraction can also be visualized using BF combined with ultrasound, which is so-called "sonofeedback" [71]. The effect of exercise with biofeedback on UI has been the subject of numerous studies [63,72], which showed that BF can be an effective support for the training process.
The other type of training PFM can be hypopressive exercises (HE) proposed by Caufriez. HE relies on the reflex activation of PFM through adequate breathing and body position changes. They also activate the transverse abdominal muscle, increase PFM endurance, but do not lead to their hypertrophy [73]. An important factor affecting the effectiveness of PFM training is the proper positioning of the pelvis and ankle. Studies show that a greater contraction of PFM and postural muscles occurs during ankle dorsiflexion [74]. These studies provide a valuable tip for conducting the most effective PFM exercises. A detailed description of the studies included in the review is presented in Table 2. Both groups present a significant reduction in the number of episodes of urine loss (a voiding diary), in the urine leakage (a pad test) (from baseline to 3 and 9 months). Both groups significantly improved a PFM function (PFMT group did not obtain a significant difference for the measurement from baseline to 9 months). Both groups showed significantly better quality of life (I-QOl). There were no significant differences between groups. There were no differences between groups in the number of monthly training, weekly frequency (days/week) and exercises sets per day after 3 months of supervised treatment and at 9-month follow-up. In all groups QOL (KHQ) significantly improved over the 12-week. In all three groups, the contractility of PFM (MOS, EMG) significantly increased. The number of pads used per day decreased and the pad weight test showed a significant improvement for every group. There are no differences between groups. The additional ES did not show any benefits.

Manual Therapy
Pelvic Floor Dysfunction (PFD) e.g., urinary incontinence is difficult to treat because of the many entangled factors: urologic, gynecologic, psychologic, and musculoskeletal factors [79]. The PF, as with any skeletal muscle, may have increased or decreased muscle tone [80]. Hypo-and hypertonia of PF causes various ailments that should be treated individually [81]. It should be also remembered that organs and muscles are connected by fascia. Endopelvic fascia is continuous with visceral and abdominal fascia, diaphragm, posterior intermuscular septum, and fascia of adductors. Any disorders in hip, core muscles may affect PFD [80].
There are studies confirming effectiveness of dry needling [80], trigger points (TrP) releasing [82,83] and massage [84] in reducing urinary incontinence symptoms and pelvic pain. TrP manual compression and dry needling result in softening of the taut band, oxygenate the problem muscles area, relieve pain, and improve disturbed movement patterns [83]. Massage is also recommended in PFD treatment. Studies indicated that massage of the abdominal muscles and directly of urinary bladder improves bladder function and blood distribution in this area. Then occurs cell regeneration, muscle elasticity and contractility increase, and muscle tone normalizes [84].

