Urinary incontinence (UI) is one of the most prevalent health concerns among women age 65 and over. The first-line treatment for UI is individual pelvic floor muscle training (PFMT). [1] Group-based PFMT was shown to be non-inferior to individual PFMT to treat UI in older women, while using fewer resources. Yet, many women living in remote areas with limited physiotherapy resources cannot benefit from PFMT. To accommodate their needs, this study aimed to assess the clinical effectiveness of online group-based PFMT for UI in older women.

This mixed-methods clinical study investigated acceptability, feasibility and effectiveness of online group-based PFMT. The present abstract presents the pre-post effectiveness of the program.

Population
We recruited community-dwelling women age 65 and over, with symptoms of stress or mixed UI for ≥3 months, who reported ≥3 weekly episodes of urine leakage on a 7-day bladder diary. Stress UI or stress predominant mixed UI was confirmed with the Questionnaire for Urinary Incontinence Diagnosis (QUID). [2] To be eligible, participants also needed to have access to the internet and a smartphone, computer or tablet. Exclusion criteria included physiotherapy treatment or pelvic surgery in the previous year, and any medication, co-morbidities or risk factors likely to interfere with PFMT or pelvic floor muscle (PFM) evaluation and treatment.

Intervention
Pelvic floor physiotherapists established participant eligibility during an individual in-person evaluation session, where participants were taught how to contract their PFMs correctly through vaginal digital palpation. 
Women then took part in a 12-week group-based PFMT program consisting of weekly online one-hour training sessions. All participants received an exercise booklet, detailing the PFMT exercises and their progression, and support material for the educational component of the program. An experienced pelvic floor physiotherapist delivered all treatment sessions online, via Zoom, to groups of seven to 11 women. Each session began with a one-on-one meeting with the physiotherapist in a private breakout room to discuss weekly leakages and exercise adherence for three to five minutes, while the rest of the group socialized in the ‘main room’ of the Zoom meeting. The session was then divided into a 10-15-minute educational component and a 30-45-minute PFM exercise component. The educational component covered topics relevant to the aging pelvic floor, UI pathophysiology, lifestyle intervention and self-efficacy. The exercise component included a progressive program of four PFM exercises gradually increasing in duration and repetitions, as well as increasingly challenging positions (from lying down, to sitting, to standing). In addition, participants were expected to perform PFM exercises at home, five-days/week, for 12 weeks. 

Data collection
We collected demographic data before the intervention (age, BMI, and gynecological health history). Study outcomes were collected twice before the intervention to document their stability over time at recruitment (PRE1) and just before the first session (PRE2), and once more immediately after the program (POST). To assess the program’s clinical effects on UI symptoms, participants reported urine leakage in a 7-day bladder diary at PRE1, PRE2 and POST. Furthermore, all women completed standardized questionnaires at PRE1, PRE2 and POST: the ICIQ-UI short form, the ICIQ-LUTSqol and the bladder subscale of the Australian Pelvic Floor Questionnaire (APFQ) [3]. The primary outcome measure was leakage reduction between PRE1, PRE2 and POST measurements.
To assess the program’s effects on UI-related symptoms, self-efficacy and UI costs, participants also reported their micturitions in the 7-day bladder diary and other subscales of the APFQ at PRE1, PRE2 and POST. They also completed the Atrophy Symptom Questionnaire (ASQ), the Geriatric Self-Efficacy index (GSE), the Broome Pelvic Muscle Exercise Self-Efficacy Scale (PMSES) and the adapted Dowell-Bryant Incontinence Cost Index (DBICI) at PRE1 and POST. 
Lastly, participants also completed the patient global impression of improvement (PGI-I) index and a single-item tool to capture their satisfaction with treatment at POST.

Data analysis
We reported baseline demographic data using descriptive statistics. We investigated the differences between PRE1, PRE2, POST using one-way repeated analyses of variance (ANOVA) and post-hoc paired-samples Tukey’s tests for normally distributed data, or a Friedman test and post-hoc Wilcoxon signed-rank tests for non-normally distributed data. We investigated the differences between PRE1 and POST non-normally distributed data using Wilcoxon signed-rank tests. Finally, we reported PGI-I and satisfaction using descriptive statistics.

