Pelvic Floor Exercise Programmes Explained: Dose, Progression, Review

A pelvic floor exercise programme is a prescribed dose of muscle training, set against an assessment, progressed over weeks and checked at review appointments, which is the whole difference between physiotherapy and a leaflet. The guideline floor is at least 8 contractions performed 3 times per day¹, and almost everything interesting about a programme is what gets built on top of that number rather than the number itself.

Mine changed four times in sixteen weeks. The fourth version had almost nothing in common with the first except that it was still contractions: different holds, different positions, and by the end it was happening while I was doing the thing that made me leak in the first place rather than lying on a plinth. Nobody had told me that a programme was supposed to move. I had assumed pelvic floor exercises were a fixed set you either did or did not do, which is exactly the assumption a leaflet creates. For the treatment as a whole see pelvic floor physiotherapy, and for the mechanism underneath the dose see how pelvic floor muscle training works.

What makes it a programme rather than a set of exercises

Three things: an assessment behind it, a plan for changing it, and a date when somebody checks. NICE NG210 requires at least one review to assess progress during a supervised programme and one review at the end of it², and that requirement is structural rather than pastoral. A review only makes sense if there is a starting measurement to compare against and a dose that is expected to have moved.

The other half of the definition is supervision. NG210 says programmes should be supervised by a physiotherapist or other healthcare professional with the appropriate expertise in pelvic floor muscle training², and the evidence agrees that this is not a formality: supervised and more intensive training is more effective than unsupervised training, and training needs proper instruction and close follow up to be effective³.

The guideline minimum, and the date printed on it

NICE NG123 recommendation 1.4.5 says pelvic floor muscle training programmes should comprise at least 8 contractions performed 3 times per day¹. That is the most quoted number in this field and it is quoted carelessly almost everywhere.

Two things need saying with it. First, it is tagged 2006 in the guideline, which means it was carried forward unchanged from the previous guidance and was not re-reviewed in the 2019 update, so presenting it as current 2019 evidence is wrong. Second, it is a minimum for what counts as a programme, not a prescription for a person. Your dose is set against what your assessment found, which is why this article will not give you one and why what happens at a pelvic health physio assessment comes before this one in the running order.

The variables a clinician actually prescribes against

There are five axes, and a programme is a position on all of them rather than a number of squeezes.

• Hold length. How long a sustained contraction is held before it is released, which trains the endurance side of the muscle.
• Repetitions and sets. How many contractions, how many times in a day, and how much rest sits between them.
• Fast contractions as well as slow ones. The floor has to respond quickly to a cough or a landing, not only hold steadily, so quick contractions are usually prescribed alongside sustained ones.
• Position. Lying, sitting, standing and moving are progressively harder, because gravity and the rest of your trunk get involved.
• Load. Eventually the training has to meet the activity where the symptom happens, whether that is lifting a child or running, which is the ground returning to running and lifting covers.

Those are the axes a clinician moves you along. They are not a menu to pick from at home, for the plain reason that the correct starting position on each of them depends on findings that came out of an examination.

Why two people do not get the same programme

Because the trial evidence this treatment rests on tested individualised training, not a standard sheet. The POPPY trial randomised 447 women with newly diagnosed symptomatic stage I, II or III prolapse across 25 centres in 3 countries, 225 to individualised one to one pelvic floor muscle training and 222 to a control group who received a prolapse lifestyle advice leaflet and no muscle training⁴. At 12 months the training group improved by a mean of 3.77 points on the 0 to 28 Pelvic Organ Prolapse Symptom Score against 2.09 in controls, an adjusted difference of 1.52 with a 95% confidence interval of 0.46 to 2.59.

That is worth reading twice, in both directions. The control arm in the trial that supports individualised training got a leaflet, which is what a great many women are still given. And the difference between the two arms was 1.52 points on a 28 point scale, which is good evidence of direction and modest evidence of magnitude. Only 295 of the 447 women, 66%, were still in the trial at 12 months. Pelvic organ prolapse sets out what that does and does not mean for prolapse specifically.

Progression, and why a static dose is not a programme

A dose that is achievable is a dose that has stopped training you. Progression means that once the current prescription is comfortable, something moves: the hold gets longer, the repetitions increase, the position gets harder, or the training moves into the activity where the symptom actually happens.

The effects the trials report come from programmes that did this. In a Cochrane review of 31 trials and 1,817 women, training against no treatment, placebo, sham or another inactive control produced cure in 56% of women with stress urinary incontinence 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 women⁵. Cure or improvement was 74% against 11%, across all types of incontinence cure was 35% against 6%, and women with stress incontinence had 1.23 fewer leakage episodes per 24 hours. The small base behind the headline figure is part of the honest reading of it, and so is the review’s own note that limited follow up beyond the end of treatment leaves long-term outcomes and cost-effectiveness uncertain.

