Int Urogynecol J (2015) 26:1735–1750

DOI 10.1007/s00192-015-2749-y

REVIEW ARTICLE

Does pelvic floor muscle training improve female sexual function?

A systematic review
Cristine Homsi Jorge Ferreira 1,2 & Peter L. Dwyer 3 & Melissa Davidson 4 &
Alison De Souza 5 & Julio Alvarez Ugarte 6 & Helena C. Frawley 7

Received: 14 March 2015 / Accepted: 21 May 2015 / Published online: 14 June 2015
# The International Urogynecological Association 2015

Abstract Results A total of 1341 women were included in the eight

Introduction and hypothesis We performed a review of the RCTs covered by this review. The studies were published
literature reporting on the effects of pelvic floor muscle train- between 1997 and 2014. Methodological scores were between
ing (PFMT) on female sexual function (SF). 4 and 7. The sample included derived from heterogeneous
Methods Pubmed (from 1946 to December 2014), Ovid populations of women. In only one study was SF the primary
Medline (from 1946 to December 2014), CINAHL (from outcome measure. Pelvic floor dysfunction was an inclusion
1937 to December 2014), PsycINFO (from 1805 to De- criterion in the majority of studies. Most studies reported a
cember 2014), Scopus and Cochrane Central Register of significant improvement in SF score after PFMT between
Controlled Trials were searched by two independent re- control and intervention groups.
viewers. Randomised controlled trials (RCTs) investigat- Conclusions Although most studies indicated an improve-
ing the impact of PFMT on women’s SF published in ment of at least one sexual variable in women with pel-
English were included. Methodological quality was vic floor dysfunction, and one study demonstrated an
scored using the PEDro scale. Data were analysed qual- improvement in SF in postpartum women selected inde-
itatively and interpreted. pendently of their continence status, the results need to
be interpreted with caution. High-quality RCTs specifi-
cally designed to investigate the impact of PFMT on
women’s SF are required.
* Cristine Homsi Jorge Ferreira
cristine@fmrp.usp.br
Keywords Female . Sexual function .
1
Pelvic floor muscle training . Physiotherapy
Ribeirão Preto Medical School, University of São Paulo, Av.
Bandeirantes, 3900 Monte Alegre, 14049-900 Ribeirão Preto, SP,
Brazil
2
Mercy Hospital for Women (Fellowship/2013), Department of
Introduction
Urogynecology, Melbourne, VIC, Australia
3
Department of Urogynecology, Mercy Hospital for Women, The
Several studies have indicated a high prevalence of sexual
University of Melbourne, Melbourne, VIC, Australia dysfunction in the general female population ranging from
4
Remarkable Physios, PO Box 2006, Wakatipu 9349, New Zealand
30 % to 49 % [1, 2]. Sexual dysfunction is defined as the
5
disturbance in sexual desire and psychophysiological changes
Department of Urogynaecology, Mercy Hospital for Women,
Melbourne, VIC, Australia
that characterise the sexual response and cause interpersonal
6
difficulty and marked distress [3]. Sexual dysfunction signif-
Department of Urogynecology, Hospital Padre
Hurtado-Santiago-Chile, Mercy Hospital for Women (Fellowship/
icantly affects a woman’s quality of life and self-esteem [4].
2012-2013), Melbourne, VIC, Australia Several risk factors to the development of female sexual dys-
7
Centre for Allied Health Research and Education, Cabrini Health,
function have been identified in the literature, including post-
School of Allied Health La Trobe University, Melbourne, VIC, menopausal status, long-term relationship with the partner,
Australia diabetes, pregnancy, alcohol consumption, nicotine use,
1736
pelvic organ prolapse (POP) and urinary incontinence (UI)
[5–8]. Treatment of any aetiological factor may improve a
woman’s sexual function (SF). Pelvic floor muscle training
(PFMT) is recommended as the first-line treatment for all
types of UI and mild–moderate POP [9], and some studies
have shown that successful treatment of UI or POP with
PFMT also improves some aspects of a woman’s sexual life
and her SF [10–15], but this topic has not been systematically
evaluated.
Different physiological mechanisms by which PFMT could
effect an improvement in SF have been postulated. According
to Kegel [16], pelvic floor muscle (PFM) weakness could
contribute to the inability of a woman to achieve orgasm,
and PFMT would therefore positively impact on a woman’s
sexual life. Other authors have stated that an increase in the
strength of the muscles attached to the corpus cavernosum of
the clitoris could lead to a better involuntary contraction of the
PFM and consequently to an increased arousal and orgasmic
response [16, 17]. Increased blood flow to the pelvis and en-
hanced clitoral sensitivity have also been suggested as a
PFMT effect that may contribute to improvement in arousal,
lubrication and orgasm [18, 19]. Despite this theoretical back-
ground, there are a limited number of randomised controlled
trials (RCTs) evaluating the effects of PFMT on female SF. A
review of the literature in a non-Pubmed-indexed journal con-
cluded that it is quite probable that arousal, lubrication, or-
gasm and desire can be improved by PFMT in women with
UI and postpartum women; however randomised controlled
trials (RCTs) and non-randomised studies were included in
that recently published review [20]. Other exploratory
and observational study designs provide sufficient ratio-
nale for the proposed physiological effect of PFMT on
SF. Therefore, the decision was made a priori to restrict
our systematic review to RCT designs only in order to
synthesise the highest levels of evidence (Level I or II)
to date [21] in order to propose grades of recommenda-
tion for clinical practice.
This study had two aims: The primary aim was to conduct a
systematic review of the literature to assess the results of RCTs
that investigated the impact of PFMT on female SF. The sec-
ondary aim was to investigate the association between the
improvement in SF and the change in PFM function (PFMF)
in these studies.
Methods
Protocol and registration
The protocol of this review was registered at PROSPERO
CRD42013005912. Inclusion and exclusion criteria are as
follows:
Int Urogynecol J (2015) 26:1735–1750
Inclusion criteria
Design
• Full-text articles of randomised controlled trials
Participants
• Female participants
• With or without pelvic floor dysfunction at baseline
Intervention
• PFMT alone or combined with other exercises or lifestyle
interventions or electrotherapy or adjunctive therapies
Comparator(s)/control
• Control group with no treatment
• Comparison group receiving only instructions to perform PFMT
without supervision, or a less intensive protocol
Outcome measures
• Primary: investigation of the impact of PFMT on at least one SF
variable, including satisfaction, desire, arousal, orgasm, pain,
lubrication
• Secondary: association between improvement in both SF and
pelvic floor muscle dysfunction
Exclusion criteria
• Studies including children and adolescents
• Review articles, guidelines, observational studies and studies with no
PFMT
Search strategy
Prior to searching for RCTs, we reviewed databases for sys-
tematic reviews; none were identified. One protocol for a sys-
tematic review was listed on PROSPERO. We performed a
computer-aided and manual search on the following data-
bases: Pubmed (from 1946 to July 2014, Ovid Medline (from
1946 to July 2014), CINAHL (from 1937 to July 2014),
PsycINFO (from 1805 to July 2014), Scopus and Cochrane
Central Register of Controlled Trials (CENTRAL). English
language was not included as a limit in the search strategy.
The Scopus database yielded the largest return (111 refer-
ences) using the terms: (Bpelvic floor muscle training^ [All
Fields] or Bpelvic floor exercises^ [All Fields]) or Bpelvic
floor exercise^ [All Fields]) or (BKegel^ [All Fields]) or
(BKegels^ [All Fields]) and (Bsexual function^ [All Fields]
or Bsexual dysfunction^ [All Fields]) and (Bfemale^ [MeSH
Terms]). From all databases, only RCTs published in English
were retrieved. The last search update was performed on 1
December 2014.
Study selection
The study-selection process is outlined in Fig. 1. All abstracts
were read to identify RCTs, and full-text referenced papers
were selected from each eligible study in an attempt to identify
additional studies. After all abstracts were carefully read, the
RCTs were selected and the full articles were obtained. The
Int Urogynecol J (2015) 26:1735–1750 1737

