Stress urinary incontinence (SUI) is the common condition of involuntary urine leakage that occurs when intra-abdominal pressure suddenly increases (e.g., coughing, sneezing, lifting, running). The primary causes of SUI are pregnancy and childbirth, which decrease pelvic muscle tone, but other risk factors are hysterectomy, obesity, menopause, or nerve damage attributable to surgery.1 SUI negatively affects a woman's quality of life and can lead to embarrassment, social withdrawal, and diminished activity.2
The clinical standard of care for SUI is pelvic floor muscle training (PFMT), which can positively affect women with mild-to-moderate SUI symptoms.3 Although PFMT is effective, long-term adherence to training is uncommon. Subsequently, the sustained benefits of PFMT can be negligible, and SUI can become a long-term condition.4
Pilates exercises improve core and pelvic floor strength5 and may be executed with breath work. During exhalation, the transversus abdominis and pelvic floor contract, whereas during inhalation, the diaphragm contracts and the pelvic floor lengthens. These synergistic muscles protect and support the lumbopelvic and urogenital structures and their function.6
Pilates classes have become widely accessible and are relatively inexpensive. Commonly instructed as a group class, Pilates promotes social connectedness and accountability, which can facilitate exercise adherence.7
Our research objectives were to (1) ascertain the feasibility of a Pilates program (twice weekly, 12 weeks) that emphasized pelvic floor strengthening and (2) determine whether it improved self-reported measures of SUI in women of age 45–70 years. We posited that a community intervention for women with SUI could serve as an affordable accessible complement to clinical care and support long-term sustainable management of SUI.
The primary objective of our single-arm noncontrolled pilot study was to assess the effect of this program by using patient-reported International Consultation on Incontinence Short Form (ICIQ-SF) scores. Secondary outcomes were scores from the Linear Analogue Self-Assessment (LASA) and Medical, Epidemiological, Social Aging (MESA) questionnaires, and the duration of continued exercises after the intervention.
The study was approved by the Mayo Clinic Institutional Review Board. Participants were eligible for the study if they had a score of 6+ on the ICIQ-SF, could transition independently to and from the floor, were able to attend 75% of classes, and could provide informed consent. Exclusion criteria were pregnancy, impaired bladder function due to a neurologic condition, or inability to comprehend English. The Pilates mat intervention was developed through a collaboration among Pilates instructors and women's health physical therapists.
Twenty-six participants provided informed consent and met individually with a women's health physical therapist to review pelvic floor anatomy and function. Eighteen participants completed the 12-week Pilates mat intervention and received a handout describing the pelvic floor exercises. They were encouraged to perform the exercises twice weekly.
Participants completed outcome measure surveys at baseline, postintervention, and 6 months after baseline (Table 1). At the 6-month follow-up, they evaluated the overall experience and noted whether they had continued with the Pilates exercises. We observed a significant decrease in ICIQ-SF and MESA SUI scores at both time points after the intervention. Adherence to the Pilates exercises during and after the intervention was high.
Table 1.
Outcomes for Participants Who Completed the Study
| Variablea | Baseline (n = 18) | 12 Weeks |
6 Months |
||||||
|---|---|---|---|---|---|---|---|---|---|
| Score | Difference in score from baseline | T statistic | p | Score | Difference in score from baseline | T statistic | p | ||
| International Consultation on Incontinence Short Form | |||||||||
| Total score (0–21) | t(17) = −5.90 | ≤0.001 | t(14) = −6.79 | ≤0.001 | |||||
| Mean (SD) | 10.83 (3.11) | 6.28 (3.46) | −4.56 (3.28) | 6.93 (3.80) | −4.53 (2.59) | ||||
| Range | 6–15 | 3–16 | … | 0–14 | … | ||||
| 95% CI | … | −6.18 to −2.93 | … | −5.97 to −3.10 | |||||
| No. of respondents | 18 | 15 | |||||||
| How often do you leak urine? (0–5) | t(17) = −4.68 | ≤0.001 | t(14) = −3.59 | 0.01 | |||||
| Mean (SD) | 3.72 (0.96) | 2.72 (1.18) | −1.00 (0.91) | 3.00 (1.25) | −0.80 (0.86) | ||||
| Range | 2–5 | 2–5 | … | 1–5 | … | ||||
| 95% CI | … | −1.45 to −0.55 | … | −1.28 to −0.32 | |||||
| No. of respondents | 18 | 15 | |||||||
| How much urine do you usually leak? (0–6) | t(17) = −2.56 | 0.02 | t(14) = −3.06 | 0.01 | |||||
| Mean (SD) | 2.33 (0.49) | 2.06 (0.24) | −0.28 (0.46) | 2.00 (0.38) | −0.40 (0.51) | ||||
