A contextual model of pelvic floor muscle defects in female stress urinary incontinence: a rationale for physiotherapy treatment.

On the basis of the current literature, we describe a model of structural defects in stress urinary incontinence (SUI) and how physiotherapy for SUI can affect each component of the model with reference to the relevant anatomy and pathophysiology. This model of SUI involves four primary structural defects: (1) increased tonic stress on the pelvic fascia due to pelvic floor muscle (PFM) tears; (2) fascial tearing due to PFM denervation; (3) fascial weakness resulting from tears; and (4) inefficient PFM contraction due to altered motor control. These four components interact to collectively weaken urethral closure and allow urine leakage under conditions of increased intra-abdominal pressure. Physiotherapy can strengthen the PFM and may improve the efficiency and/or timing of PFM contractions to reduce or eliminate SUI. It is worthwhile for motivated women with SUI to try PFM exercise therapy as a first approach to treatment. Women need to be individually instructed to ensure that they correctly perform PFM contractions and that they can monitor their own performance. Long-term, high-intensity exercise, including home exercise, is necessary to achieve maximum effect. Under these conditions the improvement in urinary continence with PFM exercise can be complete and enduring.