Pelvic floor exercises vs surgery: the short answer
For mild stress incontinence and early prolapse, supervised pelvic floor training is where the guidelines start. The American Urological Association tells clinicians to counsel women on observation, pelvic floor muscle training with or without biofeedback, other non-surgical options such as a continence pessary, and surgery. Surgery is for women whose leaking or bulge still limits their life after a fair trial of training, or whose supports have clearly failed.
What exercises can do
Strengthen the muscles that support the bladder neck and close the urethra. For mild stress incontinence with intact ligaments, supervised training helps many women within three months.
How the training works
Pelvic floor training means tightening the muscles that close the urethra and support the bladder, then letting them go. The International Urogynecological Association (IUGA) describes holds of up to 10 seconds, repeated 8 to 12 times. The common mistake is pushing down when you should be pulling up, so many women need someone to check their technique.
ACOG gives one schedule: squeeze the muscles you use to stop the flow of urine, hold for 3 seconds, relax for 3 seconds, and do 10 contractions three times a day. Add a second to the hold each week, working up to 10 seconds. Breathe normally, and do not squeeze the stomach, thigh or buttock muscles. Schedules differ between sources, so ask whoever checks your technique which one to follow.
How long to give it
Bladder control may not change for 3 to 6 weeks, and IUGA says full benefit can take up to 6 months. NICE guidance on pelvic floor dysfunction (NG210) advises a supervised program of at least 3 months for stress or mixed urinary incontinence. For symptomatic prolapse that does not extend more than 1 cm beyond the hymen when you strain, it says to consider a supervised program of at least 4 months. NICE also asks for at least one review during the program and one at the end.
A 2018 Cochrane review of 31 trials with 1,817 women found that women with stress incontinence who trained were far more likely to report that their leaking had stopped than women who had no treatment. Most trials followed women for less than 12 months.
Kegels or surgery for incontinence?
Kegels work well when leaking comes with effort, such as a cough, a sneeze or a jump, and the supports are intact. They are less likely to be enough when the leaking is severe, when you can see or feel a bulge, or when months of correct training have changed nothing. ACOG says that if non-surgical treatment does not improve stress incontinence, surgery may help, that it improves symptoms in most women, and that the types of operation are injections, urethral slings and colposuspension. A bulge you can see or feel points to prolapse, which training can ease but cannot reverse.
What they cannot do
Shorten ligaments that have stretched or lift an organ that has descended. Exercises cannot repair a failed support, though they help protect a repair afterwards.
When is surgery needed for prolapse?
ACOG says many women with prolapse need no treatment, and that treatment is considered when symptoms interfere with normal activities. Non-surgical options are tried first, and surgery is considered when they do not work and symptoms are severe. ACOG lists the severity of symptoms, your age, your plans for future children and other health conditions as factors in the decision.
NICE advises offering surgery for prolapse to women whose symptoms have not improved with or who have declined non-surgical treatment. Before any operation, the discussion should cover the benefits and risks of each option, including the chance that prolapse returns.
If you have finished a supervised program and leaking or a bulge still limits your life, that is the time to talk about surgery.
What the surgical options are
For stress incontinence, the AUA/SUFU guideline lists the midurethral sling, the autologous fascia sling, Burch colposuspension and bulking agents. For prolapse, ACOG divides operations into reconstructive surgery, which restores the organs to their original position, and obliterative surgery, which narrows or closes the vagina. The mesh-free choices, including native-tissue repair, are explained under bladder surgery without mesh.
Measuring instead of guessing
Numerical measurement of support and imaging of the vaginal wall show which situation you are in, so the decision rests on findings rather than trial and error.
What measurement involves
The clinic uses vaginal endoscopy imaging to examine the vaginal wall before treatment. Vaginal laxity is measured numerically rather than judged by hand. Together these show whether the ligaments still hold well enough for training to work.
Deciding
Try supervised training first if measurement says the supports are intact. Consider surgery if leaking or bulge limits your life despite training, or if the supports have clearly failed.
Other non-surgical choices
Non-surgical options for incontinence include radiofrequency and fractional laser vaginal treatments, chosen after measurement. In general, these aim to improve tone and do not repair ligaments that have failed. The FDA has not cleared or approved energy-based devices for treating urinary incontinence, so ask what evidence supports a treatment before you pay for it.
A pessary is a removable support worn in the vagina for prolapse. Pessaries are not fitted or managed at the clinic, and a pessary trial is not required before surgery.
At Podo
Measurement comes first; pelvic ligament suspension is the surgical option when it is needed.
Pelvic ligament suspension uses the patient's own ligaments and sutures, without synthetic mesh. Results and recovery vary from person to person. This page is general information and is not a diagnosis; a consultation is needed to decide whether a procedure suits you.
Questions
Can pelvic floor exercises fix a prolapse?
They can ease the symptoms of mild prolapse and help protect a repair afterwards. They cannot lift an organ that has descended or shorten ligaments that have stretched. Measurement shows which situation you are in.
Do I need to try a pessary before surgery at Podo?
No. Pessaries are not fitted or managed at the clinic, and a pessary trial is not required before surgery.
How can I tell whether I am doing the exercises correctly?
Ask a health professional such as a physiotherapist or continence nurse to check your technique. IUGA says the usual mistake is pushing down when you should be pulling up.
How long should I try pelvic floor exercises before considering surgery?
NICE advises a supervised program of at least 3 months for stress or mixed urinary incontinence and at least 4 months for symptomatic prolapse that does not extend more than 1 cm beyond the hymen, with a review during and at the end of the program.
Can I do pelvic floor exercises after surgery?
Exercises cannot repair a failed support, though they help protect a repair afterwards. IUGA says pelvic floor exercises are usually safe to start about 1 to 2 weeks after surgery, but confirm with your doctor first.
Sources
- NICE guideline NG210: Pelvic floor dysfunction: prevention and non-surgical management
- NICE guideline NG123: Urinary incontinence and pelvic organ prolapse in women: management
- IUGA Your Pelvic Floor: Pelvic floor exercises
- Cochrane review (2018): Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women
- ACOG patient FAQ: Pelvic support problems
- American Urological Association / SUFU: Surgical Treatment of Female Stress Urinary Incontinence guideline
- ACOG FAQ: Surgery for Pelvic Organ Prolapse
- IUGA Your Pelvic Floor: Recovery guide after pelvic floor surgery
- ACOG Committee Opinion 795: Elective Female Genital Cosmetic Surgery
Read about this at Podo
About the reviewer
Dr. Mo Hyung-jin, MD, PhD, board-certified OB-GYN specialist, is the medical director of Podo Women's Clinic. He developed the pelvic ligament suspension technique used at the clinic for stress urinary incontinence and pelvic organ prolapse. Profile