Electrical Stimulation
Electrical stimulation is one of the most commonly used therapeutic methods in the treatment of UI [85]. The method of electronic PFM stimulation was first described in 1963 by Caldwell. It is a noninvasive, passive treatment that induces muscle contraction [86]. Electrical stimulation can be an individual therapy or can be combined with PFMT or BF, which, according to research, significantly increases its effectiveness not only in urine but also in fecal incontinence [87]. However, because of pain or discomfort experienced by the patient during the procedure, it is not recommended as the first line of UI treatment [88]. The arrangement of the electrodes depends on the type of target tissue. For muscle tissue, the electrodes should be located on the muscle belly, while in the nerve tissue, they should be located along the course of the nerve or one electrode at the motor's nerve point and the other on the target muscle [89]. Current flow causes contraction of the PFMs with simultaneous inhibition of detrusor muscle activity [90]. Distinguished was transvaginal [91] as well as surface electrical stimulation [61].
Electrical stimulation does not stimulate the muscle directly, but through motor nerves. Therefore, frequencies above 70 Hz may cause neuromuscular damage [92]. The optimal stimulation frequency is 50 Hz for SUI [88] and 10-20 Hz for UUI [93]. The selection of appropriate parameters in electrotherapy is required to obtain an increase in muscle strength [94]. Electrical stimulation significantly reduces the symptoms of UI [61]. A significant reduction in UI symptoms was noted after both surface electrostimulation and transvaginal electrical stimulation [95,96]. Pereira et al. [96] noted a significant reduction of urinary loss events after 6 weeks of electrotherapy in women with SUI compared to that in patients without treatment. In addition, electrical stimulation is characterized by a low risk of side effects. In the study by Alves et al. [97], no side effects, such as pain, discomfort, or vaginal infection were noted in patients in both groups. Franzén et al. [98] examined the long-term effect of electrostimulation on the occurrence of UI. After 6 months from the end of therapy, nearly 73% of the examined patients reported an improvement in continence [98]. The long-term effect of electrostimulation has also been studied by Fürst et al. [99]. After 3 months, a significant increase in the time between voids was observed in the examined patients [from 2.24 ± 1.09 to 3.35 ± 0.86 h (p < 0.0001)]; similar differences were, however, not observed after 96 months [99]. A detailed description of the studies included in the review is presented in Table 3. Table 3. Characteristic of selected studies on the effects of electrical stimulation on the pelvic floor muscles (PFMs) activity and/or severity of urinary incontinence (UI) symptoms.

Reference
Main  In the SES group, there was a significant improvement in the loss of urine (pad test) and improved quality of life (KHQ) compared to the initial value and the control group. There were no differences between the SES and control groups in terms of PFM pressure.  All groups reported significant improved in PFM contraction capacity (Oxford Scale), but PTG and PG groups were significantly better than other groups. UI symptoms in terms of frequency, severity, and impact on quality of life (ICIQ-UI-SF) was also improved in all groups, but the PG results were significantly better than those of the other groups. The results suggest that vaginal palpation with or without posterior pelvic tilt was more effective in PFM facilitating than electric stimulation. In both the SES and T groups, there was a significant decrease in the number of voids and a significant improvement in the quality of life of patients. There were no differences between the effectiveness in the ESE and T groups. In both groups, all patients were instructed to perform Kegel and bladder training for 12 weeks. In the TTNS group, patients were also subjected to electrical stimulation of the tibial nerve for 30 min, once a week for 12 weeks (10 Hz, 200 ms, 10-50 mA). Assessment: physical examination, 3-day voiding dairy, KHQ, ICIQ-UI-SF.

Mateus
In both groups, there was a significant improvement in reducing the frequency of voiding episodes compared to pre-intervention values. However, the final values obtained in the electrostimulation group were significantly lower than those in the control group with Kegel and bladder training alone.