Fig 1 PRISMA flow diagram of

Records idenfied through
study selection process
database searching: Pubmed (from
1946 to July 2014, Ovid Medline

Idenficaon
(from 1946 to July 2014), CINAHL
(from 1937 to July 1937), PsycINFO Addional records idenfied
(from 1805 to July 2014), Scopus through other sources
and Cochrane Central Register of (n =0 )
Controlled Trials (CENTRAL).
(n = 295)

Records aer duplicates removed

(n = 213 )

Records excluded
(n = 203 )
Records screened by
independent reviews Not RCTs
Screening

(CHF, MD) (n = 213)

Full-text arcles assessed

Full-text arcles excluded,
for eligibility
with reasons
(n = 10 )
(n = 2 )
Eligibility

Studies included in
qualitave synthesis
(n = 8 )

Studies included in
Included

quantave synthesis
(meta-analysis)
(n = 0 )

search was conducted by two reviewers (CHF and MD) and
confirmed by the institutional librarian. Decisions regarding
inclusion of articles were made by agreement between the two
reviewers. Any disagreement was resolved by a third reviewer
(HF).
second reviewer (MD) and, when necessary, by a third review-
er (HF). Whenever necessary, the authors of the RCTs were
contacted to clarify any important point to conclude the review.
Risk of bias

Data collection process
A standardised data extraction form was used to collect the
following data: authors, journal, year of publication, rationale
to perform the study, primary aim, population/sample included,
sample size calculation, intervention, outcome measures/re-
sults, dropout rate. Data were collected first by one reviewer
(CHF); accuracy of information was checked and verified by a
The risk of bias of included studies was assessed using the Phys-
iotherapy Evidence Database (PEDro) scale, which is a valid and
reliable tool consisting of an 11-item checklist [22]. As in the
PEDro Web site, criterion 1 (eligibility criteria were specified)
was not used to calculate the PEDro score. Initially, two raters
(CHF and MD) independently assessed the risk of bias of all
included studies. A third reviewer was available to resolve any
disagreement if required. The score was attributed based on the
1738
information available in each article included in this review.
When the information was not available, the specific score was
considered absent and the counted value was not assigned.
Summary measures
Data are summarised in tables. Due to trial heterogeneity and
lack of standardised outcome measures, a qualitative analysis
was undertaken. Interpretation of the included trials, methods,
definitions and units conforms to the standards jointly recom-
mended by the International Continence Society (ICS) and the
International Urogynecological Association (IUGA) [23], ex-
cept where specifically noted.
Results
Study selection
The search of six electronic databases (Fig. 1) yielded a total
of 295 studies. After exclusions were applied, a total of eight
studies were included for qualitative synthesis, for a total of
1341 covered by this review. There was 100 % agreement
between the two reviewers regarding inclusion of selected
trials. RCTs were published between 1997 and 2014.
Study characteristics
Table 1 summarises the details of included studies: aims, pri-
mary outcome, whether a sample-size calculation was done
based on an SF variable, size of study cohort and population
under study. Only two studies investigated SF as the primary
outcome [13, 25]; however, only Citak et al. [25] reported a
power calculation based on the SF variable. All other studies
investigated SF as a secondary outcome. Study sizes ranged
from n=45 [26] to n=445 [11]. The samples included in the
RCTs comprised heterogeneous populations with respect to
absence or presence of pelvic floor dysfunction and which
type of pelvic floor dysfunction. Two studies included women
in the postpartum period [24, 25]. Only one study did not
specify the presence of pelvic floor dysfunction as an inclu-
sion criterion [25]. One study included women with
gynaecological cancer [26]. Ages in the included studies
ranged from 18 to 65 years old.
Risk of bias within studies
The risk of bias according to PEDro scoring is shown in
Table 2. Seven of eight trials scored 4 or 5 on the PEDro scale,
representing Bfair^ methodological quality. The lowest score
of 4 was given to three RCTs [13, 24, 25]. Only one trial was
of Bgood^ quality, with a score of 7 [14]. The study by Wilson
et al. [24] showed no effect of PFMT on SF, and that by Citak
Int Urogynecol J (2015) 26:1735–1750
et al. [23] was the only included trial in which the primary aim
was to evaluate SF. The mean and standard deviation (SD)
score was 4.8 (0.9). There was 87.5 % agreement between
the two reviewers in regard to the total PEDro score awarded
to each article and to individual criterion scores. One study
received a different total score and one received the same total
score, but the points awarded in each category diverged be-
tween reviewers. An agreement by consensus was obtained
together with a third reviewer.
Results of individual studies
Control and intervention
Details of the interventions provided in the RCTs are shown in
Table 3. The studies varied in the types of control and active
intervention provided. Control conditions ranged from usual
care in that particular setting [24, 25], to an alternative conser-
vative therapy [10–12], to education [14, 26] to a surgical
intervention [13]. Interventions ranged from individualised
supervised PFM strength (PFMS) training alone [12, 24, 25]
to PFMT supplemented with adjunctive therapies [11, 13, 26],
group training [10, 12], continence/POP-support strategies
[11, 14] and the addition of extra non-pelvic muscle exercises
[10, 26]. All trials included instructions to perform PFMT at
home [10–14, 24–26].
Intensity of PFM contraction was specified as near-
maximal or maximal in three studies [10, 14, 26], while the
remaining studies did not report contraction intensity. Training
duration varied from 1 to 9 months. The amount of supervi-
sion ranged from minimal––only one session of instructions
on PFMT over 3 months [25], to maximal––weekly sessions
over 6 months [10].
Sexual function outcome measures
The specific outcome measures used to assess SF variables are
presented in Table 4. A total of ten different tools were used
across the eight studies to assess various aspects of SF. These
included tools that measured SF and sexual health in non-
disease-specific populations [Golombok and Rust Reference
Inventory of Sexual Satisfaction (GRISS questionnaire)] [28],
the Short-Form Personal Experiences Questionnaire (SPEQ-
9) [29]; the Female Sexual Function Index (FSFI) [30]; SF and
sexual health in women with UI [Bristol Female Lower Uri-
nary Tract Symptoms (B-FLUTS)] [31]; POP; [Pelvic Organ
Prolapse–Urinary Incontinence Sexual Function Question-
naire (PISQ-12)] [32]; Australian Pelvic Floor Questionnaire
(APFQ) [33]; POP questionnaire [34]); cancer populations
(European Organization for Research and Treatment of Can-
cer Quality of Life-CX24 [EORTC QLQ-CX24] [35]; and
semistructured interview questions [14]. Aside from the
Table 1 Characteristics of the included studies

Author, country Aims of study Was power calculation undertaken Number of women i Population Age, mean (variance)
to detect a difference in a sexual
function variable? If yes, what
was the sample size?

Wilson et al. [24]; Primary: to test the hypothesis that reinforced No Total: 230 Postnatal women with UI CG: 27.8 (95 % CI:
New Zealand PFME reduce the frequency of UI that persists for CG: 117 27.0–28.7)
more than 3 months after delivery. IG: 113 IG: 29.0 (95 %
Secondary: to evaluate the effect of reinforced PFME only: 39 CI 28.8–29.2)
Int Urogynecol J (2015) 26:1735–1750