From March 2021 to April 2022, 34 older women were recruited and divided into four groups to participate in the online group-based PFMT program. One woman dropped out due to personal reasons and one woman was lost to follow-up after program completion. Participants had a median age of 69.0 (IQR 6.0) and a mean BMI of 25.2 (SD 4.0). Among them, mean parity was 1.4 (SD 1.2). Most participants (94.1%) reported symptoms of mixed UI, with a median of 5.5 (13.5) years of symptom duration.

There was a statistically significant difference in the number of leakage episodes/day between the three time points (Friedman χ2(2)=33.207, p=0.000). Post-hoc analysis with Wilcoxon signed-rank tests revealed a significant reduction between PRE1 and POST, with the median number of leakage episodes/day decreasing from 2.4 (1.8) to 0.8 (0.9) (p=0.000), which corresponds to a 67% leakage episode/day reduction. This significant reduction was maintained between PRE2 and POST (p=0.000). There was no difference between PRE1 and PRE2 (p=1.000) (Table 1). Among UI-specific questionnaires, there was a statistically significant difference in the ICIQ-UI SF, ICIQ-LUTSqol and APFQ Bladder Function subscale scores between the three time points (ANOVA F=14.93 p=0.000, F=6.70 p=0.002 and F=11.49 p=0.000 respectively). Post-hoc Tukey’s tests revealed a significant improvement between PRE1 and POST in all three questionnaires, with mean ICIQ-UI SF scores decreasing from 12.4 (2.9) to 8.2 (3.9) (p=0.000), mean ICIQ-LUTSqol decreasing from 36.8 (9.9) to 29.7 (7.4) (p=0.006), and mean APFQ Bladder Function subscale scores decreasing from 15.2 (4.6) to 10.0 (4.8) (p=0.000). The significant reductions were also observed between PRE2 and POST for all three questionnaires (p=0.000, p=0.006, and p=0.001 respectively). There was no difference between PRE1 and PRE2 for any UI-specific questionnaire score (p=0.773, p=1.000, and p=0.761 respectively).  

Among UI-related symptoms, self-efficacy and UI costs, only the GSE, PMSES and DBICI showed significant improvements after the program using Wilcoxon signed-rank tests (Table 1). Median GSE scores increased from 62.0 (36.5) at PRE1 to 93.0 (36.3) in POST (p=0.000). The PMSES median total score increased from 66.1 (23.3) at PRE1 to 79.3 (22.0) in POST (p=0.001). DBICI median monthly costs of disposable continence products went down from 13.0$ (23.1$) at PRE1 to 2.0$ (6.0$) at POST (p=0.012).
After the program, all 32 participants perceived symptom improvement, with 18/32 (56.3%) reporting their symptoms being ‘much better’, 6/32 (18.8%) ‘better’ and 8/32 (25.0%) ‘somewhat better’. Finally, 29/32 (91%) participants were satisfied and not interested in receiving any alternative treatment.

These findings suggest that a 12-week online group-based PFMT program could be effective to reduce leakage frequency and UI symptom severity, improve UI-related quality of life and overall self-efficacy, and reduce UI costs for older women with stress or mixed UI, while achieving high satisfaction. As recent work previously confirmed PFMT telerehabilitation feasibility, online group-based PFMT appears to be promising to expand currently available PFMT services.

Online group-based PFMT proved to be effective in improving UI-specific and UI-related symptoms, self-efficacy, and UI costs among older women in our cohort. A randomized control trial is needed to confirm these results.

Abrams P, Anderson KE, Apostolidis A, Birder I, Bliss D, Brubaker L, et al. Recommendations of the international Scientific Committee: Evaluation and treatment of UI, bladder pain syndrome, POP and fecal incontinence. In: Abrams P, Cardozo L, Khoury AE, Wein A, editors. 6th Ed International Consultation on Urinary Incontinence. 2. Plymbridge, UK: Health Publication ltd.; 2017. p. 2549-619.
Bradley CS, Rahn DD, Nygaard IE, Barber MD, Nager CW, Kenton KS, et al. The questionnaire for urinary incontinence diagnosis (QUID): Validity and responsiveness to change in women undergoing non-surgical therapies for treatment of stress predominant urinary incontinence. Neurourology and urodynamics. 2010;29(5):727-34.
Baessler K, O’Neill SM, Maher CF, Battistutta D. Australian pelvic floor questionnaire: a validated interviewer-administered pelvic floor questionnaire for routine clinic and research. International Urogynecology Journal. 2009;20(2):149-58.

Continence 7S1 (2023) 100947
DOI: 10.1016/j.cont.2023.100947