Magnetic Stimulation
The use of magnetic stimulation (MS) or extracorporeal magnetic innervation (ExMI) in non-surgical treatment of UI has raised extensive controversy, but recent studies have provided evidence of the effectiveness of this therapy. In 1998, PFM magnetic stimulation was approved by the US Food and Drug Administration (FDA) as a conservative treatment method of UI [102] and was indicated among non-surgical UI therapies in the latest guidelines of European Association of Urology [103]. Although the European Association of Urology (EAU) 2018 guidelines, based on evidence from 2007 and 2008 (two papers), do not recommend the use of MS in adult women with SUI (level of evidence: 2a), it however omits an important study conducted recently, which will be presented below. MS is a noninvasive, passive method of stimulating the roots of the sacral nerves or PFMs [104]. The MS method uses a special chair with a therapeutic head placed in the seat; as the magnetic field can penetrate through clothes, stimulation can be carried out in clothing, which significantly increases the comfort of therapy [105]. The head creates a magnetic field that penetrates the pelvic organs, acting directly on the motor fibers of the nerves. MS stimulates the PFMs to repeatedly contract and relax, which are clearly experienced during the procedure [106]. Moreover, MS-induced PFM contraction simultaneously inhibits the reflex mechanism of emptying the bladder [107], and consequently leads to an increase in bladder capacity in both female bladder outlet obstruction [108] as well as in UUI or SUI [109]. MS also increases the strength of PFMs [110], with no adverse effects [103,111]; level of evidence: 1b. In addition, MS therapy significant decreases the intensity of urinary incontinence symptoms in women with SUI [112,113] and UUI [109] measured in 1 h pad test or voiding diary. The beneficial effect of MS was also noted in the reduction of UI incidents in patients after radical hysterectomy due to cervical cancer [114]. Moreover, it also causes short-and long-term improvement in the quality of life of women with SUI [115] while improving the severity of depression symptoms observed in these women [106,116]. It is also important to highlight the findings of Koh et al. [108] who showed comparable efficacy of Extracorporeal Magnetic Innervation (ExMI) as alpha-blocker monotherapy in the treatment of female bladder outlet obstruction. According to Weber-Rajek et al. [106], ExMI leads to a significant decrease in myostatin levels in patients with SUI; myostatin is an inhibitor of myogenesis [117,118], which may play an important role in the remodeling and regeneration of PFM. For an optimal therapeutic effect, the recommended dose of magnetic field is between 5 and 50 Hz [112,113,119] and it is dependent on the intended purpose of the therapy. Lower frequencies (5-10 HZ), as in ES, are used to inhibit detrusor activity, while higher  are effective in stimulating PFM contraction and closing the urethra [112,120]. MS is an alternative to electrical stimulation (ES); however, compared to ES, it is a painless method and more comfortable for the patient [105]. MS is assessed by patients with SUI as a well-tolerated and satisfactory method [121]. A detailed description is presented in Table 4. Table 4. Characteristic of selected studies on the effects of magnetic stimulation on the pelvic floor muscle (PFM) activity and/or severity of urinary incontinence (UI) symptoms.

Reference Main Objective Patients Characteristic Study Description Outcome
Weber-Rajek et al.
(2018) [106] Evaluation of the effectiveness of extracorporeal magnetic innervation (ExMI) in the treatment of women with SUI. In ExMI, but not in control group, the UI severity, depression, and myosin level were significantly reduced relative to the initial value. There were no differences in the final test values between the ExMI and control groups.
(2020) [116] Evaluation of the effectiveness of PFMT and ExMI in the treatment of women with SUI. For both: women were educated about PFM and received low-intensity PFMT program to home practice. MS: 3 times a week for 6 weeks 10 min at 10 Hz, 3 min rest, 10 min at 50 Hz Sham: same as above but with blocked transmission of magnetic waves through an aluminum plate Assessment: 3-day bladder diary; 24-h pad test, CVM, and perinometry for muscle score, I-QOL, KHQ, video-urodynomics Both MS and Sham patients, performing only unattended PFMT, achieved improvement in the intensity of UI symptoms (pad test) and quality of life. There were no statistically significant differences between the MS and Sham groups, suggesting a similar efficiency of the MS stimulation parameters used in these studies for unattended PFMT.