PFME on sexual satisfaction PFME plus cones: 38

Cones only: 36
Bø et al. [10]; Norway To compare the effect of a 6-month PFMT regimen No Total: 59 Women with GSI CG: 51.7 (SD 8.8)
on quality of life, lifestyle and sex-life CG: 30 IG: 49.6 (SD 10)
variables in women with GSI IG: 29
Citak et al. [25]; Turkey To evaluate prospectively the effect of early PFMT Yes: based on Female Sexual Total: 118 Postpartum women CG: 22.2 (SD 3.1)
after childbirth on SF Function Index [30] CG: 60 IG: 23.0 (SD 3.2)
Sample size required: 34 per IG: 58
group
Handa et al. [11]; USA To describe sexual activity and SF in women with No Total: 445 Women with SUI CPG: 50.2 (SD 11.0)
stress incontinence; to compare the impact of Interventions: PFMT+CSG:
three non-surgical treatments for stress incontinence; CPG: 149 49.6 (SD 13.0)
to investigate whether successful treatment of PFMT+ CSG): 146 CTG: 49.5 (SD 11.8)
incontinence is associated with a reduction CTG: 151
in sexual complaints
Liebergall-Wischnitzer To compare the effectiveness of the Paula method No Total: 245 Women with SUI PMG: 46.7 (SD 8.0)
et al. [12]; Israel vs PFMT on SF and QoL of women with SUI Interventions: PFMTG: 46.6 (SD 8.9)
PMG: 119
PFMT: 126
Yang et al. [26]; Korea To investigate the effectiveness of this PFRP on No Total: 34 Women with gynaecological CG: 52.5 (SD 2.9)
pelvic floor function and QoL in gynaecological CG: 17 cancer who had radical IG: 52.3 (SD 5.2)
cancer survivors IG: 17 hysterectomy and pelvic
lymph node dissection
Eftekhar et al. [13]; Iran To compare the effect of surgical methods vs No Total: 90 Women with stage<3 POP SG: 37.7 (SD 5.8)
physiotherapy on SF in pelvic floor disorders Interventions: PG: 35.4 (SD 6.4)
SG: standard rectocele
repair and
perineorrhaphy group 45
PG: 45
Braeken et al. [14]; To evaluate the effect of PFMT on SF in women No Total: 109 Women with stage I, II CG: 49.4 (SD 12.2)
Norway with POP. Another objective was to determine if CG: 59 and III POP IG: 48.3 (SD 11.4)
any improvements in SF were related to IG: 50
increases in PFMF

PFME pelvic floor muscle exercises, UI urinary incontinence, CG control group, IG intervention group, CPG continence pessary group, PFMT pelvic floor muscle training, PFMF pelvic floor muscle
function, GSI genuine stress incontinence, SF sexual function, QoL quality of life, SUI stress urinary incontinence, PFRP pelvic floor rehabilitation programme, POP pelvic organ prolapse, CTG Combined
therapy group, CSG continence strategies group, PMG Paula method group, CI confidence interval, SD standard deviation
1739
1740 Int Urogynecol J (2015) 26:1735–1750

Total score
semistructured interview questions [14], the authors stated that
the tools were validated and translated to the language for
which they were used; however, in one study [12] the PISQ-

5
4
7
4
5
5
4
5
12 was used with a language adaptation. In one study the

Point estimates
and variability
authors did not justify the extensive modifications they ap-
plied to the FSFI [13].

Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
Sexual function results
Between-group
comparisons

SF results of individual studies are presented in Table 4. Five

studies found an improvement (significant intergroup differ-

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

ence) of at least one sexual variable with PFMT [10, 13, 14,
23, 25]. Bo et al. [10] reported that fewer women in the inter-
Intention-to-treat

vention group (receiving PFMT) had problems with their sex

life being spoilt by urinary symptoms. Citak et al. [25] found
analysis

an improved total FSFI and domain scores for orgasm in the

Yes
Yes

group that received PFMT compared with the control group at

No
No
No
No
No
No

7 months postpartum. After controlling for baseline scores,

follow-up
Adequate

Yang et al. [26] found a significant improvement in the APFQ

SF score [33] in gynaecological cancer survivors who re-
Yes
Yes
Yes
No
No
No
No
No

ceived PFMT.
Efekhar et al. [13] found an improvement in all domains of
assessors

the FSFI in the group that received physiotherapy compared

Blind

Yes
Yes
Yes

with women who received standard rectocele repair and

No
No
No
No
No
Risk of bias in reviewed randomised controlled trials (RCTs) using the PEDro scoring system

perineorrhaphy. Braeken et al. [14] found that more women

therapist

in the PFMT groups reported an improvement in SF compared

Blind

with the control group. The PFMT group increased in aware-

No
No
No
No
No
No
No
No

ness, strength, PFM control, sensation of tighter vagina, self-

confidence, libido, orgasm, resolution of pain with intercourse
subjects
Blind

and partner’s report of sexual gratification.

No
No
No
No
No
No
No
No

Handa et al. [11] found no change in PISQ-12 and SPEQ

scores between the three groups of conservative interventions
comparability

(continence pessary group (CPG), PFMTG+continence strat-

Baseline

egies group (CSG) and combined therapy group (CTG) at

Yes
Yes
Yes
Yes
Yes
Yes
Yes

No

baseline and 12 weeks from randomisation. However, they

found that women who had successful SUI treatment based
Concealed
allocation

on the Patient Global Impression of Improvement (PGI-I) in-

dependent of group allocation had a greater improvement in
Yes
No
No
No
No
No
No
No

PISQ-12 scores than those who did not. Women with im-
proved urinary leakage in the PFMT+ CSG and the CTG
allocation
Random

had decreased coital incontinence compared with women in

Criteria

the CPG alone. No difference was found in libido,

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

dyspareunia and arousal. One study [12] found that both in-
terventions investigated (Paula method and PFMT) improved
Liebergall-Wishnitzer et al. [12]

the mean PISQ-12 scores with no difference between groups,

but only the Paula group (intragroup analysis) presented less
pain during intercourse and less fear of incontinence
Braekken et al. [14]
Eftekhar et al. [13]
Wilson et al. [24]

restricting sexual activity after intervention. The study by Wil-

Handa et al. [11]
Citak et al. [25]

Yang et al. [26]

son et al. [24] showed no difference between PFMT and con-

Bo et al. [10]

trol groups in any question on the GRISS [28]. Across all

Table 2

Author

studies, withdrawals ranged from 0–52 % of the original co-

hort, with five studies having >15 % withdrawal rates.
Table 3 Description of control and intervention protocols in reviewed studies

Studies Control group intervention Active intervention group

Intervention Intensity of PFM Type of PFM Frequency and duration of Supervision Length of
contraction contraction PFMT programme

Wilson et al. [24] Continued with PFME as taught
once antenatally and daily
instruction to perform PFME
postnatally while women were
in hospital
PFME. The regimen involved
preparatory exercises to
identify the PFM plus a
basic exercise programme
Cones (20–100gm weighted
cones)
Not stated Fast and slow Length of contraction hold not Instruction by a physiotherapist 9 months
contractions specified; 10 repetitions per at 3, 4, 6, and 9 months after
set, 8–10 sessions per day delivery
– – 15 min holding time of cone; 2 As above 9 months
sets per day
Int Urogynecol J (2015) 26:1735–1750

PFME plus Cones (20–100-g- Not stated Fast and slow PFME: as per PFME above; As above 9 months
weighted cones) contractions cones: as per cones above
Bø et al. [10] Women had the opportunity to use PFMT exercise in a class, Close to maximum Fast and slow 6–8 s hold, with additional 3– 1× per month with 6 months
the continence guard device including PFMT, breathing, contractions contractions 4 fast contractions, rest physiotherapist for
only relaxation, posture, period of 6 s; 8–12 individual PFMT
strengthening of other contractions per series; 3 Home training supplemented
muscle groups series per day with audiotape
1× per week exercise class:
45 min
Citak et al. [25] Women in the study group only PFMT Not stated Graduated increase in Contractions and relaxation One session of instructions on 3 months
were instructed in PFMT by a contraction time over periods of 3 s, followed by PFMT and vaginal palpation
special nurse study period faster contraction and with a special nurse
relaxation of 2 s, ten times a Women were telephoned
day; duration of contraction regarding adherence to the
and relaxation was changed programme twice in the first
to 5 s; duration of month and once in the
contractions were increased second and third months
to 10 s and 15 sessions
Handa et al. [11] A continence pessary used for CPG Not stated Not stated Not stated 4 sessions over 2 months 2 months
2 months as desired to reduce 2 PFMT+CSG supervised by trained
leakage -Instructions on appropriate interventionists
pelvic muscle contraction,
prescription of home
exercise with increasing
difficulty over time, and
strategies to minimize
leakage
2 CTG: CP, PFMT and Not stated Not stated Not stated 4 sessions over 2 months 2 months
continence strategies supervised by trained
interventionists
Liebergall-Wischnitzer Paula intervention for 3 months PFMT groups of 1–10 people Not stated Prolonged, rapid or Length of contraction hold not 6 sessions over 3 months 3 months
et al. [12] including: contracting and gradual contractions specified supervised by
relaxing eyelids: the upper lip is Number of repetitions per set physiotherapists
raised to the nose as the nose is and number of sets per day
lowered to the upper lip; not specified
contracting and relaxing the 10 s between contractions and
levator ani muscle alone or with 1–2 min between exercises
long Bsh^ sound (12 private and
supervised 45-min sessions per
week for 12 weeks)
1741
Table 3 (continued)
1742

