United Kingdom

Why popular treatment for incontinence may be a waste of money

Working out whether you are doing pelvic floor exercises correctly can be a challenge. And if the technique is wrong, the squeezes — designed to improve urinary incontinence — will have little effect.

Many women are advised by physiotherapists, or decide themselves, to use biofeedback therapy, which measures how well you are performing these exercises, to improve their effectiveness.

Machines bought online, at a chemist, or available in some clinics through the NHS, allow women to ‘see’ whether they are exercising correctly — they involve placing a sensor, linked to a device or a phone app, into the vagina.

Working out whether you are doing pelvic floor exercises correctly can be a challenge. And if the technique is wrong, the squeezes — designed to improve urinary incontinence — will have little effect

The sensor records the electrical activity of the pelvic floor muscles when squeezed and rates the effectiveness, either with a score or an image, of the pelvic squeeze so the woman knows if she’s doing the exercise properly.

Some devices also set challenges to encourage women to do the exercises regularly and more effectively.

Normally improvements are seen in three months.

A 2011 Cochrane review of 24 trials, involving 1,583 women, found those using biofeedback were ‘significantly more likely to report that their urinary incontinence was cured or improved’ compared with those who did the exercises on their own.

However, women using biofeedback were also more likely to have contact with physiotherapists, so it was unclear which of these factors was behind the success.

Portable, hand-held biofeedback devices are advertised widely and the market is booming — the global incontinence devices market is expected to rise from £1.3 billion in 2017 to £3.8 billion by 2026, according to suppliers Incontinence UK.

While the portable devices are not available on the NHS, some NHS physiotherapists use the larger, more expensive machines in their clinics.

But new research by Glasgow Caledonian University has found that these devices — which can cost from £100 to £500 — make no difference to the effectiveness of pelvic floor exercises.

A 2011 Cochrane review of 24 trials, involving 1,583 women, found those using biofeedback were ‘significantly more likely to report that their urinary incontinence was cured or improved’ compared with those who did the exercises on their own

After 24 months, the 600 women on the trial, who were allocated either a hand-held device or the exercises on their own, had exactly the same results, according to the study in the British Medical Journal last October.

Each was told to do pelvic floor exercises — typically squeezing and holding muscles for ten seconds, then ten times in a row for four seconds — three times a day. Both groups saw similar improvements, 60 per cent of women reported leaking less and 8 per cent said they were cured, based on patient surveys.

Professor Suzanne Hagen, a health services researcher who led the study, says the results mean the NHS should not be spending money on the machines as they provide no added benefit.

‘In the NHS, pelvic floor therapists and continence nurses shouldn’t routinely be giving biofeedback to all women they treat for urinary incontinence.

‘It is not something the NHS needs to invest money in because there is now clear evidence that overall it makes no difference to the effectiveness of pelvic floor muscle exercises,’ she says.

‘A good, supervised programme — with a specialist physiotherapist or nurse — is enough to significantly improve women’s incontinence,’ adds Professor Hagen.

A staggering seven million women in the UK suffer from urinary incontinence, which falls into two main categories.

The most common form, stress incontinence, caused by a weakening of the pelvic floor muscles, is when urine leaks when coughing or during exercise.

Urge incontinence — also known as an overactive bladder — is when leaks are associated with a sudden, strong urge to urinate. You can also have a combination of both.

Biofeedback devices are generally used for stress or mixed incontinence.

While it is often thought of as a condition that affects only the elderly, up to 30 per cent of young women and 40 per cent of middle-aged women also have urinary incontinence problems.

Childbirth, the menopause and obesity increase the risk. Giving birth can directly damage the pelvic floor muscles, while falling levels of the hormone oestrogen during the menopause causes them to weaken, and extra weight puts strain on the bladder. Last year research in the journal PLoS One found women aged 60 and over who sit for too long may be at a heightened risk.

Lifestyle changes, such as losing weight, can help by reducing pressure on the bladder, but pelvic floor exercises are the standard treatment.

