Keeping It Up After Discharge: What the Adherence Figures Really Show

Long term adherence to pelvic floor muscle training varied between 10% and 70% across 19 studies following 1,141 women for between 1 and 15 years, and in the same review long term success among the original responders varied between 41% and 85%, with the authors concluding that short term outcomes could be maintained at long term follow-up without incentives for continued training. Most people stop doing the full programme. The benefit does not fall as far as that sentence makes you expect, and both halves need publishing together¹.

I finished my sixteen weeks in reasonable shape and then had the experience nobody had described to me: after four months of structure, the structure is handed back. There is no appointment, no diary, no review date, and the daily task now has to compete with a full teaching timetable on its own merits. That is the problem this article is about. Read red flags and when to stop and get checked if something has changed rather than simply drifted.

The number, with its edges on

A systematic review examined whether the effect of pelvic floor muscle training for female stress urinary incontinence persists, drawing on 19 studies that followed 1,141 women for between 1 and 15 years, with peripartum studies excluded¹. Its findings, in full rather than in the version that gets quoted:

• Long term adherence varied between 10% and 70%.
• Long term success, based on responders to the original trial, varied between 41% and 85%.
• Surgery rates at long term follow-up varied between 4.9% and 58%.
• Losses to follow-up during the long term period ranged between 0% and 39%, and only 2 of the 19 studies provided any follow-up intervention.
• The authors concluded that short term outcome of training can be maintained at long term follow-up without incentives for continued training.

Those ranges are wide because the studies are not replicas of each other. They followed different populations for different lengths of time, defined success differently, and measured adherence in whatever way each research team chose. A range of 4.9% to 58% for later surgery is not a forecast for a person; it is a description of methodological variety.

Why the adherence figure is softer than it looks

Because adherence itself is badly measured, and the field says so about itself.

An International Continence Society state-of-the-science research paper on adherence to pelvic floor muscle training reported that adherence was inconsistently monitored and inadequately reported across the literature². It is worth being precise about what that paper is and is not: it is a methodological critique, and it contains no adherence percentage. This site cites it for the claim that measurement is unreliable, never for a number.

That matters when you meet a confident adherence statistic elsewhere. If the underlying reporting is inconsistent, a single tidy percentage is an artefact of one study’s definition rather than a fact about people. The International Continence Society maintains the standardisation work that this kind of critique feeds into³.

The finding people skip

Read the authors’ conclusion again, because it is the least intuitive thing in this field: short term outcomes could be maintained at long term follow-up without incentives for continued training¹.

If pelvic floor muscle training were purely a strength intervention, that would be strange. Strength gained through training is lost through detraining, fairly predictably. But training changes more than force. It changes how quickly the muscle produces force and whether it recruits automatically at the moment abdominal pressure rises, and automatic recruitment is a motor skill rather than a quantity of tissue. Motor skills decay differently. How pelvic floor muscle training works sets out those three components in detail.

That is a plausible explanation rather than a proven mechanism, and I am labelling it as one. What is documented is the pattern: adherence falls a long way, and the benefit does not fall proportionately.

What the guidelines say about afterwards

Continue if it worked, and keep going.

NICE NG123 recommendation 1.4.7 says to continue an exercise programme if pelvic floor muscle training is beneficial, and recommendation 1.7.5 says the same for prolapse: if the programme is beneficial, advise women to continue afterwards⁴. NG210 recommendation 1.6.20 repeats it, and recommendations 1.3.9 to 1.3.11 go wider still, encouraging women of all ages, including those pregnant or recently delivered, to do pelvic floor muscle training and to continue it throughout life⁵.

Notice the conditional in the first two. Continue if beneficial. The guideline does not ask people for whom nothing changed to keep doing it indefinitely; it asks them to be reviewed, which is what recommendation 1.6.18 is for, with at least one review during the programme and one at the end⁵. If your programme did not work, the next step is when physiotherapy is not enough, not another year of the same repetitions.

What no source will give you

A maintenance dose.

NICE states a floor for a treatment programme of at least 8 contractions performed 3 times per day, and that recommendation carries a 2006 tag in NG123, meaning it was carried forward unchanged from the previous guidance and not re-reviewed in the 2019 update⁴. It is a minimum specification for a supervised programme, not a prescription for maintenance after one.

No maintenance dose appears in any of the sources this site is built on. That absence is the reason this page hands you no numbers of your own, and it is the reason the single most valuable question at a final appointment is what your own minimum should be. Pelvic floor exercise programmes explained covers how the original dose was arrived at, which is the same logic applied to a different question.

What the discharge conversation should contain

Three answers, written down before you leave.

• What maintenance means for me, specifically. Not “keep them up”. A frequency, a form, and a position, tied to what your programme finished at.
• What the early warning sign is. For a leaking presentation the useful marker is often a threshold rather than an event: the point within an activity at which the symptom appears, rather than whether it appears at all. Mine moved from the third hill repetition to the sixth during treatment, and it would presumably move back the same way. Knowing that in advance means noticing a slip in weeks rather than months.
• How I get back in. Whether you can re-refer yourself, whether there is a time limit on returning to the same service, and who to contact. That varies enormously by system and often by individual service; getting referred to pelvic health physiotherapy covers the routes, and it is much easier to establish while you are still a patient than after you are not.

Questions to ask at your first appointment is written for the other end of the course, and several of its questions are worth repeating at the last one.

What actually survived in my case

Not the programme. A reduced version of it, attached to things that were already happening.

The three formal sessions a day did not last past the first month after discharge, and I want to say that plainly rather than imply a discipline I do not have. What did last was a smaller amount done in fixed slots that were already fixtures in my day: before the school run, in a free period, and lying down at night. Attaching a new habit to an existing event is not a pelvic health insight, it is a general one, and it is the only thing that survived contact with a September term.

The other thing that survived was a marker. I kept the threshold measure, because it is a number I cannot argue with and my sense of how things are going has already been shown to be unreliable: at my six week review I watched a sensor fail to move while I was certain I was doing something. What that appointment gave me was not motivation, it was disproof, and the marker is a cheap way to keep a little of that after the appointments stop.

Where this sits against the rest of the evidence

Keep the scale of the original effect in view, because maintenance is maintenance of something real. In a Cochrane review of 31 trials and 1,817 women, 56% of women with stress urinary incontinence were cured with training against 6% of controls, a risk ratio of 8.38 with a 95% confidence interval of 3.68 to 19.07, graded high certainty from 4 trials and 165 women⁶. The same review’s authors note that limited follow-up beyond the end of treatment in most trials means long term outcomes and cost-effectiveness remain uncertain, which is precisely the gap the adherence literature is trying to fill.

For prolapse the long term picture is thinner again. The POPPY trial followed 447 women and had 295 of them, 66%, still in the trial at 12 months⁷, which is a substantial attrition rate for a one year primary outcome and gives you an idea of how hard longer follow-up is to obtain in this field. And the general statement that supervised and more intensive training is more effective than unsupervised training⁸ is worth remembering after discharge for what it implies: unsupervised is the condition you are now in, so a lower ceiling is expected rather than a failure.

The honest summary is the one I would have wanted at my last appointment. Most people stop. The result usually does not vanish when they do. Neither of those is a reason to skip the conversation about what your own minimum is, and pelvic floor physiotherapy is the treatment this is the tail end of.