Studies Control group intervention Active intervention group

Intervention Intensity of PFM Type of PFM Frequency and duration of Supervision Length of
contraction contraction PFMT programme

Yang et al.[26] Received the same informative
leaflet with home-based pelvic
floor exercise, lifestyle advice
and a telephone number for
further explanations
Efkthar et al. [13] Surgical repair pelvic relaxation Physiotherapy, including
(standard rectocele repair and
perineorraphy)
Braeken et al. [14] Control subjects were asked to not PFMT in individual sessions.
commence or alter pre-existing
PFMT regimes during the
intervention period. All
participants received written
information regarding POP and
were informed to avoid
straining. Subjects in both
groups were taught how to
contract their PFM before and
during increases in abdominal
pressure
PFRP biofeedback sessions
and core exercise sessions,
including strengthening
exercises for the PFM and
transverse abdominis
muscles; stretching
exercises and diaphragmatic
breathing techniques
Not stated
vaginal and anal
biofeedback, infrared,
electrical stimulation and
Kegel exercises
Near-maximum PFM
Women received a booklet
and a DVD of the exercise
programme
Maximum voluntary Slow and fast 2–3 sessions of surface EMG 4 sessions over 1 month 1 month
contraction contractions biofeedback. Every session supervised by a
lasted 20 min and consisted physiotherapist
of 40 cycles with 10 s of
activity followed by 20 s of
relaxation. After a 5-min
rest period, patients re-
ceived 20 min strengthen-
ing exercises of the PFM
10 contractions holding for up
to 10 s, 6 times per day, and
followed by 1-min pause
and ≥10 fast contractions
for 20–30 s.
Slow and quick 6–8 s of contractions with 6 s 8 weeks, twice a week 2 months
contractions rest for 15 min three times
per day
Not stated 6–8 s hold, with additional 3– Once a week during the first 6 months
contraction 4 fast contractions, rest 3 months and every second
period of 6 s; 3 sets of 8–12 week during the last
repetitions daily 3 months; supervised by a
physical therapist

PFME pelvic floor muscle exercises, PFMT pelvic floor muscle training, EMG electromyelogram, PFRP pelvic floor rehabilitation programme, POP pelvic organ prolapse, CPG continence pessary group,
CSG continence strategies group, CTG combined therapy group
Int Urogynecol J (2015) 26:1735–1750
Int Urogynecol J (2015) 26:1735–1750
Pelvic floor muscle function outcome measures
The specific outcome measures used to assess PFMF are pre-
sented in Table 5. Five studies presented data related to PFMF
[11, 14, 24–26]. We found additional data related to PFMF in
a previous manuscript reporting on the primary outcome anal-
ysis for one study [14]. In one study, no PFMF-related data
were reported, but data were available in the primary study
[10]. No PFMF-related data were found for two studies [12,
13]. The maximal voluntary contraction (MVC) and PFM
endurance were measured using manometry in five studies
[10, 14, 24–26]. The modified Oxford Grading Scale [36]
w a s u se d i n o ne st ud y [ 2 5] , a n d a t w o- c ha n n el
electromyelogram (EMG) was used in another study to esti-
mate PFMF [26]. One study used only a Brink Scale [37] to
measure PFMF [11].
Pelvic floor muscle function results
PFMF results of the individual studies are presented in Table 5.
Two studies found an increase in PFMS in the groups receiving
PFMT compared with control groups but did not perform an
analysis to assess whether improvements in SF were associated
with PFMS [25, 26]. One study showed no difference in ma-
nometry between groups [24]. Handa et al. [11] found that
successful SUI treatment was associated with higher mean
Brink score; however, in contrast, the change in PFMS
assessed with the Brink score was not associated with a change
in SF assessed with the SPEQ score or a change in SF related to
UI and POP assessed with the PISQ-12 score. Braekken et al.
[14] found a medium and small correlation between changes in
SF and PFMS and endurance, respectively; however, women
who described improved SF showed greater increase in PFMS
compared with women who reported SF was unchanged. Ad-
herence to PFMT was described in five studies measured via
attendance at appointments, completion of exercise training
diaries during the active treatment phase and postintervention
via self-report of PFMT adherence and dosage recorded on
postal questionnaires. Adherence ranged from low (19 %
[12]) to high (97 %, Braekken et al. [14]).
Justification provided for undertaking PFMT to affect SF
The stated justification to investigate the effect of PFMT in
order to improve SF was similar for most RCTs, including: (1)
lack of literature and knowledge about the topic [10, 12–14,
24, 25], (2) the hypothesis that SF could be improved by
increasing PFMS [10, 24–26], (3) the hypothesis that SF
would improve if symptoms of pelvic floor dysfunction de-
creased [11, 26], (4) the existence of previous research sug-
gesting that PFMT could improve female SF [10, 25] and (5)
the need to conduct studies with appropriate control groups to
investigate this topic [10].
1743
Discussion
The objective of this study was to conduct a systematic
review of the literature regarding the effects of PFMT on
SF. The included RCTs indicated a variety of interventions
and tools to evaluate SF. Although most studies indicated
an improvement of at least one sexual variable, results
need to be interpreted with caution due to methodological
limitations. The trial by Wilson et al. [24] found no effect
of PFMT on SF 1 year postpartum. Their study was lim-
ited by high withdrawal rates in both control and interven-
tion groups. Handa et al. [11] compared the impact of
three different conservative treatments on SF in women
with mixed UI or SUI alone. The authors concluded that
improvement in SF in the groups that received PFMT
were mediated by improved continence. However, the
power of their study was quite low, and nearly 40 % of
participants lacked a sexual partner at enrolment.
The studies that showed improvement (intergroup differ-
ence) in at least one sexual variable following PFMT [10, 13,
14, 25, 26] included quite diverse populations of women. Bo
et al. [10] investigated SF as a secondary outcome; their re-
sults need to be interpreted with caution because of the small
number of sexually active women and the lack of information
related to many SF domains at baseline and after intervention.
The study by Yang et al. [26] was the only one to include a
sample of cancer survivors. In addition to a very small sample,
the study suffered from high withdrawal rates in both control
and intervention groups and a lack of an intention-to-treat
analysis. Despite the clinically meaningful difference reported
[38], intergroup results for the EORTC QLQ-CX24 were not
presented, which compromises findings.
Although Efekhar et al. [13] used questions from the FSFI,
the original domain and total scores were not presented at base-
line and after intervention. Furthermore, the authors modified
the specific original response options for each domain. Modi-
fication of a tool requires psychometric testing in order to con-
firm measurement properties of the new tool being used [3].
Braekken et al. [14] received the highest PEDro score (7) of
the eight articles included in our review; however, the study
was a secondary analysis that included women with POP.
According to the authors, a possible explanation for the
changes in SF being apparent only in the interview analysis
was that an individualised approach allowed assessment of
change in SF in a more sensitive manner. However, they ac-
knowledged that the absence of a more specific and compre-
hensive questionnaire to assess SF was a limitation of their
study. Another secondary outcome analysis of a recently pub-
lished RCT showed that women in the PFMT group reported
significantly less interference of POP symptoms with sex life
at 6 months after trial entry but not at 12 months [15]. How-
ever, that study was not included in this review, as it did not
completely fulfill established inclusion criteria [15].
1744 Int Urogynecol J (2015) 26:1735–1750

Table 4 Description of sexual function outcomes, baseline differences, postintervention results and withdrawal rates of the studies included in the
systematic review

Study Sexual function outcomes Time points for data Results of sexual function assessments Study withdrawals
collection after intervention