The reviews, and what should change at them

At minimum, two: one during and one at the end². At the review the measurement is repeated, the dose is adjusted, and a decision is made about whether the programme continues. NG123 puts it simply: continue an exercise programme if pelvic floor muscle training is beneficial¹, and NG210 says the same about continuing after the supervised programme ends².

What a review is not is a discharge interview with a leaflet at the end. If you are approaching one, questions to ask at your first appointment has the questions that make it a checkpoint rather than a formality, and how many sessions of pelvic health physiotherapy covers how few appointments a programme usually contains.

How long the programme runs

By condition, and the guidelines are precise about it. For stress or mixed urinary incontinence, NICE offers a supervised programme of at least 3 months¹². For symptomatic prolapse, NG123 says consider at least 16 weeks for POP-Q stage 1 or stage 2, while NG210 gives at least 4 months for symptomatic prolapse that does not extend more than 1 cm beyond the hymen on straining¹². NG210 adds at least 4 months for faecal incontinence with coexisting pelvic organ prolapse².

Those are not two competing durations. NG210’s own rationale explains that 16 weeks for prolapse and faecal incontinence and 3 months for urinary incontinence were the most common points at which trials assessed their outcomes, so both numbers are measurement windows inherited from the evidence. A guideline minimum is not a prognosis, and how long does pelvic floor physiotherapy take is the article that takes that apart.

Programmes given before there is a symptom

There is one place the guideline prescribes a programme to people who are not currently leaking, and it is narrower than most summaries suggest. NG210 says to consider a 3 month programme of supervised pelvic floor muscle training from week 20 of pregnancy for pregnant women who have a first-degree relative with pelvic floor dysfunction, and during postnatal care for women who have had an assisted vaginal birth using forceps or vacuum, an occipito-posterior vaginal birth, or injury to the anal sphincter². The antenatal trigger is that one criterion, not a general at-risk category.

The evidence behind the antenatal limb is unusually strong for this field. In a Cochrane review, continent women who began pelvic floor muscle training in pregnancy were about 29% less likely to report urinary incontinence at 3 to 6 months after birth than those receiving usual care, 179 per 1,000 against 251 per 1,000, a risk ratio of 0.71 with a 95% confidence interval of 0.54 to 0.95, from 5 trials and 673 women, graded high certainty⁶. Antenatal pelvic floor training covers the timing, and postnatal pelvic floor recovery covers why starting after birth is a different question with a different answer.

What travels alongside the muscle work

Rarely only contractions. NG210 covers urinary incontinence, bladder emptying disorders, faecal incontinence, bowel emptying disorders, prolapse, sexual dysfunction and chronic pelvic pain in one guideline², and a programme aimed at one of those usually has to deal with a second one to work at all.

In practice that means bladder habit and fluid, covered in bladder training and fluid advice; bowel habit, covered in bowel habit and defaecation technique, because daily straining loads the same structures the programme is trying to train; and load management. Where a device is added on top, biofeedback and electrical stimulation covers what the addition is actually for, and pelvic floor trainers and apps covers the consumer versions.

When a strengthening programme is the wrong programme

For an overactive, or hypertonic, pelvic floor, this entire article describes the wrong treatment. The muscle is not failing to switch on, it is failing to switch off, and adding contractions to it makes symptoms worse. Pain led presentations sit disproportionately in that group, and the correct direction is set out in hypertonic pelvic floor and downtraining.

Even within straightforward strengthening, the movement itself is the first failure point. In 47 women referred for urodynamic evaluation of incontinence, 49% achieved an ideal contraction after brief verbal instruction and 25% performed a technique that could potentially promote incontinence⁷; in 779 women in community primary care, 68.6% to 85.8% contracted correctly at the first attempt depending on their symptoms, and 78% of the 120 who did not learned after brief instruction⁸. So the risk is concentrated exactly among people with symptoms, which is who runs programmes. How to do a pelvic floor contraction correctly is the companion piece to this one.

What happens when the supervised part ends

Adherence falls, and this site is not going to be encouraging about it in place of being accurate. A systematic review of 19 studies following 1,141 women for between 1 and 15 years found long-term adherence to training ranging from 10% to 70%, long-term success among the original responders ranging from 41% to 85%, and surgery rates at long-term follow up ranging from 4.9% to 58%⁹.

The part that usually gets left out is in the same review: the authors concluded that short-term outcomes could be maintained at long-term follow up without incentives for continued training. So the accurate summary is that most people stop doing the full programme and the benefit does not collapse when they do, which is a much more useful thing to know at discharge than an instruction to keep going forever. Keeping it up after discharge deals with the gap between the instruction and the behaviour, and if a fair trial has come and gone without enough change, when physiotherapy is not enough covers what comes next.