| Range | 2–3 | 2–3 | … | 1–3 | … | ||||
| 95% CI | … | −0.51 to −0.05 | … | −0.68 to −0.12 | |||||
| No. of respondents | 18 | 15 | |||||||
| Overall, how much does leaking urine interfere with your everyday life? (0–10) | t(17) = −5.80 | ≤0.001 | t(13) = −5.64 | ≤0.001 | |||||
| Mean (SD) | 5.44 (2.09) | 2.44 (2.31) | −3.00 (2.20) | 3.14 (2.35) | −2.79 (1.85) | ||||
| Range | 2–8 | 0–8 | … | 0–7 | … | ||||
| 95% CI | … | −4.09 to −1.91 | … | −3.85 to −1.71 | |||||
| No. of respondents | 18 | 14 | |||||||
| Medical, Epidemiological, Social Aging | |||||||||
| Urge incontinence score (0–18) | t(17) = −2.36 | 0.03 | t(14) = 0.48 | 0.64 | |||||
| Mean (SD) | 4.61 (2.66) | 3.06 (3.26) | −1.56 (2.79) | 5.13 (3.78) | 0.40 (3.22) | ||||
| Range | 1–10 | 0–13 | … | 0–13 | … | ||||
| 95% CI | … | −2.94 to −0.17 | … | −1.39 to 2.19 | |||||
| No. of respondents | 18 | 15 | |||||||
| Stress incontinence score (0–27) | t(17) = −5.69 | <0.001 | t(14) = −2.25 | 0.04 | |||||
| Mean (SD) | 13.00 (2.66) | 7.28 (3.64) | −5.72 (4.27) | 10.73 (4.46) | −2.40 (4.14) | ||||
| Range | 10–19 | 2–16 | … | 3–19 | … | ||||
| 95% CI | … | −7.84 to −3.60 | … | −4.69 to −0.11 | |||||
| No. of respondents | 18 | 15 | |||||||
| Linear Analogue Self-Assessment | |||||||||
| In the past week, how would you describe your overall quality of life? (0–10) | t(17) = 1.22 | 0.24 | t(15) = −0.49 | 0.63 | |||||
| Mean (SD) | 8.17 (1.29) | 8.61 (1.29) | 0.44 (1.54) | 8.00 (1.46) | −0.19 (1.52) | ||||
| Range | 5–10 | 4–10 | … | 4–10 | … | ||||
| 95% CI | … | −0.32 to 1.21 | … | −0.99 to 0.62 | |||||
| No. of respondents | 18 | 16 | |||||||
| In the past week, how would you describe your overall physical well-being? (0–10) | t(16) = 1.41 | 0.18 | t(14) = 0.00 | >0.99 | |||||
| Mean (SD) | 7.06 (1.75) | 7.50 (1.34) | 0.47 (1.37) | 7.25 (1.88) | 0 (2.14) | ||||
| Range | 3–9 | 4–9 | … | 3–9 | … | ||||
| 95% CI | … | −0.24 to 1.18 | … | −1.18 to 1.18 | |||||
| No. of respondents | 17 | 15 | |||||||
| In the past week, how would you describe your overall emotional well-being? (0–10) | t(17) = −0.40 | 0.70 | t(15) = −3.58 | 0.003 | |||||
| Mean (SD) | 8.11 (1.41) | 8.00 (1.46) | −0.11 (1.18) | 7.06 (1.88) | −1.13 (1.26) | ||||
| Range | 5–10 | 4–10 | … | 4–10 | … | ||||
| 95% CI | … | −0.70 to 0.48 | … | −1.80 to −0.45 | |||||
| No. of respondents | 18 | 16 | |||||||
| In the past week, how would you describe your overall social well-being? (0–10) | t(17) = 1.77 | 0.10 | t(15) = −0.97 | 0.35 | |||||
| Mean (SD) | 7.33 (1.75) | 7.83 (1.50) | 0.50 (1.20) | 7.06 (1.57) | −0.38 (1.54) | ||||
| Range | 4–10 | 4–10 | … | 4–9 | … | ||||
| 95% CI | … | −0.10 to 1.10 | … | −1.20 to 0.45 | |||||
| No. of respondents | 18 | 16 | |||||||
For each questionnaire, the range of possible scores is shown parenthetically. Higher scores indicate improved quality-of-life measures.
CI, confidence interval; SD, standard deviation.
Our data indicate that a community-based Pilates pelvic floor program could be an effective and sustainable method that decreases SUI. Adherence to the home exercise program was reported and reduced SUI was sustained 6 months after baseline. The outcomes for accessibility, attendance, SUI, and adherence affirm the feasibility and effectiveness of this community-based protocol. Replication of this protocol should be tested in a larger randomized controlled study. Considerations for a future study could include pelvic floor anatomy education within the class intervention, different frequencies of classes (once vs. twice weekly), and exclusion of the physical therapist session to reduce the time and cost burden. Tracking other factors that affect SUI (diet, medications, body mass index, etc.) could prove insightful.
Acknowledgments
We thank Dawn B. Underwood, PT, DPT, OCS, from the Department of Physical Medicine and Rehabilitation, Darrell Schroeder from the Department of Biomedical Statistics and Informatics, and Emanuel C. Trabuco, MD, from the Department of Obstetrics and Gynecology, for providing suggestions and research direction. We thank the staff of the Mayo Clinic Healthy Living Program for facilitating recruitment, wayfinding, and covering for the authors when they were teaching these classes. We also give many thanks to all the participants who gave their time and attention to this study.
Author Disclosure Statement
No competing financial interests exist.
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Role of the Funding Source
The sponsor had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
Funding Information
The authors acknowledge the Mayo Clinic Healthy Living Program and the Mayo Clinic Center for Clinical and Translational Science (UL1TR002377) for funding this trial.
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