Wilson et al. [24] GRISS (Rust et al. 1986) No baseline measurement Completers’ results presented (CG 91, IG CG: 26/117; 22 %
modified: reported 54); no difference between groups on IG: 59/113; 52 %
Pain with sex 12 months postnatal any question
Satisfactory sex p=0.15
Interest in sex p=0.24
Arousal p=0.79
Ability to orgasm p=0.45
Vaginal feelings p=0.11
Incontinence affects sex p=0.93
Adequacy of vaginal tone p=0.43
p=0.23
Bø et al. [10] B-FLUTS (Jackson et al. Baseline measurement CG: 24 CG: 0/30; 0 %
1996) sex life (Q21–Q24): 6 months from baseline IG: 21 IG: 4/29; 14 %
Q21: Sex life spoilt by UI Percentage of women reporting Q21, 22,
Q22: sex life spoilt by urinary 23 and 24 of B-FLUTS and intergroup
symptoms statistical results
Q23: pain in intercourse Q21: CG 50 %; IG: 16.7 %; p =0.03
Q24: UI with intercourse Q22: CG 50 %; IG: 11.1 %; p=0.02.
Q23: CG: 33.3 %; IG:10.5 %; p=0.1
Q 24: CG: 41.7 %; IG: 10.5 %; p=0.02
After controlling for prevalues (Cochran-
Mantel-Haenzel test) only Q22
reached statistical significance
Citak et al. [25] FSFI [29] Baseline measures Completers’ results CG: 22/58; 38 %
1. Sexual desire 3 months after baseline CG: 38, IG: 37 IG: 21/60; 35 %
2.Arousal, Intergroup statistical result related to
3. Lubrication FSFI domains and total score at
4. Orgasm 3 months after baseline
5. Satisfaction t=0.15; p=0.875
6. Pain t=1.83; p=0.071
7. Total score t=1.77; p=0.080
t=2.72: p=0.008
t=0.92; p=0.359
t=1.89; p=0.063
t=2.22; p=0.029
Handa et al. [11] 1. SPEQ-9 ([28] : 3 items re- Baseline measures Completers’ results presented for women CTGa: 39/149 (26 %)
ported libido, arousal, 3 months after baseline successfully treated for SUI (142) or PFMTG+CSGa: 22/
dyspareunia; not (203) 146 (15 %)–
2. PISQ-12 [31]: total score+2 No difference between groups (CPG, CTGa: 18/150 (12 %)
individual score items re- PFMTG+CSG and CTG) in SPEQ or
ported and rated in a 5-point PISQ (no data provided)
Likert scale: urinary incon- Women successfully treated for UI
tinence with sexual activity had a greater improvement (mean
(UISA), and fear of incon- difference) in PISQ-12 total score
tinence restricting sexual (2.26±3.24 vs 0.48±3.76,
activity p=0.0007); sexual activity
(0.45±0.84 vs 1±0.71, p=0.0002)
and reduction in restricted sexual
activity fear of incontinence
(0.32±0.76 vs −0.06±0.78,
p=0.008)
Women in CTG successfully treated
for SUI had a 0.45 greater
improvement in UISA (Likert
scale) in CTG compared with CPG
(p= 0.019) and 0.42 (Likert scale)
greater in PFMTG+CSG compared
with CPG (p=0.02)
Int Urogynecol J (2015) 26:1735–1750
Table 4 (continued)
Study Sexual function outcomes
Liebergall- PISQ-12 [31] with slight
Wischnitzer [12] modification (Hebrew
version): 12 items relating
to behavioural emotive
factors, physical factors and
partner-related factors
I-QOL [27] with slight
modification (Hebrew
version): single question in
the psychosocial domain of
the 22-items regarding sex-
uality: BI worry about hav-
ing sex^
Yang et al. [26] APFQ, [33], sexual symptoms
domain, 10 questions
EORTC QLQ-CX-24 [34] 4
questions related to sexual
function
Eftekhar et al. [13] FSFI (Rosen et al.2000)
1. Orgasm
2. Dyspareunia
3. Libido
4. Arousal
The answers were modified
from the original tool to:
severe disorder (SD),
sometimes good (SGO),
mostly good (MG) and
without disorder (WD).
Separate results for lubrication
and pain not reported. The
original scores for each
domain and the total score
of the FSFI not reported
Braeken et al. [14] 1. POP questionnaire [33]
a. Frequency of sexual
intercourse
b. Satisfaction with frequency
of intercourse
c. Sexual difficulties during
intercourse
d. Change in bothersome
2. Semistructured interview
evaluating changes in
1745
Time points for data Results of sexual function assessments Study withdrawals
collection after intervention
Baseline Completers’ results presented. PMG: 66; PMG:23/119; 19 %;
Following the 12-week PFMTG: 60. Mean (SD) scores: PFMTG: 38/126;
intervention PISQ: PFMTG: 38.07 (5.8); PMG: 38.72 30 %
(5.35), p=NS
I-QOL results of sexuality question not
presented: results presented as
summed score for 22 items; difference
between groups: p=NS
Baseline Completers’ results. CG: 5/17; 29 %;
Following the 4-week in- 12 per group. IG: 5/17; 29 %
tervention Mean (SD) difference from baseline in
sexual function score:
APFQ: CG −2.42 (±3.47); IG −5.62
(±2.27), mean difference between
groups after intervention −0.38. β
coefficient (95 %) −0.55 (−0.86 to
−0.01) t-v −2.292 p=0.048
EORTC QLQ-CX-24: data of change
between groups not reported; clinically
meaningful changes in the IG group
observed in domains of sexual worry,
sexual activity and sexual/vaginal
function; however, differences be-
tween groups NS
Baseline Number and percentage of women with SG: 0/45; 0 %
SG 6 weeks following SD (a), SGO (b), MG (c) and WD (d), PG: 0/45; 0 %
surgery and difference between SG and PG in
PFMTG 8 weeks 4 domains of FSFI :
following surgery 1a SG: 9 (15 %) vs 1 (2 %)PG;
1b SG: 0 vs 11 (24 %) PG;
1c SG: 12 (25 %) vs 21 (47 %) PG;
1d SG: 27 (60 %) vs 12 (27 %) PG;
p=0.001
2a SG: 37 (82 %) vs 6 (13 %) PG;
2b SG: 3 (7 %) vs 12 (27 %) PG;
2c SG: 5 (11 %) vs 14 (31 %) PG;
2d SG: 0 vs 13 (29 %) PG. p=0.001
3a SG: 11 (25 %) vs 2 (4 %);
3b SG: 14 (31 %) vs 13 (29 %) PG;
3c SG: 19 (42 %) vs 23 (51 %) PG;
3d WD-SG: 1(2 %) vs 0 PG p=0.001
4a SG: 1 (2 %) vs 0 PG;
4b SG: 10 (22 %) vs 3 (6 %) PG;
4c SG: 17 (38 %) vs 21 (47 %) PG;
4d SG: 17 (38 %) vs 21 (47 %) PG;
p=0.001
Baseline Completers’ responses: CG: 1/50; 2 %
Following the 6-month Number of completers for each group in IG: 1/59; 1.7 %
intervention each question of the POP
questionnaire and intergroup result
after intervention:
1a CG=50; IG=59 p=0.063
1b CG=37; IG=45 p=0.746
1c CG=40; IG=46 p=0.061
1d CG=40; IG=46 p=0.066
1746
Table 4 (continued)
Study Sexual function outcomes Time points for data
collection
sexual desire, orgasm,
perception of dryness,
burning or discomfort/pain,
self-confidence regarding
sex and any other changes
GRISS Golombok and Rust Reference Inventory of Sexual Satisfaction, CG control group, IG intervention group, B-FLUTS Bristol Female Lower
Urinary Tract Symptoms, FSFI Female Sexual Function Index, SPEQ Short Form Personal Experiences Questionnaire, PISQ-12 Pelvic Organ Pro-
lapse—Urinary Incontinence Sexual Function Questionnaire, CPG continence pessary group, CSG continence strategies group CTG combined therapy
group, I-QOL incontinence quality of life, PMG Paula method group, PFMTG pelvic floor muscle training group, APFQ Australian Pelvic Floor
Questionnaire, EORTC- QLQ
a
Details sourced from previous manuscript reporting on the primary outcome analysis
Only the study by Citak et al. [25] selected women after
childbirth without regard to continence status or pelvic floor
dysfunction. However, the study had a high rate of with-
drawals, and an intention to treat analysis was not performed.
The prevalence of UI in postpartum women is often high
[39–41], and this variable was not monitored. Although some
authors have not found an association between SF and UI [42,
43], recent studies using validated tools have confirmed the
presence of this association [44, 45].
To date, there is no consensus in the literature to explain the
mechanism of how PFMT improves SF. Although the results
of non-randomised studies suggest that improvement in
PFMS would improve SF [46, 47], this has not been clearly
demonstrated in this review. Most RCTs did not analyse this
association, and conflicting results were found between one
study that did not establish this association [11] and one study
that found a medium and small correlation between changes in
SF and PFMS, respectively [14].
Physiologic measures of sexual response are recommended
as secondary end points in clinical trials on sexual dysfunction
in women [3]; however, no RCT in our review used an out-
come measure to assess blood flow to the pelvis or other
physiological sexual responses. Also, the studies incorporated
a variety of protocols. Only three offered PFMT alone to the
intervention group [12, 14, 25]. PFMT was most frequently
supplemented with adjunctive therapies that might have influ-
enced SF, making it more difficult to analyse the specific
effect of PFMT alone. Two trials incorporated appropriate
control groups comparing different conservative options to
manage UI, such as pessaries, or no specific instruction of
PFMT [10, 11]. One RCT compared PFMT with the Paula
method; however, the Paula protocol also included PFM
Int Urogynecol J (2015) 26:1735–1750
Results of sexual function assessments Study withdrawals
after intervention
2. Result of the interview CG (41): 2
(5 %) women reported an
improvement in SF vs 19 (39 %) in the
PFMTG (49); p<0.01
PFMTG increased: awareness, strength,
control of PFM, sensation of tighter
vagina, self-confidence, libido,
orgasm, resolution of pain with
intercourse and partners report of
sexual gratification
No difference in frequency of sexual
intercourse between groups
contractions [12]. The imbalance in the number of supervised
sessions (Paula 12 vs PFMT 4) may have biased the results.
All but one of the included RCTs performed a secondary anal-
ysis of SF and were not specifically designed to investigate
SF. The studies were heterogeneous regarding tools used to
assess SF. Validated self-reported measures and structured in-
terviews are recommended as primary end points to evaluate
sexual dysfunction interventions [3]. Although all studies in
this review stated to have used validated tools or some aspects
of them, none of them clearly defined and assessed sexual
dysfunction as recommended, including validated measures
of distress [3, 48], and classified sexual disorders according
to an international consensus [49, 50]. Therefore, uncertainty
remains regarding the amount of sexual dysfunction in each
cohort and its influence on results.
Considering that SF and sexual dysfunction are influenced by
interpersonal, contextual, personal, psychological and biological
factors [50], future RCTs should consider these variables in de-
veloping research questions and hypotheses. The result of PFMT
on SF (Bsuccess^ or Bfailure^) requires interpretation in the light
of these other variables. It is possible that specific groups of
women with certain disorders would benefit more than others
from PFMT. Gynaecological pathology and partner factors may
adversely affect SF and diminish the benefit of PFMT.
A limitation of this review may be the exclusion of other
study designs, such as observational studies and case reports.
However, non-RCTs cannot answer the question of therapy
effectiveness in a robust and unbiased way; therefore, inter-
pretation of the findings can only be uncertain at best.
Our Pubmed search revealed no systematic reviews on the
effect of PFMT on female SF, but a recent literature review on
this topic concluded that it is quite probable that arousal,
Table 5 Description of pelvic floor muscle outcome and adherence measures, pelvic floor muscle assessment results and adherence to PFMT
Study Time points for data collection
Wilson et al. [24] No baseline measurement
reported
12 months postnatal
Bø et al. [10] Baseline measurement
6 months from baseline
Citak et al. [25] Baseline measures
-3 months after baseline
Handa et al. [11] -Baseline measures
-3 months after baseline
Pelvic floor muscle outcomes;
adherence measurement
PFMS (MVC) and endurance (s held)
measured with manometry;
Frequency and number of PFME
performed per day, measured by
postal questionnaire
PFMS (MVC) with a vaginal balloon
catheter. pressurea
Training diary and monthly clinical
visitsa
MOGS
Manometry
PFMS- Brink score
A self-administered adherence ques-
tionnaire at follow-up
Results of PFM assessment Results of adherence to PFMT
Completers’ results Returned questionnaires: CG: 91 (78 %);
CG: 79; IG: 54 (48 %).
IG: 51: PFME in previous month: CG: 59 (65 %); IG:
MVC: 48 (89 %); p=0.003
CG: 13.1cmH2O (95 % CI: 11.4–14.8); Daily PFME:
IG: 13.1cmH2O (95 % CI: 10.7–15.5); CG: 8 (9 %); IG: 26 (48 %); p<0.0005
p=0.99 Number of daily contractions: CG: 35 (95 %
Int Urogynecol J (2015) 26:1735–1750
Endurance: CI: 30–40);
CG: 6.7 s (95 % CI: 5.5–8.0); IG: 59 (95 % CI: 48–70; p<0.0005
IG: 7.4 s (95 % CI: 5.8–9.1);
p=0.52
Completer’s resultsa Mean adherence for PFMTa: 93 %
CG: 30
IG: 25
CG-MVC 14.6 cm H2O before vs 16.2 cm H2O
after testa
IG-MVC 11.0 cm H2O (95 % CI 7.7-14.3) before
test vs 19.2 cm H2O (95 % CI 15.3-23.1) after
test p<0.01
Additional intention to treat analyses did not change
the resultsa
Completers’ results: Not reported
CG: 38
IG: 37
MOGS: scores grouped according to 0–2/5 and 3–5/
5 0-2/5 CG: 11 (28 %) vs IG: 2 (5.4 %); score 3-
5/5 CG: 27 (71 %) vs IG: 35 (94.6 %) p=0.017
Manometry:
scores are grouped according to <1, 1–2, 3–4, >4.
<1 CG: 11(28.9 %) vs IG: 2 (5.4 %);
1–2 CG: 23 (60.5 %) vs IG: 20 (54.1 %)
3–4 CG: 4 (10.5 %) vs IG: 15 (40.5 %)
p=0.002
No results presented per group of intervention; No. PFMT+CSGa: 112/149;
of completers is not specified 75.6 % CTG: 69/150; 46 %a
At baseline, the mean (SD) Brink score was CPG: 99/146; 67.8 %a
8.6±2.1. After treatment, the mean score was
9.3±2.0
Successful treatment of SUI was associated with a
significantly higher Brink score (9.5±2.0 vs
9.0±2.0, p=0.028). The change in Brink score
was not associated with change in PISQ-12 total
score (p=0.19).
1747
Table 5 (continued)
1748