Whole-Body Vibration
Whole-body vibration training (WBV) is a valuable tool supporting both sports training and physiotherapy [124]. The use of a vibrating platform in exercises supports the therapeutic process in patients with nonspecific lumbar pain [125], multiple sclerosis [126], Parkinson's disease [127], or hemiplegia [128]. The method consists of carrying out a set of exercises performed on a vibrating platform that oscillates at a given frequency and amplitude [129]. Mechanical vibration conducted during exercise leads to a change in muscle length. Information about muscle lengthening is transmitted by sensory nerves to the spinal cord and consequently provokes muscle contraction through the activity of α-motor neurons [130]. The induction of myoelectric activity during WBV is well documented [131,132]. Moreover, studies have confirmed that high-intensity synchronous WBV (frequency 40 Hz, amplitude 4 mm) with a long duration (60 and 90 s) elicits a response from PFM, leading to an increase in the mean amplitude of the sEMG signal from PFMs in young continent women [133]. Moreover, studies have indicated that the activation of PFM is caused by both sinusoidal (S-WBV) and stochastic resonance WBV (SR-WBV), and the level of PFM activation depends on the intensity of the vibration [134]. It has also been shown that SR-WBV-induced PFM contraction is higher than voluntary muscle contraction, which is particularly pronounced in the case of PFM weakened by delivery [134]. However, there were no differences in efficiency between continuous and intermittent RS-WBV [130]. WBV also exerts positive effects on dysfunctional PF in women with UI. Farzinmehr et al. [135] showed that 4-week WBV training has a comparable therapeutic effect to PFMT, causing a significant reduction in UI symptoms and improving the quality of life of patients, which was also maintained in the 3-month follow-up. A detailed description of the studies included in the review is provided in Table 5.
A slightly different form of vibration therapy is the use of techniques directly affecting PFM using a transcutaneous vibratory perineal stimulation [136] or intravaginal vibratory stimulation [137][138][139]. These techniques use different stimulation parameters from those used in the indirect techniques described above for review see [129,140]. Nevertheless, studies show that the intravaginal vibratory stimulation significantly increase the effectiveness of PFMT [137], while being more effective in improving PFM strength than transvaginal electrostimulation when applied in women with SUI. Hence, it can be considered to be a support for the therapeutic process in patients with PFM or UI dysfunction. An overview of the mentioned articles is presented in Table 6 below. Table 5. Characteristic of selected studies on the effects of whole-body vibration (WBV) training on the pelvic floor muscle (PFM) activity and/or severity of urinary incontinence (UI) symptoms.

Reference Main Objective Patient Characteristic Study Description Outcome
Lauper et al. 2009 [134] Verification of the effectiveness of sinusoidal and stochastic resonance WBV on PFM activation in healthy and postpartum women.   There were no post-therapeutic differences between IVVS and IVES in terms of PFM functions such as endurance, fast contraction, and repetition. However, after vibration training, the PFM strength significantly increased relative to that in the IVES group.

Conclusions
As indicated above, physiotherapy is certainly an important element of conservative treatment of UI; however, its effectiveness is limited to less advanced conditions. In advanced UI stages, however, physiotherapy is an important element in preparing the patient for surgical treatment, significantly increasing the success of surgery. Moreover, physiotherapy significantly improves the quality of life of women with UI [136]; however, to achieve optimal therapeutic effects, it is sometimes beneficial to use a combination of several physiotherapeutic techniques. PFMT and ES are the most commonly used therapies for treating UI. In the first line EAU recommends PFMT to prevent and treat UI (level of evidence: 1). However, for many women, isolated voluntary PFM contraction is a major concern. Studies show that often patients with UI are unable to perform isolated voluntary and involuntary PFM contraction; hence, in this case, basing the therapy only on exercises will be ineffective. In these situations, it becomes extremely important to use techniques focused on PFM sensitization. Sometimes it will be necessary to use palpation or apparatus techniques, but without PFM activation, the implementation of training programs will be ineffective. Electrical stimulation [59,[95][96][97][98][99][100][101] and biofeedback [57,75,78] can be used in addition to PFMT or to help women to initiate a contraction and improve therapeutic effects (level of evidence: 2). In such cases, it is a preferable activation of PFM to fully use the potential of the female pelvic floor. Recent studies [112,116,122] suggest that MS induces improvement in the severity of incontinence (level of evidence: 2); however, EAU does not recommend using magnetic stimulation to treat UI (strong evidence) and they do not mention vibration training [103]. EAU guidelines do not include the latest RCT work indicating the effectiveness of the above techniques in reduction of UI symptoms, these works are presented in this review. Our results are familiar with other reviews regarding physiotherapeutic methods in UI (Table 7). Given the above, it can be concluded that physiotherapy is an important and effective element of therapy in patients with UI, with high levels of evidence. Nevertheless, the still small number of RCTs makes further research necessary to increase their reliability and improve the effectiveness of therapy.