Other options include vaginal cones (small weights placed inside the vagina, which you hold in place to strengthen the muscles), Botox to freeze nerves in an overactive bladder, and surgery.

The National Institute for Health Research commissioned the new study to provide clear evidence of whether the biofeedback devices provided any added benefit for the treatment of incontinence problems.

It involved women from across the UK and was a collaboration between the universities of Stirling, Aberdeen, Exeter and Otago in New Zealand, as well as NHS Greater Glasgow and Clyde and NHS Ayrshire and Arran.

Each woman, whether they were using the biofeedback device or not, was offered six appointments with a healthcare professional over two years.

‘Now we have a clear answer and this means that in the NHS in the UK, those treating women with incontinence can be confident that they should not routinely use biofeedback,’ says Professor Hagen.

However, Myra Robson, a specialist pelvic floor physiotherapist at Lewisham and Greenwich NHS Trust, while welcoming the findings, said biofeedback can be useful for some.

‘The challenge is how to get women to understand the pelvic floor contraction,’ she says. 

‘Around half do this with verbal instructions but for some, especially visual learners, biofeedback works well.’

The key, she says, is being taught how to do the exercises by a specialist physiotherapist (although women can check their technique by inserting a finger into the vagina and feeling the ‘lift and squeeze’, she says).

Under new guidelines issued in 2019 by the National Institute for Health and Care Excellence, women with incontinence should be offered at least three months of ‘supervised pelvic floor muscle training’ — with a nurse or physiotherapist.

However, a shortage of specialists means ‘many patients are sent away with a leaflet while biofeedback devices are aggressively marketed at those embarrassed to seek help’, adds Myra Robson.

Under the microscope

Former MP and war correspondent Martin Bell OBE, 82, takes our health quiz

Can you run up the stairs?

Not any more, but I keep active. Every day my wife Merita and I walk for up to 20 minutes in the park.

Get your five a day?

My diet has never been healthier — because of lockdown, I can’t eat out or even go to the pub.

Pop any pills?

I take multivitamins, pills for blood pressure and cholesterol, and a tiny pill called propranolol for a slight neurological tremor. I think I inherited it from my mother who had difficulty drinking a cup of tea as her hand shook.

Ever dieted?

No, But maybe I should have. I became a bit overweight as an MP, grazing in the members’ tea room. I’m 5ft 11in, but not sure what I weigh, though my belt is now easier to tighten.

Any vices?

I smoked a few cigarettes when reporting on the Balkan wars in the 1990s — to steady the nerves. I enjoy Chilean white wine a few times a week and have a glass of scotch before bed.

How have you coped in lockdown?

I found time goes incredibly fast the less you do. The sad thing is not being able to see my daughters Melissa, who lives in Paris as a CNN correspondent, and Catherine, who works in admin at the University of Exeter.

Had anything removed?

I’ve had shrapnel removed, and both hips replaced when I was an MP.

Worst illness/injury?

I had a bad fall two years ago at Gatwick. I was carrying a suitcase in each hand and fell over so there was nothing to break my fall except my face. The surgeons at St George’s Hospital in London put me back together. I now have four metal plates in my mouth and 16 screws. When I was 11 or 12 I had measles and pneumonia, which was so serious prayers were said for me in the local church.

Cope well with pain?

I am a total coward and not keen on pain. In 1992 I was hurt by a mortar bomb in Sarajevo. I was tended to by a French team in a UN field hospital, but when I came out my passport and money had disappeared, so I was mortared by the Serbs and robbed by the French on the same day.

Hangover cure?

My cure is — time!

What keeps you awake?

Bizarrely I have frequent nightmares — about losing my bags at Heathrow or sitting in the House of Commons.

Like to live for ever?

No but I am deeply aware that every day passed is a day gained. I am as old as my father was when we lost him and I have lost both my sisters in the past two years, so I am determined to enjoy every moment.

Martin’s new book, War And Peacekeeping, is published by Oneworld (£20).

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