Study Time points for data collection Pelvic floor muscle outcomes; Results of PFM assessment Results of adherence to PFMT
adherence measurement

Liebergall-Wischnitzer Baseline Not reported Not reported Participated in > 50 % of the prescribed
[12] Following the 12-week interven- Adherence was assessed by counting lessons: PMG: 86 (73.5 %); PFMTG: 68
tion the number of lessons participants (55.2 %)
attended and by daily reports of Did not attend any lessons PMG: 12
home exercisesa (10.2 %); PFMTG: 14 (11.4 %)
Reported home exercising: PMG: 31
(26.5 %); PFMTG: 23 (18.7 %)
Yang et al. [26] Baseline PFMS measured with: Completers’ results presented, adjusted for baseline Not reported
Following the 4 week Manometry combined with 2-channel scores
intervention EMG 12 per group, 71 % of original cohort
Motor evoked potential of the sacral Mean (SD) change from baseline scores at 4 weeks:
nerve (excitability threshold to sacral Manometry:
stimulation) CG group 7.56 (±8.65) cm H2O
Exercise diaries IG 21.8 (±7.64) cm H2O; p=0.036
Eftekhar et al. [13] Baseline Not reported Not reported Not reported
Surgery group 6 weeks following
surgery
PFMT group 8 weeks following
surgery
Braeken et al. [14] Baseline PFMS with a manometer PFMS: CG: five (10 %) women reported they had
Following the 6-month interven- Training diarya CGa: 1.1 cm H2O; 95 % CI, 0.4 –2.7 vs IGa:13.1 cm performed more PFMT than they did
tion H2O; 95 % CI, before baseline: IG: 89 % trained 180 days
10.6–15.5 p<.001 and attended 97 % of 18 PT supervised
Endurance: sessionsa
a
CG : 8 cm H2O s; 95 %
CI: −7.4 to 24.1;
IGa: 107 cm H2O s; 95 % CI 77.0–36.4 vs
p<0.001)a
Medium correlation between change in SF and in
PFMS (r=0.43, p<0.01)

PFM pelvic floor muscle, MVC maximum voluntary contraction, PFME pelvic floor muscle exercise, EMG electromyelogram, CG control group, IG intervention group SF sexual function, PFMT pelvic
floor muscle training, PFMS pelvic floor muscle strength, MOGS Modified Oxford Grading Scale, CSG continence strategies group, CTG combined therapy group, CPG continence pessary group, PMG
Paula method group, PFMTG pelvic floor muscle training group, CI confidence interval
a
Details sourced from previous manuscript reporting on the primary outcome analysis
Int Urogynecol J (2015) 26:1735–1750
Int Urogynecol J (2015) 26:1735–1750
lubrication, orgasm and desire can be improved by PFMT in
postpartum women and women with UI [20]. However, the
study conclusion was based nonrandomised studies and on
only three [10, 24, 25] of the eight RCTs included in our
systematic review. A number of non-randomised studies that
found no effect of PFMT on women’s sexual life/function
[51–53] were not included in Willans’ review, [20]. Therefore
we believe our review adds a unique and unbiased contribu-
tion to the topic. It was not possible to confirm strong evidence
for improvements in arousal, lubrication, orgasm and desire in
the populations of women investigated. The specific SF do-
main analysis was especially impaired by the use of different
assessment tools that frequently could not clearly evaluate
those domains. Additionally, the intergroup comparisons ac-
cording to these specific domains were infrequently
performed.
From this review, we propose the following clinical recom-
mendations and directions for future research:
1. Clinical recommendations: There is level 2 evidence [21]
that PFMT seems to improve at least some aspects of SF
in women either postnatally or those with pelvic floor
dysfunction. We propose a Grade B recommendation that
clinicians may prescribe PFMT to improve SF; however,
we strongly advise that adherence to a dose-effective level
of therapy be emphasised and the effects carefully evalu-
ated to confirm whether benefit is conferred. Possible im-
provement in SF may act as a motivator to adherence to
PFMT. The therapy is low cost and appears to be associ-
ated with no adverse events, it may confer benefit on
coexisting pelvic floor disorders and does not preclude
other subsequent treatments for SF if required.
2. Research recommendations: Many aspects of the effects
of PFMT on SF remain understudied. There is an urgent
need for RCTs specifically designed to investigate the
effect of PFMT on female SF and the treatment of sexual
dysfunction as a primary aim. Homogeneity of pelvic
floor dysfunction in participants is desired. Women in
the postpartum period or cancer survivors are in a special
category and should be investigated taking this into ac-
count. Appropriate outcome measures should be incorpo-
rated into the study design, and the range of variables
known to affect SF need to be considered.
Acknowledgments We thank all Urogynecology Department staff of
the Mercy Hospital for Women, Melbourne, VIC, Australia and especial-
ly to Christine Murray and Elizabeth Thomas.
Funding The first author received a scholarship from São Paulo Re-
search Foundation (FAPESP- 2012/215239).
Conflict of Interest None
1749
References
1. Abdo CH, Oliveira WM Jr, Moreira ED Jr, Fittipaldi JA (2004)
Prevalence of sexual dysfunctions and correlated conditions in a
sample of Brazilian women–results of the Brazilian study on sexual
behavior (BSSB). Int J Impot Res 16:160–166
2. Nobre JP, Pinto-Gouveia J (2006) Dysfunctional sexual beliefs as
vulnerability factors for sexual dysfunction Universidade de
Coimbra, Portugal. J Sex Res 43:68–75
3. Clayton AH, Dennerstein L, Fisher WA, Kingsberg SA, Perelman
MA, Pyke RE (2010) Standards for clinical trials in sexual dysfunc-
tion in women: research designs and outcomes assessment. J Sex
Med 7:541–560
4. Lewis RW, Fugl-Meyer KS, Corona G, Hayes RD, Laumann EO,
Moreira ED et al (2010) Definitions/epidemiology/risk factors for
sexual dysfunction. J Sex Med 7:1598–1607
5. Knoepp LR, Shippey SH, Chen CC, Cundiff GW, Derogatis LR,
Handa VL (2010) Sexual complaints, pelvic floor symptoms, and
sexual distress in women over forty. J Sex Med 7:3675–3682
6. Pontiroli AE, Cortelazzi D, Morabito A (2013) Female sexual dys-
function and diabetes: a systematic review and meta-analysis. J Sex
Med 10(4):1044–1051
7. Ibrahim ZM, Ahmed MR, Sayed Ahmed WA (2013) Prevalence
and risk factors for female sexual dysfunction among Egyptian
women. Arch Gynecol Obstet 87:1173–1180
8. Diehl A, da Silva R, Laranjeira R (2013) Female sexual dysfunction
in patients with substance-related disorders. Clinics 68:205–211
9. Dumoulin C, Hunter KF, Moore K, Bradley CS, Burgio KL, Hagen
S, Imamura M, Thakar R, Williams K, Chambers T (2014)
Conservative management for female urinary incontinence and pel-
vic organ prolapse review 2013: Summary of the 5th international
consultation on incontinence. Neurourol Urodyn. doi:10.1002/nau.
22677
10. Bø K, Talseth T, Vinsnes A (2000) Randomized controlled trial on
the effect of pelvic floor muscle training on quality of life and
sexual problems in genuine stress incontinent women. Acta
Obstet Gynecol Scand 79:598–603
11. Handa VL, Whitcomb E, Weidner AC, Nygaard I, Brubaker L,
Bradley CS, Paraiso MF, Schaffer J, Zyczynski HM, Zhang M,
Richter HE (2011) Sexual function before and after non-surgical
treatment for stress urinary incontinence. Female Pelvic Med
Reconstr Surg 17:30–35
12. Liebergall-Wischnitzer M, Paltiel O, Hochner Celnikier D, Lavy Y,
Manor O, Woloski Wruble AC (2012) Sexual function and quality
of life of women with stress urinary incontinence: a randomized
controlled trial comparing the Paula method (circular muscle exer-
cises) to pelvic floor muscle training (PFMT) exercises. J Sex Med
9:1613–1623
13. Eftekhar T, Sohrabi M, Haghollahi F, Shariat M, Miri E (2014)
Comparison effect of physiotherapy with surgery on sexual func-
tion in patients with pelvic floor disorder: A randomized clinical
trial. Iran J Reprod Med 12:7–14
14. Braekken IH, Majida M, Ellström Engh M, Bø K (2015) Can Pelvic
Floor Muscle Training Improve Sexual Function in Women with
Pelvic Organ Prolapse? A Randomized Controlled Trial. J Sex Med
12:470–480
15. Hagen S, Stark D, Glazener C, Dickson S, Barry S, Elders A,
Frawley H, Galea MP, Logan J, McDonald A, McPherson G,
Moore KH, Norrie J, Walker A, Wilson D (2014) POPPY Trial
Collaborators. Individualised pelvic floor muscle training in wom-
en with pelvic organ prolapse (POPPY): a multicentre randomised
controlled trial. Lancet 383:796–806
16. Kegel A (1952) Sexual functions of the pubococcygeus muscle.
West J Surg Obstet Gynecol 60:521–524
1750
17. Shafik A (2000) The role of the levator ani muscle in evacuation,
sexual performance and pelvic floor disorders. Int Urogynecol J
Pelvic Floor Dysfunct 11:361–376
18. Graber B, Kline-Graber G (1979) Female orgasm: role of
pubococcygeus muscle. J Clin Psychiatry 40:348–351
19. Ma Y, Qin H (2009) Pelvic floor muscle exercises may improve
female sexual function. Med Hypotheses 72:223
20. Willans A (2014) The role of pelvic floor muscle exercise in the
treatment of female sexual dysfunction. J Assoc Chart
Physiotherapists Women’s Health 115:22–29
21. Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C,
Liberati A, Moschetti I,Phillips B, Thornton H, Goddard O,
Hodgkinson M. The Oxford Levels of Evidence 2″. Oxford
Centre for Evidence-Based Medicine. http://www.cebm.net/index.
aspx?o=5653
22. Macedo LG, Elkins MR, Maher CG, Moseley AM, Herbert RD,
Sherrington C (2010) There was evidence of convergent and con-
struct validity of Physiotherapy Evidence Database quality scale for
physiotherapy trials. J Clin Epidemiol 63:920–925
23. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B,
Lee J, Monga A, Petri E, Rizk DE, Sand PK, Schaer GN (2010) An
International Urogynecological Association (IUGA)/International
Continence Society (ICS) joint report on the terminology for female
pelvic floor dysfunction. Int Urogynecol J 21:5–26
24. Wilson PD, Herbison GP (1998) A randomized controlled trial of
pelvic floor muscle exercises to treat postnatal urinary incontinence.
Int Urogynecol J Pelvic Floor Dysfunct 9:257–264
25. Citak N, Cam C, Arslan H, Karateke A, Tug N, Ayaz R, Celik C
(2010) Postpartum sexual function of women and the effects of
early pelvic floor muscle exercises. Acta Obstet Gynecol Scand
89:817–822
26. Yang EJ, Lim JY, Rah UW, Kim YB (2012) Effect of a pelvic floor
muscle training program on gynecologic cancer survivors with pel-
vic floor dysfunction: a randomized controlled trial. Gynecol Oncol
125:705–711
27. Patrick DL, Martin ML, Bushnell DM, Yalcin I, Wagner TH,
Buesching DP (1999) Quality of life of women with urinary incon-
tinence: further development of the incontinence quality of life
instrument (I-QOL). Urology 53(1):71–6.
28. Rust J, Golombok S (1986) The GRISS: a psychometric instrument
for the assessment of sexual dysfunction. Arch Sex Behav 15:157–
165
29. Dennerstein L, Anderson-Hunt M, Dudley E (2002) Evaluation of a
short scale to assess female sexual functioning. J Sex Marital Ther
28:389–397
30. Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R,
Ferguson D, D’Agostino R Jr (2000) The Female Sexual Function
Index (FSFI): a multidimensional self-report instrument for the as-
sessment of female sexual function. J Sex Marital Ther 26:191–208
31. Jackson S, Donovan J, Brookes S, Eckford S, Swithinbank L,
Abrams P (1996) The Bristol Female Lower Urinary Tract
Symptoms questionnaire: development and psychometric testing.
Br J Urol 77:805–812
32. Rogers RG, Coates KW, Kammerer-Doak D, Khalsa S, Qualls C
(2004) A short form of the Pelvic Organ Prolapse/Urinary
Incontinence Sexual Questionnaire (PISQ-12). Int Urogynecol J
Pelvic Floor Dysfunct 15:219
33. Baessler K, O’Neill SM, Maher CF, Battistutta D (2009) Australian
pelvic floor questionnaire: a validated interviewer-administered pel-
vic floor questionnaire for routine clinic and research. Int
Urogynecol J Pelvic Floor Dysfunct 20:149–158
34. Mouritsen L, Larsen JP (2003) Symptoms, bother and POPQ in
women referred with pelvic organ prolapse. Int Urogynecol J
Pelvic Floor Dysfunct 14:122–127
Int Urogynecol J (2015) 26:1735–1750
35. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A,
Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JC
et al (1993) The European Organization for Research and
Treatment of Cancer QLQ-C30: a quality-of-life instrument for
use in international clinical trials in oncology. J Natl Cancer Inst
85:365–376
36. Laycock J et al (1994) Clinical evaluation of the pelvic floor. In:
Pelvic Floor Re-education, 1st edn. Springer-Verlag, London, pp
42–48
37. Brink CA, Sampselle CM, Wells TJ, Diokno AC, Gillis GL (1989)
A digital test for pelvic muscle strength in older women with uri-
nary incontinence. Nurs Res 38:196–199
38. Osoba D, Rodrigues G, Myles J, Zee B, Pater J (1998) Interpreting
the significance of changes in health-related quality-of-life scores. J
Clin Oncol 16:139–144
39. Van Brummen HJ, Bruinse HW, van de Pol G, Heintz AP, van der
Vaart CH (2007) The effect of vaginal and cesarean delivery on
lower urinary tract symptoms: what makes the difference? Int
Urogynecol J Pelvic Floor Dysfunct 18:133–139
40. Wesnes SL, Hunskaar S, Bo K, Rortveit G (2009) The effect of
urinary incontinence status during pregnancy and delivery mode
on incontinence postpartum. A cohort study. BJOG 116:700–707
41. Brown S, Gartland D, Perlen S, McDonald E, MacArthur C (2014)
Consultation about urinary and faecal incontinence in the year after
childbirth: a cohort study. BJOG. doi:10.1111/1471-0528.12963
42. Weber AM, Walters MD, Schover LR, Mitchinson A (1995) Sexual
function in women with uterovaginal prolapse and urinary inconti-
nence. Obstet Gynecol 85:483–487
43. Lukacz ES, Whitcomb EL, Lawrence JM, Nager CW, Contreras R,
Luber KM (2007) Are sexual activity and satisfaction affected by
pelvic floor disorders? Analysis of a community-based survey. Am
J Obstet Gynecol 197:88.e1–6
44. De Souza A, Dwyer PL, Rosamilia A, Hiscock R, Lim YN, Murray
C, Thomas E, Conway C, Schierlitz L (2012) Sexual function fol-
lowing retropubic TVT and transobturator Monarc sling in women
with intrinsic sphincter deficiency: a multicentre prospective study.
Int Urogynecol J 23:153–158
45. Schoenfeld M, Fuermetz A, Muenster M, Ennemoser S, von
Bodungen V, Friese K, Jundt K (2013) Sexuality in German
urogynecological patients and healthy controls: is there a difference
with respect to the diagnosis? Eur J Obstet Gynecol Reprod Biol
170:567–570
46. Lowenstein L, Gruenwald I, Gartman I, Vardi Y (2010) Can stron-
ger pelvic muscle floor improve sexual function? Int Urogynecol J
21:553–556
47. Martinez CS, Ferreira FV, Castro AA, Gomide LB (2014) Women
with greater pelvic floor muscle strength have better sexual func-
tion. Acta Obstet Gynecol Scand 93:497–502
48. Latif EZ, Diamond MP (2013) Arriving at the diagnosis of female
sexual dysfunction. Fertil Steril 100:898–904
49. Basson R (2005) Women’s sexual dysfunction: revised and expand-
ed definitions. CMAJ 172:1327–1333
50. Basson R, Berman J, Burnett A et al (2000) Report of the interna-
tional consensus development conference on female sexual dys-
function: definitions and classifications. J Urol 163(3):888–893
51. Roughan PA, Kunst L (1981) Do pelvic floor exercises really im-
prove orgasmic potential? J Sex Marital Ther 7:223–229
52. Trudel G, Saint-Laurent S (1983) A comparison between the effects
of Kegel’s exercises and a combination of sexual awareness relax-
ation and breathing on situational orgasmic dysfunction in women.
J Sex Marital Ther 9:204–209
53. Lara LA, Montenegro ML, Franco MM, Abreu DC, Rosa e Silva
AC, Ferreira CH (2012) Is the sexual satisfaction of postmenopaus-
al women enhanced by physical exercise and pelvic floor muscle
training? J Sex Med 9:218–223
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